A Brief Overview to help answer questions about:
Attention Deficit Disorders
Edited by:
Erik A. Fisher, Ph.D. : www.erikfisher.com
David S. Cantor, Ph.D.
For more information call:
770-513-0577
or Email at: Erik_Fisher_Phd@Mindspring.com
Some information in this booklet has been adapted from Russell Barkley, Ph.D.
Introduction *
Symptoms of Attention Deficit Hyperactivity Disorders *
· 1. Inattention / Distractibility *
2. Impulsivity *
3. Difficulty Delaying Gratification *
4. Hyperactivity *
5. Hyperfocusing *
6. Noncompliance *
7. Social Problems *
8. Disorganization *
9. Emotional Overarousal *
10. Neurological / Neurochemical Issues *
How the Brain Works & Its Relationship to ADD *
· Neurochemical versus Emotional Distractibility *
What Could Possibly Be Good About ADD?: Re-framing the Issue *
Statistics and Information *
· Prevalence *
Gender ratio *
Causes and Rumors of Cause *
A. Genetic Links *
B. Structural Brain Damage *
C. Diet *
D. Allergies *
E. Bad Parenting *
Adopted children *
Why Is There Such An Increased Incidence of ADD in the Population? *
· 1. Incomplete and Inconsistent Assessment and Evaluation Procedures *
2. Challenges in the Education System *
3. Looking for Answers *
4. ADD as One of Many "Normal" Brain Activity Profiles? *
Evaluation and Diagnosis *
· Background Information and Family Data *
Behavioral Observations *
Intellectual Strengths and Weaknesses *
Auditory and Visual Attention/Distractibility versus Processing Skills *
Neurometrics: Quantitative Electroencephalogram *
Analysis of Data and the Report *
Treatment *
· A. Medication *
1. Stimulants *
2. Antidepressants *
3. Anti-convulsants *
B. Natural Supplements *
1. Pycnogenol *
2. Colloidal Minerals *
C. Psychotherapeutic Interventions *
1. Individual Therapy *
2. Group Therapy *
3. Parent Training *
D. Neurofeedback Therapy *
Prognosis: How to Tell the Future *
Developmental Course *
Closing Comments and Wrap-Up *
The information in this packet presents a variety of issues that one needs to consider in the diagnosis of attention deficit disorders and other syndromes that often "look like ADD." These issues are very important to us as clinicians when making decisions toward a diagnosis, and because of their importance, we want you to be educated on these issues. A great deal of concern has been drawn toward ADD in terms of controversy over medications prescribed as well as the efficacy of other therapies that are applied. The primary issues that one needs to consider in the diagnosis are observable behavioral symptoms, neurological characteristics, emotional and personality dynamics, learning disorders, other cognitive issues, and the impact of historical events in one’s life. In this packet, we will try to familiarize you with these issues as you and/or someone you care for may enter into the diagnostic and treatment phases. Some of the information included in this packet is adapted from various works done by Russell Barkley, Ph.D., a nationally renowned expert in ADD.
One of the first issues to address before we get started is the difference between ADD and ADHD. Professionals often use the terms interchangeably, the primary difference being the absence or presence of hyperactive behaviors. Hyperactivity often involves fidgeting, excessive motor behavior, difficulty sitting still, and difficulty regulating or monitoring behavior in terms of becoming easily excited. When many professionals speak of ADD, they are often referring to the inattentive subtype, characterized by daydreaming and increased distractibility. Individuals with ADD are often described as "spacey" or distant and non-caring; however, it is important to note that their behavior is by no means indicative of such attitudes. For the purposes of this information, unless specified, ADD will refer to the general syndrome of attention deficit disorders.
Symptoms of Attention Deficit Hyperactivity Disorders
The following are behaviors or characteristics commonly viewed as symptoms of Attention Deficit Disorders. This is not an exhaustive list, but capture many important issues.
