ADHD: A Return to Psychology
Craig Wiener Ed.D.
Assistant Professor: University of Massachusetts
Medical School, Department of Family Medicine
and Community Health
Clinical Director: Family Health Center of Worcester
Private Practice
Current view
• Delayed
“inhibitory mechanism”
• Biogenetic problem
– Difficulty restraining
short sighted responses
• 9% of children
Akinbami, L. J., X. M. Liu, P. N. Pastor, and C. A. Reuben.
2011
Traditionalists believe that people will be enticed by instant
gratifications unless they can
• Inhibit
immediate
reactions
– engage “executive
functioning”
• and
concentrate so
that effective longerterm responses can
be considered
(Fuster, 1997; Barkley, 2006).
Inferior biological/mental inhibitory mechanism
Less able
To stop, look, listen, and
think before taking action
(Douglas, 1972).
They will not manage their futures effectively
Traditional ADHD is based on three pillars
(Pliszka, Mc-Cracken, and Maas, 1996).
ADHD is thought to be a biological problem because
It runs in families
•
Identical twins are almost always concordant
•
Molecular Biology is different
–
–
7-repeat allele (DRD4)
Increase diagnosis 50%
LaHose et al., 1996; Barkley, 2006
Brain structure and function are different
–
Brain structures
•
smaller and less differentiated
–
Diminished arousal and activation
–
Less availability of neurotransmitters
•
dopamine and norepinephrine
Barkley, 2006; Brown, 2010
Medications work instantaneously
• Since changing biology improves ADHD
– the etiology of the behaviors must be biological
In critique of the three pillars
• In comparison to other medical problems
– No biological markers or dysfunctions that reliably
coincide with the diagnosis
• Too many false positives and false negatives
The genetic argument is not as strong as it appears
– There are many diagnosed persons without
the genetic variations
– There are many non-diagnosed persons
with the variations
– Identified molecular biology
• Only increases the chance of diagnosis from 9%
to 13.5%
– Hardly a reason to panic is your child has the
identified genes
(Chang, 1996: Shaw, 2007)
It is anticipated that family members will show similar
behaviors
• Related people have
similar bodies and
environments
– Their probabilities for
learning are similar
• Extreme with identical
twins
– A heightened confounding
of genetics and learning
Yes, biology changes the probability of
what is learned
– Height  Basketball player
– Physically Attractive  Popular
– Physically Awkward  Low Social Status, Sports Avoidance
Biological difficulties can increase the probability of
learning ADHD
For example
– Developmental Delay
• Coordination Disorder
– Specific speech or learning
problems
– Health complications
– Short attention span with objects
– High activity levels
– Demanding and intense
responses
– Negative infant temperament
(Barkley, 2006)
• Socializing a person to be concerned for
others and independently responsible is
difficult under these arduous conditions
But not all children with these
problems will learn ADHD behaviors
And learning can also change biology
– Dopamine levels can increase with positive
experiences
Schultz, Dayan, & Montague, 1997; Wickelgren, 1997
With musicians
The planum temporale
–becomes larger
–more asymmetrical
As a consequence of playing a
musical instrument
Gaser and Schlaug, 2003
This means that structural brain differences
can occur as a result of learning
•These differences show relationships between
–patterns of living and biological developments
•The consequence of the co-occurrence of
biology and environment
And Differences in brain response may relate to learning as well
• MRI data shows
– Brain blood flow varies in relation to observing
someone with the same or different political affiliation
– Patterns of brain activation and arousal can be a
function of what the person is doing and what the
person has learned
Elias, 2004
Finally, Medicine might lessen ADHD Behavior
• But this does not identify the cause of ADHD
– Alcohol helps with sociability, but this does not tell us
why the person was not social
ADHD medications can be a potent
and practical solution
o Due to urgency and
resources of participants
o But they do not tell us
about the genesis of
ADHD
Instead of thinking that ADHD is a biological
deficit caused by genetics
Ask yourself:
– Why would a biological disability respond so remarkably to
• Bribery
• Personal interest
• Instruction source (child initiated or expected by others)
– How can a person outperform his disability?
• Many parents ask, “Why can my child function so well when he
is doing what he wants to do?”
