ADHD Psychology, Co-morbidities, and Outcomes – Coursera Class Weeks 6 & 7

ADHD is complex. While defined as an executive function impairment, there are different genes, parts of the brain, brain chemicals, and behaviors involved. We know that certain drugs and behavioral interventions can relieve symptoms of ADHD, yet the medical establishment does not know what combination of interventions will promote optimal functioning in any given ADHD patient. Frequently the best course of action and medication is found through an educated trial and error method. This is stressful for both the child and the family. However, finding ways to manage and treat ADHD impairments is essential. Weeks six and seven in Pay Attention: ADHD Through the Lifespan have focused on the functional impact and complications of ADHD. It has been a bit depressing.

Disorders seen with ADHD include oppositional defiant disorder (ODD), conduct disorder (CD), anxiety disorder, mood disorders (including bipolar disorder, persistent minor depression, and major depression), learning and language disorders, Tourette syndrome, obsessive compulsive disorder (OCD), autistic spectrum disorder, fetal alcohol syndrome, sleep disorders, substance use disorders, and post-traumatic stress disorders.  Whew. The more sever the ADHD, the more likely it is to co-exist with one or more of the above disorders. Parental issues such as depression, low-income, and decreased interest in the child and a deviant child peer group will also increase the likelihood of a comorbid disorder.

Children with ADHD:

  • Are more likely to have learning issues:
    • Speech, language, reading, spelling, math, handwriting, and listening comprehension deficits can all present at higher than normal levels in children with ADHD.
    • Overall, drugs do not correct the learning problems that may be present with ADHD and parents should insist on additional educational help for their ADHD kids with learning issues. Medical interventions can make a child behave better in class but they do not make the child learn more. Specifically, reading, spelling and math issues do not improve with ADHD stimulants although the stimulants may improve handwriting and comprehension. Atomoxetine (Strattera) may sometimes help with reading abilities.
  • Have lower than average intelligence (possibly the result of poor executive function);
  • Are less self-sufficient.

Perhaps due to their initial ADHD-caused difficulties academically and socially, children with untreated ADHD can develop low self-esteem and a type of learned helplessness. They prematurely give up when faced with seeming difficult problems and don’t develop the ability to seek challenges, expect success, persist, and take failure in stride.

The behavioral and cognitive effects of ADHD can cause lifelong issues. 30% to 80% of children diagnosed with ADHD will continue to have symptoms in adolescence and up to 65% will have them as adults. ADHD may just look different as a child grows up. External manifestations such as high activity may decrease, yet internally, inattention and disorganization can persist. The world expects us to develop more and more executive function as we age and this expectation can create real issues for adolescents and adults with ADHD. When key executive functions such as self-regulation, sequencing behaviors, planning ability, organization, working memory, and internalized self-talk are impaired, personal relationships and careers suffer.

Adults with ADHD are more likely to:

  • Have an annual income of less than $25,000;
  • Be high school dropouts or if they do graduate from high school, they are less likely to graduate from college;
  • Be addicted to tobacco and/or use recreational drugs;
  • Be unemployed;
  • Be arrested;
  • Be divorced;
  • Have poor driving records, including revoked licenses, and vehicle crashes;
  • Have poor money management;
  • Have trouble organizing a household and raising children.

The lack of executive function that is a primary deficit in ADHD can cause secondary executive function problems, similar to the learned helplessness created in children with ADHD. These secondary EF problems may respond to coaching and training. People with ADHD can live in the moment and while they may know what to do, they have trouble with execution. Lecturing someone with ADHD or merely teaching them organizational skills is rarely successful. They know what is expected, they just don’t have the internal support to always follow through.

Instead of assuming individuals with ADHD will change their brain wiring and suddenly have organizational skills, it is more effective to “reverse engineer” and externalize executive functions. Technology is making this easier. Smart phones can give time reminders and have nagging due lists. ADHD coaches can help individuals learn how to break tasks into small steps, externalize sources of motivation, and post critical reminders at the point of performance. While drugs are an important treatment component for some people with ADHD, behavior training is essential. Natural settings should be restructured to externalize executive functions and then these accommodations must be maintained.

Given the increasingly high societal and economic cost of ADHD, it is distressing that the current sequester has cut programs for low income children. Early interventions for children with parental support is one of the most effective ways of preventing the negative comorbidities associated with ADHD. Individuals with ADHD have the greatest success when important people in their lives compassionately and willingly help them with their organizational needs. This is only possible if parents, educators, and spouses understand how to best support someone with ADHD.

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