1. Inattention / Distractibility
The ADD individual often has great difficulty concentrating on tasks and may appear easily bored. However, should the task be interesting to him/her (such as a video game or movie) or the situation be novel, scary, or one-on-one (such as in a doctor’s office!) the symptoms may completely disappear. Because symptoms may seemingly appear or disappear, others may often view ADD as a motivational problem that is under the control of the individual. It should be noted at this time that ADD is a neurochemical disorder that can, in part, be identified by current technologies to be discussed later. We often hear from parents that their child could not possibly have an attention problem because they may apply themselves to tasks that they enjoy or want to do. Sometimes this is the case, and there is a motivational or emotional issue that is responsible for their behavior, but these behaviors should not be construed as laziness.
The other side of this problem is that the child is too easily
distracted by irrelevant stimuli, such as movements and noises around him and
even by bodily sensations and daydreams. Conversations can be very difficult to
complete and eye contact may be a continual problem. On the other hand, issues
of distractibility can be strongly related to emotional avoidance, allergies,
and even chemical or electromagnetic sensitivities.
ADD individuals are generally characterized as speaking or acting without thinking or weighing consequences. This may involve verbal comments, emotional reactions, running or hitting, and silly or nonsensical efforts at humor. Once again, these behaviors are not only characteristics of ADD, but can often indicate emotional difficulties, allergies or other cognitive dysfunctions.
3. Difficulty Delaying Gratification
Many individuals with attention deficits often have a difficult time waiting for things. "I want it NOW!" is frequently the attitude displayed. This may involve difficulties waiting in lines or waiting for snacks, rewards, birthdays and holidays. Other behaviors may involve not putting things away when moving to a more interesting task or rushing through homework. One of the most difficult challenges for others around them is being patient enough to wait with them. When these individuals do not get what they want when they want it, they may throw a tantrum, whine, pout, withdraw, etc. Behavioral problems that we often see with individuals with difficulties delaying gratification are due to others giving in to them on an inconsistent basis, which results in them surreptitiously learning, "If I bug them long enough, I am going to get what I want." Consistency in reinforcement of behavior is perhaps the most important skill for the parent, teacher, and/or significant other to learn when working with ADD.
ADHD individuals are more likely to exhibit hyperactive behaviors before puberty. They are constantly on the go, from sun-up to sun-down, prefer running to walking, yelling to talking, and appear to be "driven by a motor." Many are verbally hyperactive and will wear others out quickly with their seeming inability to be quiet. This behavior in itself may cause many difficulties in relationships as ADD individuals often notice others shying away or avoiding them when they enter a room. Diagnostically, hyperactivity can also be a sign of anxiety, trauma or stress, which is important to consider in itself. Remember that hyperactive behaviors may rapidly disappear when the individual is faced with situations that are novel, interesting, intimidating, or one-on-one.
Hyperfocusing is a symptom that is overlooked by many as a characteristic of ADD. Hyperfocusing is generally observed as an individual’s ability to work on a task such as playing a game, reading a book, performing computer tasks and job skills for an extended period of time, with little awareness of the amount of time that has passed. Loss of time is common during a period of hyperfocusing, and performance on these tasks can be superior. It is because of this ability to complete tasks of interest that many question the presence of an attention deficit. Kids who hyperfocus on computer games will often know "all the tricks" and learn to "beat the game with ease." While many may view this as antagonistic evidence, we often view this characteristic as supporting evidence.
ADD individuals often have difficulty following rules. For the hyperactive person, they will impulsively disregard do’s and don’ts, even though they may be able to accurately state the rules later. Children who have ADD with hyperactivity can be aggressively noncompliant, often showing fits of temper, yelling, acting defiant, and being generally "strong-willed". Individuals who are inattentive are often passively noncompliant, forgetting or "not hearing" their chores and frequently being messy or becoming distracted mid-task. There is a growing body of evidence that children who exhibit frequent temper tantrums and noncompliant behaviors may also be suffering from allergies to molds, pollens, foods, chemicals, etc. These allergic reactions create a biochemical imbalance, which contributes to the behavior problems observed in these children.
The social problems of the ADD can vary from being too bossy and competitive when playing with others, and generally showing a very low frustration tolerance, to being aloof and not interacting. Individuals may be prone to arguing, fighting, cheating, lying, and blaming their problems on others. As a result of these behaviors, they often learn to perceive failure in their social interactions and learn to push others away before they are rejected. When these trends develop early in childhood, they frequently contribute to great difficulties in relationships later in life. This is why it is integral to have some form of therapeutic intervention to alter the course.
