The Frontier of ADHD Interventions

In my last post, Let the Games Begin?, I shared the recently approved video game prescription for ADHD and this got me thinking about other interventions on the frontier… 

Trigeminal Nerve Stimulation. In the spring of 2019, the FDA approved TNS as a “treatment” for childhood ADHD based on research out of UCLA: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6481187/

The device the researchers used is called Monarch eTNS. It sends gentle electrical pulses to the trigeminal nerve, which then leads to stimulation of various brain regions.

For a user-friendly description of the research, see https://www.apa.org/monitor/2019/07-08/adhd-children

Neurofeedback. A 2020 review by scholars from several countries found it useful for children with ADHD: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7250955/

Other research suggests its promising use with adults, too: https://link.springer.com/article/10.1007/s11920-019-1021-4

 

Discovered blog post on my ADHD book

Recently found this 2017 blog post on the ADHD book I co-authored while searching for resources on ADHD-friendly environments. It’s like walking into an independent book store to pick up a book and having the bookstore owner suggest yours to you. Or so I imagine. Gratifying. : )

It’s at http://psyinfo3.blogspot.com/2017/05/have-adhd-designing-environment-that.html.

But to make it easy, it’s also here:

Monday, 22 May 2017

Have ADHD? Designing an Environment That Ignites Your Attention

When you have ADHD, it can feel like anything and everything hampers your focus. Everything is big and blinding. Everything is distracting. The TV. The slightest sound. The silence. Social media. Your coworkers. Your computer. Your dog.

It can feel like anything and everything is messing with your ability to get stuff done, whether you’re at work, at school or at home. And you need to get this stuff done. Which only adds to your already through-the-roof frustration.

In their book Transforming ADHD: Simple, Effective Attention and Action Regulation Skills to Help You Focus and Succeed, Greg Crosby, MA, LPC, and Tonya K. Lippert, Ph.D, share helpful tips for creating an attention-enhancing environment. They suggest thinking of yourself as an interior designer: You’re designing an optimal exterior environment that works with your interior. Which means that it’s very important to know yourself, to know your inner workings. It’s very important to know what distracts you and derails you. It’s very important to know what bores you and what excites you.

In order to enhance your attention, according to Crosby and Lippert, “your environment must contain cues, prompts, and reminders that guide your attention to where you need it and exclude distractions that tempt your attention away.” The authors suggest thinking of cues, prompts and reminders as guiding lights, “the reliable lights of lighthouses”; and thinking of distractions as flashing lights, “the blinking bright lights of a big city billboard.”

Crosby and Lippert share an excellent exercise for finding what works for you. It includes these steps:

  1. Pick an environment, such as work, school or home. Think about what you have a hard time doing there. For instance, you might struggle with writing at home. Next jot down the various flashing lights, the things that pull your attention away from that task. This might be anything from requests from your family to do chores to alerts on your phone to websites on your computer.
  2. For the same environment, list your guiding lights, the things that do or could guide your attention toward that task. This might be anything from posting a task list to using a white noise machine.
  3. Finally, identify how you can replace your flashing lights with guiding lights. For instance, you might work at a library, where you’re less available to your relatives. You might wear headphones while listening to classical music. You might tape a Post-It note on the side of your laptop with the three main steps you need to take to write your article. You might use an internet-blocking program. You might set an alarm to go off randomly, which prompts you to ask: “Am I on task?” (One example is the free Android app StayOnTask.) You might post visiting hours on your office door or a sign that says “crunch time.” You might use cues like checking your planner every morning while sipping coffee; and dedicating the same desk for solely studying and schoolwork. As the authors write, “our brains are association machines…Routines and rituals are brain reminders.”

Here’s a real-life example: Lippert’s husband, Sergio, has ADHD and was attending an MBA program. Even though he started with high test scores, by the end of his second semester, he was close to academic probation. His entire environment seemed packed with flashing lights: During class, he’d read news websites and articles on his laptop. When he’d lose his internet connection, he’d focus on getting it back. When a class didn’t have internet access, he’d play games on his phone. He’d also do work for his part-time job or study for another class. Every time he’d get distracted, he told himself this would be the last time. But it wasn’t.

