ADHD: Why don’t you answer me, darn it?

Tired of talking to someone with ADHD and not get any timely response from them? Annoying as f…, right? But is it due to bad will or fundamental anatomy? Get the answer, right now, right here … on NOVA … No, wait a minute … on ADDspeaker

Summary

This article explains the inner workings of the auditory attentional symptoms of ADHD and how they pollute the social interactions for both the person with ADHD and their family, friends, co-workers etc. I provide evidence for the anatomical cause of this auditory deficit, as well as try to create an understanding based on impairment, not ill-will, which causes the symptoms of ‘quick to anger’, ‘Ill-temperedness’, ‘frustration’, ‘aggression’ and that’s just for the person WITHOUT ADHD, while it, for the person WITH ADHD results in ‘constant nagging from others’, ‘irrelevant social interaction’, ‘sensory over-stimulation’ and outright ‘Zone-ing Inwards or Mind Wandering’.

So if you are ready to get your convictions and prejudices provoked and challenged, please feel free to read on. Otherwise … See Ya!

/Peter

Introduction

One of the major symptoms of ADHD is poorly sustained attention, which is usually referred to as vigilance. Children with ADHD, as well as children with learning disabilities, have been found to perform more poorly than neuro-typical (normal) children do on vigilance tasks (Krupski, 1986). Sustained attention is best measured by Continuous Performance Tests (CPTs), and CPTs are playing an important role in the assessment of attention processes.  Originally developed as a tool in the assessment of brain damage (Rosvold, Mirsky, Sarason, Branssome, & Beck, 1956), CPTs have grown in sophistication and purpose. Many variations such as visual and auditory CPTs are available.

Anatomy & Fysiologi

Visual vigilance involves the superior parietal lobes, superior colliculus, thalamus, supplementary motor, anterior cingulate, basal ganglia, and right frontal lobe (Posner & Peterson, 1990)

Functional magnetic resonance imaging has identified the right superior frontal gyrus, left inferior frontal gyrus, left medial prefrontal cortex, right superior temporal gyrus, and right hippocampus and anterior cingulate as areas involved in auditory vigilance (Seidman et al.,1998).

The auditory and visual systems have different developmental trajectories (Dawes & Bishop, 2008). It is possible that the difference between auditory and visual attentional performance reflects maturational asynchronies; the auditory system starts functioning during the last trimester of gestation, whereas the visual system does not start functioning until after birth (Jusczyk, 1998).

As a result, the development of visual system may still lag behind the development of auditory system in early childhood (Lee et al., 2014).

Combining the two viewpoints, the developmental delay of ADHD and the maturational asynchronism between two modalities, may explain why visual attentional performance shown to be more deficient than auditory attentional performance in children with ADHD (Lee et al., 2014).

Modality Differences

Scientific evidence suggests; […]that children having attention, and particularly impulsivity, problems that extend across visual and auditory modalities are at increased risk for difficulties in academic performance. Impulsivity appears to be a particular problem; this is in line with Barkley’s (1997) unifying theory of ADHD. Conversely, children not falling into the problematic quartiles on either CPT tend to do best on most measures. These data indicate the potential clinical utility of using both visual and auditory CPTs in combination. This is especially noteworthy, given the finding that adults with different subtypes of ADHD have dysregulation of separate frontal brain regions (Gansler, Fucetola, Krengal, Stetson, Zimering, & Mohary, 1998). Comparison of quantitative electroencephalographic scanning and CPT performance (Monastra, Lubar, & Linden, 2001) or event-related brain potentials (latencies) and CPT performance in children (Koelega & Verbaten, 1991; Narbona-Garcia & Sanchez-Carpintero, 1999) would be promising areas of research[…] (Aylward et al., 2002)

Testing Continuous Performance In Persons With ADHD

ADHD is a neuroanatomical, neurophysiological and neurodevelopmental disorder which impairs major Executive Functions (verbal & non-verbal working memory, planning & processing, emotional self-regulation, attention and overall self-control) (Barkley, 1997; ADDspeaker, 2019).

Since this is a complex, yet specific neurodevelopmental disorder (operate word here being specific, as opposed to e.g. Autism which is a pervasive neurodevelopmental disorder) it is possible to identify key areas of abnormal functioning that leads to impairments (ADDspeaker, 2019).