Adults who have ADD may also have a variety of social problems. These include difficulty being on time for meetings, remembering tasks for their co-workers or for their spouses, and difficulties listening to what others are communicating with them.
As one can imagine, when it is difficult to pay attention, it is that much more difficult to keep things organized. There is a great deal of focusing that needs to take place to successfully organize oneself, which is why an ADD individual’s life is often in disarray. This is not to say that they cannot be organized, they just have to learn habits and often need to have task lists. Even when task lists are made out for them, if the lists do not make clear the priorities, the ADD person is likely to "hopscotch" over items on the list at random. Many times, we see parents who enable their children and feel belabored by feeling that they have to do everything for them because of their disorganization. The key is to help them feel empowered to be able to do what they need to do, even if it is hard. It is typically better to work with them in getting them organized but make sure that they feel in control of the process. This is no easy matter, particularly with adolescents. A few sessions of therapy can help teach both sides to work with each other in this process.
Individuals with ADD are typically known for their quickness to display emotions as well as for their range of emotions. As children, their emotions are more variable, and as adults emotions can change rapidly, depending on variables in the environment or other factors (taking drugs or alcohol or premenstrual syndrome). Emotions may vary from intense excitement to extreme anger and sadness. While these behaviors may be driven by hyperactive and/or impulsive behaviors, these "symptoms" are not necessarily characteristics of ADD but consequences of the experiences of the challenges of an attention deficit. This is very important to consider in the treatment phase, since ADD, in itself, should be able to be treated through behavioral intervention, medication, or other means to be discussed. Emotional issues, while strongly prevalent with attention deficit disorders, are NOT a symptom. It is important for one to understand that many behaviors that a child engages in are not understood, and in the face of others telling them that they have done something wrong or inadequately, they have no choice but to feel responsible, guilty, blame, and/or shame. These emotions are often internalized and vented in periods of conflict or stress. There are many complex issues to understand in the development of emotion and personality, and while there are predictable trends that typically occur with inattentive and hyperactive subtypes, many individuals develop their own idiosyncrasies that are important to consider in the evaluation.
10. Neurological / Neurochemical Issues
Many are unaware that ADD can be identified in part through the use of modern technological advances. The Neurometric Quantitative Electroencephalogram and Cognitive Evoked Response aid in the identification of neurological tendencies toward ADD and other related syndromes. Through these processes one is able to identify various brain wave profiles that are indicative of attention, mood, or other neurologically/neurochemically based disorders. Such technology has greatly enhanced diagnosis and treatment in terms of identifying types of medication appropriate for treatment, if it is needed at all.
Research has found that attention deficits are characterized by differences in brain wave activity, primarily in the frontal lobe of the brain. Brain waves are, in turn, affected by neurochemical activity, which can be manipulated by medication. When one can identify the brain wave activity objectively, confidence in diagnosis is greatly increased and treatment can be adjusted to the idiosyncrasies of the individual.
How the Brain Works & Its Relationship to ADD
The brain can be characterized as a loose connection of nerve cells (neurons) that are held together by a gooey substance (glia). No two neurons are connected together. Information passes through the brain through an electro-chemical process that occurs within the neuron and between the neurons. At any one second, there are millions and millions of neurons that are firing to help one to think, sit, talk, feel, focus, balance, breathe, move,… When one begins to ponder on all of the different events that occur in the brain at one time, they can appreciate the incredible complexity of actions that need to occur for one to exist. All of these actions occur because of the chemical and electrical interactions that happen every fraction of a second.
