ADHD IN CHILDREN AND ADULTS: WHAT YOU NEED TO KNOW (Part 1)
Much of the online and written material about ADHD, while clearly informative, does not offer information that is sufficiently specific and readily convertible into well-defined steps to be taken by parents who suspect that their child may have ADHD, or to individuals who question whether they themselves or their spouses suffer from this disorder. There are many controversial topics associated with ADHD’s diagnosis and management, including confusion in the differentiation of symptoms from developmentally normal behaviors (especially in young children), confusion in diagnosing ADHD as opposed to other disorders that have overlapping symptoms, confusion about the use of medication in the management of ADHD, and confusion about the availability of effective non-medical treatments, either as additions to or as substitutes for treatment with pharmaceutical agents. It is my hope that this short series of articles will permit readers to gain an understanding of ADHD so that they can make informed and appropriate choices.
A starting point for this article, and a good primary resource for the reader, regardless of whether a child or adult is the person of interest, is the revised Clinical Practice Guideline recently adopted by the American Academy of Pediatrics. Entitled, “ADHD: Clinical and Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents”, it may be accessed for free on the Academy’s website (www.aap.org). Adults with ADHD will find the guideline to be a useful template against which to compare their own childhood. The document, which targets the pediatrician, includes new information and evidence concerning diagnosis and treatment, and it expands the age range covered by the revised guideline to 18, up from a 12 year limit in previous versions. The document is the product of a two year collaborative effort involving several professional organizations, including the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, the Society for Pediatric Psychology, the Child Neurology Society, the American Academy of Family Physicians, Children and Adults With Attention-Deficit/Hyperactivity Disorder (CHADD), and the Centers for Disease Control and Prevention (CDC). Incidentally, the CHADD website (www.chadd.org) is very comprehensive and also contains valuable practical information. It is a highly recommended resource for anyone with an interest in ADHD.
My first article in this series deals primarily with diagnosis. Unlike many disorders, there is not a specific objective test that is sufficient to define it; there is no one lab test, neuro-imaging procedure, or psychological assessment tool that can, with certainty, make the diagnosis. Yes, there is some evidence indicating that various imaging and brain wave assessment techniques can differentiate people with and without ADHD. However, based on my review of the literature, this evidence is not yet supported by prospective, randomized, controlled, double-blind studies that have been independently replicated. Unless experimental procedures conform to these requirements, obtained results may be tainted by error; one should not put absolute faith in conclusions based on such research. With this caveat, however, I do believe that digital analysis of data obtained via brain imaging and/or via QEEG (Quantitative Electroencephalograph) techniques, following further refinement and study, holds out the promise of scientifically validated, accurate, and more specific diagnosis. Currently, however, the clinical utility of such procedures does not clearly justify their expense; a combination of less costly methods, as described below, is generally sufficient to identify the presence of the disorder.
The precise diagnosis of ADHD requires the accumulation of information about the patient from a variety of sources. These include a neurological or medical examination, consultation with a psychologist, and the reports of parents, school personnel and, in the case of adult ADHD, spouses (optimally via interview and completed questionnaires). Neuropsychological assessment, another relatively expensive approach, can shed light on an individual’s specific strengths and weaknesses and can serve as a baseline against which to monitor changes in functioning, but such an extensive assessment is not generally required in order to diagnose ADHD. At times, depending upon the results of lab work and the range of symptoms exhibited by the individual, examination by other medical specialists may be necessary (e.g. an endocrinologist, infectious disease specialist, etc.) to differentiate ADHD from other disorders as the causal basis of the observed symptoms. Finally, information obtained directly from the individual, through observation and self-report, is always useful. The accumulated data is then compared to the pre-defined criteria necessary for the diagnosis of ADHD, as listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR). The disorder itself is divided into several subtypes, one in which the primary symptoms reflect deficits in attention, the second in which the primary symptoms reflect hyperactivity and/or impulsivity, and the third that is a combination of both.
The first challenge to the practitioner is the ability to differentiate normal from disordered behavior. According to the DSM-IV, “The essential feature of Attention-Deficit/Hyperactivity Disorder is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development.” The significant terms in this statement are persistent and comparable level of development. A person with ADHD does not demonstrate periods of remission; the behaviors associated with the disorder are always present in one degree or another. Of course, symptoms are going to be more or less obvious in accordance with situational demands; for example, the school or work situation might require the individual to demonstrate organizational skills, working memory capacity, and focusing ability, whereas such requirements may not be so obvious or pervasive in a vacation setting. The term comparable level of development, included in the general definition above, is required because many of the symptoms listed, depending on severity and frequency, are normal at different age levels, and are common during early childhood. Note that, according to the DSM-IV, although the diagnosis may be made at any time in a person’s life, a review of the individual’s past reveals that symptoms were present before the age of seven; hence, the need for a comprehensive developmental assessment. Finally, some impairment must be present in at least two settings (e.g. home, school, or employment).
