Ep #6: Understanding Attention, ADHD, and the Frontal Lobe with Dr. Alina Fong

What is the frontal lobe and what role does it play in your child’s brain? Today I’m talking with Dr. Alina Fong and she is sharing with us how this low development of the frontal lobe affects our children’s ability to be able to reason. How it can lead them to have impulsive behavior. We’ll talk a little bit about symptoms and signs of ADHD and when not to be concerned as well. She also shared some amazing tips for healthy brain development.

Dr. Alina Fong received her PhD in clinical neuropsychology with an emphasis in neuroimaging from Brigham Young University. In 2004 she received the American Psychological Association Clinical Neuropsychology Division 40 Graduate Student Research Award. She proudly serves as the President of the Brain Injury Alliance of Utah. She’s also a board member of the United States Brain Injury Alliance and is a member of the Public Policy and Governance Committee for that alliance. My fun and interesting conversation with Dr. Fong is coming up right after this.

Welcome to the Raising Healthy Kid Brains podcast where moms and teachers come to learn all about kids’ brains, how they work, how they learn, how they grow and simple tips and tricks for raising the most resilient, kind, smart, compassionate kids we can. All while having lots of grace and compassion for ourselves because you know what? We all really need and deserve that too. I am your host, Amy Nielson. Let’s get ready to start the show.

Amy: Alright, Dr. Alina Fong, welcome to the show. We’re so happy to have you here with us today.

Alina: It’s an honor, thank you.

Amy: And I was really excited to talk to you about the frontal lobe. We talked a little bit about that and I wanted to know, what is it and what kind of role does it play in our brain?

Alina: Well so the brain is a very complex organ. In fact one of my favorite quotes was from a past patient who is literally a NASA rocket scientist who actually said that after undergoing some of our imaging, we do a specialized type of imaging called functional MRI. And I can explain a bit more about that later. But he said after seeing what the brain looks like in that imaging he is convinced that our brains are the most complex organism in the multiverse, not just universe, but multiverse. Yeah, and it just really kind of puts things into perspective.

And so the front lobe specifically is the front part of our brain. In fact if you were to put your hand right on your forehead, that is your frontal lobe right behind your skin and your skull there. And the frontal lobe is really what makes us adults. It’s what makes us reason, and be logical, and control impulses, and weigh up pros and cons, and be able to make some decisions. So that frontal part of our brain, that frontal lobe is very, very important with regards to growing up and developing into an adult.

Amy: So is there something then that children don’t have all the way yet?

Alina: That’s absolutely correct. And being a mother of three children, my oldest is 17 and getting ready to go to college. Even as a neuroscientist and a neuropsychologist I think, why hasn’t her frontal lobe developed yet? I kind of just want to talk to her as though she’s a fully functioning adult because she thinks she’s one. But I have to remember that at 17 she still has another, gosh, maybe eight, nine more years of neural development. And it is unfortunately when they start leaving our houses at 18 when a lot of that pruning or a lot of the kind of prioritizing occurs with the frontal lobe.

The frontal lobe then kind of decides, the brain itself and the frontal lobe decides, okay, what’s really important? What shall we start paying more attention to in a process called pruning? And a lot of that occurs once they leave our home.

Amy: Wow. So with younger children then we’re working with, when we see that we are not feeling like they’re logical or they’re having a hard time doing some of these things that we feel like is really normal as an adult. Should we be worried about that or is that just partly because their brain is not fully developed yet?

Alina: Well, I think we as parents are going to worry. How do we not have some concern about that? But we also have to remember that we have to somewhat kind of counter our expectations a bit because in some aspects they are just not capable of the higher order thinking that we would expect them to be able to have. And I’m saying, even as someone who studies the brain for a living and all my research is devoted to the brain, it’s easy to forget when you’re a parent in the middle of that situation going, “How could you make that decision? What were you thinking?” And often they’re not thinking.

