Wednesday, July 24, 2013 11 Comments
Looking More Closely at Hyperactivity
by Madelyn Griffith-Haynie, CTP, CMC, ACT, MCC, SCAC
Part of The Challenges Inventory™ Series
Do you know hyper like I know hyper?
. . . Oh, oh, oh what a term!
Well, the DSM-5 has seen fit to ignore the likely consequences of keeping that darned “H” in the official name of that attentional disorder many of us would prefer to see named EFD (Executive Functioning Dysregulation), or returned to “ADD, with or without hyperactivity.”
Since, if history repeats itself, we might well be stuck with it for another 20 years before the next full revision of the DSM is published, I thought it would be a good idea to take time to explore some parameters of the meaning of the terms “hyperactive” and “hyperactivity.”
Again, if history repeats itself, we may need to explain them to the
non-expert doctors left to grapple with the diagnosis and care of most of us.
NOT just for Hyperactive Kids
A frequent criticism of the DSM diagnostic criteria has been that its description of the core symptoms reflects how it shows up in school-aged children, not how it presents in older adolescents and adults.
I am one who believes, along with many others, that different symptom sets need to be developed for different age groups, and that “hyperactivity” needs to be removed as central to the diagnosis because it is misleading.
This placement better reflects the way ADD is currently seen and needs to be diagnosed, but the continued inclusion of that darned “H” continues to obscure the clear recognition of ADD as a problem of access to executive functions and the volitional regulation of ATTENTION.
- What, exactly, are we talking about that the professional researchers keep insisting belongs in the diagnostic criteria?
- What will MOST non-expert doctors be likely to look for to identify “hyperactivity?”
- What might that mean to ADDers who do not exhibit the expected presentation of “hyperactivity” as a primary symptom – the fidget-to-focus folks, or those individuals often described as “dreamy-spacy,” or “inattentive” types?
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Expectations, Contrasts and Continuums
We all THINK we know what the term “hyperactivity” means in the context of an ADD diagnosis — something along the order of a biologically-based, inability to remain still, right?
So, perhaps the opposite of extreme hyperactivity might be comatose?
And we all THINK we know what “normal” looks like.
- We tend to place only those behaviors clearly outside the range of the expected normal rate of “activity” in the “hyper” (or “hypo”) category
- We don’t like it when anyone’s range of “normal” activity is “pathologized.”
- We REALLY object to the suggestion that medication might help lower the frequency of particular struggles that “a NORMAL person” handles with better self-discipline or self-application — particularly when we deem it “a perfectly NORMAL childhood behavior” that we expect will change with time.
And we totally overlook the reality that what is considered “normal” human behavior is an expression of the expectations of the environment into which one is placed, and that we have different expectations of “normal” male and female behavior and native abilities in every culture on planet earth.
Yes, that’s true. But “normal” expectations fall along a continuum where everyone within “normal’s” boundaries is fairly equally equipped-by-design to be relatively successful managing the core activities that combine to contribute to an experience of a reasonably successful life.
Think of life like a race.
It would be lovely – and fair – if we all began at the same starting-line, but that’s not how it plays.
The realities of birth contribute to a staggered start where some fairly mediocre runners will fare better than some amazingly talented ones, simply because of placement advantages at the start of the race.
- As long as they remain dedicated to the pursuit, the talented advantaged will soar, along with the lucky ones, and we will read about their successes in the press.
- A few of the most talented (or fortunate) placement-disadvantaged runners will be able to outpace the advantaged mediocre with a display of continued grit and single-minded focus.
Motivational magazine stories to the contrary, most of us understand without explanation that the unusual display of success from the few does not imply, that ALL could – or will – be willing or able to forgo what is usually necessary to rise to the top, no matter how iron-willed their resolve. There’s more involved.
HOWEVER, runners handicapped with lead shoes and back-packs full of rocks struggle MORE unfairly than the rest of the pack, no matter where they begin the race or how talented otherwise.
They are not running a “normal” race. They need a little help shouldering the additional burden placed upon them if we expect them to do as well as those not so encumbered.
We do them a HUGE disservice chastising or poking fun at them for not “running harder,” preferring to believe that other runners are expending an equal amount of energy, faring better simply because they have tapped into a necessary source of motivation or strategy, available for successful application by any runner with the will to take advantage of it.
- Once we identify the backpacks and encourage the runners so handicapped to stop long enough to remove some rocks and change shoes, they begin to move up in the race.
- The earlier we make that identification and level the playing field, the greater their chance of finishing the race with a modicum of success.