To demonstrate how this occurs, one can imagine that a neuron is like
an island with a train traveling from one end of the island to the other. In
the brain there are millions and millions of islands that are surrounded by
gooey water. There are also no bridges between the islands that the trains can
follow. When a neuron is stimulated, an action potential occurs, which means
that a sufficient amount of neurochemicals have stimulated the end of the
neuron. This basically means that the train has enough cargo to take it to the
end of the line. At that time in the neuron, there is a chemical reaction that
results in a change in electrical current that travels down the distance of the
neuron. When the train reaches the end of the line, the conductor has to figure
out a way to transfer the cargo from one island to the next. This is where the
neurotransmitters come into play. A neurotransmitter is a chemical that carries
information from one neuron to the next. Different neurotransmitters carry
different types of information. In our example, we will say that each piece of
cargo is loaded into its own boat. These boats (neurotransmitters) then travel
into the channel (synapse) to the next island (neuron) where they will unload
their cargo piece by piece. When the waiting train is filled with cargo (action
potential), then the conductor begins the process again and the train travels
to the end of the line` to begin the process one more time.
In the time it took to read that example there were countless neurons that were stimulated. Why do we keep drawing attention to this fact…because we want you to realize the incredible complexity of the brain. What do you think may happen if there were even slight imbalances in the chemical of nerve structure of the brain? When an individual experiences an attention deficit, in many cases there is a lower level of neurochemicals (fewer boats) to carry the information from one neuron (island) to the next. When this occurs and there are less neurochemicals (boats) to transfer information (cargo), the process takes longer (i.e., it takes longer to ship the cargo from one train to the next). If this happens repeatedly, then the information that is traveling through that area will take longer to be processed. This is precisely why individuals with ADD seem to be one step or so behind the rest and will do things impulsively.
Remember that neurochemical discrepancies with ADD are believed to occur in the frontal lobe, often referred to as the center for executive functioning. This part of the brain is responsible for attention, concentration, shifting attention, regulation of emotions, strategic planning, moral decision-making and other similar operations. In cases of ADD, the entire frontal lobe is not necessarily affected, but instead certain locations that may vary widely from individual to individual. When there is a lower level of neurochemicals, information that travels through that area is affected by the process. Information affected by this slow down may relate to withholding behaviors, decision making, managing levels of excitement and emotion… What is often not slowed down is emotional input, immediate wants and desires… Yes there is a reason why ADD people do what they do. At any one time, diet, allergies, fatigue, excitement, mood, electricity and chemicals in the environment, and other influences can affect neurochemical levels. This is why behaviors may vary so drastically from one moment to the next.
Neurochemical versus Emotional Distractibility
At this time, it would be important to discuss the difference between neurochemical distractibility and emotional distractibility. They may look identical in terms of the behavior of the individual, but are very different in terms of the internal motivations for the behavior. Neurochemical versus emotional issues are very important in diagnosis and inaccurately identified emotional issues are often responsible for so many inaccurate diagnoses of ADD.
When an individual experiences emotions, they try to communicate them in whatever way they can. However, there are many ways that we learn as children that the expression of emotions is wrong or bad. Through time, we learn to "stuff" or repress our emotions for fear of disapproval or punishment. As we push these emotions down deeper and deeper, they do not go away, they just become quiet until there is an overload on the system. When this overload occurs, many people will have an emotional outburst that often is a combination of many different emotions: sadness, anger, guilt, fear… When viewed on the surface it may look confusing and the individual often feels failure or defeat after the outburst.
One way to envision this process is as if we imagined our emotions as different colors of paint in a bucket. When we mix these different colors together they often make a black "mess." As these colors make this black "goop", we often forget the beautiful colors that we mixed in the bucket. When we feel overwhelmed, it is as if our bucket has overflowed, and once one makes any mess, many feel that they might as well make a big one. So we dump the bucket and get it all out. However, unless the bucket is washed clean, there is always residue left behind that dries and cakes and eventually fills the bucket more and more quickly. Because of this, the bucket fills more and more quickly, and the person’s temper appears to be shorter and shorter, and they appear more and more impulsive.
When emotions feel overwhelming and our bucket is filling, many of us try very hard not to make a mess. Emotions often command a great deal of attention to keep them held back. As a result, we are less able to concentrate on every day matters. Emotional issues can be divorces, arguing parents, teasing, physical and sexual abuse, learning disabilities, and any situation from which an individual may experience emotional pain. With increased numbers of issues present, the higher the likelihood that behavior will be affected. It is very common for children who are depressed and/or anxious to exhibit symptoms of hyperactivity, impulsivity, mood swings, inattention, and other similar symptoms. For these reasons, it is integral to always consider emotional components of behavior. Many parents often do not want to think that their children may be experiencing emotional difficulties. We all want our kids to be happy and successful and often feel that if they are having emotional problems, the parents must be at fault in some way. In part, we all share responsibility for our child’s experience, but part of life is learning to feel and understand emotions. If our own guilt as parents prevents us from getting our children the help they need, they still do not get help.
