ADHD - How Normal Self Control Develops 2009 C

I would want parents to understand something that the vast majority of the lay population does not understand self-control is not learned it is not the result of your upbringing and how good your parents were this is one of the most profound insights from our research on ADHD ADHD as we will see is largely a neurogenetic disorder but then let's pursue the implication if that is true and ADHD is a self-regulation disorder then self-control is largely neurogenetic in origin that has a philosophically profound conclusion the vast majority of variation in the people sitting in this room and their ability to manage their behavior is not from how they were raised it is a part of who they are it is a part of their neurogenetic gifts and that is very stunning indeed that our capacity for regulating ourselves is a neurobiological trait not some socially learned phenomena that you just happen to pick up from your parents so I would want them to know that ADHD being a self-regulation disorder is arising out of neuro genetic causes and that this inability to direct behavior toward yourself comes from impairments in the following five executive abilities and these have to do with brain development not with training it does not mean the training cannot enhance them it means that they don't originate at the beginning in training in the social environment the social environment requires that they be there already and then it will help to shape them to become more proficient think of your language ability you didn't learn language but it doesn't mean that you can't become more proficient in how you speak and how you write but speaking and writing are not accounted for on the basis merely of training by your parents you're going to develop a language no matter where you grow up that is a neurobiological treyton and it unfolds as the brain unfolds it is an instinct and so is self-control but self-control can be reduced to these five things what are the five things you do to yourself these are the things your child struggles to do number one can you stop can you wait because as Rabelais said in the novel gargantuan which most of you have never read I'm sure but it is where this phrase comes from everything comes to those who can wait the waiting is the tough part you must build in a pause between the event and what you plan to do about it and in ADHD there is no pause the event happens and your response is up out done is it as if there was no front part to the brain it is as if you were like any other species with a spinal cord event response event response or as in a Gary Larson cartoon remember the far side two amoebas a husband and wife talking to each other one amoeba the wife of course says to her husband stimulus response stimulus response don't you ever think characterizes ADHD right there don't you ever think once you stop you will engage in four subsequent actions the first is mental imagery you will recall the past and you will play a DVD of it in your head you have a theater in your mind it is your visual imagery system the mind's eye so your child not only cannot stop they cannot visualize as well as other children and what they do not visualize before they act is the past the relevant past do you have experiences in this situation previously if so what would they have told you to do lay people call this hindsight and the word sight is no coincidence you are visually imagining your history what does it have to say and you lack hindsight now this will lead to foresight you look back to anticipate what does ADHD lead to no foresight you are not thinking ahead because you weren't looking back either hindsight and foresight are the opposite sides of the same coin visual imagery so you will not use your images of your past to tell you what to do you will just do and then by 5 years of age you will get the third executive deficit you can't talk to yourself young children by 5 years of age are beginning to internalize their speech and use it on themselves just watch any first and second grade classroom and you will see this if you have a three to five year old you'll hear it they're talking to themselves out loud most of the day whether anyone is in the room or not listen to bedtime and you will hear what I mean but over the next 10 years this external voice gets directed to themselves and slowly made private and mental in its form and so originates the voice in your head and that voice in your head is there for one very important reason it's to help control yourself you start telling yourself what to do and it starts to work and now any family I would explain this to would understand that not only can your child not stop and only do they not have the mind's eye they don't have the mind's voice and what is there is very weak it's not controlling them so now you know why they can't do what you tell them to do they can't follow instructions they can't follow rules they can't internalize the rules of the situation because everything I have just said requires a voice in your head and they don't have that the next comes from the first three and that is the minds heart the ability to manage your emotions so that they are more socially acceptable so that they are consistent with your goals not conflicting with your welfare and so we will see the ADHD child as we've already described them easily frustrated quick to anger impatient and just overall more excite and more emotional than others but what gets lost in this explanation is something more fundamental our emotions are our motivations if you cannot manage your emotions you cannot manage your motivation either because the fourth executive ability is the source of self motivation self motivation is the fuel tank for all future directed behavior there is no getting