Attention Deficit or Just Naughty?… We have talked with Dr.Bora Küçükyazıcı, from the clinic of Brain Center of Istanbul, about Attention Deficit and Hyperactivity Disorder (ADHD) in students:
Attention Deficit Hyperactivity Disorder (ADHD) generally presents itself as a problem when the child starts school. While parents apply for preschoolers with severe conditions, problems become clearer upon entering an environment where certain rules exist. Attention deficit disorder or distractibility is not a problem related with the intelligence of the student; operation system of the brain is different in children with attention deficit disorder. Signs of attention deficit disorder are observed around age four in children. Symptoms of attention deficit disorder are observed more distinctly in elementary school years when the child begins academic life. Class teachers may easily observe among many kids in the class that several students are at different attention level from the others.
The feedback of class teachers should be an important parameter for families. If the feedback from both family and teachers suggest that the child might have attention deficit disorder, the family should take an appointment from a medical doctor in child psychiatry without delay and they should see that their child undergo the necessary examination in order to determine he/she has attention deficit disorder. Attention Deficit and/or Attention Deficit Hyperactivity Disorder diagnosis is determined by medical doctors of child psychiatry starting from age four and the required treatment is designated. Attention deficit disorder is diagnosed by a child and adolescent psychiatrist with detailed psychiatric bio-psycho-social examination and in light of information obtained from the school and parents. Many different attention tests are applied to provide support for the clinical findings of the examination for the diagnosis and level of the disorder.
“The fact that the student with Attention Deficit Disorder is unable to reflect their potential knowledge at school, in class, in exams, etc. is exhausting and hurtful for their social development and self-confidence.”
As all parents, we should embrace our dear children limitlessly. Big or small, the potential of the children is not and should not be a problem for parents. However, if there is a problem with reflecting and using the potential knowledge of the student, parents should realize this problem first and step in for improvement and development.
Attention Neuro Test – Continuous Performance Test (CPT) mathematically measures the attention error deviation of the student according to his/her age group by revealing the error point in attention and impulse management. Attention Neuro-Test – CPT score is significant both for diagnosis and treatment follow-up. For example, the test is repeated for determining the level of benefit ensured by the applied and selected treatment for a student with 12 attention error points and 8 impulsiveness error test score in the first diagnosis.
Frequently observed symptoms observed in children due to attention deficit disorder are:
In order to determine Attention Deficit Hyperactivity Disorder in a child, the symptoms detailed above should begin before age seven, they must be observed in more then one environment, they must be permanent and must be in levels that affect the daily life of the child.
The limbic system in the lower part of the brain manages the behavior, motivations and long-term memory functions of a person. The nucleus accumbens, prize center of the brain, is an important part of the limbic system. Nucleus accumbens runs prize, pleasure and addiction mechanisms in the limbic system. Dopaminergic axons that extend from ventral tegmental area towards nucleus accumbens direct a person to perform the work, duty, action, activity that the person wants and enjoys again with more enjoyment.
The part that directs a child or an adult to do an activity he/she prefers and wants for hours without getting bored is the nucleus accumbens inside the limbic system within the lower part of the brain. While the student plays games on the computer for hours, happiness and addiction is developed due to the copious amount of dopamine transmitter secreted by nucleus accumbens.
Meanwhile, prefrontal cortex, administrative manager of our brain, ensures for activities we do not prefer that we do, we can do, we start to do and continue them since they are our duties and responsibilities. The complete development of the part of the brain containing prefrontal cortex continues until young adulthood and administers following driving functions: attention management, impulse control, processing, analysis and reasoning, decision making, autonoetic consciousness (designating behavior depending on past experience).
“The condition called Attention Deficit Disorder is different and faulty operation of the parts of the brain responsible for the driving functions in the prefrontal cortex.”
For this reason, depending on the changes in the affected parts of the brain, there is no problem with focusing on an activity the child wants at a time he/she wishes.
In the limbic system within the lower part of the brain, nucleus accumbens is not active at times the student did not choose himself/herself and for activities he/she did not prefer, because secretion of plenty of dopamine and thus getting enjoyment is not enabled!
Even though it is an activity he/she did not prefer, if the parts of the brain in prefrontal cortex that manages driving functions and provides the performance of responsibility activities operates accurately and suitably, meaning the upper part of the brain that manages attention is operating without any problems, the student will focus on his/her lessons and responsibilities without any trouble.
AUXILIARY METHOD IN ATTENTION DEFICIT DIAGNOSIS: BRAIN WAVE ANALYSIS
On 2013, the imaging of brain waves is approved for Attention Deficit diagnosis in children 6-18 years old with the approval of US FDA. In this way, it is determined with brain wave analysis whether the student has a real discipline problem with the lessons or it is a malfunction of the parts of the forebrain responsible for driving functions such as focusing, maintaining attention, analysis. With this analysis, brain functions of the student are examined objectively.
