In any given situation (a person says hello to you, someone takes a step onto your sandcastle, or a girl kisses you), there are many different ways that a person can respond. What most people do is to make a decision of how to respond based on a lot of different information. What do they think of that person? How do they want that person to think of them? What did they do the last time? Did that response last time go over well?

It is a good thing that most people think things through like this: the first impulse most people have of how to respond in a situation is usually a pretty bad idea. Imagine, then, if you couldn’t hold in your initial idea or thought, because the brakes in charge of doing that were a bit ‘leaky’. Besides being constantly on the move or talking then, lots of times you’d be saying or doing the worst things you could possibly say or do in a situation, even though you knew better! How frustrating!

This is called Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type (ADHD-PHI). A good way of thinking about ADHD-PHI is summarized in the following quote by Dr. Russell Barkley: “ADHD-PHI is a problem not of knowing what to do, but doing what you know”. A computer might have some really great games on it, but if it doesn’t have any RAM then you can’t run any of them. In the same sort of way folks with ADHD-PHI may have remembered lots of good ideas about what to do, when to do it, and who to do it with but they can’t pull that information up quick enough when it really counts. Before you know it, you have already ‘gone with your gut’ thanks to that leaky brake. Individuals with ADHD-PHI often have what I call an “Oh Crap” face – it’s the expression they get when the correct solution (what they really wanted to do) comes to them after it is too late. The “Oh Crap” face proves that these individuals aren’t being purposefully bad.

For example, a set of parents might say that their son seems incapable of not bothering his younger brother on a trip in their van. It may very well be that the elder brother intends, and wants, to follow this rule but nevertheless acts ‘in the moment’ as he is lacking the pause necessary to remind himself of the rule, the consequences, and even his own preferences in the matter.

Because of this, a number of skills that require a ‘pause’ be inserted between incoming information, and a reaction to it, are going to be lacking. These skills include managing time, solving problems, talking to yourself inside your head, metacognition (thinking about thinking), applying something you learned in one situation to a new situation, and being able to hold it together when something doesn’t go the way you wanted it to. Recognizing these deficits is the first step in finding ‘detours’ around them, or accommodations for them, so that problems are minimized.

