Toward an understanding of ADHD: a developmental delay in self-control.

Josh can't keep his hands to himself when waiting in line. Seth seems to act irresponsibly. Megan never completes an arts anti crafts project. These campers' behaviors may have a common link - attention deficit hyperactivity disorder.

Attention deficit hyperactivity disorder (ADHD) is one of the most studied and controversial disorders in child development. This disorder, which is present in approximately 4 to 7 percent of the childhood population in the United States, is characterized by behavior difficulties such as inattention, impulsivehess, and hyperactivity. The child, or adult, with ADHD has problems starting, staying with, or completing tasks. The result is a life that may often be chaotic.

Characteristics of ADHD

Current research theorizes that ADHD is a developmental disorder of self-regulation. A person's ability to exhibit self-regulation or self-control flows along a continuum. At one end, a person would have all the internal arousal, motivation, and persistence needed to self-regulate toward his future best interests. In the middle of the continuum, a person would have a great deal of selfregulation and self-control but still need outside performance or compliance incentives or consequences, such as laws or rituals.

As the person moves toward the other end of the continuum, he begins to exhibit less self-control. As the person moves even further down the continuum of self-regulation, his or her life begins to appear chaotic and disorganized or without direction to one's future best interests. The person may show little hindsight, forethought, or preparatory action. This level of interruption causes serious impairments in social, academic, or vocational functioning. ADHD is a diagnosis for those at this lower end of the continuum.

A Developmental Delay 

These difficulties in self-regulation represent a delay in development rather than a halt in development. This means, that with age, people diagnosed with ADHD will always be improving, but they will always be behind their same-aged, non-ADHD peers. The ADHD person does not, age appropriately, gain the progressively internalized capabilities of self-control.

As a person matures, his capacity to self-regulate his own behavior comes more from internal or selfimposed neurological processes. At birth a child has practically no internalized mechanisms to selfregulate. He relies entirely on regulation or guidance imposed by others. After a few years of normal development, the child gains more internalized processes of behavioral self-control, while still needing lots of externally applied rules, guidelines, and incentives. With adulthood maturity comes behavior that is controlled via one's own internalized self-regulatory mechanisms.

The developmental delay in the person with ADHD is in the internalization of the ability to selfregulate his behavior. It consists of a problem of "behavioral inhibition" interacting with what developmental psychologists and neuropsychologists call "executive functions." These functions are operations within the brain that promote and allow for self-regulation or sclf-control. This includes nonverbal memory, verbal memory, selftalk, emotions, motivation, arousal states, problem analyzing, problem solving, and thought and behavioral sequencing.

Living in the Moment

The ADHD person, in the presence of stimuli, is less able to stop or prevent an immediate, powerful, or automatic (helpful or harmful) response. This diminished behavioral inhibition then interacts with and leads to diminished functioning of the other brain operations dealing with self-regulation.

The combination of these factors cuts or blocks the connection that leads a person's thoughts to action and his knowledge to performance. It prevents the person from using the past to work toward or maximize his future. The person is often called a repeat offender. He commits the same error over and over again. This is because the inhibitory response system has not allowed for the effective employment of the thinking and problem-solving processes of self-regulation, so the person does not plan or apply new strategies that would normally result from processing one's past mistakes. Therefore, the person's behavior often appears disorganized, irresponsible, chaotic, and ill directed.

A person with ADHD may have difficulties waiting in line or taking turns. Their brain functioning leads them to anticipate and feel that the time period will last excessively and unbearably long. Thcy then show high levels of impatience or frustration with the delay and sooner or later act to escape from it. The delay is seen as boring or bothersome and, therefore, escape behaviors become difficult or impossible to prevent.

Difficulty Remaining Focused

Another very important part of the executive functioning of the brain is the utilization of arousal, motivation, and persistence in goaldirected behavior. Through normal maturational development the brain shifts from being dependent on external incentives to being independent through internal self-generated arousal, motivation, and persistence. This is seen when an adolescent carries out the decision to go to college, continue with graduate school, and survive a long internship training. This represents goal-directed behavior aimed over a prolonged period of time.

On the other hand, a person with ADHD will be more focused on the present moment with its immediate interests. If a task such as homework lacks immediate, external incentives, then there will be a resultant lack of arousal, motivation, and persistence. If a task is deemed of little importance or is too distant into the future, then the performance of the ADHD person drops dramatically. The failure to perform is not an issue of irresponsibility or laziness. The child with ADHD fails to perform because the internal mechanisms to self-create the arousal, motivation, and persistence are lagging behind developmentally.

Developing Social Skills

A lag in social development is another result of ADHD. There may be poor performance in applying social skills (sharing or cooperating), minding his manners, following moral conduct codes, and acquiring adaptive behaviors (rule development and safety consciousness). The deficiency is not in having knowledge of these skills, but rather, in the deployment of the skill at a strategic moment in time when it would be most adaptive to one's own immediate or distant well being. This deficiency may lead to extreme behaviors, such as lying, stealing, selfishness, and possibly impulsive social aggression.

As a result of the brain determined functioning in self regulation, there is often an effect on psychological and emotional development. A person with ADHD may develop less competencies, make more mistakes, have fewer successes, or be labeled as irresponsible or lazy. It is not uncommon for the child with ADHD to experience more pessimism with resultant passivity. It is not infrequent that the person with ADHD have or develop a co-existing problem of an oppositional defiant disorder, a conduct disorder, a depression disorder, an anxiety disorder, an obsessivecompulsive disorder, Tourette's syndrome, or other disorders.

