The “biomental” perspective suggests that the complex presentations currently recognized by the single diagnostic label “ADHD” may be a complex array of multiple disorders requiring non-cookie-cutter scrutiny and non-routine treatments.
ADHD involves a performance deficit---a significant difficulty in performing academic skills, not specifically in learning. Primary obstacles in attention, memory, and executive cognition exist that block performance of what may be known.
This brief overview from a psychiatric perspective outlines core issues.
Prevalence Worldwide Varies
Take, for example, the significant, variations in diagnostic descriptions, referral practices, and use/not use of medications in the United States and Europe. DSM-5 states the US prevalence of ADHD is about 5% of children and about 2.5% of adults. The United Kingdom statistics state a prevalence of about 3.6 %.
As a practicing child psychiatrist working with children and adolescents for over three decades, my regular experience is that of all the patients referred to me, greater than 90% come in with a leading diagnosis of ADHD along with other psychiatric disorders. Such an abundance of ADHD diagnoses does not match the DSM-5, 5% prevalence statistic. And these patient’s presentations also do not always meet the basic criteria for ADHD. This leads me to suspect that over-diagnosis may be a regular and worryingly common occurrence.
The cluster of “ADHD” presentations reflects developmental, neurobiological, and neuropsychiatric impairments. The group involves significant difficulties in psychological self-control, self-modulation, self-management, behavioral management, and particularly performance utilization implementing a goal.
I will refer to ADHD at times simply as “performance deficit.” This avoidance of accomplishing a goal is its functionally impairing end-product and a source of combined difficulty for children, parents, and schools.
When present, performance deficit shows clear evidence of clinically significant impairment in social, academic, or occupational functioning. The complexity of this condition needs precise recognition; hence the conjectures offered here are heuristic propositions serving to inform clinical management but also awaiting further scientific delineation.
At the present level of clinical and neuroscientific understanding, at least, three distinct groups or subtypes of “performance deficit” are distinguished:
(1) executive functions impairment manifest as inattention and
(2) hyperkinetic/impulsivity impairment manifest as behavioral dysregulation
(3) combined type of 1 and 2.
Executive functions (EFs) is not a unidimensional construct, but, in fact, has multiple subcomponents. These include a wide range of forward thinking processes spanning attentional selectivity through volitional implementation---attention, sustained focus, organizing, planning, and implementing. This dimension of ADD and ADHD correlates with what is described as the “attention deficit” component.
Whereas each child’s range of executive functions typically varies in the strength and weakness of its subcomponents, in ADHD presentations with dominant EFs impairment, a central weakness resides in the cognitive inhibition sub-component of EFs. Impaired executive functioning shows up in a clear-cut inability to properly estimate the time needed to complete tasks. Those with performance deficits often underestimate how long it will take to plan and accomplish a task, i.e., forward thinking is faulty.
Of interest is the National Institute of Health "Cognition Assessment Toolbox" defining one (cognition) of its four domains of neurological and behavioral health (the others are motor, sensation, and emotion) to include executive functions and episodic memory.
"Episodic memory" is the memory of autobiographical events: times, places, associated emotions, and other contextual who, what, when, where, why knowledge—that can be explicitly stated or conjured. It is the collection of past personal experiences that occurred at a particular time and place. Episodic memory is "remembering" parts of one's autobiography or life story.
Main areas of the brain participating in attending, organizing, planning, motivating, and performing a goal to completion include the following.
The dlPFC (dorsolateral Prefrontal Cortex) is the area in the cerebrum considered the “cool” cortical neurocircuitry responsible, in part, for critical thinking and executive functions and for determining “how to implement.” [Alerting/sustained attention; executive monitoring; see pictorial diagram].
The vlPFC (ventrolateral PFC) attends to and selects which features of environmental stimuli need responses, that is, selects goals; “what” to act on. [Executive monitoring; see pictorial diagram].
The fronto cerebellar neurocircuitry adds motor components to this and to determinations of “when” to act.
The fronto-limbic areas are considered the “hot” brain areas because they modulate and manage emotional processes and contribute to appraising, timing, motivation, and thus determine the “why” that energetically drives performance.
The entire ADHD inhibition dysregulation condition involves the above functional and anatomical dysfunction in the brain’s cortico-basal ganglia-thalamo-cortical circuitry. These areas regulate attention, complex motor responsivity, and the reinforcement of learning. Convincing data exist supporting a fronto-striatal dysfunction in ADHD anatomically associated with thalamo-cortico-strial circuits. These are mediated by GABA (gamma amino butyric acid) and modulated and altered in tone by catecholamines like norepinephrine, and also dopamine.
Cognitive inhibition is the ability to inhibit competing thoughts and shift mental set in a fluid manner. ADHD’s cognitive disinhibition results in cognitive inflexibility seen as an inability to focus, attend, and maintain concentration. The “biomental” perspective proposed here suggests that this cognitive variation or weakness in psychological processes is a disorder best managed by educational remediation and cognitive training. Highly targeted interventions are still in their infancy. Such remediation is imperfectly systematized at the present time. Highly structured environments and academic curriculums can provide externalized cues acting to signal the brain to inhibit, redirect, and focus.
