Early diagnosis, appropriate treatment , education & understanding: critical factors in determining the future success of individuals with attention deficit/hyperactivity disorder (ADD or ADHD).
Attention Deficit/Hyperactivity Disorder (abbreviated as ADD in this report) is an invisible disability. It is a neurobiological disorder that affects behavior, self-control, motivation, motor activity, impulsivity, emotions, ability to direct and sustain attention, availability for learning and the way information is processed by the brain.
At least 5-7% of children have ADD, and as many as 50% of the estimated 3.5 million American children thought to have this disorder are never diagnosed. Current research shows that it affects 3 boys for every girl. Approximately 75% of these children continue to experience problems into adulthood, primarily in organization, self-management, social interactions and impulsivity. ADD is the most prevalent hereditary disorder (30-50% of children with ADD have a relative with the problem).
People are born with ADD, although it may not become a problem until the child’s environment becomes more demanding. This usually happens in 1st or 2nd grade, when students have to sit still for longer periods of time, focus for extended periods on required tasks, follow multiple rules and more complicated directions. Some children who are able to compensate during the early grades may not experience problems until demands increase during the middle or upper grades (coordinating different teachers and moves to different classrooms), in college (less parental and teacher supervision) or the workplace.
There are no definitive psychological, laboratory or blood tests for this disorder. The diagnosis is a clinical one, made by carefully examining the “evidence” — a combination of medical and psychological tests, appropriate personal interviews, patient and family history, etc. The knowledge, experience and skill of the person or persons doing the evaluation is critical. Since all of the symptoms of ADD can be seen in “normal” children at different times, diagnosis requires that a number of symptomatic behaviors be chronic (long-term), pervasive (present through most of the day, although not necessarily all of the time, and in different environments, such as home and school) and of sufficient intensity as to negatively impact on the child’s life and activities. There are three primary subtypes of Attention Deficit/Hyperactivity Disorder: Primarily Inattentive, Primarily Hyperactive/Impulsive, or Combination Type. A child does not have to be hyperactive to have ADD, although hyperactivity may be present but not perceived, as in compulsive hair-twirling, talking, doodling, etc.
Evaluations can be done by an individual or a team, which may include: Child Psychiatrist, Neuropsychologist, Child Psychologist, Developmental Pediatrician, Pediatric Neurologist, Psychiatric Social Worker, Educational Evaluator, Specialists in Speech & Language, Auditory Processing, Occupational Therapy, and others.
Testing should occur in both the school environment and the doctor’s office. A diagnosis of ADD requires a comprehensive, multifaceted assessment, which should include: a Detailed Individual & Family History, Parent, Child & Teacher Interviews, Physical Exam with Appropriate Lab Tests, Neurological Screening, Parent & Teacher Rating Scales, Self Rating Scales, and, depending upon the child’s age, Classroom Observation, Educational Evaluation, Psychological Testing and Behavioral Evaluation
Individuals with ADD often have other problems that co-exist with the ADD. Sometimes the ADD is the underlying reason for other problems, such as drug or alcohol abuse – treat the ADD and reduce the incidence or intensity of the related problem. In some cases the co-existing condition needs to be treated before the ADD; as in the case of high anxiety. Few individuals have ADD without any comorbid conditions:
A good evaluation determines if a child has ADD, if there are other problems causing ADD-like symptoms, or if the child has both ADD and other medical, neurological or environmentally-caused problems.
It may look like ADD but that doesn’t mean much. Sometimes a child who appears to have ADD, particularly when young, is just immature, or at the low end of normal development. (Using common clinical questionnaires, 1st grade teachers could rate as many as 50% of the boys in their class as having ADD.) That’s why a comprehensive diagnosis is necessary. Many students who are very active, disruptive in class or have problems completing assignments do NOT have ADD. However, if it is ADD, the younger a child begins treatment, the more effective it is. Hyperactivity can be caused by a particularly stressful situation. When the situation changes, or the child learns to deal with the stress, the hyperactivity usually stops. This is not the case in hyperactivity as a symptom of ADD. Sometimes another problem is the underlying reason for ADD-like symptoms, such as inattentiveness and distractibility being caused by dyslexia.
A differential diagnosis will separate ADD from its look-alikes. ADD is often undiagnosed, sometimes incorrectly diagnosed and frequently misdiagnosed. It is crucial that any evaluator be very familiar with both ADD and its possible look-alikes. Although diagnostic criteria for ADD exists, children are all different. While a diagnosis is helpful in defining the problems and as a basis for treatment, it is not infallible nor definitive. Even when a person is determined to have ADD, it can be mild, moderate or severe. How much the person is affected by his or her ADD will also depend on variables such as environment, stress, intelligence and other disabilities that may also be present.