First of all, parents should take close interest in their children. I recommend them to follow their children against any differences compared to their peers for focusing or maintaining attention. Especially for preschool children between four-six years old, it is beneficial to have a close dialogue with preschool teachers about whether or not there is a problem with completing his/her homework or being in tune with the class compared to other kids. Suspecting that the child has a problem with focusing and maintaining attention is the most important step for families. If the child has a hyperactivity disorder, families recognize earlier that there is something not right with their children’s condition. Children are generally active, curious and excitable. Sometimes it is not easy for the parents of the attention deficit child to accept that their child has such a problem. Particularly in single-child families, since it is not possible to compare child’s behavior with other siblings, all actions and attitude of the single child tend to be perceived as right and befitting in itself.
Parents with multiple children apply to our clinic with the following feedback if there is a problem with attention management in one of their children: Our child is acting differently from his/her sibling about studying discipline and other responsibilities in his/her life!
In addition to attention management problem in children, if there is accompanying impulse control issues and/or hyperactivity, life can be very compelling for parents. When the child with ADHD encounters a public problem due to his/her behavioral disorder, parents recognize it as their fault.
Especially in school and similar social environments, accusing and insinuating stares of other parents and useless recommendations from another parents who do not have information on ADHD may be challenging and exhausting for the parents of the ADHD child.
Dear parents, first of all, widen your perspective and realize the reality of the situation!
Children with ADHD often act impulsively and they cannot regulate their own behavior even if they want to. Faulty actions and attitudes of your child reflect the nature of ADHD. Including following steps in your life may be beneficial in order to help your child with ADHD to ensure regulation of his/her behavior:
1- Agree on a Plan
Ask your child with ADHD this question before going to a mall or market: What will calm him/her if she gets bored or angry? In this way, you’ll have a solution plan you have agreed on with your child. Your child will be inclined to cooperate with the solution he/she has stated and you both have agreed on.
Provide an opportunity to your child with ADHD to recognize that you understand what he/she is going through. Address in a calm and reassuring voice that you understand him/her such as “I know you are sad that we can’t find the toy you want” or “I understand you are upset that your friends did not invite you to play”. Later, ask your child with ADHD to rate his sadness or anger between 1 and 10. This will give you a clue for the size of trouble your child feels or its urgency.
3- Determine Clear Boundaries
Tel him/her that time is running out and you should continue your current activity. For example, you can try to tell that: “Come on now, look how fast you are calming down, this way we can do whatever we want for the rest of the day” or “In order to continue shopping, you need to calm down no matter how sad or angry you feel, and you can do this!
4- Teach Them to Focus Their Feelings on a Different Point
Tell your child with ADHD to imagine a colored candle in his/her palm. Then tell them to get their palm closer to their face for taking out the flame on the candle and blow strongly on their palm. Taking a deep breath and blowing will lead them to get out of the control of their feelings in a moment the child feels angry or sad, and it will direct them to another focus. Alternatively, have a balloon in your bag or at your home and tell them to blow up the balloon.
5- Use Energy Correctly and Positively
If you are at home and at an angry or sad moment of your child with ADHD, tell them to pick up a pillow or similar soft materials and do a pillow fight together. Tearing out newspapers together or going into a race with squeezable soft balls will short-circuit your child’s angry behavior. For example, tell your child with ADHD to imagine a remote control his/her hand. Let it be a remote for arranging his/her feelings. Direct him/her to describe a button to remove his/her angry or upset state and push this button when required.
If the children with Attention Deficit and Hyperactivity Disorder are diagnosed on time, forming a treatment without facing academic and social problems is possible. If diagnosis and enabling accurate treatment is delayed, success in school and lessons is affected negatively in children, primarily in academics.
In addition, for children with delayed treatment onset, disturbance and nonconformity may be developed in social environment of the class and in friendships. Children with Attention Deficit and Hyperactivity Disorder often trusts people quickly and they can take risks easily
. These properties of children with ADHD may be abused by their circle of friends and ill-intentioned people. For this reason, children with Attention Deficit and Hyperactivity Disorder are under the risk of meddling with improper gangs and groups, alcohol intake and substance abuse and being directed to commit crimes. If attention deficit disorder is not treated, it is known that functionality of the child in social and academic field gradually decreases and loss of self-confidence is often experienced.
The use of medicines for the treatment of attention deficit disorder
Mostly, medicines become a part of ADHD treatment. Only a medical doctor on child psychiatry may decide whether medicines are required for a student with ADHD by evaluating the clinic state of the student. Medicines are used in treatment since they regulate the biochemical irregularities observed in ADHD and they affect the treatment process of the child positively.