The hyperkinetic/impulsivity dominant type of ADHD presentations, by contrast, has a greater brain-based neurological impairment. This behavioral inhibition disorder (when combined with executive functions impairments) may be the leading and most common ADHD presentation. These children’s reactions to situations, however, remain highly variable, inconsistent, and often unique. Context and motivation (e.g., emotional enthusiasm) have significant impacts on performance.
This type of performance deficit involves a deficit in inhibitory control of motor behavior and can be described as a hyperkinetic impulsivity—an impaired ability to inhibit actions and inhibit responses, notably associated with intentional movements of the opposite side of the body. This glaring involuntary, nonconscious motoric overactivity or drivenness is typically associated with excessive motor overflow or mirror movements—unintentional, often-bilateral hand, foot, and limb movements.
Motor overflow is called “synkinesis” and often understood as a soft neurological sign associated with motor cortex inhibitory dysfunction. Fidgeting and foot tapping are typically seen. While the precise neurobiological mechanisms of this neurologically-based motor overflow are yet undeciphered, their clear-cut impairment is certain, particularly because they may weaken kinesthetic memory for refining intentional, goal directed behaviors (an important part of learning from experience). The hyperkinetic/impulsivity dominant subtype of ADHD is most responsive to psychotropic medications that downregulate hyper-arousability and indiscriminate overreactivity.
Correct Diagnosis Yields Precision Remediation
Effective remediation demands correct identification.
If performance deficit/ADHD is present, this “diagnosis” must be placed in a hierarchy of sequenced priorities in the child’s overall presentation of multiple current problems. Thus, “ADHD” must not overshadow or obscure what may be other more primary disorders that demand immediate attention.
Since children who come to treatment have multiple emotional and behavioral difficulties that require ongoing exploration, it may be prudent that ADHD not be the main diagnosis since it can obscure the child’s complex presentation. ADHD as a primary diagnosis often leads to neglect of core problems—emotional, family, and school-based. Precision must mirror clinical priorities in the specific context with the specific treatment options available.
The emotional overlay of primary problems other than ADHD is typically under-recognized.
Yet, this basket of emotional and behavioral life conditions felt as deplorably impairing determines a great deal of the child’s (and adult's life) behavioral presentation. Properly recognizing core emotional and behavioral issues affects the family’s cooperation and participation with treatment that, if acknowledged, can lead to a positive working-relation with treaters and the school system.
Typically accompanying disorders (“comorbid conditions”) include disorders such as oppositional defiant, posttraumatic, borderline intellectual functioning (IQ 70 to 85 and impaired adaptive skills; grossly under-recognized; may be found in up to 10 to 13%, if checked), learning disabilities, anxiety disorders, school avoidance, work/occupational 'burnout', iatrogenic causes (unrecognized psychostimulant drug side effects) and lack of access to need-appropriate schooling, to name merely a few.
Often, the coexisting disorders are the primary problems needing first line attention. They tend to be the underlying causes, typically chronic, of the child’s overall impairments personally, in the family, and at school.
Normative temperamental over-activity for chronological and developmental age requires skilled and experienced clinical judgment to prevent making unnecessary diagnoses, giving unnecessary medications, and risking adverse side effects.
Three mainstays of rational treatment are the following:
1.Educational remediation is the core treatment since it targets attention, memory, and developing performance utilization skills. I think this must be the foundation of all ADHD treatment. Parents must be intimately involved with the school, and a clear-cut educational protocol suitable to the student’s needs must be formulated and refined on a regular basis. Externalizing everything that the child needs to successfully perform is key. Make environmental cues tangible, visible, concrete, and clear-cut. Details can be found in the referenced material.
2.Psychosocial and behavioral interventions involve a vast array of individual, family, and school-based approaches. One-to-one work (e.g., talking therapy, psychotherapy) with children—and adults—helps them explore feelings, emotions, and develop social competencies so necessary to group and academic successes. The frustrations inevitably felt at inadvertent and unwittingly repeated performance failures over time lead to chronic demoralization and anger. This dispiritedness, as well as teaching anger management coping skills, require active listening and psychotherapeutic sensitivity. Those with ADHD presentations have used these "excursions from the norm" and turned them into creative strengths powering them toward success in life. The person's "life story" is much more than a "diagnosis" and a medication prescription.
Focus on the person, not merely diagnostic labels in isolation, yields transparency to child, family, school, and providers. Evolving understandings to all emerge and changed frames of reference introduce new attentional/performance-enhancing strategies. Motivated attention and concentration make performance fun and more frequent.
Cognition is an array of multiple cognitive abilities, foremost of which are executive functions and episodic memory (i.e., emotional, declarative working memory). Neuropsychologists highlight fluid reasoning (Gf) and crystallized knowledge (Gc) weaknesses in these abilities as constraining the measurable IQ platforms or “fulcrum” of learning and achievement. This innate predisposition of individual differences is a limitation or restriction often reflected in low or uneven IQ profiles.