That part of the brain that allows them to kind of have delayed gratification, or to reason something out is honestly not yet developed. Now, that doesn’t mean that we don’t continually try to teach them because that is how the pruning process works. That is exactly how we are able to teach their brain what is important and what’s not important. So we should be concerned and we should still try to teach them but understand that it is a learning process.

Amy: So we can start some of those things even when they’re really young, starting to try to reason with them, starting to try to motivate them or give them processes and things even though they might not be all the way ready for that until they’re older?

Alina: Exactly. It’s essential that we do try because that is how they learn. And we definitely as parents, I feel like that, that is definitely our job is to continue to teach them. Because like I said, a lot of that end development occurs once they’re out of our homes. And our job, you really start to realize and again I only have three, but you realize that you only have a certain amount of time to influence them because at a certain point they start caring about what their friends think more than what we think.

And so I think that that’s one thing that as a parent of teenagers I would love to impart to younger parents, which is treasure that time you have. I mean we really only have if we’re lucky, 13 years or so maybe before they want to start hanging out with friends more. And so the more that we can instill upon them at a younger age the better foundation they will continue to have.

Amy: Yeah, that’s so, so true. I have some that are still under that age of 13 and then I have some teenagers as well. There’s definitely, yeah, you get less and less influence it feels like as they get older and less time with them.

Alina: Yeah, it’s heartbreaking and I think that’s why the youngest child gets so much attention because by the time that youngest comes around, as parents we are like, “My gosh, where did all the time go? This is my last one.” So yeah, it’s definitely hard but it makes our job as parents even harder knowing that we have a certain amount of time. Now, of course we always want to be a good influence to them but the reality of it is that yeah, they kind of want to hang out with other people at a certain point.

Amy: So true. So true. So if we’re looking at this kind of range of is my child having trouble with attention span, or reasoning, or executive functioning. When do we say, “Okay, this is just that their frontal lobe isn’t fully developed?” And when do we start to become concerned about maybe some other issues that something’s maybe not right or not normal?

Alina: So that’s a great question. And the frontal lobe is not the only part of the brain that’s responsible for focus and attention. Attention is part of what we call a hierarchy of cognition. And so if you think of cognition kind of like a pyramid, that frontal lobe functioning, that this higher order functioning that we’ve been referring to is really just the tip of the pyramid. But foundationally under that are other types of really important processes, for example, memory. And then under memory is focus and attention.

But foundationally to focus and attention is what we call sensory processing or our brain’s ability to take in the external world, organize that in a way that makes sense and filters a lot of that out so our attentional and focus strata, or level, or foundation can be best utilized. So for even younger children, often some parents can pick out and some teachers, and maybe healthcare providers can pick out, maybe there’s some type of a sensory processing issue that might be going on. And then maybe next to that on top of that, that may be the reason why they’re having an attentional or a focus issue.

If there’s an attentional or focus issue there’s often going to be memory problems because each level kind of builds on the next. What’s so interesting though about attention deficit if we’re going to talk about that a bit, or what we call ADHD. Is that some of these patients with ADHD have no problems with memory. They memorize every single word and every single song. They seem to have an amazing memory for things they care about and things that interest them. But on the flipside if it doesn’t interest them and they’re not focused and they’re not paying attention, it doesn’t even make it in for the brain to code.

And so it can be really difficult as a parent to figure out, okay, what is this? And that’s why it’s really important to go to a professional, a healthcare provider, who can give your child the right diagnosis. I think ADHD is one of those issues where it can sometimes be a little over-diagnosed and overmedicated especially in some of these youth. Even as adults, it’s really important to go to someone who has the clinical training to be able to piece apart, okay, is this a central auditory processing disorder? Or is it an attentional deficit hyperactivity disorder and so on?

Amy: It’s so interesting how the memory is connected but then sometimes it’s something different and I love that picture of the pyramid and how those pieces all build and work on each other. It’s so interesting. What recommendations do you have then for parents that are wanting to kind of work with their children around focus, if they’re trying to build attention span in these younger kids, what are some ways to do that or do we just kind of have to wait it out? What does that look like for younger children?