ready for tomorrow if there is no self motivation so what does the ADHD child lost here they cannot motivate themselves what does that mean it means that you will always be dependent on the environment around you and its immediate consequences for how hard and how long you can work and if there are no consequences in that context you cannot work you cannot persist you will not get it done the fourth executive ability now explains to these parents why this child can play video games for hours and cannot do homework for more than a few minutes because the video game provides external continuous a hundred percent consequences for interacting with it and the homework does nothing when a problem is solved on a sheet of paper nothing happens the consequences are delayed and therein lies the trouble so the corollary of this is if you want to see an ADHD person fail you put him in any an environment where there are no consequences and I guarantee you failure the work will not get done because the person cannot self motivate and this is not a choice and this is not willful and this is not a child who just could if they wished wake up tomorrow and smell the coffee and get busy and do the work they cannot this is an internal neurogenetic executive failure you can't self motivate like other people so it doesn't matter what your goals are you won't get there because self motivation is acquired for all goal-directed action the final executive ability which will not emerge until a childhood in the person with ADHD is the mind's playground this is the ability to plan and problem-solve how many different possible options can you generate right now to get around this problem this ability to simulate multiple possible future options is the highest executive function in humans it is the source of all cultural innovation but it originates in problem solving how quickly in your mind can you think of multiple ways to overcome the problem you've just encountered and people with ADHD will struggle with this one as much as with the others so if you want to understand ADHD as a parent you have got to understand these are the five things that are delayed in this child the ability to stop to use visual imagery to use your mind's voice to use your minds heart and emotion and motivation and when called upon to do so to simulate multiple possibilities when faced with a problem or when planning out what you hope to do planning and problem-solving those are the five executive abilities we know where they are in the frontal lobe we know that ADHD children have lost all five of them actually that's a bit of an overstatement it's not that they don't have them it's that they are quite delayed and we will discuss the delay in a moment so ADHD leads you to act on impulse not resist distraction you are less able to think back about what you are doing about the action that lies ahead you cannot use your hindsight and therefore your foresight is gone you do not plan ahead you live in the moment this is going to rob you of your sense of time because the sense of time comes from looking back to look ahead looking across time and knowing where I'm going you will not have a subjective sense of time and that alone is going to be a devastating adult disability you have the consummate disorder of time it's no wonder they're always late you will not be able to talk to yourself to reason with yourself to ask yourself questions and to remind yourself of the rules that are governing the immediate situation and therefore it doesn't matter what people say to you over and over and over again you won't do it no amount of nattering by your teacher or your mother will overcome the internal Minds voice deficit you will not be able to use language as well as other people to regulate yourself and that is going to also lead you to have a self motivation problem and a problem with regulating your emotions and with self-soothing when you do become emotional and then as we've said you will have trouble with planning and problem-solving so if you want to know the symptom list of ADHD this is it the DSM is but a mere superficial reflection of the most obvious symptoms of these five executive deficits but to truly understand ADHD you need to know that these five are all there underneath to refer to ADHD as inattention is to refer to autism as hand flapping and speaking funny they are the most obvious symptoms of a failure to develop the ability to relate to others as special objects as humans and that is what autism really is underneath the rest of it is just the most superficial set of symptoms so I would want my family to understand the profundity of these deficits because in attention hardly captures what is going wrong in development now the DSM says there are three kinds of ADHD let's shift gears here and get honest there is not a combined inattentive or hyperactive type and dsm-5 will abandon them they are contaminated with each other because there really is only a single ADHD in the human population and it varies in its severity and all these types have done is to capture the degree of severity of a single disorder so we are now grappling for ways of subgrouping people with ADHD that is more clinically useful then the DSM view is because the DSM view is useless and one of those ways that is very compelling is ADHD with and without conduct disorder the Europeans have done this for decades in the North American continent we viewed conduct disorder as a comorbidity we are now looking at it as a sub grouping criteria because you see ADHD children who have conduct disorder differ from ADHD children without it in many many respects so many in fact that we are now coming to think of this subset of children who have both disorders as a unique form of ADHD because both disorders are more severe both disorders