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“My Child with ADHD Can Sit Still and Pay Attention When They Aren’t Bored:” Insights from Neuropsychology

 

Attention-Deficit Hyperactivity Disorder (ADHD), as the name suggests, is characterized by developmentally inappropriate levels of excessive movement and inattention. However, parents often report that their child with ADHD only exhibits these symptoms during certain situations. For example, although their kid may fidget, squirm, and leave their chair in the classroom or when doing homework, they can sit perfectly still for hours if they are doing something they enjoy (e.g., video games, YouTube videos, action movies). This begs the question: Is ADHD simply a problem of boredom and motivation? There is no doubt that making educational material more fun, hands-on, and interactive will improve engagement, but this is true for all children. For children with ADHD, the answer might lie in the cognitive underpinnings of ADHD.

Modern conceptualizations of ADHD identify executive dysfunction as a core feature underlying the disorder (Barkley, 2015). Executive functions are a collection of cognitive processes that make it possible to maintain attention, maintain self-control, plan/organize, and temporarily store and process information (i.e., working memory) (Diamond, 2020). Working memory, in particular, is critical for performing academic tasks such as mental math, reading comprehension, and writing. It just so happens that the area of the brain that governs executive functions is underdeveloped in children with ADHD by approximately 2-3 years on average (Shaw et al., 2007). So, what’s the link here between cognitive functions and symptoms of ADHD?

Well, recent studies suggest that children with ADHD need to move to perform better on tasks that have a large working memory burden (Rapport et al., 2009), such as classwork/homework. A recent study at the University of Central Florida demonstrated this phenomenon experimentally (Orban et al., 2018). Children aged 8-12 years old watched an instructional math video and a clip from an action scene of a movie. The group diagnosed with ADHD moved much more during the instructional video than typically developing children, whereas both groups were laser-focused and barely moved an inch during the movie clip. So, hyperactivity, a core feature of ADHD, may serve as a compensatory behavior, serving to maintain adequate functioning of the prefrontal cortex. Most video games, action movies, YouTube videos, and reels require very little cognitive work and therefore, there is less necessity to move and stimulate blood flow in the brain. In fact, when children with ADHD are allowed to move (as long as it doesn’t distract them from the task), they actually improve their performance on working memory tasks, whereas typically developing children see no such benefit.

Now we come to the question of motivation. Perhaps kids with ADHD are simply bored by educational or cognitively demanding material? It is true that providing some external motivation (i.e., small rewards such as stickers, toys, allowance) seems to help all children, and especially those with ADHD, complete non-preferred tasks such as homework and chores. However, this is not the whole picture. Children with ADHD have a harder time completing tasks with large working memory demands, partially because the area of their brain required for such tasks is underdeveloped. Most of us do not enjoy tasks that are hard for us to grasp. So, before we conclude that “they don’t pay attention because math is not interesting,” we may first have to consider that they may not like math because it is actually more challenging for them. Therefore, it is important to closely monitor the academic performance of children with ADHD, seek academic achievement testing from the school in early elementary years, and intervene with educational interventions/accommodations so we can build the child’s confidence and make it less likely that they become “bored” later on.                 

References:

1) Barkley, R. A. (2015). History of ADHD. In R. A. Barkley (Ed.), Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (pp. 3–50). The Guilford Press.

2) Diamond A. (2020). Executive functions. Handbook of clinical neurology, 173, 225–240.

3) Orban, S. A., Rapport, M. D., Friedman, L. M., Eckrich, S. J., & Kofler, M. J. (2018). Inattentive behavior in boys with ADHD during classroom instruction: The mediating role of working memory processes. Journal of Abnormal Child Psychology, 46(4), 713-727

4) Rapport, M. D., Bolden, J., Kofler, M. J., Sarver, D. E., Raiker, J. S., & Alderson, R. M. (2009). Hyperactivity in boys with attention-deficit/hyperactivity disorder (ADHD): a ubiquitous core symptom or manifestation of working memory deficits?. Journal of Abnormal Child Psychology, 37, 521-534.

5) Shaw, P., Eckstrand, K., Sharp, W., Blumenthal, J., Lerch, J. P., Greenstein, D. E. E. A., … & Rapoport, J. L. (2007). Attention-deficit/hyperactivity disorder is characterized by a delay in cortical maturation. Proceedings of the National Academy of Sciences, 104(49), 19649-19654.

 

About the Author

Sam Eckrich, PhD, is an assistant professor within the field of child neuropsychology at the WVU Rockefeller Neuroscience Institute (RNI). He received a master’s degree in Neuroscience at Florida State University before earning a doctorate in child clinical psychology at University of Central Florida. He gained specialized pediatric neuropsychological training (internship and fellowship) at Kennedy Krieger Institute/Johns Hopkins School of Medicine. His clinical work focuses on medically complex individuals with pediatric traumatic brain injury (TBI), neuro-oncological conditions, genetic disorders, and neurodevelopmental disorders, especially autism and ADHD). He also provides online-based cognitive behavioral intervention (Teen Online Problem Solving) for teens with brain injuries. Dr. Eckrich is co-founder of three multidisciplinary clinics: WVU Medicine Children’s Neurofibromatosis and Neuro-Oncology Clinics, and RNI’s Pediatric TBI Clinic. His research has centered around cognitive underpinnings of ADHD and is expanding to investigate several outcomes related to enhancing quality of life among West Virginian youths across medically complex conditions.

General disclaimer:
This content is not intended to address all possible diagnosis methods, treatments, follow up, drugs or their related contraindications or side effects. Standards of practice change as new data becomes available. Therefore, it is strongly recommended that practitioners independently assess and verify diagnosis, treatments and drugs for each individual patient. The authors of the WV ACC guidelines assume no liability for any aspect of treatment administered by a practitioner with the aid of this publication.

Drug disclaimer:
The authors do not endorse or recommend the use of any particular drug mentioned in this publication. Before prescribing a new drug to a patient, practitioners are advised to check the product information accompanying each drug to ensure it is appropriate for a specific patient and to identify appropriate dosage, contraindications, side effects and drug-to-drug interactions.

Standard of care disclaimer:
This publication is not intended to establish a standard of care applicable to practitioners who treated patients diagnosed with ADHD. “Standard of care” is a legal term, not a medical term, which refers to the degree of care a reasonable practitioner would exercise under the same or similar circumstances. The standard of care is a continuum and does not imply optimal care. Practitioner discretion and clinical judgment are paramount and this publication is only intended to aid practitioners’ judgment, not to serve as a substitute for said judgment.