- The longer we wait, the less realistic our expectations that they will be able to make up for lost time they might have managed easily earlier in the race.
It seems to me that only the truly lazy, unmotivated, self-focused (or cruel) would advocate denying them that opportunity.
If a diagnostician were to take my analogy literally, looking for backpacks and weighted shoes, they would fail to identify individuals with brain-based challenges slowing down the patients who come to them for help, handicapping them unfairly.
It’s the same unfortunate dynamic when doctors are subconsciously encouraged to look for their own understanding of “hyperactivity” to make the diagnosis of AD“H”D.
Driven to Drive
MOST doctors will readily identify a hyperactivity problem in a kid who never sits still, exhausting a reasonably fit adult attempting to keep up with him or (less commonly) her. Most parents will eventually come to realize that a particular child with that level of energy is nowhere in the vicinity of “normal,” whether they identify it as a problem that will handicap that child’s efforts toward a successful life or not.
Until we understand that the chronic activity is a unconscious compensatory strategy designed to wake up a sluggish brain, it’s difficult to understand or accept why the recommendation is stimulant medication, and why that particular kind of hyperactive kid appears to calm down when they take them.
But there are many other ways that hyperactivity presents!
They aren’t that difficult to identify IF you know to look for them and understand what questions to ask to begin to quantify your observations.
ONE presentation, what I call cognitive hyperactivity, and what Dr. Charles Parker refers to as the “thinking without acting” brain-style, can look like its extreme opposite: that dreamy-spacey individual who frequently seems off in a world of his or her own, unconnected to any reality that the rest of us notice and pay attention to, never mind any seeming awareness of a need to do anything about it.
Who would suspect that particular person of having a MIND that “never sits still?”
Complicating matters, the unconscious coping strategy for that type of hyperactivity is hyperfocus: tractor-beam like concentration on an activity or thought sufficiently stimulating to wake up the sluggish area of the brain, resulting in a sudden ability to concentrate.
“SEE!” we opine without understanding, “s/he can concentrate when s/he WANTS to!”
AD*H*D less common in girls? Oh, really?
Making my point, those studies where girls were included in sufficient numbers to be able to tell seem to indicate that “hyperactivity” is NOT, in fact, less common in girls (as reported in articles that don’t investigate very well), and (despite what you read far too often) that a relatively equal number of males and females warrant an ADD diagnosis.
- It IS, however, diagnosed more often in boys because it looks different in girls, for reasons not completely understood since they have not been well-studied.
Girls with attention deficit disorder tend to “internalize” their symptoms or channel them into excess talking or a focused fascination with others, whereas boys are more likely to manifest symptoms externally and physically.
Girls tend to be less defiant or overtly rebellious, so they initially seem less “difficult” than boys with ADD. Because they’re less likely to be as openly disruptive, the symptoms they DO show frequently get overlooked at home and at school.
- Do we REALLY want to leave access to assistance to an impression of what constitutes an ADD diagnosis in the minds of the non-expert doctors that most of us will encounter?
I know I don’t.
As you learned in a former article, ADD Overview 101:
Basically, in the ADD brain, the filtering & focusing areas and connections are not operating effectively, so its “juggling ability” is limited by the number of “attentional balls” it is forced to juggle already.
There is difficulty sorting out incoming stimuli – prioritizing focus as well as “back-grounding” ambient or persistent stimulation (refrigerator hum, street noise, clutter, clothing tags, florescent light flicker, itchy bug-bites, stuffy noses, etc.).
When the brain’s automatic filtering mechanisms are impaired, the strongest stimuli capture an individual’s conscious awareness (color, movement, sound, tactile or kinesthetic feedback, and so on).
What is considered “strongest” is a matter of individual perception, brain by brain, but the resulting lack of consistency in functioning usually appears to an observer in one of the following ways:
a) motor hyperactivity (gross or fine-motor — sometimes combined
b) hypo-activity (cognitive hyperactivity that tends to look more like
daydreaming, “spaciness” or “never getting off the dime”)
c) mixed, by stimulus and circumstance (both involuntary)
Contrary to what logic might dictate, an ADDer’s unmedicated brain is less active than a neurotypical brain in the conscious “supervisory” areas that FOCUS behavior — in particular, the prefrontal cortex [PFC].
That leads to an under-performance of the neurological mechanisms that make it possible for human beings to observe the environment and supervise responses, guiding decision-making and directing subsequent action effectively.