start earlier both disorders are far more persistent and the combination of these disorders will predict ongoing difficulties with antisocial behavior into adulthood and just as important these individuals carry a high risk for psychopathy one in five of these children is a budding psychopath a child who lacks guilt conscience empathy and remorse a child who is a predator ADHD does not contribute to psychopathy but ADHD with conduct disorder is the single best predictor of the psychopath that we know of so in the future we may be making the same distinction the Europeans have that when conduct disorder and ADHD go together we have an extraordinarily virulent disorder case you're not familiar with conduct disorder it is the early appearance of lying stealing fighting and preying on other children in an instrumental way it is violating the rights of other people for your own gain and it manifests early as the lying the stealing and the fighting but other symptoms will develop thereafter the hyperactive type of ADHD never existed because 90% of all cases go on to get the combined type within three years and even if they don't get the combined type they're just one symptom short and so we call them sub-threshold combine types but they're not a different type so if we take these two groups of children who really are variations on the good old combined type of ADHD that's 95% of all the kids put into this group there is a small group left over who are purely oppositional but because they have pure oppositional disorder and they never had ADHD they will outgrow their OD D usually within two to four years and their ADHD will go away why are they there because parents confuse OD D with ADHD and if their child is only oppositional they often report that they have symptoms of ADHD when they don't but OD D alone is a relatively benign disorder unless it goes with ADHD and that it is a highly persistent disorder now the real action during the past decade has been with this inattentive group of children most of whom are combined type children and they grew up and they lost some hyperactivity along the way as we said and as a result there's going to come a time in adolescence and especially by adulthood where there does not either active enough to stay in the combined type anymore and so clinicians real able them as inattentive type but they shouldn't once combined type always combined type but you can see how at least half of the individuals get put into the inattentive group they're just outgrowing their hyperactivity and then there's that group of children who just are one or two symptoms short of being in the combined type but they have the combined type anyway they're just a milder version of it but interestingly 30 to 50 percent of the children who are now called inattentive type probably have a different disorder and researchers have called them SCT it's about 30 to 50 percent of all inattentive type children and we now believe this is a qualitatively unique disorder the debate now is whether this is a separate type of ADHD a point with which I disagree or is it a qualitatively separate disorder a point with which I agree why would I view this as a different disorder first of all the symptoms are the opposite of ADHD but you won't see them anywhere in the DSM but these are the most compelling symptoms that go with SCT but because these children also have an attention problem there was no place else to put them because ADHD is the only attention disorder in the so they get dropped into ADHD even though they have no symptoms in common with it these individuals have a problem with processing information which ADHD children do not have these children have trouble with focused attention choosing what's important from what's not ADHD children do not their problem is in persistence these people may have a long-term memory storage problem or it could just be the same attention problem that appears when they search their memory what is quite distinct about them is that they are socially withdrawn reticent shy apprehensive and often prone to social anxiety but certainly socially reticent is a very good word for them this is not a word that would ever be applied to an ADHD child most importantly and tellingly they do not have an inhibition disorder an inhibition is the heart of ADHD and therefore they do not have a self-regulation disorder and ADHD as a self-regulation disorder and these individuals do not have the executive deficits that I just listed for you that go with ADHD for those reasons alone you could argue that this is a distinct disorder but there are others there was a very low rate of oppositional conduct disorder associated with this type of child Oh didi and CD are much more common in ADHD children these children have more anxiety problems ADHD children while one in four may have anxiety it's far higher in this group we're not sure if depression goes with this group both groups have about a 20 to 25 percent risk of depression but it doesn't distinguish the two disorders when we interview families of these children their parents are concerned only about school nothing else these are good kids not disruptive outside of school they even have a few friends not as many as other children but more than ADHD children will ever have so the big concern is let's get that school work done and the mistakes they're making in school you interview the parent of an ADHD child they're worried about everything peer relationships family functioning community behavior not to mention what happens as the teen gets older and starts driving and having a job and managing money and becoming sexually active SCT families don't worry about any of that stuff ADHD families worry and well they should these children mainly have trouble with accuracy of schoolwork they