In our experience with many of the children who have been previously diagnosed with ADD, we have found that approximately 50% or more were misdiagnosed or not completely diagnosed. In these cases, they were often put on inappropriate medications and/or school placement was affected. In most cases, when a label is placed on someone, they have a difficult time removing it from their own perception of their self-concept. This in itself can cause emotional turmoil.
Another issue to consider in the discussion of neurochemical versus emotional distractibility is the case in which an individual does have an attention deficit. In many of these cases, these individual experience numerous disappointments, failures, corrections, punishments…, which ultimately has an effect on the way they feel about themselves. What then occurs as a result of their perceived failures is that their self-concept suffers and they develop anxiety about future situations and symptoms of depression about past situations. However, remember that the goal often becomes protecting the emotions and not expressing what is felt. In these situations, emotional distractibility increases and produces an additive impact on neurochemical distractibility. When an individual is experiencing both neurochemical and emotional issues, medication will only have a partial effect on improving behavior. In 80% or more of the cases we see, some type of therapeutic intervention is necessary with the individual, child, and/or parents to improve behavior with lasting results.
What Could Possibly Be Good About ADD?: Re-framing the Issue
Up to this point, we have focused on many of the consequences of attention difficulties, which are often seen as having a negative impact on the child, family and environment. In our approach to ADD and other disorders, it is imperative to focus on the strengths that accompany these challenges so that one can reframe their life in a positive aspect. When one is able to look to the brighter side of the issue, the behavior and challenges become more bearable and understandable. So, with that in mind, how can one find the lighter side of ADD? These are often individuals who are highly energetic, and when they set their mind to something they will stick to it until completion. These individuals often find ways to do things that no one ever thought of and think of things that no one ever dreamed of. They challenge individuals with whom they have relationships to look deeply at themselves and why they do the things they do, if they are willing. They are persistent. They are inventors, doctors, lawyers, diplomats, parents, husbands, and wives…
If we look throughout history, can you think of anyone famous who may have had characteristics similar to ADD? Ben Franklin, for example, was an author, an inventor, a diplomat, a visionary… He helped to define the manner in which our country operates to this day. Do you think he wished he had thought twice after flying his kite in the thunderstorm? Do you think his mother would have let him do that? A little impulsive…wouldn’t you say? Albert Einstein was diagnosed with a learning disability in Math and many of his characteristics are very representative of ADD. These are just two examples, of which there are many more. What a parent often has to consider is that we are all different and those differences that we have can add value to our families and to the world. Many times, we want our children to listen and obey our every word for fear that they may harm themselves or others. However, if that happened from the beginning of time, we probably would not have learned how to use fire. Everyone has strengths that are of merit. It is our task to help our child find their strengths so they may find their success.
There is not a great deal of consensus among professionals as to the actual statistics regarding prevalence and gender ratios. The following information is based on some of the research, as well as clinical impressions from our personal experience with ADD. Most researchers do agree that a true attention deficit is not curable but can be successfully managed through behavioral techniques, medication, natural health supplements, and other emerging interventions. There is some argument, however, as to whether or not EEG Neurofeedback cures ADD as the brainwave patterns are "re-trained."
Statistics once indicated that there was approximately a 10% prevalence of ADD in the population. With the increases in inaccurate/incomplete diagnoses, some classrooms have reported up to 50% of their students having some type of diagnosis that resulted in prescribing some type of stimulant. It is more likely that the true prevalence is roughly 15% - 20%. Due to the genetic nature, often when one of the children in the family is diagnosed with ADD, one of the parents is able to find similar trends in their childhood or in their siblings.
Within the population of those with ADD, there is a higher incidence of depression, anxiety, alcohol and drug abuse, divorce, legal problems, and other emotionally related difficulties.