However, learning efficiency, retrieval fluency (Glr), and working memory (Gsm) are weaknesses that typically obstruct---in more flexibly modifiable ways---learning and achievement. These changeable obstructions act as "blocks" to accessing what is already known. Yet, they are malleable and can be improved on or compensated, at least to some degree. Thus, limitations in intelligence ability and "blocks" to access knowledge already present both must be identified, addressed, and not mislabeled.
IQ and other innate predispositions such as one’s biomental temperament are dynamic capacities. They act as a fulcrum or balance point---given and developed---in infancy whose adaptive “readiness” can be positively changed by strength building approaches. The supportive, caring relationships of one’s actual material environment can be internalized and act as scaffolding for a child’s mental, emotional, and behavioral repertoire. Sensitive therapeutic interventions support this. Not only is emotional intelligence built. Executive functions as cognitive abilities, developing skills and behaviors, and episodic autobiographical memories with motivational sustainability also grow.
Therefore, an integrated view of executive functions sees them as intelligent abilities, behavioral performance skills, and social-emotional skills. Put differently, cognitive intelligence and emotional intelligence are not irrevocably split. They can become more integrated yielding optimal utilization performance---in the classroom and in life. Targeted educational, psychosocial, and psychotherapeutic interventions aim to do this.
Empathetically attuning to the emotional lives of children and families is key to powering successful treatment. Engaging families helps bring reparative work into the home and support caregivers. Working with school systems is essential since ADHD shows itself as nonperformance most glaringly in the classroom.
3.Drug treatments are only one component of rational care. Approved drugs can support a less than efficient neurocircuitry. Support means to strengthen and optimize what may be the inherent potential of the existing system’s capacity. Drugs do not increase intelligence or raise IQ, they merely modulate brain systems toward working more efficiently, some researchers say "faster." Of course, this is only a partial support, not a 100% boost. "Fluency" in thinking, feeling, and performing is critical to assess and typically shows up in unusual ways as a result of stimulant medication.
Although psychostimulant medications such as methylphenidate (MPH) and the amphetamines have been mainstays of conventional drug treatment, common side effects of these drugs include anxiety, loss of appetite, insomnia, suppression of growth in height, and slight increase in blood pressure. Weight loss, moodiness, mood swings, facial grimaces/tics, and possible temper tantrums may be seen. Children on stimulant drugs tend not to smile or laugh. Their emotional expression is constricted, not fluid to show a range of feelings.
Often, considered to be “short-term” side effects, their impact on a child’s development, emotional life, and family can be long lasting. Pharmaceutical company package inserts advise watching for possible psychosis, substance addiction, and criminal drug diversion.
MPH appears to act primarily as a dopamine-norepinephrine reuptake inhibitor. Amphetamine blocks the uptake of both dopamine and norepinephrine but also facilitates dopamine release through reverse transport, a mechanism possibly responsible for its strong anxiety provoking effects and mood irritability.
Useful FDA approved medications with relatively fewer side effects are:
1. guanfacine ER: 1 to 3 mg po QDAILY. (selective alpha 2a agonist that downregulates hyper-arousability and modulates working memory, attention, impulse control and planning in PFC neurocircuitry; some evidence-based studies show benefit for oppositional-defiant behaviors and aggression). Guanfacine ER is extremely useful and moderately effective. Educational and psychosocial supports are essential for success in the long-term.
2. atomoxetine, an SNRI (boosts norepinephrine and dopamine in PFC; sometimes causes stomach upset; drug insert box warning cautions with an alert about suicidal ideation for children and adolescents).
Note: The minimal number of different psychotropic medications and the minimal amounts of each psychotropic medication are always best. Medication is "lame" so to speak without authentic individual, family, and school interventions.
I hope this ADHD "reframing" has offered a new perspective on "performance deficit' disorder."
Look for a follow-up on Learning Disabilities---the specific disorders of learning and using academic skills: the literacy of reading, writing, and mathematical calculations.
Ninivaggi, Frank John “Borderline Intellectual Functioning and Academic Problems.” In Sadock, B. J., Sadock, V. A., & Ruiz, P. (Eds.): Kaplan & Sadock’s Comprehensive Textbook of Psychiatry, 10th Ed., Wolters Kluver: Baltimore, Maryland, 2017: 2430-2442.
Spaniardi, Alma M. et. al. “Attention-Deficit/Hyperactivity Disorder.” in Sadock, B. J., Sadock, V. A., & Ruiz, P. (Eds.): Kaplan & Sadock’s Comprehensive Textbook of Psychiatry, 10th Ed., Wolters Kluver: Baltimore, Maryland, 2017: 3587-35-98.
Ninivaggi, Frank John, Making Sense of Emotion: Innovating Emotional Intelligence. MD: Rowman & Littlefield, 2017 (amazon.com).
Ninivaggi, Frank John. Biomental Child Development: Perspectives on Psychology and Parenting. MD: Rowman & Littlefield, 2013.
Barkley, Russell A. Taking Charge of ADHD, 3rd Ed. Guilford Press, 2013.
Flanagan, Dawn, Ortiz, Samuel O., and Alfonso, Vincent O. Essentials of Cross-Battery Assessment. 3rd ed. New York: Wiley, 2013.