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Children with ADHD have permanent disabilities that require permanent compensation, according to ADHD expert Russell Barkley. This article is based on his lecture on what he believes are the thirty most important insights that parents should take with them when they have children with ADHD in the family.

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ADHD is understood as a neuropsychiatric disorder, and the diagnosis is made on the basis of symptoms of difficulty concentrating, impulsivity and hyperactivity. Treatment for ADHD is primarily aimed at compensating for the difficulties that result from the condition and preventing additional problems, according to Russell Barkley.  

The overall project that school / kindergarten should have for the child with ADHD is therefore to compensate for the child's basic difficulties with executive functions. This requires permanent accommodation for the permanent disability that ADHD provides.





In addition to the specific ADHD-related difficulties, children with ADHD may have additional difficulties such as learning disabilities, anxiety, and depression. There are also some children who have both autism and ADHD.

Here you read more about what characterizes the child with ADHD, and what measures can be useful. It must be emphasized that for children with additional difficulties, it may also be necessary to take separate measures against these difficulties.

 

Here is the lecture with dr. Russell A. Barkley





 

ADHD is a delay in normal development

ADHD is not a disease, but a developmental disability, characterized by behaviors that deviate from what is normal for age. This discrepancy is not absolute in the sense that children with ADHD are qualitatively different from other children, but rather it is a quantitative discrepancy; that is, a degree difference.

This degree difference between a child with ADHD and a child without, can be compared to the degree difference between a high and a low person, or between an athletic and a non-athletic person.

What distinguishes a child with ADHD from another child who does not have this disorder is the degree of delay in the normal development of the ability to inhibit and in relation to executive functions related to attention and working memory.

 

Common difficulties in children and adolescents with ADHD

Common difficulties in children with ADHD include problems related to impulsivity (ability to inhibit), difficulties in relation to key executive functions, a failing self-regulation, problems related to time (time blindness), and difficulties in applying skills and abilities, which gives a mismatch between what the child can and what it shows in practice. Here you can read more about each of these points.

 

1. Difficulties related to impulsivity / ability to inhibit

The first and primary area that is delayed in a person with ADHD is the ability to inhibit; that is, the ability to inhibit or hold back impulses.

 

  1. Motoric impulsivity

    Often but not always, the problem of inhibition becomes apparent through hyperactivity. You can be motorically hyperactive, which means that you are very active with your body, you are "high and low", always on the move, restless and have problems sitting still.

  2. Verbal impulsivity

    One can be verbally hyperactive, that is, one talks a lot and impulsively. Slightly worded, it has been pointed out that the person with ADHD has "mouth diarrhea." There can be sounds, singing and talking in one go - without any kind of brake.

  3. Cognitive impulsivity

    Cognitive hyperactivity means that decisions are made very quickly, you do the first and best thing that comes to mind, and often without thinking about the consequences of your own actions. The external, visible hyperactivity in children with ADHD usually calms down over the years. In adulthood, this is almost gone, according to Russell Barkley, while in adolescence and into adulthood it gradually becomes an inner state that affects the life of thought - an inner feeling of constantly having to be on the go and do many things at once - a cognitive impulsivity.

  4. Emotional impulsivity

    Emotional impulsivity is also a central part of having ADHD, and manifests itself in relation to becoming irritable, being easily carried away by excitement, having a low tolerance for frustration, being irritated by relationships around you, and expressing own emotions to a greater extent than other people do. At the same time, it is pointed out that ADHD is not a mood disorder.

 

- What characterizes mood disorders, such as depression, is that there is "too much" of an emotion. With ADHD, there are not too many emotions, but problems regulating the emotions. ADHD is a self-regulatory disorder.

People with ADHD have difficulty calming themselves, comforting themselves, and the emotional dysregulation can create many challenges for the person with ADHD.

 

Negative consequences of emotional impulsivity

According to Russell Barkley, the pronounced degree of impulsivity or difficulties with inhibition creates a number of difficulties for those with ADHD.

First, children with ADHD have an 11 times greater risk than other children of developing oppositional behavior disorder.

According to Barkley, it is an artificial simplification to say that some people with ADHD also have a comorbid behavioral disorder. Barkley expresses that oppositional behavior is inextricably linked to the impulsivity that results from having ADHD. At the same time, he points out that oppositional behavior is often dramatically reduced when treatment is given for the ADHD condition in general, for example in the form of medication.

Second, social difficulties are common in children with ADHD.

