ADHD, Parenting, and the Brain

You're reading this book because you want something in your family's life to be different. Maybe you know your child has attention deficit hyperactivity disorder (ADHD), or you suspect it. Perhaps a parent, teacher, or close friend has drawn your attention to what they feel is a problem with your child's behavior. Or you believe your child is absolutely perfect as they are—but you would like them to be more at ease outside the family.

Maybe your child has been acting out. Or they are well behaved but struggling in school, and no one can explain exactly why. Even if you've received an ADHD diagnosis and some kind of plan, life may feel out of control. Perhaps you're wondering why, in spite of doing everything you can imagine, the same behavioral and academic problems persist. You've read every book and followed the advice of more people than you can remember, and still another call comes from the teacher: Your child is brilliant but never hands in their work. Your child pushed someone at recess again.

Maybe you're not overwhelmed and you have an easy relationship with your child, but you wish that life could be easier for them. You're sure they have the potential to succeed without so much effort or without so much support from you and their teachers. You're looking for a different perspective, and there's a nagging sense that life does not have to be so hard.

The Politics of ADHD

Attention deficit hyperactivity disorder, often called ADHD or ADD, is one of the most common behavioral conditions affecting children today—and one of the most polarizing. Parents of children who struggle in school and have behavior issues are swamped with information—and misinformation—about ADHD. There is a deluge of unsubstantiated lore about the most effective ways to treat symptoms that often hint that parents or society are to blame. You may have been led to think that if only you could parent better, your child's ADHD symptoms would vanish. Poof. Just like that. But ADHD is a medical condition—would anyone expect asthma to disappear because of parenting changes?

ADHD care has devolved into factions. Some people, ranging from doctors to psychologists to news personalities and neighbors, believe ADHD is a myth, nothing more than a catch-all label for badly behaved children. Others suggest to parents—often aggressively—that medications are dangerous and they'll turn children into zombies. Parent groups and Internet sites swear that only their particular behavioral or alternative option will work safely—and suggest that other choices are useless.

And to complicate matters, what is ADHD anyway? Some people say it's real. Some people say it isn't. But as a developmental pediatrician specializing in children with behavioral disorders, I will tell you that ADHD is real—very real.

Decades of research have defined what ADHD is (a specific biological condition) and what it is not (a deficit of parenting or a figment of our collective imagination). Nevertheless, a morass of misinformation has muddled the perception of ADHD in the modern world.

Sensationalist authors make broad claims that a certain lifestyle intervention will "cure" ADHD, suggesting that our modern culture is perhaps the cause. Or that like fragile flowers, children with ADHD blossom only when raised "well"—whatever that means. Yet there are endless numbers of well-meaning, hard-working parents raising children who battle problems with focus, impulsivity, hyperactivity, and all the related disruptions ADHD triggers—and it has nothing to do with anything that happened or failed to happen at home. Because of these baseless societal claims, parents often end up blaming themselves: If only I could come up with a new plan, or figure out how to motivate my child, ADHD would go away. Through no fault of their own, parents often become blinded to the straightforward biological facts.

Stepping beyond the politics requires a return to the basics, with a clear vision of ADHD science. ADHD is a medical condition in which the part of the brain responsible for monitoring behavior and thoughts isn't working efficiently. ADHD is far more than a behavioral or academic problem; it has the potential to disrupt relationships, lower self-esteem, hinder social skills, and interfere with many other areas of life. Only through understanding the underlying biology of ADHD and its effects on brain development can you begin to make clear choices for your child.

ADHD by the Numbers

ADHD is not a product of our modern society; descriptions date back to the early 1900s. More recently, various studies in the United States show that around one in twenty children have ADHD, regardless of socioeconomic class or location. Other studies show this average, to be slightly higher, rarely slightly lower, but, it is always close to this number.

Wherever ADHD has been tracked—in Europe, South America, the United States, and most everywhere else—the incidence is near 5 percent. How could an environmentally caused or culturally biased diagnosis have such a similar pattern, however and wherever children are raised? It is unlikely that a behavioral phenomenon could be so consistent.

Compared to the general population, when someone in the immediate family has ADHD, their parents and siblings have a three- or four-fold increased risk of the same. An identical twin lives with at least a fifty-fifty chance of ADHD when the other twin has it, and most studies suggest an even greater likelihood. This increased incidence persists even if they were not raised in the same household, revealing that the tendency is genetic. Non-identical twins have a one in three chance—again, even when raised separately. Even the fact that boys are several times more likely to have ADHD than girls points us toward a genetic cause.

