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Dr. Kacir's ADHD Blog

ADHD and executive function

TV and 4-year-old executive function

Since finishing ADHD and the Nature of Self Control, I hadn't found any new and interesting articles to describe until today.  This is an article in Pediatrics: a monthly peer-reviewed journal for Pediatricians.  Previous research has seemed to indicate that more television-watching by children leads to more attention problems.  The evidence, however, is mostly observational and does not indicate exactly how attention is affected by television.
 
The authors of this study thought that the problem could be the fast pace of images in many TV shows.  When we see something for only a short time before it is replaced by something else, our brain spends its energy identifying what it sees each time.  This takes place in the sensory part of our brain, not in the pre-frontal cortex, where the brain prioritizes our attention with executive function.  If this is the way that the rapid change of scenes on TV caused attention problems, then executive function should be worse after watching them than after doing something else.
 
To test their theory, they recruited sixty 4-year-old children and divided them into three groups each of which was assigned to a different activity for 9 minutes.  The first group watched a cartoon about "an animated sponge" with complete scene changes every 11 seconds.  The second group also watched a TV show, but this one was from PBS and changed scenes every 34 seconds.  The third group was given paper, crayons and markers and told to draw freely. 
 
Each child pursued their activity in a separate room and after the time was up, the researcher tested their executive function.  They used standard activities which measure verbal and non-verbal working memory, spatial planning and delay-of-gratification. 
 
The result was that the group which watched the fast paced cartoon scored significantly worse than either of the other groups.  I was surprised that those who watched the PBS show scored better than those who colored on two of the tests, but it is good news for those of us who support Public Television for kids!
 
This study gives new information about the effect of different activities on the 4-year-old brain.  At least at this age, exposure to rapidly changing sensations interferes with the ability to process more complicated information.  It would be interesting to see the results of a similar study on adults with and without ADHD... I think that similar effects might be shown and would be more pronounced if ADHD were present.

Long time, no post.

I had been trying to post on the blog much more frequently than this, but I am shocked to find that it has been 2 months!  The office has been very busy -- but that has been because I have taken several short vacations and I have had to "squeeze in" appointments when I have been here.  The major reason for my silence has been a lack of inspiration -- I am still reading the book by Barkley to which I referred on May 31.
 
I finally found another issue which struck me as worth posting about.  It is in the portion of his book where he is predicting the likely problems which will result from ADHD if, as he has proposed, the disorder is primarily a delayed ability to stop immediate responses to environmental stimuli.  (He denies that these "predictions" have stemmed from actual observations of people with ADHD rather than coming only from his hypothesis and the evidence with which he supported it. Personally, I don't see how his years of experience in evaluating children and adults with ADHD can help but inform these predictions, but I won't argue the point any further.)  After he predicts "Diminished and Disorganized Verbal Thought," he addresses "Impaired Self-Regulation of Affect/Motivation/Arousal."
 
I was intrigued by his mention of motivation, as some of my patients state that their lack of motivation is one of the aspects of ADHD they find most frustrating.  One parent complained that her teenage son didn't seem to like doing anything and that she was hard pressed to reward good behavior, since there was so little he regarded in a positive light.  This worried me and I examined him carefully for signs of depression, but he had no other symptoms suggestive of it.  An older patient came in to resume treatment after being off of medication for some time.  He complained that when he was unmedicated "I just didn't want to do anything!"
 
Barkley suggests that a lack of self-motivation results from the difficulties with remembering emotional states associated with previous similar situations.  (Remember the executive functions of self-regulation and working memory.)  Because a person with ADHD has trouble calling to mind previous rewards from a given activity, he or she is less likely to repeat that action unless immediate positive feedback is anticipated.  The actual wording is as follows: "By being less capable of mentally representing and sustaining internal information about prior contingencies, those with ADHD are less able to reawaken their associated affective and motivational states.  This should create a condition in which those with ADHD are unable to covertly emote to  and motivate themselves....  and so remain dependent on external forms of immediate reinforcement in order to persist at tasks and activities and to defer gratification."  (You can see why it's taking me so long to read his book.  Every paragraph is like that.)
 