Other conditions that may cause ADD-like symptoms must be ruled out in favor of the ADD-diagnosis. However, they may co-exist along with the ADD (co-morbidity). These include:
| SLD (Specific Learning Disorders Childhood) | Substance abuse (drug or alcohol) |
| Depression or Mood Disorder | Hyperthyroidism |
| Anxiety | Poor nutrition |
| PDD (Pervasive Developmental Disorder) | Lack of sufficient sleep |
| Asperger’s High Functioning Autism | Impaired hearing, auditory or visual deficit |
| Tourette Syndrome | Boredom due to lack of challenge |
| Seizures | Toxicity (lead, mercury, fetal drugs, etc.) |
| Bi-Polar Disorder (Manic-Depressive) | Immaturity or slow development |
| SED (Serious Emotional Disturbance) | Age-appropriate overactivity |
| ODDÂ (Oppositional Defiant Disorder) | Inadequate parenting |
| CD (Conduct Disorder) | Major change in family (new sibling, death of parent, relocation) |
| Physical or sexual abuse |
The most current assessment guidelines for ADD are published by the American Psychiatric Association in its Diagnostic and Statistical Manual for Mental Disorders IV (DSM4). The pages which follow list many of the characteristics — both negative and positive — that can be found in individuals with Attention Deficit/Hyperactivity Disorder, including some that are not specified but are commonly found:
Activity/Energy Level – Attention/Distractibility – Impulsivity – Emotional
Some character traits/deficits are more prevalent in children who are Primarily Hyperactive/Impulsive; others are more prevalent in children classified as Primarily Inattentive. Not all behaviors are shown by each individual. It is not unusual for a child, adolescent or adult with ADD to have problems related to each category, e.g.: difficulty with self-regulation, aggression, and conduct, poor academic performance and relationships, social skills deficits, emotional immaturity and instability, mood swings, difficulty with motivation, organization and time management, completion, losing things, etc. Behaviors also overlap categories (a quick temper is both emotional and impulsive). Deficits, or problems, can also be strengths; depending upon situation, attitude and application. Each section details both weaknesses and strengths.
There is no cure for ADD – with appropriate treatment the child learns to compensate for problems and maximize his or her strengths.
Medication, when required, Family involvement Psychological/behavioral intervention Academic/educational intervention It’s also important to include: Regular exercise Proper nutrition (especially in the morning) Training in & practice of stress reduction & relaxation techniques Education – the more you know, the more you can achieve.
The professionals you select to treat ADD must be exceptionally knowledgeable about it:
There are still child psychiatrists who insist a non-hyperactive child can’t have ADD. (The situation is much worse for adults who go for evaluations.) There are still psychologists who dismiss the idea that ADD is a problem for an individual who has done well in school or been successful in business.
There are many physicians, including psychiatrists, pediatricians and neurologists, who are not very familiar with the various medication alternatives for treating ADD, or who prescribe dosage “by the (often out of date) book,” or who fail to properly titrate for maximum efficacy.
There is still a lack of understanding that ADD affects all aspects of a person’s life, and that taking medication should not be limited to school hours.
You are your child’s advocate (and your own!). If you don’t see the results you want within a reasonable period of time, or if you have doubts about a treatment provider – GET A SECOND OPINION!
NOTE: Traditional psychotherapy has not been effective in treating the ADD
Classroom interventions – modification of classroom environmental and teaching strategies Appropriate modifications/accommodations in testing, homework & classwork, including the use of assistive devices such as computers, teacher/student headsets, calculators, etc. Remedial assistance for academic skills, speech and language, fine motor coordination, etc. Skills training in organizational, time management and study skills
NOTE: You are your child’s advocate — find out what your child needs to succeed in school and work to get it (See sections on School Advocacy & Legal Issues). Don’t assume the school will automatically provide appropriate services and modifications.
Medication enables the child to better attend, utilize more self control & show more self-directed behavior. “It’s like there’s someone tapping me on the shoulder to remind me what I should do, …but it’s still my choice – I don’t have to listen.” Medication is extremely effective in most cases: 75 to 80 percent of children with ADD respond favorably to psychostimulant medication, and to the newer non-stimulant medications. Only 5-8% of children with ADD fail to respond to either stimulants or antidepressants.
Medication helps the child’s self control and focus, so he or she will concentrate better on specific tasks and be more likely to think before acting.