Commonly used medicines contain methylphenidate drug substance
that has a particular positive effect on attention functioning. Before the child psychiatrist prescribes those medicines, it is beneficial to determine whether the child has a condition posing an obstacle for medicine use (such as cardiac arrhythmia, hyperthyroid, hypertension, angina pectoris). Medicines are used in doses and at hours recommended by the physician, often in accordance with study hours of the child. After starting medicine use, patient follow-up is continued closely. It will be correct to assess medicine use in ADHD treatment as an emergency approach. For someone in the middle of the sea who did not complete their swimming lessons, the priority will be a life ring. It will be right to assess medicines used in ADHD treatment as life rings. At a later point, it will be right approach for the person to develop their swimming ability rapidly and learn to swim in order to be alone in the water.
The most misguiding fact for the families is that they think their child has no attention problems since he/she is able to watch television or plays computer games for hours… There are no problems for children with Attention Deficit and Hyperactivity Disorder when they watch TV or play computer games as they wish. In this condition, depending on the changes in the affected parts of the brain, there is no problem with focusing on an activity the child wants at a time he/she wishes. The problem is losing attention in a subject that requires particular focusing. Attention deficit reveals itself upon moments that require specific focusing such as class environment, listening to lesson, doing homework, and concordance with team play in a sport activity.
Firstly, parents should understand accurately and identify the notions of “naughty child” and “child with hyperactivity disorder”.
Unfortunately, in recent years naughtiness and hyperactivity notions are frequently used inaccurately and in an entangled manner by both parents and teachers. The hyperactivity of a child with ADHD is purposeless, it is not aimed at a specific target. The parents denying that their child has a purposeless hyperactivity that is not right do not act towards the academic achievement and social adaptation of their child. The step with the highest priority in Attention Deficit and Hyperactivity Disorder is parents suspecting that something is not right with their child and apply to a child psychiatrist for diagnosis. Delaying or ignoring the situation means putting off the treatment of the child and this may mean hindering the social communication and academic achievement of the child.
Neuro-biofeedback therapy provides doing exercises of focusing and maintaining attention in parts in the prefrontal cortex of the brain that cause attention deficit disorder and/or hyperactivity problem in the student. With these exercises, the student learns how to manage the malfunctioning attention center and how to develop this skill. Skill of focusing
and maintaining attention, which is an improvable skill, is successfully improved with neurofeedback therapy, that is a computer assisted program.
Neurofeedback (attention deficit disorder) is called as EEG biofeedback or neurotherapy. Neurofeedback is a treatment method used also in disorders with changed brain wave amplitudes such as depression, anxiety, sleeping disorders, learning difficulties, attention deficit and ADHD.
There are approximately a trillion cells localized in brain tissue in different activity areas. Those cells generate 4 different types of brain waves from too fast to too slow. According to latest research, decreased activity is observed in areas ensuring attention control, focusing, forming thoughts and feelings in the brain wave activities of people with ADHD.
Research shows that faulty brain waves may be corrected by performing correct exercises with brain waves. Neurofeedback exercises are a learning process that strengthens the brain. With neurofeedback exercises, parts of the brain that will strengthen attention control, feelings and behavioral areas of the brain are exercised. On this way, you will learn to control your brain rhythm in a way that enhances the daily activity of your brain. Neurofeedback exercises are similar to tuning a piano or configuring the motor of a car for it ensures correct and productive operation.
A neurofeedback device connected with the computer is used in the session. The sensors of the neurofeedback exercise device are placed on patient’s scalp and ears in order to record the electrical activity of the brain. Electrical activity of the brain sent to the computer with neurofeedback device is displayed on the screen. Meanwhile, the client sits before another screen. Client directs the games displayed on the screen with brain waves. Images on the screen present feedback to the person about different levels of attention skill. Neurotherapist will monitor the brain waves of client during session and provide directions when required in order for performing the adjustments that will provide the client to succeed in game protocols.
With neurofeedback exercises, improvements are provided in areas managing brain functionswith 2 mechanisms.
Research demonstrates that new neuronal networks are developed in parts of the brain related with neurofeedback exercises and brain is developed to learn that how to operate better. Development of myelin sheath in neural networks provides faster data transmission.
With Neurofeedback exercises, exercises that provide permanent development are applied in the selected area of the brain for the following cases that will benefit from higher level of brain function:
Neurofeedback exercises provide efficient benefit for increasing mental performance. While high mental performance is ensured in some periods of life, repeating and maintaining it is generally difficult. However, the person learning to manage brain waves and using his/her brain more efficiently with Neurofeedback exercises ensures permanent improvement in developing and maintaining mental performance.
Brain waves that manage attention skill are monitored and attention boosting exercises are applied for focusing or maintaining attention. The computer assisted attention exercise program, neurofeedback, that is applied with certain sessions and protocols, depends on re-organizing attention system against signals obtained from the attention center of the student. Neurofeedback is especially preferred in treatment for children and adolescents with ADHD that do not prefer medication, observed to have intense and frequent side effects, for whom medical therapy cannot be used for various reasons or discontinued.