Through tracking ADHD in families, scientists have begun to identify genetic markers for the condition. Genes have been found that increase the likelihood that someone will develop ADHD, and others may one day predict responses to different treatments. Just as some kids are born destined to be tall, or develop asthma or seasonal allergies, some children are born destined to have ADHD. Genetic evidence continues to mount; a 2010 study found a much higher risk of chromosomal variants in people with ADHD, compared to the general population. However, as dozens of genes influence brain development, there is no genetic test to diagnose ADHD (and there probably never will be).

Biological factors affect the brain well before the potential impact of home life or culture. Premature birth, fetal exposure to alcohol, or lead toxicity in early childhood have been identified as ADHD risk factors and all make ADHD more probable. These external factors also interact with genetics, as studies suggest that exposure to certain toxins causes trouble only when a disposition towards developing ADHD already exists.

So in spite of all the media-hyped controversy, when correctly diagnosed ADHD is a medical disorder like any other.

Brain Basics

The frontal lobes of our brains are responsible for what we call executive function—the brain's ability to think, react, and modulate emotion. Executive function skills, which are reviewed further in chapter three, act like the brain's manager. Through pathways starting in the frontal lobes, the brain watches over behavior and emotions, monitoring, motivating, anticipating, and planning. The frontal lobes also regulate impulses and allow us to pause before acting. They determine how we organize our thoughts. They supervise how we think and act. They manage information, help us learn from mistakes, and influence dozens of related abilities.

In both children and adults with ADHD, the frontal lobes of the brain are smaller than in the general population. Research using mental imaging has also found decreased activity in these areas when people with ADHD perform certain mental tasks, while in the general population the frontal lobes leap into action in the same situation. When there is decreased activity in the frontal lobes, the effects on daily life can be profound.

Doctors now say with confidence that these functional brain differences are the medical root of a behavioral condition and the cause ADHD. The differences do not stop with the frontal lobes, as they involve much more complex, detailed findings in various areas throughout the brain. While research is ongoing, these pathways likely include regions responsible for learning, emotional control, motor coordination, time management, and other mental abilities. Keep in mind, these findings all represent trends—not every child with ADHD will have each of these problems, and they do not define any individual's long-term potential. (For simplicity's sake, I'll refer to overall brain findings as relating to the frontal lobes through the remainder of the book.)

As you can see, ADHD is far more than an attention deficit. ADHD is a disorder of self-regulation and a set of skills called "executive function." The stereotypical symptoms of ADHD—hyperactivity or distractibility, fidgeting or daydreaming—occur as a part of these broader issues. When these abilities lag, as happens in ADHD, children cannot effectively organize their thoughts or coordinate actions. The manager is asleep on the job, so to speak, and a child gets off task and becomes disorganized and inefficient.

A more descriptive name for ADHD might be "attention management, self-regulation, organization, and planning disorder." Challenges with self-monitoring, distractibility, irritability, and memory influence all aspects of life. Unchecked, ADHD affects brain development, how children learn and relate to others, and other far-reaching parts of their worlds, and it disrupts relationships with parents, social development, and schooling. ADHD symptoms cause intense suffering not only for children diagnosed with ADHD but for their parents and family as well. Everyone involved deserves equal support from the start.

Parenting Children with ADHD

I'm starting to get it. I got tired of all the energy I spent pushing them to do what I thought they should be doing. I was upset. I felt like I shouldn't have to make a behavioral plan. They should always behave like they know how to behave, like we teach them.

Now I'm starting to see, maybe they can't. It's their ADHD. They're not bad kids. They try, most of the time.

They aren't behaving like I want. For whatever reason, they aren't. Now when I go there in my head, I stop. What can I do that might help? How can I teach them something new? There are still behavioral issues—plenty of them—but the fighting stopped, and we're working on it together.

* * *

Almost certainly, we want more for our children than just the absence of ADHD symptoms. We want true well-being, whatever that means to each of us. Well-being can mean a stable, comfortable relationship with family and friends. It could be an internal state of confidence and self-esteem, or maybe an ability to face the ups and downs of life with equanimity and resolve.

Parenting a child with ADHD presents concrete challenges. Endless energy is poured into getting from breakfast to the bus, or from dinner to bedtime. Your children may misbehave with other children, fail to listen to adults, or struggle in school. You may need to supervise schoolwork excessively, or hover over every social interaction. Your family or friends may not understand what's going on, and you might begin to feel alienated socially.

You love your children without reservation and still, ADHD symptoms may push you to be more punitive or inconsistent in your discipline than you might otherwise choose. It may be hard to imagine easy times are even possible. At home you might feel like you are doing no more than putting out fires.