Alina: I am, and this might be a little controversial. I am really one of those parents that I think medication should be one of the last resorts, especially with children with developing brains. And that’s really kind of contrary to what the line of treatment is in our medical world. Medications are the first line of treatment for these young kids. But I come at it of course from more of a neurodevelopmental aspect. I have seen enough patients to know that some of these children maybe do not need the medication and maybe they could really benefit from more behavioral modification.

So some of the things that we look at here and again, for a lot of doctors, it’s easy to give a prescription for a medication. But what is recommended by the American Academy of Pediatrics is some kind of a combination with behavior modification therapy and medications. So one of the things that I really strongly recommend is some therapy, some types of actual talk therapy or behavior therapy to help that child understand maybe what their particular triggers are, what interests them, if there’s some strategies or coping mechanisms that can help distract them to some degree so they can study.

And many of these are again without any sort of medication. Now, of course there are some children that absolutely need a combination. But I’m seeing that there are so many patients, there’s so many children that could actually benefit from more behavioral modification techniques. One of the things that we’re looking at in my clinic is attention deficit hyperactivity disorder under FMRI. So I know I talked about that a little bit in the beginning. FMRI stands for Functional Magnetic Resonant Imaging. I’m sure many of your listeners have heard of just regular MRIs, or they’ve gotten regular MRIs for broken bones and things like that.

But a functional MRI is different. So we’d have a child in an MRI machine but they have a screen and kind of a gamepad in front of them and they’re doing different cognitive tasks. So we’re going to look at sensory processing ability, focus and attention, memory task, problem solving. But we can actually see how their brain is firing and how it’s wiring. And so one of the things that I would really recommend is some advanced neuroimaging like this to actually see if there are ways that we can make the brain more efficient even at that young of an age.

Amy: Wow, that is so fascinating that you can actually see that processing happening. Wow. Is there anything to be said for if you’re trying to increase attention span or work with attention span to making it more play based, or more sensory and kind of increasing attention that way, does that help at all?

Alina: Yes, and in fact there are so many specialists, for example I’m fortunate enough to be the President of the Brain Injury Alliance of Utah going on three years now. And we are very aware of a lot of resources in the community. There are really cool therapists and different types of therapies that are very behavior, very kind of outside of the box. For example, there are music therapies, there are art therapies. There are so many different types of really neat techniques to be able to get that child to be able to engage and maybe find something that interests them.

I think being able to have music and use that as a tool for therapy is wonderful. In fact I just spoke with someone yesterday, he’s an adult now but was diagnosed with attention deficit disorder as a young child. And he said that he’s always needed to use music whether it was something in the background, something that he could keep a rhythm with his left hand and then do homework with his right hand. Allowed him to kind of compensate for this and accommodate for some of his distractibility. So music is a wonderful tool.

And like I said, art therapy is something that is, it’s been around but there’s not enough people that do it. But a way for these children to express themselves in a creative way. You might notice that parents with attention deficit children have, there’s doodling all over the pages. And again it’s a way for them in a sense to almost distract themselves or distract some part of their brain so they can attend to what the teacher’s saying for a short period of time. So yes, there are a lot of other types of techniques. There’s also a lot of research that looks at diet.

There are nutrition aspects. There are exercise therapies that can be done. What we find is with traumatic brain injury patients, having them do a form of high intensity interval training before having to do something cognitive can really help that child or that patient for about two hours after. Especially if there’s something really cognitive demanding that needs to be done. So there are absolutely different treatments and different tools that can be used.

Amy: That is so interesting. So do you feel like some of these things would apply too to children without maybe some diagnosable attention issues if you are wanting to just kind of help your class of students or your child at home with attention and focus? Is it helpful to have them doing gross motor activities and having them move around and do things in addition to or before kind of doing some cognitive work?