As many as 50-70% of children with ADHD experience being rejected by close friends, according to Russell Barkley. The reason why the child with ADHD is so easily rejected by friends, and that they can be disliked by other children, is not the difficulty concentrating, that one is easily distracted, that one is forgetful, or that one is hyperactive. On the contrary, it is the emotional impulsivity that often creates the social challenges. More specifically: It is the fact that one gets angry so quickly, can easily take on a hostile attitude, and so easily expresses oneself so strongly emotionally towards other people that contributes to being rejected socially.

Thirdly, it is common for people with ADHD to have difficulties in cohabitation, in relation to their own children, and in relation to working life.

Barkley emphasizes that it is seldom concentration difficulties that create the biggest problems in a work context, but that you get on edge with other people emotionally - again due to the emotional impulsivity.

In short, Russell Barkely points out that if one is to understand the risk that ADHD presents in a life course perspective, then it is the emotional impulsivity that creates the biggest problems.

 

2. Difficulties related to concentration and working memory

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The second area that is delayed in people with ADHD is the ability to pay attention, or more specifically the brain's executive functions related to concentration and working memory.

Russell Barkley says that having difficulty concentrating in itself is a very deficient indicator of ADHD. These difficulties can be faced with a number of other challenges, such as anxiety, depression, autism, learning difficulties, and more.

However, the difficulty concentrating, or attention deficit, that characterizes ADHD is specifically related to difficulties in the executive functions.

There are three such executive functions in particular that are affected by ADHD, according to Barkley:

 

To keep the attention over time

The lack of attention in a person with ADHD is characterized by an inadequate ability to maintain concentration over time, and thus to work purposefully towards a goal. This is both about motivational difficulties, and about having a future-oriented behavior to a lesser extent than others. This could be, for example, completing an assignment in the classroom; where the child with ADHD simply loses focus long before the others.

 

To resist distractions

The attention deficit in people with ADHD is also characterized by an inadequate ability to resist and not be disturbed by various distractions. To take an example: We can all hear the noise from the kitchen; the person with ADHD, on the other hand, is bound to provoke a response (eg go and check what the sound is) - and this response cannot be stopped. It is not that the person with ADHD perceives more distractions than other people, but that one is far less able to ignore or resist the distractions.

 

Problems with working memory

A third characteristic of attention deficit disorder in a person with ADHD is that one returns to the original goal to a lesser extent if one has first been distracted from it. The reason for this, according to Russell Barkley, is difficulties related to working memory, that is, remembering what we are doing while we are doing it. People with ADHD quickly forget themselves, and thus it becomes difficult to complete tasks.

This can be, for example, forgetting that you are on your way out with the rubbish, and instead of throwing away the rubbish bag, you came up with something else on the way to the rubbish bin, so that the rubbish was only moved around the house.

 

3. Failure in self-regulation

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There is more to ADHD than just inhibition and concentration difficulties. Basically, ADHD is about a failure in self-regulation, says Russell Barkley. Therefore, ADHD is a very serious condition. There are some key human skills that are not developing properly. One therefore sees not only difficulties associated with concentrating, but also in a number of areas of life.

Self-regulation is about being able to change and control one's own behavior. Not only in relation to short-term goals, but also for long-term ones.

The question must be taken into account: Should I act in this way, given the consequences of doing so? Stopping and thinking about this is a prerequisite for self-regulation, and this is precisely what is difficult for people with ADHD.

ADHD is largely a neurobiological disorder, emphasizes Russell Barkley, and he also emphasizes that self-control is not a learned skill. The ability to self-control is not a result of upbringing, or how good your parents have been, but is very much about our innate, neurobiological traits - that is, about who you are.

He compares the ability to self-control with the ability to language. A child naturally learns to speak and use the language, but not as a result of whether the upbringing is good or bad. The foundation for learning language lies in the neurobiological features of the brain, and the language develops in line with the brain developing through childhood. In the same way, Barkley says that self-control also develops naturally in line with primarily innate, genetically controlled traits.

More specifically, self-control is about five executive functions:

 

The ability to wait

That is, the ability to accept that there is a break, a waiting time, from when you want something to happen until it actually happens. In children with ADHD, this is difficult.

 

Mental imagination

Given that one is able to wait, the next executive function required for self-control is the ability to imagine something mental. We have a "theater in our minds", where we can play events from the past, and based on this imagine future events. Children with ADHD are worse than other children at visualizing before they act; that is, to recall relevant experiences from the past. Thus, it is difficult to learn from previous experience and to use this in the face of new situations. Children with ADHD do not look back and are therefore unable to think ahead.

 

To be able to have an inner dialogue

Barkley says that at the age of 5, children begin to learn to internalize the language, ie to be able to talk to themselves / think through the language. This inner voice can be used to exercise self-control, to tell oneself what one can / should do in a given situation.

