Attention Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder (onset before age 12) with a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. ADHD usually persists into adulthood as well and needs long-term management. Inattention is manifested in several ways such as failing to pay close attention to details, difficulty focusing on tasks or daily activities, reluctant to engage in tasks that require sustained mental effort, or difficulty in planning and organization. Hyperactivity refers to excessive motor activity when it is not appropriate: tapping, fidgeting, talking excessively. Impulsivity may manifest as social intrusiveness, difficulty in turn taking, hasty actions and decisions that can have harmful consequences. These features do not occur due to defiance or lack of comprehension and are present in more than one setting (home, school, work). All these features are related to executive functioning which can loosely be defined as the ability to direct behavior to attain goals and solve problems. Executive functions are then used for self-regulation. Most theories of ADHD suggest a lack of sustained motivation to carry out tasks or follow rules necessary for living especially in a larger social context. Thus due to neurological differences, people with ADHD find it more difficult to perform tasks that require a longer period of effort and without immediate and tangible rewards. It is important to note that the difficulty is with motivation and not intellect or ability. Possible deficits in academic or working capacity come about as a result of inattention as secondary outcomes but can be managed and worked around.
Therefore, behavior modifications have an extremely important role in managing ADHD for children and for adults. Some behavior management approaches that can be used when dealing with children with ADHD are:
Creating a system of immediate rewards as much as possible: People with ADHD have difficulty waiting for an outcome to occur. They are aversed to delay in gratification or reinforcement. Thus the time gap between a desirable behavior and appropriate reinforcement needs to be as less as possible. Ex: tokens awarded for small advancements in behavior or accomplishing parts of a larger behavior pattern which can later be used for a desirable activity like TV time or dessert
Dividing tasks into smaller, manageable portions with rewards for each: As mentioned before, ADHD comes with a difficulty in sustained effort and motivational deficits. Thus breaking up a task into daily activities that are rewarded more often is helpful. Ex: a month-long project can be broken into daily tasks which are assimilated and rewarded weekly or bi-weekly as per the motivational needs of the individual.
Externalizing the internal self-regulatory information: For people with ADHD, management of behavior is problematic as the internal dialogue/processes used by people to control behavior are not effective enough to sustain behavior. Thus charting out a daily routine or putting up rules to be followed in engaging ways can help fill the gap in internal motivation. The child/adult can be made to repeatedly verbalize the rules as well. Picture exchange communication system (PECS) can be a useful device. It helps visually represent objects or tasks that the child has to follow through the day making up externally for the shortage of internal regulation.
It is of utmost importance that the modifications being made in controlled environments should be made applicable in natural settings as well: Working within the playroom or therapist’s office without applying the learning to the child’s natural environment will not lead to any actual functional improvement. Thus the parents/caretakers need to be on the same page as the therapist/teachers so that the same set of behaviors is being replicated across different settings.
Resource pool of effort (willpower) is the cognitive energy available with the individual to apply to a particular task: ADHD makes this resource less available especially over time. Therefore, timely breaks, experiencing positive emotions, periodic small rewards, consuming a glucose-rich beverage between strenuous tasks help rapidly replenish the resource pool. Over time, regular physical exercise and routine practice of tasks involving self-regulation can increase the capacity of the resource pool.
Further, as the parent/primary caregiver, it is important to manage one’s own emotions and frustrations. Not only does that impact the child’s self-esteem, but children also mirror the emotions and actions of the authority figures. Support groups with other parents, family therapy, individual counseling for the parent are also useful. Even as adults, people with ADHD can have difficulties in relationships and would need partners who are aware about and sensitive to the particular struggles with the condition. Therapy and support groups can be useful for partners and close friends/relatives as well.
Barkley, R. A. (2012). Executive Functioning and Self-Regulation: Extended Phenotype, Synthesis, and Clinical Implications. New York: Guilford Publications. Projected publication date, early 2012.