To identify these specific deficits, researchers have worked on creating tests that can identify and qualify what unique and specific deficits, a person with ADHD experience, as well as what is quantifiably significant for all persons suffering from ADHD. The scientific consensus is that the Continuous Performance Testing (CPT) format is most suitable for this diagnostic realm (ADDspeaker, 2019).

Continuous Performance Testing

CPT measures are designed as detection tasks in which the subject is asked to watch a sequence of stimuli for the purpose of detecting a certain sequence.

Virtually all versions of the CPT generate the recording of errors of omission, which are presumed to reflect inattention, and error commission, which are thought to be indicators of impulsivity (Klee & Garfinkel, 1983).

Most CPT programs also record reaction time in which a slow reaction time is indicative of ADHD. CPTs are used to assess ADHD and evaluate medication effects for the schizophrenic population as well (Seidel & Joschko, 1991; Kloman, Brumaghim, Fitzpatrick, & Borgsted, 1991).

Continuous performance tests (CPTs), such as the Continuous Performance Test (Rosvold, Mirsky, Sarason, Bransome, & Beck, 1956) and its variants (Conners, 1992; Gordon, 1983; Greenberg, 1991; Greenberg & Waldman, 1993; Swanson, 1983), have become increasingly popular components in the clinical evaluation of attention deficit hyperactivity disorder (ADHD); Aylward, Gordon, & Verhulst, 1997).

This is due in part to the assumption that laboratory-based symptom measures of ADHD may not be as susceptible to biases that affect clinical ratings and other techniques in the evaluation of inattention, impulsivity, and hyperactivity (Marks, Himelstein, Newcorn, & Halperin, 1999).

TOVA

One such CPT is the Test Of Variable Attention (TOVA) which is an objective, standardized, and highly accurate continuous performance test, contains two test conditions: target-infrequent and target-frequent (Duppy & Greenberg, 1993).

In the first half of the test (the target-infrequent half ), the target/notarget ratio is 1:3.5. For example, a target is randomly presented only once every 3.5 nontarget presentations. In this half, which is similar to most other CPTs, the task is boring and fatiguing, and the subject has to pay close attention in order to respond to the infrequent targets (Duppy & Greenberg, 1993). When the subject does not respond to the target, it is called an error of omission and a measure of inattention.

In the second half of the test in which targets appear frequently, the subjects are expected to respond most of the time, but they must occasionally inhibit the tendency to respond. According to Duppy and Greenberg (1993), when the subject responds to the nontarget, it is called an error of commission and is a measure of impulsivity. 

Thus, the ability to pay attention to a boring and repetitive task is best measured in the first half of the TOVA while the ability to inhibit oneself is best measured in the second half.

TOVA also produces the response time and variability of responding which is regarded as another indicator of ADHD.

Reaction Time Variability

RT Variability (RT Variability)—An index of attentional inconsistency, this score is evaluated as the standard deviation (SD) of the mean of correct RTs.

Studies have found, that among four attentional indexes, only the index of attentional inconsistency (RT Variability) showed significant group differences (p < .05) and also had large effect sizes in both auditory (d = 1.01) and visual (d = 1.10) modalities (see Table 2). (Lee et al., 2014)

This finding highlights the importance of performance variability in ADHD when both auditory and visual modalities are considered. (Lee et al., 2014)

Previous empirical research and controlled observations suggest that individuals with ADHD are consistently inconsistent across a wide range of tasks, including tasks measuring reaction time on motor speed, choice decision, vigilance, behavioral inhibition, cognitive interference, visual saccade, and visual discrimination (Buzy, Medoff, & Schweitzer, 2009; Kofler, Rapport, & Alderson, 2008; Kofler et al., 2013; Willcutt, Sonuga-Barke, Nigg, & Sergeant, 2008). However, these  studies considered only indexes based on visual modality. (Lee et al., 2014)

Studies further proposes, that the consistent inconsistency also appeared on tasks measuring reaction time of auditory attention. This result is supported the finding of a recent study (Díaz-Orueta et al., 2014), which adopt the CPT developing in a virtual setting to explore similar topic, stated the importance of reaction time variability, a measure of consistency of attention, in both auditory and visual attention of children with ADHD. (Lee et al., 2014)

Lee et al., 2014

The Attentional Deficiency of ADHD Is Modality Specific

Studies have shown that attentional performance was lower in the auditory modality (higher percentage of error, higher reaction time, and higher variability) than in the visual modality of children without ADHD (see Table 2). (Lee et al., 2014)