get all their work done and half of it's wrong ADHD children don't do any work so the difference SCT is an accuracy door disorder ADHD is a productivity disorder that's a qualitative difference another one is that these children may be more prone to math disorders but we're not sure about that these children come from quite different families families with the same kinds of problems higher rates of anxiety higher rates of learning problems in school that's about it children with ADHD come from families with a lot more ADHD a lot more school failure a lot more antisocial behavior alcoholism depression and drug abuse these children do not when we look at the treatments that work for these children and this has not been very well studied by the way but even here differences appear the medications for ADHD don't work very well for these children they don't hurt them you can try them the lowest doses are the best they just don't help them in fact in our study only one in five children was kept on their medication after the trial in ADHD it's 92% these children are the best responders to social skills training but no surprise social skills training was invented 40 years ago for shy people and we know it works best for shy people not for aggressive people and so these children actually do very well in social skills training ADHD children do not do well at all and social skills training if they do it needs to be done in the school environment with the children they go to school with not in a summer camp and certainly not in some Saturday morning clinic with other children they'll never see again the rest of their life if you're doing that you're probably wasting your money so if they benefit it's because they benefit the teachers and others doing the training outside of the clinic environment in the natural setting where the social problems arise and even then it's not so much the skill training that's prompting and queuing and rewarding the occurrence of the skill now do be aware that research now shows that one in four children put in a social skills group will be made worse by the group this is known as deviancy training and it happens to occur because the more aggressive children in any peer group will train up the less aggressive children to become more aggressive if only in self-defense it happens every kindergarten year to normal children as well so clinicians need to be careful because there are side-effects to social interventions 25% of ADHD children get worse by being in a social skills group and we wish to avoid that now the MTA study has found that anxiety is the best predictor of response to the behavioral interventions we could argue therefore that SCT children are probably the best responders to behavior modification even better than ADHD children are we know that cognitive therapy which is teaching children to talk to themselves fails for ADHD we know why now because the minds voice is not developing on time and in order for talking to yourself to have any success you must have a normally developing internal speech and they don't at least not until adulthood and then some cognitive training does help as a supplement to medication but in childhood cognitive training doesn't help ADHD but this isn't ADHD so shouldn't we revisit this and do cognitive training for SCT no one has done it there's a dissertation you know somebody who wants a dissertation I just gave you one what about medication well we don't know we know the stimulants are particularly wonderful for them they don't hurt them but they don't help them all that much what else might work well I don't know honestly but let me conjecture if I were writing a grant tomorrow I might speculate that Stratego because these are more anxious children and strattera treats anxiety when it coexists with ADHD so maybe atomoxetine might have a shot at this disorder we don't know nobody's done it another drug that might be interesting is pro Vigil modafinil modafinil is an anti narcoleptic and it does seem to help people with ADHD it might help this group even more because you remember those symptoms I showed you two slides ago does that sound a little narcoleptic to you lethargic slow-moving drowsy staring inattentive hmm maybe a brain step drug might help you again all speculative we don't know by the way that is all we do know on lct so please don't ask me any more questions about it because you now know everything I know what I do want you to know as a family is to understand that that's not ADHD ADHD is quite different from that and so if you happen to have an SCT child or you know someone who does please don't tell them to read the books on ADHD they will be sadly misinformed they will be told of all kinds of risks and all kinds of treatments which as far as we know have little if any application to these children there is no book for parents on SCT not yet nor should there be we don't know enough but researchers are now studying these children the very first psychological treatments for SCT were published about a year ago at the University of California San Francisco and so we're now beginning to see more and more research on SCT children as distinct from ADHD children but what I won't want a family of an SCT child to understand is that this is an ADHD so what you should be worried about are not the things families of ADHD children should be worried about it's pretty much going to be a school-based issue and the treatments that don't work for those kids might well work for your child and the treatments that do work for those kids such as medication might not be so great for your child no harm but not necessarily so great

Channel: CADDAC Centre for ADHD Awareness Canada

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Length: 26min 9sec (1569 seconds)

Published: Thu Nov 19 2015