While it was once thought that ADD boys outnumber ADD girls by about 6-7 to 1, recent trends indicate that there is about a one to one ratio. The difference is in the presence or absence of hyperactivity. Genetic trends indicate that females are not passed over by the potential gene/gene combination, they are just more prone to inattentiveness without hyperactivity. The proposed percentages of hyperactivity vs. inattentiveness in the ADD population is about 70% of males being hyperactive, while 70% of females are inattentive.
It is often observed that symptoms of ADD may disappear if the situation is novel, interesting, and/or intimidating. This is why many times fathers will experience fewer difficulties with their children than mothers. Mothers often spend more time with their children, are not as physically intimidating, and have more opportunities to exhibit inconsistencies in behavioral interactions with the increased time they spend with their children.
Some of the biggest keys to success with ADD individuals that we have seen are developing consistency in behavioral interactions and having well-defined structure. Behavioral management charts that are used throughout early childhood teach the child necessary organizational skills that encourage independence. Teaching empowerment, functional habits and organization is well suited to many children’s success, and we have found that while each child is unique, the techniques we teach parents work wonderfully with almost any child. We also feel that one should avoid physical punishment at all costs. Often what the child learns is that big people control little people through violence.
General research has indicated that true attention deficits are genetically inherited. As was eluded to, that are many syndromes that have attention deficits as a component, but are explained more precisely by other diagnoses. Fetal Alcohol Syndrome, Learning Disorders, Pervasive Developmental Disorders, Traumatic Brain Syndrome, and emotional disorders are only a few of the diagnosable syndromes with attention deficit components.
In the 1960’s, ADD had been referred to as Minimal Brain Damage. This description is perhaps one of the most damaging labels placed upon many individuals that could not have been farther from the truth. Actual physical brain damage is not a component of ADD, however attention deficits are common result when one has had a head injury. In the absence of identifiable incidence of closed head injury, less than 10% of children who do have evidence of brain damage show hyperactivity. These facts are the main reasons why the old term "Minimal Brain Damage" was discarded.
Contrary to Feingold’s claims, diet does not produce Attention Deficit Disorder. Systematic research has consistently failed to support the idea that artificial colorings, flavorings, or natural salicylates are the nutritional troublemakers that produce ADD or LD in the majority of children. It may be true, however, that there are small groups of children that are diet sensitive, and parents’ claims to that effect should never be taken lightly. It is very possible that dietary issues may exacerbate symptoms in ADD and non-ADD children as part of the fore mentioned allergy related syndromes.
There is a high coincidence rate of allergies and asthma in ADD individuals, and while there may be a genetic link between allergies, asthma and ADD, the mechanism is still not well understood. At the very least, allergies can cause transient attention problems due to the physical irritation and discomfort that often accompany them.
Accordingly, sugar does not cause attention deficit disorders. In fact, within the body, sugar will actually calm a child down often within 30 minutes after ingesting the sugar product due to the nature in which it is metabolized by the body.
Bad parenting does not cause ADD. This was an unfortunate piece of information that was spread before there was a clear understanding of the issue. While bad parenting can contribute to many difficulties with ADD, it will often lead to other syndromes such as depression, anxiety, post-traumatic stress disorder… These syndromes may "look-like" attention deficits to the untrained eye.
Often when parents do come to us, they have internalized a great
deal of guilt and responsibility for their child’s behavior. They may be
frustrated to tears with what to do with their children. We often help them to
understand that while there may be a few things to change in their approach to
their children, they have done the best they knew. It is important to realize
as a parent, that one does not have to go to school or get training to become a
parent. Parenting is often the most important job anyone will have in his or
her life. One cannot expect to know everything about it, and extra help is
often a plus, no matter if the child is ADD or not.
There is some evidence that the incidence of ADD in adopted children is higher than in the rest of the population. This would make a great deal of sense when one considers the higher incidence of impulsive behaviors in ADD populations. Therefore, there is likely to be a higher prevalence of unplanned pregnancies and the inability for the parent to care for these children, which would result in more of these children being put up for adoption. We also find that there may be a higher prevalence of single parent families with an ADD parent for the same reasons. Prenatal care is not typically as rigorous for unplanned pregnancies and thus, biochemical imbalances may also occur in the early developmental process.
