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January 6, 2016

What is ADHD?

Written by Dr. John Carosso

Is ADHD just a bunch of symptoms?

We tend to describe and explain ADHD by its outward appearance and core symptoms: impulsivity, hyperactivity, and distractibility. However, that does not explain ‘what is ADHD’ or what causes the disorder.

Let’s dig deeper

If we look beyond and beneath the signs and symptoms, and consider the cause of ADHD, we can get a much better grasp on effective strategies.

So what’s the actual cause of ADHD?

ADHD is a condition where the pre-frontal cortex, which is the area of the brain that is the most advanced and responsible for the highest-order and executive of functioning, is not quite doing its job. The pre-frontal cortex can be said to have a number of ‘executive functions’ that help us to carry-out our daily routines with increased effectiveness and efficiency. These ‘executive functions’ include:

  • Shifting, and Flexible Thinking: Move freely from one situation to another both in thought and behavior.
  • Inhibition and Impulse Control: Stop ones behavior at the appropriate time, and think before acting.
  • Emotional Control: Modulate emotional responses by bringing rational thought to bear on feelings.
  • Task Initiation: Ability to begin a task and to independently generate ideas, responses, or problem-solving strategies.
  • Working Memory: Capacity to hold information in mind for the purposes of completing a task.
  • Planning/Organization/Prioritizing: Ability to manage current and future-oriented task demands, and order in terms of importance.
  • Organization of Materials: Impose order on work, play, and storage.
  • Self-Monitoring: Ability to monitor one’s own performance and to measure it against some standard of what is needed or expected.
  • Monitoring Time: The ability to self-regulate based on time-constraints and have a sense of urgency. The capacity to plan for a task or goal, no matter short or long-term. The ability to accurately judge the passage of time.

What if a child’s executive functions are not working so well?

If some of the child’s executive functions don’t work so well, we then need to externalize the function(s), or make the function occur, for the child, in the natural environment.

How do we do that?

Well, that takes quite a bit of creativity, and any given strategy will be tailored and individualized for the child. However, in general, here are some general strategies and principles to consider:

Immediate feedback and consequences

Children with ADHD tend to be under control of the moment (they have trouble looking into the future, or focusing on the end-goal), so become part of the moment by your presence, praise, and encouragement. When involved in a boring or challenging task, these kids feel an urge to do something else, so make the task more rewarding. Quick rewards and feedback are vital. Praise, affection, rewards, tokens… Make it immediate. Look for the ‘good’ behavior and praise it. Give immediate consequences as well.

More frequent feedback

Kids with ADHD need more immediate and frequent feedback; best to give often especially in the beginning. Give feedback (praise, tokens…) periodically during the task, not just at the end. Use visuals to remind yourself to check on your child to give feedback.

Use larger and more powerful consequences

Use more powerful consequences than with other kids, because they must overcome more to reach the goal or complete the task; they simply need more motivators.

Use incentives before punishment

Praise before you punish, or you’ll be punishing far too often. Too much punishment only interferes with your relationship with your child. “Positives before negatives” and Praise what you want to see. Find replacement behaviors to the negative behavior, and praise when you see the replacement behavior. Punish consistently but selectively; only punish the one targeted misbehavior.

Externalize time and bridge time where necessary

Children with ADHD have a disturbed sense of time; consequently, they struggle with time-lines. They subsequently live in the ‘now’ and are better when they have external reminders about time. Use a timer, or a visual timer, (large time-timer), watch with alarm, or a recorder with your voice… Longer time intervals: bridge time, i.e. break into small daily steps. See A.D.D Warehouse for helpful items and materials.

Externalize the important information at the time of the task

Working memory is impaired, so place helpful information out in the open, where the work is being done. Use a list of rules and reminders (read directions, double-check work, pay attention…). Take aside your child before their friend arrives and remind/practice to: share toys, take turns, ask friend about her interests…

Externalize the source of motivation during the task

There can also be trouble with motivation. Consequently, increase the motivation and make it obvious by giving incentive or reward. Create a win-win situation; offer to get reward when work is done, or when segments of work is done.

Make thinking and problem-solving more manual or physical

Keeping information organized in their thoughts is tough, so it’s best if the kiddo can see or feel the problem or solutions. For example, type all the points on the computer screen to capture every idea. Child can then expand using the prompts. Use index cards, tangibles, symbols, and other types of cues to remember the specific points. Make the problem tangible so child can see or touch it, such as seeing the plans for a house, or how the furniture will be arranged in a room.

Be consistent

Must use same strategies every time. Be consistent and persistent. Respond in same fashion even when setting changes. Both parents respond same way. Use for at least two weeks before deciding something does not work.

Do not rely on your words, or your emotion

Don’t pester, rely on your actions and consequences. The issue is not a lack of information.

Plan ahead for Problem situations

If you can predict the problem, plan for how to manage the problem. Clear expectations, share the plan with your child, and follow-through. Five-step plan: stop before entering site or encountering the problem; review with child 2-3 rules (brief), ask to repeat; set-up reward or incentive; explain punishment; follow the plan.


Hope you found this information to be helpful. Consultation with a therapist can be advantageous to work on improving the child’s coping strategies, and helping parents to refine their behavioral plan. Feel free to call the office at 412-372-8000 or 724-850-7200 to arrange such a consult. Also, feel free to email me with your thoughts and questions at I’ve also found the book, Taking Charge of ADHD, by Barkley, to be helpful in terms of its comprehensive and practical approach, and some of the aforementioned strategies are highlighted and detailed in that resource.

See you next time when I’ll provide some more strategies to help with ADHD. God bless.

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