 

The ability to self-motivate

This skill springs from the ability to regulate emotions. Children with ADHD show a lack of ability to regulate emotions, which is seen through low frustration tolerance, higher irritability, more outbursts of anger, are more easily carried away by excitement, and are generally more emotional than other children. A very important point here is that "our emotions are our motivation." If you can not regulate your own emotions, then you can not regulate your own motivation.

Children with ADHD are unable to motivate themselves, and are therefore dependent on the current situation and the immediate consequences this situation offers for a given behavior. If there is no external source of motivation, then the child with ADHD is unable to work with, stay focused on and complete a task. It is simply not done.

A common observation here is that the child can play computer games for hours, but is unable to do homework for more than a few minutes. While computer games continuously offer external consequences for the actions, the homework offers no consequences. If a lesson has been completed and a sentence has been written on a sheet of paper, the sheet will not give any feedback. The consequences of homework are "exposed" and this is precisely the problem.

In other words, if you want to see children with ADHD fail, then place the child in an environment without consequences. This is not a choice, it is not will-controlled, and it is not about the child being disobedient or poorly brought up, but is a neurobiological failure in the ability to self-motivate.

 

The ability to do targeted problem solving

A prerequisite for this ability is to be able to stop in the face of a challenge and ask what possible action options exist to solve this problem. The person with ADHD struggles with this.

In short: The child with ADHD can not stop and wait, it does not have the visual ability to predict what will happen in a given situation based on previous experience, it does not have the inner dialogue, lacks the ability to self-motivate, and has difficulties related to to think of different options to solve a problem. Then it is easy to understand why they do not follow messages, why they do not absorb and learn from repeated messages, and why they do not learn from consequences.

ADHD leads to impulsive actions, to being easily distracted, to not learning from past experiences, to not planning and acting on the consequences in the future, which also means that the sense of time is disturbed. As an adult, this can be a big challenge.

 

4. Timing problems / time blindness

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Barkley tells a true story about a woman who told about the man who has ADHD. One day the man was going to mow the lawn, but when he came out he found that the petrol can was empty. He therefore got in the car to drive and buy petrol. But then a friend grabs him and gets him to go fishing. After six hours of fishing, they become thirsty and go to the pub for a few more hours. Meanwhile, police have found his car parked with the engine on, and an empty gas tank next to it.

According to Russell Barkley, people with ADHD have a pronounced time blindness. It lives in the present, and what was originally the goal in a situation can very quickly be forgotten, and one is led through impulse actions from one to the other.

In other words, people with ADHD are "myopic in the future." They can only handle things that are close in time. The further into the future an event lies, the harder they have to deal with it. Life thus becomes a series of crises that arise because one has failed to do what is necessary to prevent them.

These timing issues are some of the biggest problems for adults with ADHD. A three-year-old does not have to have a concept of time in relation to his behavior, but a 30-year-old must have. All such timing problems come from a failure to build a hierarchy of planned actions over time. An example here is planning a wedding. A person with ADHD has greater difficulty creating hierarchies of planned actions.

People with ADHD have intentions about what to do, but have difficulty implementing it in practice. It is not a lack of good intentions that is the problem, but to organize their behavior based on these intentions.

 

5. Mismatch between skills and achievements 

Russell Barkley also says that people with ADHD do not lack skills or abilities, but that putting these into practice is often a problem. Therefore, it also makes little sense to give people with ADHD skills training. It's making them stupider than they are.

A more sensible intervention is therefore about focusing on the person with ADHD's performance; that is, to provide help to use the skills they actually have, to put these into practice in the natural setting where the skills are to be used.

If the child does not have friends at school, measures must be taken at school to improve this. If there are problems in the homework situation at home, then it is at home in the homework situation that measures must be taken. There is no point in trying to solve these problems through psychotherapy or conversations in an office - far away from the problem situation.

 

Interventions for children with ADHD

The central principle for improving performance and changing behavior in a natural setting lies in increasing the precision of the consequences for the behavior; that is, consequences must come close in time and be relevant to the behavior one wishes to promote.

Therefore, behavioral interventions must be used; reward systems, token systems, sticker systems, where there is a clear and close-in-time connection between the desired behavior and the consequence of the behavior. Such an approach only has a temporary effect, because it compensates now and then for a lasting failure to motivate oneself.

There are two reasons why behavior modification techniques are the solution for parents of children with ADHD. First, using such techniques is instructive for the child. In other words: The child is given information about what is the desired behavior and what it is trained on. Second, using such techniques creates motivation in the child to try out precisely this behavior.