So let’s give them a brake 

  • There are all sorts of medications that help to get this brake working better, and they are effective enough that you should talk to your physician about them. Some pills you take once a day (like Concerta), some you take more often (like Ritalin), and some you can break up and sprinkle on your morning cereal (like Adderall XR). Some work for just a little while in the day (like Dexedrine) and some continue working all day every day (like Strattera). People used to worry about these medications for a number of reasons:
    • For one, many thought these medications could lead to drug abuse in individuals with ADHD-PHI. Actually, it ends up that people with ADHD-PHI are less likely to abuse substances if they take medication.
    • There was also a concern that kids on these medications wouldn’t grow as tall, or eat as much as kids who weren’t on these medications. It is true that many of these medications make you less hungry when you are on them, but usually this means that you just eat more when the medication wears off. And while you may not grow tall as quickly as your friends, by the time you are an adult you will have caught up in height.
    • Finally, some people used to believe that these medications might give you tics (involuntary movements or sounds), or make any tics you have escalate. It ends up that this typically doesn’t happen; in fact tics lessen in as many people as they increase in. Plus, even when the tics do increase, often this increase is only for a little while.
  • Medications insert that needed pause between event and response – they give you an inner workbench to sort things out on – but they can’t fix all of the things that went wrong during the times your brake was leaky. Don’t assume, then, that the medication will suddenly make up for years of missed learning and don’t think that the medication “doesn’t work” if this doesn’t happen. Remember this about medications: Pills don’t teach skills. Once you have that brake, you still have to learn how to use it! Expect to be behind in certain skills, and to have to spend time getting caught up.
  • The techniques described below are far more successful when medications have already tightened up the leaky brake; this is one of those times when medications and behavioural techniques work much better together.
    • “Anticipate and Avoid” strategies are very helpful in avoiding the set-up that can occur when everyone wants things to go a certain way, but because of leaky brakes the individual with ADHD-PHI is incapable of pulling it off without accommodations. To illustrate using the example above of the brothers in the van, perhaps the brothers can be separated preventatively at the onset of the trip, with one parent in back and one in front, rather than waiting for the inevitable failure and the frustration it breeds.
    • People can always think more clearly when they are not excited or agitated; for this reason finding ways of calming the individual (e.g. deep breathing, listening to a progressive muscle relaxation CD) will work in your favour. Playing a, “I bet that I can make you yawn” game (where you pretend to yawn and trigger the response in the child, and vice versa) is an idea from Garber, Garber & Freedman-Spizman (1995).
    • Implementing a “hesitation habit” (e.g. requiring the individual to count to a certain number between an event and his/her response to it) may help increase insight into a reactive response style, allow other response options to occur to him/her, and/or train that needed but missing pause. Garber, Garber & Freedman-Spizman (1995) suggest you first chart the critical situations in which the person’s impulsiveness causes problems, and together then establish appropriate responses for each of those situations. For instance, a good “hesitation habit” for leaving one’s room on the way to school might be to always walk over and scan one’s desk for items needed at school. For it to truly become a habit it will have to be practiced many, many times – to help encourage this practice, points could be earned each time the person is seen engaging in one of these hesitation habits.
    • Continue to establish structure in the person’s life. It may take a long time for it to become automatic, but it is still very helpful. It will help to make transitions easier as fewer shifts will be unexpected ones. It will also put fewer demands upon working memory (that “pause” we said wasn’t working very well), as many aspects of the day will consolidate into habits and so you don’t have to remember them anymore – they are automatic. Finally, it is often in unscheduled times that these individuals find themselves in trouble, as it increases the chances that (s)he will respond impulsively to something or someone.
    • It may help retention of the structures/schedules to make them visual (e.g. a picture-board of his morning between when he wakes up and when he leaves for school). Aim to have rules, consequences and routines so predictable that the individual can finish your sentences for you. This will help him/her to feel more independent and in control as well.
    • Use immediate, explicit ‘token’ rewards for accomplishing tasks, that can be accumulated and ‘cashed in’ for extra privileges or snacks or other desired items (decided upon in partnership with the individual). This will help children with ADHD/PHI to “keep their eye on the prize” and increases their ability to comply with requests.
    • This need for visual structure and a reward system should be considered when choosing new teachers, and also when planning for times that are traditionally quite unstructured (such as recess, or time on the bus).
    • Without a brake to tell you to keep your thoughts to yourself until you have decided what to say out loud, every thought these individuals have may be said out loud. In fact, they may get in a lot of trouble for talking all the time. This is called “pressured speech”, and it is what would happen to anyone who doesn’t have a filter between their thoughts and their mouths! In a way it isn’t fair – other people get to keep certain things to themselves. That’s why it is not only important, but also respectful of the person with ADHD-PHI, to learn to distinguish what is intended to be “inner private talk” and what the individual actually means to share. Things meant to be inner private talk should not be reacted to or judged. Maybe a notebook could be provided as a place for this talk or these images to be put.
    • Help to train the individual to be more deliberative and less impulsive in his/her decision-making. Proper decision-making involves brainstorming different solutions, walking through the potential advantages and disadvantages of each of those solutions, deciding which solution to go with, and then evaluating how successful that solution was. As individuals with ADHD-PHI will show difficulty in automatically doing this internally, model how this looks externally and explicitly. Role play identifying what the problem is, generating possible solutions, discussing and even writing down the predictable consequences of each solution, evaluating and ranking each solution, implementing the best solution, and taking note of the outcomes.
    • Help the person identify certain staff, family members, or friends to be “impulsivity checkers” – individuals whom (s)he can go to in order to help him/her with this process.
    • Language mediated strategies can sometimes help children concentrate and control their behaviour. For example, when given instructions the individual should be asked to repeat them in his/her own words to ensure that (s)he understands what is expected. This strategy can also be helpful as (s)he is doing work to help him/her focus in on the task.
    • Another tip about instructions; because any mention of a behaviour to a person with “leaky brakes” is only going to make that behaviour MORE likely to occur, make sure that in giving instructions you tell the person what you want him/her to do, not what you don't want him/her to do!

Individuals with ADHD-PHI are, by definition, poor at time management; the passage of time must be made more explicit and visual for these individuals. Sources of stress might be: knowing when you will be done a certain task, or mistakenly feeling that one’s entire week is filled with appointments with no time left for fun. By providing visual outlines to look at (e.g. a pen to scratch off each step as it is completed, or by showing the individual what appointments (s)he has and when on a calendar), more security can be infused into the situation, keeping frustration levels lower and distractions to a minimum.

Finally, parents, be sure you request that any relevant accommodations found on this hand- out are added to a formalized Individualized Education Plan (IEP). An informal IEP may not be implemented or transitioned, whereas a formal IEP is a legislated process that also includes the Identification Placement and Review Committee (I.P.R.C.) that must be adhered to, under the Education Act, (Education Act, Regulation 181/98). Any child with identified special needs has access to this process.