These finding suggests that the auditory task (TOVA-A) is more difficult than the comparable visual task (TOVA-V). (Lee et al., 2014)

If the auditory attentional task is more difficult than comparable visual task, then why is visual attentional performance shown to be more deficient, including more deficient attentional indexes and larger effect sizes, than auditory attentional performance in children with ADHD? The answer may be related to the developmental lag of ADHD and the different developmental trajectories between the two modalities. (Lee et al., 2014)

More specifically, the results of the 2014 Lee et al. study showed that most children with ADHD have a problem with visual inhibition, but not with auditory inhibition. (Lee et al., 2014)

This finding is supported by a previous study, which explored developmental changes in visual and auditory inhibition (Guy, Rogers, & Cornish, 2012). Guy et al. (2012) found a more profound effect of inhibition in terms of accuracy and reaction time in the visual task than in the auditory task. (Lee et al., 2014)

In other words, it was more difficult for their normal preschoolers to inhibit visual stimuli than to inhibit auditory stimuli. (Lee et al., 2014)

Combining the viewpoints of developmental lag, maturational asynchronies, and Guy’s research, it is not hard to imagine the different features of inhibitory function between the two modalities in children with ADHD. (Lee et al., 2014)

These findings provide strong evidence that the attentional deficiency of ADHD is modality specific. (Lee et al., 2014)

Conclusion

In conclusion, scientific evidence highlight the fact that the attentional deficiency in children with ADHD is modality specific, and that the deficiency of visual attention is more serious than that of auditory attention in children with ADHD [ADDspeaker, 2019).

In the auditory modality, only the deficit of attentional inconsistency was sufficient to explain most cases of ADHD (Lee et al., 2014).

In the visual modality, the deficits of sustained attention, response inhibition, and attentional inconsistency were all sufficient to explain most cases of ADHD (Lee et al., 2014).

In addition, an identical attentional deficit, the performance of attentional inconsistency, in both modalities was also found in the present study (Lee et al., 2014).

This deficit is sufficient to explain most cases of ADHD in both auditory and visual attentional performance; in other words, the index of attentional inconsistency is the most important indicator for diagnosing and intervening in ADHD when both auditory and visual modalities are considered (Lee et al., 2014).

Everyday Significance Of This Scientific Evidence

When you call your child with ADHD, who is emerged in some awesome new app on their iPad, you are battling not only the perseverance aspect of ADHD (not being able to stop an activity which one finds rewarding, to shift focus and attention to another task, which one do not find equally rewarding) which is caused by neuroanatomical deficits (lack of Dopamine causes neurons and synapses to have more excitatory than inhibitory functioning, hence less Inhibitory Control over verbal and non-verbal behavior), and the child either don’t respond at all or takes 5-10 seconds to respond, it is a tall order for a parent not to go ballistic when experiencing this for the tenth time that day.

Human nature have developed into a highly reciprocal social structure, where communication plays a key role. Likewise, nature have selected for individuals that function best in groups, understanding that ‘safety in numbers’ and collective food sharing, as well as procreation, are most beneficial for protecting the continuation of the species.

With that complex social interaction comes a set of values, behaviors and cultural rules, which all aim at creating a well-organized, effective, resilient and evolutionary successful development of the human species.

One such value is;

When spoken to, reply immediately …

When people fail to meet this basic criteria, it invokes a emotional response within the questioners physical body, a sense of frustration, anger or disillusion and since we know that our emotions impact our physiology and psychology equally, we experience both a cognitive result (anger, frustration, annoyance etc.) as well as an physical response (fist-clenching, jaw-clenching, sighing, teeth grinding, blood pressure elevation etc.).

So when you ask and get no reply, you instantaneously perceive the person not replying, as willfully ignoring you, which then again will raise your arousal level internally, causing an emotional response, as well as a verbal and/or non-verbal behavioral response, e.g. you yell back at the kid:

WHY DON’T YOU ANSWER ME, DARN IT!?

The key point of this article, is to help you understand that it is NOT a willful act of disobidience or disrespect on the childs end, it is however a fundamental and defining trait or core symptom of ADHD, on par with hyperactivity, impulsivity, inattention, emotional dysregulation and mind wandering, and that punishing the kid for not answering you at all (perserverance combined with auditory lag in response time) or taking forever to answer you (5-10 seconds of Reaction Time feels like a week, when you’re waiting for that darn kid to answer you, right).