There is a very important point in this: Many parents and teachers use such techniques only for the purpose of "instructing" the child - and in other words: If you succeed with behavioral changes, you withdraw the techniques. But then you will often be disappointed. A basic difficulty in people with ADHD lies in the motivational - and there may therefore be a chronic need for behavior-modifying techniques, such as reward systems.

When teachers are told that it is wise to have a reward system (token system) in meeting a child with ADHD, the first thing they ask is: “How long do we have to use this? When will the child have become independent of this system? ” And to this Russell Barkley tends to reply, "Never." In other words, the child will never end up being dependent on a completely concrete, external system for artificially creating near-in-time consequences for their own behavior. It is a lasting, constant need.

Russell Barkley says that such reward systems are as fundamental in the facilitation of people with ADHD as a wheelchair ramp to school is for people in wheelchairs. You will never say to a wheelchair user that "Now you have succeeded in entering the school for 30 days in a row, so now we remove the wheelchair ramp." On the other hand, this is frequently said to the person with ADHD. That is, the reward system should not teach the child with ADHD to become independent of the system; it's like a prosthesis - and should be there permanently to compensate for a permanent disability.

People with ADHD will always need more and more frequent near-term consequences around them to perform on a par with others.

 

Parents and teachers are the most important elements in the treatment plan for ADHD

Parents 'and teachers' willingness, interest and passion to make the necessary arrangements for the child with ADHD is the central prerequisite for making the child function better.

The ADHD condition is comparable to diabetes. Diabetes is not treated to get rid of diabetes, but to compensate for the effects of it, and to prevent additional difficulties. In the same way, ADHD is not treated to get rid of the ADHD condition, but to compensate for the difficulties it causes, and to prevent the development of additional problems.

 

Compensation for executive difficulties

Barkley also highlights key measures to compensate for the executive dysfunction that the child with ADHD has. The key is not exactly what you do, but why you do it. In other words: one must understand what the child is struggling with, and thus put in place measures to compensate, and then in practice it may turn out that many different measures can have a compensatory effect.

Here are the measures that Russell Barkley especially highlights.

 

  1. Visible and easily accessible information about what is happening here and now

    The child with ADHD cannot keep information in working memory. So also do not try to get the child to do this. Rather, make the necessary information that the child needs externally visible and available at all times. In practice, this means notes, notes, figures, lists, reminders, etc. The point is not what this should look like, but why it must be done - and the reason is difficulties with working memory. All information that is fundamentally important to remember here and now must be available in the external environment in which the child is - in the visual field.

  2. Use of timer / time control

    The child with ADHD has problems with time comprehension and has no clear sense of time. Therefore, there must always be a timer that indicates the time period for what you are doing. Here, clocks that can be set up with alarms to vibrate about the desired number of minutes or daily schedules that show the daily program and time here and now can be useful.

  3. Break the day down into many small parts

    The child with ADHD is unable to plan and organize the behavior towards future goals. The day must therefore be broken down into many small parts, which constantly give a direction on what is to happen here-and-now.

  4. Continuously create external motivation

    The child with ADHD lacks inner motivation for the tasks required of it. Therefore, external motivation must be continuously created. As a parent or teacher, you should not be worried about "perverting" the child to only do good things for the sake of the reward, but work to find good reward systems that in practice prove to motivate the child - and to make sure to use them.

  5. To make mental things physically tangible

    The child with ADHD struggles to visualize alternatives in the head when it comes to problem solving and often gets into trouble when mentally demanding tasks have to be solved in the head. Therefore, it is a good idea to try to turn the mental into something physical in one way or another. Problem solving must be taken out of the head and into the external world. This could, for example, be about providing visual aids in various subjects at school, or about making theoretical learning more practically oriented. It is also about acknowledging that oral messages are often not enough for the child with ADHD to respond, and that such messages must be supported by something physically tangible (eg a light touch, a list, a picture, a visual daily schedule).

 

Medication

Russell Barkley refers to research that shows that as many as 92% of children with ADHD benefit from using medication in relation to the condition. However, he emphasizes that a subgroup of children and adolescents diagnosed with ADHD inattentive type, often has no effect of treatment. 

Parents of children with ADHD should be aware that medication can have a very good effect in the treatment of ADHD, and that any testing of medication is done in dialogue with the specialist health service.

 

Dealing with additional difficulties

As additional difficulties are common in people with ADHD, such as learning difficulties, anxiety, depression and also autism, it must also be emphasized that many children with ADHD need their own measures that are aimed at these additional difficulties.

 

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