What worked for Sergio? When he attended his class lectures, he’d leave his computer, phone, work for his part-time job and other class materials at home or in a school locker. He also got honest with himself about his distractions and tomorrow being different. As Crosby and Lippert write, “He had to acknowledge that if he brought his distractions with him, each day would be like the previous 180 days he thought would be different.”

Sergio’s guiding light was a paper planner that he color-coded. Each class had its own color, so it was easy to see what classes he was attending in a given day and what materials he needed to bring. He also set alarms that signaled when to start homework and when to stop.

When it’s time for you to get to work, you might feel like you have a thousand bells going off in your brain. And you might feel like you’ll never get anything accomplished. However, you can use your environment to facilitate your focus, and support you. Experiment with different tools and techniques, and you’ll absolutely find what works well for you.

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Two Awesome ADHD Resources

One resource focuses on children and teens; the other is for adults. Both can be remarkably useful for those with ADHD.

The first is understood.org (here) for “learning and attention issues.”  What it offers is vast and, though, it’s targeted to parents of children and teens with ADHD, many adults with ADHD can find it of use. Much of what’s suggested for teens applies to adults, except for the context (e.g., work vs. school).  Also, given that 25-35% of parents of youth with ADHD are likely to have ADHD (source), parents using the site may want to use the recommendations for themselves as well as their children.

The second resource is JAN, Job Accommodation Network (here), which is all about workplace accommodations for employers and employees needing or wanting to know what the American with Disabilities Act (ADA) encompasses, including job coaches…even the possibility of free ones.  Who knew? From what I can tell, fewer than would have liked to have known.

I hope something here is of use to you.

MIT & NYU Study: Your Input Gatekeeper may be to Blame for your “Distractibility”

Some people with ADHD have a Ptchd1 gene mutation (more often these are males).  MIT and NYU scholars studied the Ptchd1 gene using mice and discovered that its loss may be the basis for symptoms of ADHD (as well as autism spectrum disorder and schizophrenia).

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Why?

Because its loss most significantly affects the part of the brain responsible for keeping out sensory input that’s irrelevant.  This part of the brain is the thalamic reticular nucleus (TRN).

According to one of the senior authors of the study, the TRN determines what input reaches the cortex, where thinking and planning occurs.  “We receive all kinds of information from different sensory regions, and it all goes into the thalamus,” Feng says. “All this information has to be filtered. Not everything we sense goes through.”

Except when Ptchd1 mutations lead to TRN defects.  Then, more of everything can go through, leading to, you guessed it, being distracted and overwhelmed.

Can you imagine no filter or one that loosely functions? For some, there’s no need to.

Last year, the prestigious science journal Nature published the study.

Find a summary of it here.

The Multiple Faces of ADHD

When I run my ADHD group, I start off with an orientation that includes sharing how complex ADHD really is.  And one of the things that surprises most group members is hearing that ADHD is actually seen as multiple conditions.

And I’m talking about something bigger than whether one’s diagnosed as having a “presentation” of ADHD as primarily inattentive, primarily hyperactive or a mix of both.    grid-2111788_1920

As Joel Nigg at OHSU puts it, ADHD appears to be an “umbrella diagnosis,” such as cancer once was (see here).

Cancer was thought to be a single disease, and we now know there are various types of cancer.

Researchers are currently trying to identify the various conditions found under the umbrella of “ADHD.”  Each may have different genes, environmental causes, and clinical outcomes.  They likely have different brain signatures (see Understanding ADHD for more on brain differences).

And they may have different optimal interventions.

This complicates research findings that include participants only because they share a diagnosis of ADHD.  It might be like trying to understand cancer by averaging results across participants with skin cancer and liver cancer.  Or perhaps it’s more analogous to averaging results across participants with different forms of skin cancer.  It’s unclear.

Once the fog clears, I’m excited to know what we’ll learn about the different conditions all now diagnosed as simply ADHD (with three “presentations”).

 

 

Understanding ADHD

Per Russell Barkley (RB), ADHD guru (i.e., scholar and scientist):

ADHD is a disorder of self-regulation that can also be described as a “disorder of age-inappropriate behavior” that looks like inattention and lack of inhibition.