Regular readers of this blog may recall that the PFC has “regulation responsibility” for what we term the brain’s executive functions, which include planning, organization, and critical thinking as well as time management, effective judgment, and impulse control.
The “normal” human ability to sift through options, plan ahead, use time wisely, focus on goals, maintain social responsibility and communicate effectively is heavily dependent on a PFC that is up to the task.
When the PFC under-functions, we see the organization of daily life spiraling into chaos while internal supervision and ability to self-correct goes awry, one of the reasons why “externalizing” the Executive Functions with the aid of ADD Coaching is so effective.
With one or two years of ADD Coaching combined with medication for access to intentional focus, most ADDers can “make up for lost time.”
- Some of those with less severe presentations subsequently choose to manage with behavior strategies alone (or with medication taken only for those activities for which it is REALLY needed!)
- Others, like me, need to remain medicated in order to stay in the race at all – to function in a manner commensurate with our level of intelligence and drive, life-style appropriate.
There are also those fortunate ADDers whose life-styles are a perfect match for their brain-styles – for NOW.
When you hear about their amazing successes “without that over-prescribed medication,” keep in mind that, if life changes for them, they may well discover that they, too, need a bit of pharmaceutical help to “wake up” PFCs that are no longer up to the tasks they expect of themselves — for example if:
- injury prevents continued high-level physical activity
- they hit a level of responsibility that requires more intentional focus than they can muster (like college or med school, a promotion that comes with a great deal more accountability or tasks in areas that are not strengths-matches)
- the birth of a child with special needs suddenly throws more at them than they can handle with their usual unmedicated aplomb.
ADD is a continuum disorder, so effective management strategies vary along a continuum as well. The appropriate objective is not to do it all without medication or outside assistance – it’s to function near the top of your game so you can fashion a life of success, security and happiness.
The moment the current task does not reward the ADDer’s attention the mind flits off to something else, in an experience of living that is not unlike watching television with a “channel surfer” controlling the remote.
Some of the tasks that “reward” attention include entertainment, excitement, fascination, novelty, food and sexual attraction.
Notice that those basic “boring” activities that keep life on an even keel or prepare us for future successes are rarely included in that list of attentionally rewarding activities: paying the bills, doing the laundry or the housekeeping or the homework, or moving from task to task in a time-efficient manner that supports adherence to a schedule decided upon or agreed to in advance.
Concentration difficulties escalate with boredom and fatigue.
The ADD brain has a MUCH harder time getting started on a task and sustaining the energy of interest that allows a so-called neurotypical individual to stay with a task to completion.
- The longer an ADDer is working on a familiar task without the reward of completion, the greater the increasing tendency for the mind to “wander,” and the greater the need for stimulation to compensate for that tendency.
- It is also observed that when an ADDer has managed to focus on an unrewarding task for a period of time, s/he may exhaust the supply of neurotransmitters necessary for concentration and may have difficulty with the next project or task, or with activation.
The goal of ADD diagnosis and treatment is not to prevent mental excursions that are, after all, something even the neurotypical brain experiences, but to bring them under better voluntary control – in other words, to snatch the remote out of the hands of that metaphorical channel surfer.
- Finally we can “watch an entire program” without having to keep track through dozens of cognitively exhausting distractions and interruptions in concentration – and life becomes similar to the experience of those who don’t struggle with ADD.
- We are suddenly cognitively available to learn and apply the tips and tricks that the rest of the universe uses to keep them on track toward successful lives.
Why medication helps
In the ADD brain, there is insufficient bioavailability of certain catecholamine neurotransmitters that carry the electro-chemical impulses between nerve cells, along with a sluggishness in the uptake of those chemicals by the neurons that need them to function effectively.
So the ADD brain is under-stimulated, and it will do what it must to make sure it gets some!
Stimulation seems to regulate the brain by strengthening catecholamine signals. And that is why stimulant medication with brand names like Vyvanse and ADDeral (dexedrin-based), or Concerta and Ritalin (methylphenidate-based) have been the treatment of choice for years — so that the stimulation the brain needs is provided neurologically rather than remaining at the effect of maladaptive compensatory strategies.
HOWEVER, access to medication (or a little help and understanding from our friends and family) mandates recognizing that something is “off” in the first place, which brings us back to the problems with that darned “H” again!