Parenting a child with ADHD challenges the hardiest parents, as the effort required to watch over a child's behavior exhausts. Trying to maintain consistent routines in the midst of the chaos is draining. Children with ADHD learn new behaviors slowly, leading many parents to assume traditional techniques are not effective, or to doubt their own ability to manage their children.

While most parents recognize the value of setting limits, or have read about it in parenting books, ADHD itself pushes them toward inconsistency, further amplifying the behavioral cycles. Parents may set limits when they feel strong enough but skip them when they are tired or out in public, where the stakes seem too high. And managing all of these ADHD-related issues over the years—it is no wonder that parents report feeling less in control of their lives than other families.

Yet the catalyst for change is parents, not their children with ADHD. Parents have the broader perspective, and when they regain control, their children benefit. Parents are at the center of most interventions, whether they are addressing their influence on behavior, collaborating with schools, or making treatment decisions. While, the bottom line is the long-term health of a child, intervention often hinges on adults.

Effective parenting of ADHD requires both patience and vigilance. To teach a child with ADHD skills and change behaviors, parents must maintain their resolve over far longer stretches of time than they would with other children. Under stress, or with the wrong information, decision making is difficult—but children flourish when their parents remain open-minded about expectations and discovering new solutions.

A Stacked Deck

I hate the word "focus." I really hate it. My dad is always yelling at me, "Focus, Larry! Focus!"

* * *

Many of the symptoms of ADHD—such as acting without thinking, getting off task, or failing to sit still—can appear to be under a child's control, but are not. Kids with ADHD experience biological distractibility and have problems remembering responsibilities; they don't intentionally duck chores any more or less than anyone else. When caregivers mistake poor impulse control for deliberate "badness," children may become marginalized—on one occasion in my practice, a teacher even implied a preschool child might be "evil." Any advice that comes from the skewed perspective that a child with ADHD is bad or unmotivated is doomed to fail.

When writing off ADHD as "only" a personality trait instead of a biologically driven set of symptoms, children and parents end up being blamed for the problems. ADHD is no one's fault, but many people make this assumption when watching the erratic, impulsive behavior of a child with it. Parents feel judged, like they should be doing something different to control their child's actions. Yet while parenting will certainly influence how ADHD symptoms are expressed, it cannot overturn basic neurology.

Most often, children with ADHD try as hard as they can—even when their behavior appears intentionally difficult, poorly motivated, or maddeningly inconsistent. They could list all the rules in the book themselves, but do not have the skills to follow them. As Dr. Russell Barkley, one of the world's leading ADHD researchers, has said, "ADHD is not a disorder of knowing what to do but of doing what you know."

ADHD is as frustrating for the children who have it as it is for adults trying to raise them. After they've acted out, children may calm down and realize, "I'm not supposed to yell." Or once it's pointed out they forgot their homework—again—they make up a story to cover up. They know exactly what they should have done and that they've let their parents down. And then they find themselves in trouble both for not doing their school work and for lying.

Most children with ADHD recognize their differences as they get older. They may notice that other children are not corrected in class as often by their teacher. Or that other siblings at home aren't in so much trouble. Or that their parents are frustrated with their behavior, day after day.

In a 2008 study, researchers analyzed college student interviews about growing up with ADHD. Participants recalled "a childhood and adolescence shaped by feelings of difference, isolation, and misunderstanding." They said that, as children, they felt frequent tension around household responsibilities, academics, and peers. They craved understanding. They wanted to discover a sense that the adults in their world recognized their challenges and the reality of ADHD and were reaching out to support them and intervene.

Children with ADHD have their strengths and weaknesses like the rest of us, and ADHD does not define a person any more than any other medical condition or physical characteristic. Some people are skilled at paying attention, some at playing an instrument, and some are adept at physics. However, a fundamental difference from many medical disorders is that ADHD affects so many aspects of life, including traits and mental abilities often assumed to occur separately from their biological roots. Supporting a child with ADHD begins with recognizing this reality in their daily experience.

Quality ADHD treatment must address this truth, while never eliminating or altering a personality, or limiting someone's skills. Successful intervention allows a creative person to not only have a radical idea, but follow it through to completion. It allows an extroverted person to be social and entertaining but respect other people's boundaries, and maintain their own.

Treatment needs to protect children's strengths and at the same time target where kids could benefit from support. Children with ADHD have poorly functioning frontal lobes. They require care that builds from understanding what is willful versus what is a neurologically based lack of a particular skill. Well-being then grows from looking beyond the stereotypical list of symptoms and instead focusing on whole children, families, and communities.