Though I want to clarify that the inattention depends on what you are doing; another guru of ADHD, Thomas Brown, says the “central mystery” of ADHD is that those with it can pay attention to some things and seem incapable of paying attention to other things.white-matter-fibers-hcp-dataset-red-corpus-callosum

But back to RB and ADHD as a disorder of self-regulation.

RB defines self-regulation as “self-directed action intended to alter subsequent behavior so as to change the probability of a future event or consequence” (to improve your longer-term welfare).

For example, say you have a problem with money and keep getting into debt by living off credit.  You want to pay off your debt (self-directed action) to be able to cancel your credit card and limit spending (subsequent behavior) to reduce the chance you’ll get into debt again (change the probability of a future event).

Where does ADHD fit? With ADHD one has the intention to alter behavior (e.g, limit spending) to change the future (e.g., live debt-free) but struggles with the self-directed action (e.g., paying off debt) required for this.

Barkley says it’s a disorder where knowledge fails to guide performance.  You know what to do but struggle to do it.

WHY?

RB highlights that ADHD brains show prefrontal cortical network differences (these networks are responsible for Executive Functioning and self-regulation is the core of Executive Functioning).  Here is where the differences exist and what comes into play:

  • Frontal-striatal circuit, the “what” network (what we think influences what we do) Here lives…
    • Freedom from distraction
    • Working memory
    • Organization and planning
  • Frontal-cerebellar circuit, the “when” network (timing of thought, behavior)
    • With ADHD, there’s “time blindness,” and
    • A “myopia to the future”
  • Frontal-limbic circuit, the “why” network.  Here lives…
    • The decision-maker of the brain (if you have multiple goals, which do you pursue? this circuit, as RB puts it, “makes the final call”)
    • Motivation
    • Emotional control or dyscontrol

These network differences show up as self-regulation differences that encompass

Self-directed action, Self-awareness, Self-motivation, Self-directed attention, Self-restraint, Self-directed sensing, Self-directed emotions, and Self-directed play.

WHAT TO DO?

Outsource these brain functions.

RB calls this externalizing the brain functions where there are deficits.  For example, he says, use “artificial prosthetic cues to substitute for working memory deficits.”

Ideally, this is what ADHD coaches will help you do (for more on this, see Does ADHD Coaching Work?)

Here are some pointers for externalization:

  1. Per RB, the externalization of brain functions is needed at the point of performance and within your natural setting (e.g., if you struggle to write a report at work, you need external factors to guide your attention at work at the time you need to write); and
  2. To externalize, change your environment (think planners, alarms, points, signs).

Replenish your self-regulation (think self-control) resource pool.  It’s depleted by simple use as well as stress, drug abuse, illness.  Replenish through

  • Rewards, positive emotions
  • Positive self-talk
  • 10 minute breaks between tasks requiring self-control
  • 3 minutes of relaxation or meditation
  • Glucose ingestion (Gatorade, lemonade, sugar water) while working on tasks requiring self-control
  • Daily physical exercise

Also, break lengthy or complicated tasks down.  One of my favorite reminders of this, though I really like elephants, is, “How do you eat an elephant?”

Answer:  one bite at a time.

RB adds that accommodations or scaffolding and the compassion and willingness of others to make accommodations are “vital” to your self-regulation effectiveness.

Sources:  Two talks by Russell Barkley on ADHD, one from 2013 entitled, “The Importance of Emotion in Understanding and Managing ADHD (here) and one from 2012 entitled, “ADHD, Self-Regulation, and Executive Functioning:  Theory and Implications for Management” (the part of it I used is here).

Go, Go, Go and Slow, Slow, Slow?

A few years ago, researchers at MIT showed that adults with ADHD have two brain networks that compete for their attention instead of “playing nice,” as they do for adults without ADHD.  These networks are essentially a go, go, go one that lights up when we have a task to do (“task-positive network”) and a slow, slow, slow one that activates when we have nothing to do and can daydream or let our minds wander (“defccv-jp-ngault mode network”).  Without ADHD, when one network has its turn to be active, the other one turns down…they cooperate.  With ADHD, they appear to often be active at the same time.  Imagine what that’s like.  If you have ADHD, you already know.  If only others could experience your brain to know what it’s like….

See for yourself.

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