7 Ways ADHD is Misunderstood

Seven (of the many) ways in which ADHD is about so much more than difficulty sitting still. 

"But he can focus on things he enjoys for hours at a time!" 

That was my own reaction when the school psychologist gently suggested that we learn more about ADHD to see if we wish to have our son assessed.  

Despite my degrees in Social Work and Psychology, I actually knew very little about the complexity of ADHD and the myriad of ways it can impact peoples' lives.  Having not been in University since 2009, it was certainly time to update and increase my knowledge.  Fast forward a year and a half and both our son and myself have been formally diagnosed (me at age 36! - My son by the school psychologist and his pediatrician, and myself by a psychiatrist specializing in Adult ADHD).  

Little did I know that this hyperfocus was also part of ADHD and that hyperactivity and inattentiveness are just two parts of a very complex disorder that Dr. Russell Barkley explains is not actually a disorder of attention, it's a disorder of regulation.

Following up on my previous post on the seven executive abilities that are impacted by ADHD, which Dr. Barkley reviewed in a recent podcast discussing Adult ADHD.  I wrote a separate blog post on this specific podcast, which you can read here.  

I have reframed and expanded on each of them below, relating them to struggles in children rather than adults.   

ADHD Results in a Deficit in Executive Functions:

1. Impulse Control.  The ability to STOP.  The ability to pause between the action and reaction.  The ability to pause before responding.
  "Response inhibition refers to the ability to withhold a cognitive or behavioural impulse that may be inaccurate or maladaptive." (Barkley, 2015).  
   
   Children are particularly vulnerable to this because their prefrontal cortex (important in decision making) is not yet fully developed, and even neurotypical children are impulsive.  Children with ADHD are thought to be approximately 30% behind their peers in PFC development, making the "stop and think" process even more difficult.  
   
   
2. Hindsight.  The ability to think about previous relevant information and use past experience to guide your current response. 
"Working memory deficits may adversely affect the social functioning of children with ADHD." (Kofler et al., 2011).  
   
   "Hmm, last time I did this... and this happened...  so maybe I should try...  this instead?"
   
   While most children with ADHD have average or above-average IQ (many are twice exceptional), learning from past experiences is more challenging when there are differences in the way they store and later access information as memories.  
   
   
3. Foresight.  Thinking ahead to longer-term consequences of your current behaviour before acting.  
   
   Children with ADHD have greater difficulty predicting possible outcomes of their choices and have greater difficulty connecting current behaviour with future consequences.  This means that delayed consequences such as detention, suspension, grounding, removal of future privileges, etc. are not likely to be effective in changing undesired behaviour.  Intervention, guidance, and support have to happen at the point of performance (meaning at the location and in the moment the behaviour is occurring). 
   
   Similarly, reinforcing positive behaviours must also occur at the point of performance, so we must make efforts to "catch" the child being good and not only be on the look out for negative behaviours.  
   
   
   
   
   
   Children with ADHD often struggle with low self-esteem and are often blamed for their disability.  Many children with ADHD internalize the constant negative messages from others, believing that it is their fault rather than being taught that their brains are wired differently.    
   
   So often I hear adults ask (and yes, I have heard myself say it!) "why isn't he learning from these consequences?"  That is why.  Impulsivity combined with a deficit in both hindsight and foresight (also referred to as working memory) make it very difficult for children with ADHD to learn from past mistakes without compassionate, non-judgemental support and guidance.  
   
   
   This means that a neurological difference is responsible for difficulty learning from consequences, not a desire to be "bad", and not from a lack of a desire to be "good".  
   
   
4. Self-talk.  Self-directed language to facilitate self-control.  
(Also referred to as verbal working memory or inner speech). 
   
   This is our inner monologue and refers to how we talk to ourselves inside our head to guide our decisions and remind ourselves of things we need to do.  Children start out having these conversations out loud when they are very young and as they mature these conversations gradually become internalized.  
   
   Each person's experience with ADHD is different, however ADHD experts such as Dr. Russell Barkley explain that the capacity for self-talk is less-developed and also develops later in life in people with ADHD.  The ability to talk to oneself in a positive and helpful way impacts one's self-esteem, memory, motivation, and decision-making.  Challenges with this executive function can have a significant impact on daily functioning.  
   