Titration: Establishing the correct dosage and timing for taking medication is critical. Too often medication is prescribed, but not properly monitored and adjusted. This should be done under a doctor’s care, carefully monitoring different levels of medication for efficacy, until the most appropriate dosage is established.. A medication may appear ineffective when the dose is too low. A child may appear “drugged” if the dose is too high. Optimal dosage for attentional efficacy may be different than optimal dosage for control of hyperactive behavior. The amount of time medication “works” varies from person to person. Know how long it takes for your child’s meds to start working and how long the beneficial effects last. Then establish dosing schedules that overlap slightly (the next dose begins to “kick in” as the prior dose stops working, which prevents highs and lows or “rebound”). If needed, medication should be given to assist the child with homework and social activities, not just school. Medication should be continued during the summer if it helps the child’s self-esteem by improving peer interaction, emotional stability or the ability to focus and enjoy sports and leisure activities. The speed of onset and the efficacy of a dose may be affected by certain foods, drinks or other medication (including over-the-counter meds, supplements, etc.). Talk to your doctor.
Although most of the medications commonly prescribed to treat ADD in children have been extensively tested and found safe, your child may still experience side effects. Some of these may be temporary and soon disappear; others are more serious. Always tell your doctor!
Possible side effects include:
The effects of exercise on the brain are often similar to those of medication. Physical exercise or activity is an important component of an overall treatment plan. Also, children “forced” to sit for long periods in school do better when they have short “movement breaks.” Changes in diet to accommodate food allergies (such as the Finegold Diet) – have a beneficial affect on fewer than 1% of children diagnosed with ADD, in double-blind research studies Food and vitamin supplements – have not been proven effective when studied in independent, controlled scientific testing, although there are anecdotal stories attesting to efficacy.
Also, the required dosage of prescribed medication may change with the addition of certain supplements. Biofeedback – being researched by the NIMH; it has some positive affects on some children, but long-term benefit is questionable. Even the advocates of biofeedback usually recommend that it be used as an adjunct to conventional treatment (particularly medication) L-Tyrosine – an amino acid (protein) that helps the body produce norephinephrine. Now undergoing testing. Chiropractic adjustments – still no scientific basis for the claim to cure, or even help, ADD. May be helpful for relieving tension and stress.
Many children who are not treated for their ADD grow up to be productive adults (although many report they have difficulty in achieving goals and holding relationships). The ability to compensate is linked to both IQ and social environment. Fortunately, many ADD youngsters are very bright (and charming), and so manage to “get by.” However, these are the kids teachers criticize as “not trying to reach their potential” or as being “underachievers.”
Strong family support and consistent structure at home helps. Unfortunately, children with ADD often gravitate towards peers exhibiting “fringe” or “antisocial” behavior, feeling more comfortable with children who are different, enjoying the stimulation of “risky” behaviors and feeling less pressure to achieve academically. The more prevalent the opportunities for engaging in fringe behaviors, the more likely the untreated child with ADD will do so. This translates into a generally less successful prognosis for children from poor environments. In a study of prison population, almost 80% of the inmates were found to have undiagnosed Attention Deficit Disorders and/or Dyslexia and other learning disabilities.
Early intervention and appropriate, multimodal treatment can change the patterns of alienation and frustration, turning potential “failures” into achievers.
Often, the way we think about something is based on history and habit. the words we use can describe the same thing in either a positive or negative manner. When we choose our words, we also communicate an attitude. The words our children hear help frame their self-image. Unfortunately, words commonly used to describe children with add include: lazy unmotivated irresponsible immature selfish inconsiderate insensitive disappointing careless sloppy inept troublemaker / bad when you use these words, the child hears: “I’m a failure.” “I can’t do anything right.” “I’m stupid.” “I’m not worth loving.” “I do nothing but cause problems.” “I’m no good.” “I’ll never amount to anything – It’s useless to try.†Instead of feeling good about what they can do, the child feels: guilty hopeless ashamed hurt inadequate.
Their self-image becomes distorted (disabilities far outweighing abilities) and their self-esteem is damaged. They become less capable of succeeding than they were initially. A child might cope with his or her negative feelings by: acting out, becoming aggressive, getting into fights, being verbally combative, engaging in reckless and/or antisocial behaviors, etc. internalizing the pain, guilt and shame by withdrawing, becoming depressed, taking on the passivity of a victim mentality, etc. channeling feelings through their bodies, with headaches, stomach or backaches, generalized aches and pains in hands or legs, feeling sick, lethargy, developing food -related disorders, etc. attempting to control their environment, avoiding stressful situations through manipulation. an example is when a child is the class clown. This role provides the child with attention (stimulation), and a way to avoid appearing dumb in class or having to do boring work: say something which will disrupt the lesson, or push the button tht gets you thrown out of class.
We ask our children to try harder, when they are already putting in tremendous effort just to be where they are. We want them to do better, when they haven’t the skills or appropriate motivation. We tell them, you can if you wanted to, when they can’t, at least not without help. They may even want the same things we do, but aren’t able to figure out the how or drum up sufficient internal motivation to just do it.
Provided by Shire
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