It is quite reasonable to assume
• If the problem goes away when
there is “personal interest” then the
problem is psychological
Do you see your child in the
following cartoons?
by Brian Nelson “Sun Spott Studios”
Hyperactivity occurs when parents are on the phone
But not if bedtime is extended while the parent talks
Distractibility prevails when writing a “thank you” note
But not when writing a Christmas list
Blurting occurs when vying for attention or provoking
But not when there could be incrimination
Unpleasant appointments are often missed
But it’s first in line for scheduled trips to the movies
The daily planner
•Is cast aside
While plans on “My Space” are being made
Personal belongings are
–scattered about
But battle scenes are meticulously arranged
Chores are left undone
But the house sparkles when “buttering up” the parent
Contemplation is evident when making a purchase
But not when shopping for a sibling
Rather than disability
ADHD behavior is reinforced in
particular situations
Your goal is to stop those reinforcements and instead
foster your child’s self-reliance and cooperation
Works cited
Akinbami, L. J., X. M. Liu, P. N. Pastor, and C. A. Reuben. 2011. “Attention Deficit Hyperactivity Disorder among Children Aged 5–17 Years in the
United States, 1998–2009.” NCHS Data Brief No. 70. August. http://www.cdc.gov/nchs/data/databriefs/db70.pdf.
Barkley, R. A. Advances in ADHD: Theory, Diagnosis, and Management. J & K Seminars, 1861 Wickersham Lane, Lancaster, PA 17603, 2008.
______. Attention Deficit Hyperactive Disorder: A Handbook for Diagnosis and Treatment . New York: Guilford Press, 2006.
______. Attention Deficit Hyperactive Disorder: A Handbook for Diagnosis and Treatment.. New York: Guilford Press, 1998.
______. ADHD in Children, Adolescents and Adults: Diagnosis, Assessment, and Treatment. New England Educational Institute, Cape Cod Summer
Symposia (Audio cassettes). New England Educational Institute, Pittsfield, MA, 2000.
Brown, T. Recognizing and treating adult ADHD. In Shnitzer, N. New England Psychologist. Vol. 18, no. 5, p. 2, June 10, 2010.
Chang, F., Kidd, J., Livak, K., Pakstis, A., Kidd, K., “The World-Wide Distribution of Allele Frequencies at the Human Dopamine D4 Receptor Locus”,
Human Genetics, 98, (1996): 91-101.
Douglas, V. I. “Stop, Look, and Listen: The Problem of Sustained Attention and Impulse Control in Hyperactive and Normal Children.” Canadian
Journal of Behavioural Science 4 (1972): 259–82.
Elias, P. “Brain Scans a Political Tool?” Telegram & Gazette. October 29, 2004, A13.
Fuster, M. M. The Prefrontal Cortex (3d ed.) New York: Raven, 1997.
Gaser, C., and G. Schlaug. “Brain Structures Differ between Musicians and Non-Musicians.” The Journal of Neuroscience 23, no. 27 (2003): 9240–45.
A. O., & Bedi, R.P. The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to
patients (p. 37-69). New York: Oxford University, 2002.
LaHoste, G. J., J. M. Swanson, S. B. Wigal, C. Glabe, T. Wigal, N. King, et al. “Dopamine D4 Receptor Gene Polymorphism is Associated with
Attention Deficit Hyperactivity Disorder.” Molecular Psychiatry 1 (1996): 121–24.
Pliszka, L. R., J. T. McCracken, and J. W. Maas. “Catecholamines in Attention Deficit Hyperactivity Disorder: Current Perspectives.” Journal of the
American Academy of Child and Adolescent Psychiatry 35 (1996): 264–72.
Schultz, W., P. Dayan, and P. R. Montague. “A Neural Substrate of Prediction and Reward.” Science 275 (1997): 1593.
Shaw, P. et. al. Polymorphisms of the Dopamine D4 Receptor, Clinical Outcome, and Cortical Structure in Attention-Deficit/Hyperactivity Disorder,
Arch Gen Psychiatry. 2007;64:921-931.
Wickelgren, I. “Getting the Brain’s Attention.” Science 278 (1997): 35–37.