American Academy of Pediatrics – Neurofeedback in the treatment of attention deficit disorder
AAP – American Academy of Pediatrics, reported NeuroBiofeedback exercises to be “Level 1 – Best Support” for the treatment of Attention Deficit and Hyperactivity Disorder in their treatment manual issued on 2012.
Neurofeedback attention-developing exercises provide a significant level of success in “Attention Deficit Treatment in Students.
WHAT IS BEHAVIORAL AND COGNITIVE THERAPY?
Developments are ensured in how to use attention skill more productively by performing arrangements in school, home and social environment of the child. Arrangements may be performed at school, in class environment. A student with attention deficit disorder is recommended to sit on the front row and near the wall instead of near the window. It is known that Attention Deficit and Hyperactivity Disorder is a condition that has a neurochemical basis. This means that the hyperactive child does not behave this way due to being spoiled or lack of discipline at home. For this reason, teachers should try not to present an accusing approach for parents, on the contrary, they should present a supportive and motivating attitude for treatment. First of all, being familiar with this condition is very important in order to understand
the hyperactive child and his/her family and to assist them in the correct way.
Considering the fact that the student is easily distracted due to the Attention Deficit and Hyperactivity Disorder, giving him/her active duties in class will buy some time to gather himself/herself. When it is recognized in the lesson that he/she is involved with her environment or lost in thoughts, a verbal warning may be given to attract his/her attention to the subject. Instead of always focusing on the negative behavior of the student with ADHD, bringing positive behavior on the forefront will increase the positive behavior. The times when he/she performs his/her duties properly should not be missed and he/she should be awarded with positive messages.
DIFFERENCES OF CHILDREN WITH ADHD FROM THEIR PEERS
Students with attention deficit disorder may present a level of success lower than what is expected from their intelligence. While they get a high grade from one exam, they might get a lower grade from another. They are observed to give incorrect answers to questions from subjects they know well since they do not read the question. Even if they read the question correctly, they may skip calculations while answering. They also cannot read questions with longer texts patiently.
Since they cannot use their time productively in exams, they do not have the time to read and answer all questions. Following lessons, listening, applying, following a daily program is difficult for these children. They have trouble with following, understanding and applying directions. This is not observed only in school, it also causes problems in daily life and they may turn into children who push limits, do not listen, do not perform their responsibilities, and have behavioral problems.
Students with Attention Deficit and/or Hyperactivity Disorder tend to be more creative, more free-thinking and more sympathetic compared to other students. In order to reveal the special skills of a student with ADHD, healthy communication in the family should be well-established. In this way, the child with ADHD will learn to use his/her creative intelligence and impulses in a positive way instead of unfitting friendships and bad habits. A team sport will also be an important step for treatment in children with ADHD in order to direct their hyperactivity significantly towards team sports.
DIFFICULTIES AND TREATMENT OF ADHD IN ADULTS
While difficulties with hyperactivity disorder have decreased with age in adults with ADHD, problems due to attention deficit disorder continue to affect life negatively. Especially in professional life, due to difficulties experienced in cases requiring focusing and maintaining attention, it is possible that the person will be required to change his/her job many times. Due to problems with the driving functions of attention (focusing-maintaining), troubles are experienced in types of operations requiring attention, such as driving. Primarily, correct diagnosis is of great importance in treatment since having trouble with focusing is a common symptom for many other psychiatric disorders. After psychiatric examination, medical treatment, neurofeedback therapy and behavioral therapy may be applied in adults diagnosed with ADHD.
Dr. Bora Küçükyazıcı
Medical Doctor, Neuro Trainer
Spec. Clinical Psychologist & Family Counselor
He was born in Istanbul on 1973. He is one of the first graduates of 1990 Cağaloğlu Anatolian High School. He completed his undergraduate studies at Akdeniz University Faculty of Medicine on 1997. He worked in government between years 1997-2003 as an Emergency Physician. He worked as Medical&Marketing Manager in many international medical and biotechnology companies such as Actavis and Genzyme in years 2003-2010. He was awarded with “Most Successful Application” on 2009 with his study titled “Differentiation Strategy and Communication”. On 2007, he joined Family Physicians program. On 2010, he performed studies on following subjects in the Clinical Psychology doctoral program of St. Clement’s University: Child and Adult Psychology, Conventional Psychotherapy, Family Sociology, Communication Psychology. On 2011, he studied on Attention Deficit Neuro-Anatomy, Neuro-Physiology and NeuroBiofeedback areas in the program titled “ADHD Through the Life Span” in Philedelphia University. He was certified as “Family Counselor-Therapist” by PETAD (Psychological Education, Therapy and Research Association). He still provides support to consulting families in his clinic, Brain Center of Istanbul in Atasehir.