Although it is annoying as f… it is not by choice – it is a anatomical fact of having ADHD … so please adjust your behavioral reactions to include this knowledge, and experience how much more likeable your kid becomes, when you now know that you need to walk up to the kid, place your hand on their shoulder or arm, demand that they revert their gaze and attention to you, before you deliver your question or command. It’s amazing how weel that works – compared to going into a fit of rage … again …

/Peter


Further reading & References

Reacion Time (RT) is the time that elapses between a person being presented with a stimulus and the person initiating a motor response to the stimulus. It is usually on the order of 200 ms. The processes that occur during this brief time enable the brain to perceive the surrounding environment, identify an object of interest, decide an action in response to the object, and issue a motor command to execute the movement. These processes span the domains of perception and movement, and involve perceptual decision making and motor planning.

There are several commonly used paradigms for measuring RT:

  • Simple RT is the motion required for an observer to respond to the presence of a stimulus. For example, a subject might be asked to press a button as soon as a light or sound appears. Mean RT for college-age individuals is about 160 milliseconds to detect an auditory stimulus, and approximately 190 milliseconds to detect visual stimulus. The mean RTs for sprinters at the Beijing Olympics were 166 ms for males and 189 ms for females, but in one out of 1,000 starts they can achieve 109 ms and 121 ms, respectively. This study also concluded that longer female RTs can be an artifact of the measurement method used, suggesting that the starting block sensor system might overlook a female false-start due to insufficient pressure on the pads. The authors suggested compensating for this threshold would improve false-start detection accuracy with female runners.
  • Recognition or go/no-go RT tasks require that the subject press a button when one stimulus type appears and withhold a response when another stimulus type appears. For example, the subject may have to press the button when a green light appears and not respond when a blue light appears.
  • Choice reaction time (CRT) tasks require distinct responses for each possible class of stimulus. For example, the subject might be asked to press one button if a red light appears and a different button if a yellow light appears. The Jensen box is an example of an instrument designed to measure choice RT.
  • Discrimination RT involves comparing pairs of simultaneously presented visual displays and then pressing one of two buttons according to which display appears brighter, longer, heavier, or greater in magnitude on some dimension of interest.

Due to momentary attentional lapses, there is a considerable amount of variability in an individual’s response time, which does not tend to follow a normal (Gaussian) distribution.

To control for this, researchers typically require a subject to perform multiple trials, from which a measure of the ‘typical’ or baseline response time can be calculated. Taking the mean of the raw response time is rarely an effective method of characterizing the typical response time, and alternative approaches (such as modeling the entire response time distribution) are often more appropriate.

The T.O.V.A. measures a set of different variables to determine whether or not response times and attention is at the normal range for the sex and age of the test taker. Over 2000 people without attention problems were measured to determine what is a normal response time for the sex and age of the test taker as a basis for the interpretation provided.[5]

  • Response Time Variability: A time measurement of how consistently the microswitch is pressed.
  • Response Time: A time measurement of how fast or slow information is processed and responded to.
  • d’ Signal Detection: A time measurement of how fast performance drops.
  • Commission Errors: A measure of impulsivity: how many times the non-target is pressed.
  • Omission Errors: A measure of inattention: how many times is the target not pressed.
  • Post-Commission Response Time: A time measurement of how fast or slow a response is after a commission Error.
  • Multiple Responses: A measure of how many times the button is pressed repeatedly. (Indicator of other problems)
  • Anticipatory Responses: A time measurement how often a person is guessing rather than responding.

Relations between visual and auditory continuous performance tests in a clinical population: a descriptive study. Aylward GP, Brager P, Harper DC., Dev Neuropsychol. 2002;21(3):285-303.PMID: 12233940

Auditory and Visual Attention Performance in Children With ADHD: The Attentional Deficiency of ADHD Is Modality Specific., Lin HY, Hsieh HC, Lee P, Hong FY, Chang WD, Liu KC., J Atten Disord. 2017 Aug;21(10):856-864. doi: 10.1177/1087054714542004. Epub 2014 Aug 1.PMID: 25085651

Behavioral inhibition, sustained attention, and executive functions: constructing a unifying theory of ADHD., Barkley RA., Psychol Bull. 1997 Jan;121(1):65-94. doi: 10.1037/0033-2909.121.1.65. Review.PMID: 9000892

This site uses Akismet to reduce spam. Learn how your comment data is processed.