Alina: Absolutely. What we have found is that some sort of mild aerobic, some cardiovascular activation before homework or before something difficult is essential. And in fact we use it as part of our program almost on an hourly basis. We’ll have the patient do something a little physical and a little active before sitting down to do an hour long therapy. Having that integration, so that gross motor skill, being able to even do movements like jumping jacks or touch your left eye with your right hand. That kid has to think a little bit but it’s recruiting different parts of the brain.

And it’s kind of like opening up and kind of preparing and priming the brain for therapy in our clinic, for hard work. I think that this is something that can be absolutely used even for children that do not have any type of an attentional issue. We all have had toddlers and sometimes it’s good to have them run around the kitchen a few times. For all of us whose world shut down with COVID and we had to now become teachers, I don’t know how teachers do it. I give them so much credit because it just solidified my belief that I could not be a teacher because I’m ready to kind of strangle my kids in a sense.

But I would just have them run around the house or go jump on the trampoline when they were just getting restless and come back in and then we could sit down and do 30 to 45 minutes of really good work. So I definitely see that that gross motor, even fine motor ability and getting them to get their energy out is really, really helpful. And then as well as making sure that they’re being fed well, making sure that they’re eating good foods. And I’m not here to say this is what exactly what they need to eat. But we’re finding that food sensitivities, food allergies can be a part of this.

Sugar can be a part of this as well. And so kind of paying attention to that part, and then the last thing too that I want to make sure that I impart is sleep. Our brain needs so much sleep. And I have a brain model right here, Amy, I know that your listeners can’t look at it. But I could show you here. One of the most essential things that our children need is sleep. I was what I kind of considered kind of a sleep Nazi with my children and by the age of two and a half months I did some sleep training with them. And they slept about 12 hours a night from the time that they were about two and a half months.

And yeah, and that was based on just a lot of research by my colleagues and some other professionals, other pediatricians, that just understood how valuable sleep is for a developing brain. And so that is kind of the other thing I want to make sure that your listeners pay attention to is these kids should be getting 10 to 12 hours of sleep a night. And if they’re not getting that, we need to try to help protect their sleep a little bit more. But that is a huge part of getting that brain to be ready for the next day and to develop normally.

Amy: So is that 10 to 12 hours what you would recommend for small children all the way up through teenagers or does it kind of change depending on the age?

Alina: It’s a good rule of thumb, especially as toddlers, babies, toddlers, definitely 10 to 12 hours. I have a teenager that can easily sleep 12 hours now but it’s just not the times that I want her to sleep those hours. But yeah, give or take an hour or two but in the teenage years they really need that sleep as well. So really it’s kind of throughout their development through their teens and then once we reach adulthood I know that the recommendation is eight hours. For some people they can do an hour less, some people need an hour more but we should really be striving to try to get that eight hours of sleep.

Amy: I’m going to share that with one of my children. We’ve got to get a little more sleep, let’s go to bed early. That’s amazing, thank you so much for sharing this. Do you have suggestions for resources for parents? I know we talked a little bit about different kinds of therapies. Do you have specific resources or suggestions for parents that are working with children that have healthy brains or children that they are concerned might have some of these focus challenges or memory challenges?

Alina: Absolutely. We actually have some resources through the Brain Injury Alliance of Utah. You can find us, I think it’s braininjuryutah.org. We have some resource facilitation specialists there that they can call and be provided with some resources. But one of the really great resources that I stumbled upon, because I actually did a presentation on an international view of attention deficit hyperactivity disorder. So we looked at the prevalence rate of ADHD across the world.

And I found that there is a great magazine that I’m not sure if people are aware of but it’s called Additude, but it’s A-D-D Additude, A-D-D-I-T-U-D-E. And I’m not sure if people are aware of that but one of the reasons I was drawn to that. And I think one of the things that I want to make sure that I leave parents with especially parents that are struggling with children with attention deficit disorders is that there is this movement to kind of rename and to kind relabel this.