Diagnosis is facilitated through the use of checklists that have been previously proven valid. These are completed by parents, teachers, and other relevant adults. There are norms associated with each of these instruments, such that any individual’s checklist scores may be compared to the scores of thousands of similarly-aged people (the normative sample) who have been previously rated using the same checklist. A positive diagnosis is made when an individual’s obtained scores fall within a pre-defined range that reflects individuals known to have the disorder.
Part of the problem in diagnosing ADHD involves differentiating neurologically-based attention deficits from those caused by emotional and social factors. This differential diagnosis is a prerequisite for the development of an effective treatment program. Some of the more prevalent ADHD symptoms include:
· deficits in working memory
· difficulty focusing
· lack of planning
· loss of temper
· poor task follow-through
· poor planning ability
· deficits in high level (executive) cognitive skills
· social difficulties
· inability to sit still for prolonged periods of time
· academic underachievement
It is important to note that not all of these symptoms need be present in order to make the diagnosis of ADHD, and that, in addition to neurological factors, all may result from interpersonal and psychological causes as well. This underscores the necessity of having a comprehensive assessment of the patient’s emotional, social, and family situation by an experienced psychologist.
It is also important to note that the above-referenced American Academy of Pediatrics’ prescribed diagnostic and treatment guideline for ADHD is just that…a guideline; it does not support a cookie-cutter approach to assessment and remediation. There is a clear recognition of the differences between patients, families and circumstances… and that is where the practitioner’s creativity and experience come into play. Like any disorder, ADHD presents itself at different levels of severity. In practice, there are clear quantitative (amount, frequency, intensity) and qualitative (procedural) differences in the type of treatment regimens adopted for any given patient.
- Many, but not every patient with an attention disorder needs psychotherapy. Yet when self-esteem, family relationship and social issues become prominent as a result of the disorder, therapy may be crucial.
- Whereas a very significant majority of ADHD patients (children and adults) benefit from the one currently existing research-supported approach to intensive working memory training (reflected in enhanced organizational, mathematical, and reading comprehension abilities, and positive behavioral changes in the home situation), a minority do not (approximately 20%). With regard to children, this approach is only effective when parents are able to commit to providing the supervision and support needed to ensure that the patient invests the required time and effort in the training program.
- A common approach in the treatment of children and adults with ADHD is the use of medications, most of which fall into the category of psycho-stimulants. Yet, very often such medications have side-effects. One must balance the negative effects of a patient’s continuing without rapid positive changes against the negative side effects of medication. If the patient’s environment (home, school or work situation) is effectively accommodative, then the patient or parent may decide to postpone medical treatment in favor of an exclusively behavioral or cognitive approach. In other situations, the mere initiation of a medication regimen seems to satisfy the patient and his/her significant others, to the extent where additional approaches to treatment are not necessary. It is generally believed that a treatment approach that involves both medication and cognitive/behavioral training is most effective.
The bottom line is that there is no one-shoe-fits-all approach to the diagnosis and treatment of ADHD. And the therapeutic intervention that is ultimately adopted must often go beyond the child or adult who actually has the disorder; it is not uncommon for the parent or spouse of a person suffering from ADHD to seek counseling. It is difficult to live with someone who cannot follow through on their responsibilities, who constantly forgets things, loses things, does not listen, does not obey, has temper tantrums, forgets commitments, interrupts, is unreliable, does not complete jobs, is constantly in motion, has numerous accidents, gets into trouble in school, loses jobs regularly, and makes impulsive decisions. For a spouse, it may mean having a mate who is often more like a child requiring monitoring and supervision than a reliable partner. Moreover, as there is often a genetic predisposition involved in the development of ADHD, a parent who has a spouse with an attention disorder is also likely to have a child with an attention disorder. The stress of living with both can at times be overwhelming.
Finally, for parents of a child with ADHD, the amount of attention and energy needing to be expended on the child can lead to a marital relationship in which neither spouse has any time for the other. One or both may feel alienated and, though living together, may feel painfully alone. In addition, it is common for a parent of an ADHD child or the spouse of an ADHD adult to report losing their sense of “self.” Consequently, it is not difficult to see why, even though it may begin with a focus on behavioral skills training, counseling often expands to include relationship enhancement and/or individual psychotherapy.
This brief overview of the topic of ADHD is the forerunner of a series of more detailed articles that are planned for future publication. The series will take a much closer look at all of the separate topics covered in the current article. Please note that I look forward to hearing your reactions to this article and any suggestions you may have. Please submit your feedback via email to me at: [email protected]