The Positive Side of ADHD

ADHD is not all negative. The same ADHD brain functioning that causes problems for a child may also give that child qualities for success, such as intuition and spontaneity, excitement and energy, creativity and artistic skills. A comprehensive treatment program, an educational understanding of ADHD, and a focus on the skills and positive qualities that the child possesses are important for the child's success.

Long-term Outlook

The long-range outcome for a child with ADHD varies and is often dependent on what help or interventions he receives. For some, the prognosis is a life of chaos and disorganization combined with depression, anxiety, anti-social conduct, or other mental disorders. For many the prognosis is less severe, but they may have many interruptions or disappointments in careers and relationships. Still others have very satisfactory, happy, and or productive lives.

Camp's Place

Camp can provide a very positive experience and therefore can be an asset in the developmental life of the child with ADHD. Many ADHD children attend and fit will into resident and day camps. More severe ADHD or those who have moderate to severe co-existing opposition and defiance may need camps that provide special assistance or staff. Seek a mental health professional for guidance.

Camp staff need to be knowledgeable about ADHD. They need to avoid making negative judgment statements to or about children, for example, "You are so irresponsible," "She never finishes anything," or "You don't try hard enough." They should also keep in mind that an ADHD child will need immediate, age-appropriate, and valued "performance incentives" to behave appropriately. Secondly, camp staff can, through their knowledge of ADHD, develop programs that consider emotional or social enhancements for this population. Camp experiences can focus on and magnify the assets, islands of competencies, and other skills in ways that can be a powerful counter to the child's previous negative experiences.

By learning more about ADHD, you can begin to understand why campers may behave in certain ways. This may help you formulate strategies to help them focus their energy on positive activities and ensure that all campers have an enjoyable camp experience.

A Neurobiological Understanding of ADHD

Neurobiologically, there is a developmental delay in very specific selfregulatory management areas within the prefrontal cortex of the brain. Research has begun to compare anatomical pictures of the brain, MRIs, with scores on psychology tests measuring response inhibition. (Response inhibition is the initiating major problem in ADHD.) Researchers have found a significant correlation between lower scores of response inhibition on psychology tests and MRIs that often show a smaller right Caudate Nucleus and right Globus Pallidus in the right cortical-striatal-thalamic-cortical circuitry of the brain. This points to the possibility that people with ADHD may have functional and behavioral deficits that are related to anatomical variances in their brains.

In addition, during the infancy stages of development, the brain produces many excitatory messages causing a high level of motor activity with resultant increased drives for exploration. As the individual moves into and through the childhood years, these excitatory messages decrease and are replaced with inhibitory messages. Inhibitory messages allow the child to pause, think, recall, and resolve. (Remember that ADHD is a problem of inhibition.) This change parallels a normal maturational reduction of levels of dopamine concentrations from initial high levels to later reduced levels. Dopamine is a neurotransmitter that carries communications across synapses in the brain and is very important to the brain's braking or inhibiting system. Of significance is the fact that researchers have found that dopamine concentrations remain high and do not become age appropriately diminished in the brains of ADHD hyperactive boys.

Finally, other brain imaging studies, PET and SPECT scans, have also shown support of either structural or functional differences in an ADHD child's brain.

Tips for Managing the Camper with ADHD

1. Understand what ADHD is. Understand that ADHD has different behavioral manifestations in each person. Understand that even in the same person there are behavioral and performance fluctuations from day to day as well as from hour to hour.

2. Guide these campers rather than excusing them. Bear in mind that the ADHD child is on average about 30 percent behind in ageappropriate self-control. On average, a 7-year-old camper would equal a 5-year-old camper; 10 = 7 1/2; 13 = 9 1/2; and 16 = 12!

3. Offer external performance incentives! When incentives, or reinforcers, cease, the ADHD child's performance drops. Be creative and vary the reinforcers, and present them in a continual rather than a sporadic manner. To the camper, you are their source of performance regulation.

4. Control the issue of time. Give instructions for immediate expectations rather than for some needed performance that is hours or days in the future. This brings the future into the moment.

5. Keep them active and don't have a lot of unplanned time.

6. Use stories, imagery, and emotions to provide external arousal, motivation, and persistence in tasks.

7. Vary your voice tone. When appropriate, use eye contact when speaking.

8. Vary the use of all techniques for guiding behavior.

9. Be supportive. Use reflective listening. Help them to connect their past to their present with incentives for their future.

10. Rules are contingency-specifying stimuli; there is a relationship between event, response, and consequence. To follow rules is to guide behavior with a strategy. Remember that this ability is delayed in their development. With their help, establish two to four rules. Keep them simple and specific. Write them down and post them. Create incentives to reinforce compliance.

11. Use brief time-outs (but only when needed). This works wonders for children under the age of twelve, and many ADHD kids are already accustomed to time-outs.

John K. Durall, M.A., MFCC, is a licensed marriage, family, and child counselor. During the summer, he directs Camp Oakes. He is also the program coordinator for the ADHD program of the Greater Long Beach Child Guidance Clinic.

Many of the concepts presented here are conceptualized by Russell A. Barkley, Ph.D., through his own research, his reading and compiling of other research from across the world, and his clinical work with those with ADHD.