Flavors of Hyperactivity
Future articles about Hyperactivity will expand on the following information. For right now, I want to underscore the reality of several different presentations of hyperactivity, primarily three:
• Gross Motor Hyperactivity (high-speed, no brakes)
• Fine Motor Hyperactivity (chronic fidgeting)
• Cognitive Hyperactivity (a brain in overdrive, with various presentations)
Only some of those we identify as hyperactive are what are insensitively referred to as “adrenalin addicts,” engaging in high-stimulation/high-risk activities like gambling, fast driving, sky diving — or creating conflict simply to increase stimulation. Many other compensatory strategies are less well-known and less easily identified.
The Moving Diagnostic Target
It was once thought that what became known as ADD in the DSM-III was primarily identified through the presentation of hyperactivity, onset before age seven. Since many of the symptoms of gross motor hyperactivity seemed to resolve themselves by the time the [mostly male] children studied reached their teen years, it was interpreted to mean that ADD disappeared at puberty.
Thanks to studies of ADDults that began in the late 1970s, it is now observed that symptoms continue into adulthood in 30% to 70% of cases, depending on whose statistics you read and choose to take seriously. Early diagnostic standards, the Utah Criteria, were developed to help diagnose adults, and the disorder was renamed named Attention Deficit Disorder (ADD) in the 1980 version of the Diagnostic and Statistical Manual, DSM-III.
In 1994, with the publication of DSM-IV, the diagnostic criteria were altered again to include three different types: predominantly hyperactive-impulsive, predominantly inattentive, and the combined type, as the “H” reappeared in the name, to the consternation of many. Personally, I mourned the addition.
DSM-IV included a category of “ADHD” in apparent partial remission for persons who were currently symptomatic but no longer met full criteria — which may be due more to the use of inadequate or misleading diagnostic criteria than an indication of a true “remission.”
Unfortunately, the new diagnostic criteria essentially retain the same symptoms as before, as the “H” marches on without sufficient explanation of what, exactly, that means. So stay tuned – because WE are going to explore that very thing together.
Graphics gratitude: blessings on artist/educator Phillip Martin
for allowing the cost-free usage of the
“Sherlocking the Double Helix” artwork above
Racers & Befuddled Doctor from free-clipart
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IN ANY CASE, stay tuned.
There’s a lot to know, a lot here already, and a lot more to come – in this Series and in others.
Get it here while it’s still free for the taking.
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Don’t Forget that I am on sabbatical from July 10, 2013 until the second week of September.
Related articles right here on ADDandSoMuchMore.com
(in case you missed them above)
- Brain-based Coaching with Madelyn Griffith-Haynie
- Brain-based Coaching Fees & Formats
- The Group Coaching LinkList – explaining how this format works
- ADD Overview IV: Hyperarousal
- ABOUT Executive Functions
- What ARE Executive Functions?
- ODD and Oppositional Rising
- ADD Overview 101
- ABOUT Activation
- ABOUT Impulsivity
- Working with Impulsivity: Peeping at the Gap between Impulse & Action
- ADD – What’s in a Name?
- The Top Ten Stupid Comments from [supposed] ADD Pros
Related articles ’round the ‘net
- Mechanism of calming hyperactivity by psychostimulant drugs identified (eurekalert.org)
- Testamonial Page for Charles Parker’s NEW ADHD Medication Rules (corepsych.com)
- How To Cope With Symptoms Of Hyperactive Child (after50health.com)
- How To Observe Hyperactive Child Symptoms (after50health.com)
- 6 Types of ADD?! (addpositively.wordpress.com)
- Recognizing the Types of ADHD (everydayhealth.com)
- ADD and ADHD – The Reason Why Children’s Symptoms Are Often Overlooked (sanpedro69.wordpress.com)
- Blessed with ADHD – Attention Deficit Hyperactivity Disorder (richardemanuel.wordpress.com) Cute, positive video
- Changing The ADHD Channel (tuitionpaidlessonlearned.wordpress.com)
- Physical activity program leads to better behavior for children with ADHD (medicalxpress.com)
- “Owls” more likely to have ADHD? (noustuff.wordpress.com)
- ADD – the sluggish brain [Ulla Sarja] (ecademy.com)
- Attention Deficit and Hyperactivity Disorder Impacts Career Options (adultadhdtips.wordpress.com)
- Can a child have ADHD if there’s no history of it in the family? (zocdoc.com)
- Is ADHD really on the rise? (psychologymum.wordpress.com)
BY THE WAY: Since ADDandSoMuchMore.com is an Evergreen site, I revisit all my content periodically to update links — when you link back, like, follow or comment, you STAY on the page. When you do not, you run a high risk of getting replaced by a site with a more generous come-from.