   
5. Emotional regulation.  The ability to manage one’s emotions to make them more socially acceptable.  

Our emotions are our motivation.  
   
   So, if a child with ADHD has "big feelings" (or emotional dysregulation), then they cannot entirely control the resulting behaviour.  They first need help with managing the feelings and developing self-regulation skills, only then can the behaviour change follow.  
   
   
   We don't hand a kid a basketball and expect them to sink a basket their first try, we teach them skills first.  Why, then, do we expect children to have the skills to manage their emotions if they haven't been taught?  
   

6. Self-Motivation.  Children with ADHD are dependant on the environment and its immediate consequences.
   
   
   This means that we, the adults, have to help them develop tools for self-reinforcing, especially (hopefully only - more on why below) for tasks they find less desirable.
   
   

   Addressing the presenting behaviour only "trains" a person to comply and do what is being asked of them, completely ignoring the underlying struggle that really needs to be addressed.

   
   

   For example, if we start a token economy system in the classroom or at home, it's highly important to involve the child(ren) as much as possible and give them as much ownership and control over the program as possible.  It is even more important that we gradually transition complete ownership and control of the program over to the child(ren) or students, once they are ready for this step.  
   
   Children and students need to find what is reinforcing for them, not have the adults decide what their rewards are, and they eventually need to be able to run this program for themselves so that they can do it on their own when they no longer have a teacher or parent's support.  
   
   Sound a little strange?  Think about the ways you do this for yourself in your own life.  
   
   "I had a good workout today, I'll reward myself with a beer"
   
   "I got in all my steps today, I think I've earned a little dessert"
   
   "After I finish this chore, I'll put my feet up and read a book" 
   
   

   Author's Note:  In my opinion, token economies should be used sparingly, and should only be used for undesirable tasks such as chores or homework, and should never be used to address behaviour challenges.  

   
   

   The reason for this is because behavioural problems come from a lack of skill, a lack of coping strategies, and/or underlying issues or concerns.  Addressing the presenting behaviour only "trains" a person to comply and do what is being asked of them, completely ignoring the underlying struggle that really needs to be addressed.  It's a bandaid solution because it does not teach skills or provide emotional support, and it puts the onus on the child, rather than on the competent adult with a fully developed prefrontal cortex.  

   
   

   

   
   

   For more on the problems with behaviourism and behaviour modification, Alfie Kohn wrote a blog post on the topic, as well as books on the subject called "Punished by Rewards" and "Unconditional Parenting".  

   
   

   But I digress....  Back to the List...  Now, where was I?  Oh yes!

7. The ability to plan and problem solve.  The ability to simulate multiple possible future options is the highest executive function in humans.  
   
   The ability to quickly run through multiple "hypothetical situations" in our mind, and then the ability to quickly change course when we run into a problem or when one of our options fails.  
   
   A lot of children (and adults) with ADHD struggle with cognitive flexibility (or flexible thinking).  When we have our mind set on something happening a certain way and that changes, it can be very difficult for us to adapt.  This is also a common struggle for people with anxiety, a comorbid condition with ADHD (meaning they commonly occur together).  Sometimes people with anxiety need to mentally prepare themselves for a situation, then if circumstances change this can greatly increase their anxiety because they haven't had an opportunity to mentally prepare.  

Important to note:

• Children with undiagnosed, untreated, or inadequately treated ADHD are 30% behind their peers when it comes to executive functioning.

2021 Note:  This was our most popular blog post in 2020, so we decided to expand upon this concept and have added a new blog about Common ADHD Myths.  

References 

Barkley, Russell A. (2015). Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis & Treatment. The Guilford Press.  

Kofler, M. J., Rapport, M.D., Bolden, J., Server, D.E., Raiker, J.S., & Alderson, R.M. (2011). Working memory deficits and social problems in children with ADHD. Journal of Abnormal Child Psychology, 39, 805-817. 

About the Author

Jillian is an ADHD 2e Coach and Child Advocate in Manitoba, Canada.

Jillian has a diploma in Child & Youth Work and a Degree in Psychology, as well as being the parent of an amazing 2e/ADHD child.

Visit ADHDPro.ca and Facebook.com/ADHD2ePro to learn more.