Why Is There Such An Increased Incidence of ADD in the Population?
As we are learning more about the causes of ADD and correlates to it, we are finding that the prevalence may be higher than once thought. We, in our own practice, have also found that there has been a very high prevalence of misdiagnoses and incomplete diagnoses. Much of the caution around this issue has to do with the massive increase in prescription writing for stimulant class medications such as Ritalin, Dexadrine and Adderal. Taken together, ADD is often looked at as an excuse for behavior and a "cop out" to which people are trying to attach blame, and medication is often seen as a magic bullet to quiet the unruly child. In our eyes, it is very unfortunate that these events have occurred; however, as a result it has forced people to look more closely at the issue. Regardless of these events, why are there so many people with attention deficits these days?
1. Incomplete and Inconsistent Assessment and Evaluation Procedures
First of all, as was mentioned, the evaluation and diagnosis of ADD has been very non-uniform and inconsistent over the years. It is not uncommon for pediatricians to send a symptom checklist to the schools and parents and make a judgment from the completed forms. Based on these observations, a diagnosis is made and medication is dispensed. Also psychologists will often perform an intelligence test and look at behavioral observations. What we feel is often ignored in these evaluations is the clinical level of distractibility, and even more, the difference between visual and auditory distractibility, emotional components, presence or absence of learning disabilities, chemical sensitivities, allergies, and even visual-motor integration issues. When any of these issues are neglected, there is a chance that information may be missed that could greatly aid in treatment and outcome.
2. Challenges in the Education System
Another issue is that teachers have to teach more and more students in the classroom, and, as a result, need students to be cooperative and compliant to demands. As a result, when there are students who are not cooperative and appear hyperactive, defiant, or inattentive, often their first thought leans toward ADD. They are faced with the challenge of teaching all of the children in the class and we appreciate these challenges; however, we have had a few isolated cases where the teacher requested the child to be put on Ritalin to solve the problem. Situations such as these only add to the confusion and subsequent misdiagnosis.
For these reasons, we have developed summer workshop series for educators, practitioners, and the public to inform them of the diagnostic issues and behavioral correlates surrounding ADD and other childhood problems. We feel that the more individuals that know about the issues, the more choices they will be able to make in their style of teaching and approach to difficult to handle children. Our intent is to work with the system to help the educators and the family.
People are often looking for answers to many problems or issues that they may have. When a new disorder or syndrome arises, there is a certain percentage of the population that feels that they have found the answer to their problem. Of this percentage, many do find real answers, but for the other group, they are often incorrectly searching for an answer to find understanding for their difficulties in life. Unfortunately, individuals willing to "latch" onto any disorder may cause people to be skeptical about the authenticity of the disorder not only for them, but also for those who truly experience those difficulties.
4. ADD as One of Many "Normal" Brain Activity Profiles?
Through the QEEG technology, we are able to see various brain wave activity profiles, which predispose individuals to certain strengths and perceived weaknesses educationally, cognitively, socially, and vocationally. It is entirely possible that ADD is not a "true" disorder or syndrome, but instead represents a brain wave profile that a certain percentage of the population may have. If ADD has been present in individuals throughout time, then why is it that so many more people are being identified with ADD now? If one looks at the changes in our society over the last 30 years, there have been increases in the demands on individuals to be able to focus on many tasks at once. There are also demands to learn more information in a shorter period of time. Children have to shift between school, daycare, and home, and both parents often have to work. While these are some examples of changes in the environment, trends seem to indicate that many of these changes may be affecting an individual’s ability to focus. In situations where an individual may have an attention deficit, their weaknesses will be tapped by the demands of the environment because they will not be able to live up to many of these demands. There has recently been a book published on a similar theory that discusses ADD individuals as being hunters in a farmer’s world. What do you think?