It was gratifying to be able to apply his complex prediction to my simpler model of ADHD.  Essentially, the problem in ADHD brains is that they cannot always stop the automatic shift of attention that occurs for every sensory event.  The message to do so is sent, but does not get through.  More messages are sent (and thus one of them will be more likely to reach its goal) if positive reinforcement is anticipated for sustained attention, or if negative reinforcement will result from distraction.  When a brain does not efficiently recall previously felt emotions, it cannot anticipate either good or bad results and no additional messages will be sent.  A general lack of motivation then results from an inability to sustain attention to a situation long enough to predict a positive or negative outcome.  Such prediction may be even less likely in a person with ADHD since they cannot easily "relive" previous similar situations.

psychological terminology and ADHD treatment

I am currently reading a book by Russell Barkley in which he proposes a new theory of ADHD and it is slow, heavy going.  I have reached the chapters where he reviews
 other psychologists' theories on executive function.  They are filled with terms like "cross-temporal behavioral structures" and "retrospective function utilizing provisional memory."  As I say to my patients, the concepts of executive function are useful for describing the symptoms of ADHD, but they aren't very practical in most cases, since complex psychological testing is required to evaluate them.
 
Given the above statements, I was intrigued to find the summary of an article where developmental specialists used these psychological tests to evaluate the effect of Concerta on executive function in children.  They performed a double blind, placebo controlled study on 30 children, 6 to 12 years old.  It appears to be a good study, since they first determined each child's best dose, then randomly assigned them either to that dose or placebo for a week.  At the end of the week, on therapy, the children underwent the complex testing of different aspects of executive function and were then switched to the other treatment (that is, placebo or Concerta) for the next week.  Again, after a week, the testing was repeated and only after the results had been recorded did anyone check to see which were medicated and which were not.
 
The results were not impressive.  The tests of working memory showed no improvement on medicine and the tests on specific aspects of generativity and self-regulation had variable results with improvement on one or two out of several measures of performance.  They did show a positive change in "response inhibition" on 2 out of 3 tests performed -- this can be an aspect of self-regulation if it stops the response to emotional content of a situation or quells a physical "fight or flight reaction.  (This is particularly interesting to me, since I regard the basic mechanism of ADHD symptoms to be the failure of the pre-frontal cortex to trigger inhibition of the natural response to a distraction when one needs to stay focused.)
 
All in all, this study reinforces the current practice of evaluating ADHD and its treatment by reviewing symptoms, rather than performing complex psychological tests.  Indeed, it would have been interesting to review symptom checklists at the same time the tests were performed to see how effective the Concerta was on a more practical level.

brain cartoon with dopamine

My stepson sent me this cartoon:
He said that the dopamine made him think of me!  Although the cartoon is not about ADHD, it does illustrate a potential result of over-focus on the internet.  It also shows what happens when executive function isn't doing its job.  The patient is not following the rules of normal speech in words and in action; her self-regulation is not appropriate and the end behavior in this situation is not effective.  It may be that ADHD is a contributing factor to the trochee fixation after all! 
 
Remember that ADHD is a disruption of executive function and that executive functions consist of verbal working memory, non-verbal working memory, self regulation and generativity.  Longer term effects of these deficits result in difficulties with working toward future goals and an inability to stop behaviors that provide immediate gratification in order to attain delayed rewards. 

ADHD, Executive Function and Alcohol

 
ADHD is considered a disorder of "executive function."  I generally simplify it and describe this function as being a matter of prioritizing attention.  That is, does the brain keep paying attention to what it is doing, or does it shift its focus to a distraction?  The psychological literature, on the other hand, looks at the bigger picture and lists four components of executive function: verbal working memory, non-verbal working memory, self regulation and generativity.  Verbal working memory consists of the words with which we describe our present situation.  (Some psychologists call this "self-talk.")  Non-verbal working memory involves all the other "stuff" we have to remember about similar situations: how close to stand, how loud to talk, where to look, etc.  Self-regulation involves our "inner workings." How deeply do we need to breathe?  Should our heart beat fast or slow?  Do we need extra sugar in our blood?  How awake do we feel?  Generativity is a fancy word that summarizes what we do with all the other elements-- what plan will we follow in the situation we face?
 
 
What, you may ask, does this have to do with alcohol?  Well, I just read an article about scientists who did special EEG testing on 11-year-old children whose mothers admitted to binge drinking during their pregnancies.  The testing measured brain activity in different parts of the brain while these kids performed certain tasks and compared these measurements to those of other 11-year-olds whose mothers did not drink.  Both groups of kids were able to form memories well, but the children who had been exposed to alcohol in the womb had more difficulty retrieving those memories later (verbal and non-verbal working memory).  They also had more trouble stopping an automatic response to triggers when they were instructed not to respond (self regulation) and were slower at shifting their attention to one task from another as well as having difficulty describing the meaning of a given task (generativity).
 
I was intrigued by the parallels between the problems of ADHD and those demonstrated in this study.  A brain exposed to alcohol before birth might have changes that mimic those in the developing brain with ADHD.
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