So it’s not really seen as like a negative disorder but to be renamed something called VAST which stands for Variable Attention Stimuli Trait. So Variable Attention Stimuli Trait, have you heard of this before?

Amy: No, this is interesting, yeah, tell me more.

Alina: Yeah. I thought this was so interesting as well but they had an article in this magazine, Additude, Inside the ADHD Mind that talks about how it needs a better name and they have one. And this VAST, they’re talking about how ADHD actually comes in what we call pairs. So you have children that can be very, very attention focused on certain things and then not attention focused at all. You can have children that are really, really, really active for a bit and then not active at all. You can have people that are very, very distractible but they’re very curious at the same time.

And so there is this kind of dichotomy that occurs and it’s not all bad. I mean some of our geniuses have attentional issues and it’s really to kind of cast a more positive light on this. Now, it’s a little controversial because we’ve definitely had people whose lives have been upended because of attention deficit issues. Because as we know, it can lead to risky behavior, impulsive behavior. It can lead to a lot of other things. But what this kind of reformation is calling for is to help these children reframe this ability in a more positive light and to see some of the positives out of that.

And what parent doesn’t want to help their child feel good and feel important, and not broken? But understanding that there are positives to this and maybe it’s a superhero power to be able to attend to numerous different things. But like superhero movies, there’s always kind of a downfall that occurs and then this realization that I have something and it can be used for good. And so I really encourage parents to kind of look into this kind of new movement called VAST and to look at, it’s actually a principle called, I think it’s called Recognition Euphoria I believe.

It’s a recognition response euphoria which is praising them for the things that they do well and seeing how much that positive reinforcement can help them just as a rejection response, dysphoria can hurt them. So I just think that that was a wonderful tool for parents to kind of help them reframe it and help their child kind of reframe what they’re going through.

Amy: Yes, I love that so much. And we get the negative pieces of it either way but being able to see the super power in it and being able to then focus your attention towards what you can do with it I think is such a powerful thing.

Alina: Yeah, thank you, Amy. I mean that really is kind of the key to this is how we label ourselves and what those labels can really lead to. And then the last thing I just want to say is with all of this ADHD research, early intervention is the key. If you have any suspicion, get them in as soon as possible. Get them in to some therapy, some behavior modification, some treatments like that as soon as you can.

Because there are, on the flipside of this there’s a lot of research that shows that kids and adults that go untreated, who don’t understand what’s going on, it can really lead to some really negative side-effects. And in fact one that I found in a lot of my research is that if you’re an adult and you didn’t get the proper diagnosis before the age of 18, you are up to four times more likely to actually die earlier. And a lot of that is because there’s a lack of understanding about what you’re going through. There’s a lot of risky, high risk impulsive behavior that is not understood.

A lot of thrill seeking kind of attention, thrill seeking behavior that can lead to that. And so again, early intervention is the key, not being afraid to talk to a specialist about it, and as parents, knowing that there’s no stigma to this. If we can show them, hey, you have kind of a super power but let’s get this in check, make sure that you can use it for good could really be a way that we kind of shift the narrative.

Amy: That is so good. Thank you so much for sharing all of that with us today. And if we want to send people, if people want to learn more about you and find out more of the work you’re doing, what is the best way for them to find you?

Alina: So I am on Instagram, I think my handle is just Alinakfong. And we can put that in there. And also my clinic is Cognitive FX and we can actually put that in, I’m sure, in the notes there. But Cognitive FX, capital F, capital X. We don’t just help with attention deficit. We actually do a lot with concussions. That’s our mainstay. And we do a lot of COVID Long-Hauler as well. But our clinic really focuses on advanced neuroimaging to help guide our treatment and that pushes our research forward.

Amy: I love that so much, thank you so much for coming on today and having this conversation with us. We appreciate it so much.

Alina: My pleasure, any time, it was very, very nice too to be able to be here and I hope that your listeners gleaned some new information today.

Amy: I’m sure they did. Thank you.

Alina: Thanks, Amy.

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