Contrary to many beliefs, the diagnosis of Attention Deficit Disorders is a complex process that involves the collection of information from a variety of sources. These sources include:
·
- background information and family data
- behavioral observations
- intellectual strengths and weaknesses
- auditory and visual distractibility
- learning abilities
- emotional issues
- neurological trends
Any competent mental health professional that is an expert in Attention Deficit Disorders can diagnose them, but as has been demonstrated, there is often more to an attention deficit than meets the eye. The psychologist performs many of the evaluative procedures that accurately assess the symptoms and relevant issues. A team of professionals may be involved, including a psychologist, pediatrician, neurologist, or other professional(s). Teachers and parents are also integral to the process of an accurate diagnosis. Since ADD is a multifaceted psychophysiological disorder, each ADD individual will present a somewhat different profile of difficulties and strengths, and these need to be explored thoroughly.
Background Information and Family Data
Background information is important to review. Information pertaining to medical history, educational histories, past behavioral trends, living environment, socioeconomic status and other historical events should be sought. Because ADD is highly linked to genetics, it is often integral to collect information on family histories including psychological, medical, and behavioral information about parents, grandparents, aunts, uncles, cousins, brothers, and sisters. This information can help in corroboration of results of other data.
Behavioral observations may be collected in the office during intake, testing, or therapy, but in many cases it is helpful to observe the client in natural settings such as in school, at home, or at work. It is also advantageous to collect information from teachers, spouses, co-workers, or others who have had many opportunities to observe the ADD individual, and thus, we will typically request to have such individuals complete questionnaires relative to observations in different situations.
Intellectual Strengths and Weaknesses
Intellectual testing is conducted to obtain a baseline of the client’s abilities to perform in educational and vocational settings. Intelligence tests assess a variety of skills, including acquired knowledge, vocabulary, mathematical abilities, visual motor skills, visual organization skills and other abilities. Results of testing address strengths and weaknesses, which offer hypotheses and clues as to whether or not attention difficulties or other learning problems may be present.
Auditory and Visual Attention/Distractibility versus Processing Skills
As was mentioned earlier in the text, a discrimination was made between auditory and visual distractibility. In order to make reliable recommendations for school, job, and home, appropriate assessment of these sensing modalities is important. Many times we find that individuals who have been previously evaluated either were not assessed reliably on measures of distractibility, and/or there was no discrimination made between visual and auditory strengths and weaknesses. The manner in which we perform this assessment is through a computerized technique that presents information to the individual through both auditory and visual modalities. The participant’s task is to identify certain targets from the data presented. Through this technique we are able to assess the differences in focus, impulsivity, hesitance, and sustained attention with reasonable accuracy.
However, just because we may have identified observed strengths or weaknesses on this task, there are other possible intervening variables, which could produce similar output. It is very important to examine the manner in which individuals process and perceive information coming through auditory and visual senses, as well as how information is translated between vision and motor coordination skills (writing, hitting, kicking, etc.). These areas of assessment are often overlooked and, if not at least screened for in the evaluation, may look very similar to attention difficulties. There are distinct differences between processing skills and attention skills, but the output can look similar to the untrained person. Processing has to do with how the information is received by the brain and what is done with the information. Attention skills have to do with the person’s ability to focus on the information presented, regardless of the brain’s ability to optimally process it. If the distinctions are not properly identified in the assessment, this will many times lead to an inaccurate or incomplete diagnosis. While medication aimed at improving attention may help a problem in attention, medications used to improve attention may not improve a learning deficit or some other cognitive problem.
Neurometrics: Quantitative Electroencephalogram
Neurometrics, as was discussed previously, is a relatively new assessment procedure used with Attention Deficit Disorders and other cognitive dysfunctions. The technology has existed for some time, but its application was limited. This technology is an electroencephalogram (EEG), in that it collects information on brain waves in the various lobes and hemispheres of the brain. The difference is that computers are used to collect the information, dissect the information, and permit a more detailed analysis of the brain activity than conventional EEGs. This Quantitative EEG (QEEG) provides objective evidence of a brain’s pattern that underlies attention difficulties and other cognitive disturbances. It should be strongly noted that the QEEG does not provide a diagnosis, but is one of the tools used in providing an accurate diagnosis.
Other tools that are often used in conjunction with the QEEG are the Auditory and Visual Evoked Potentials. These tests measure the brain’s specific response to a specific sensory or cognitive challenge. These are often performed with the QEEG and help to identify variability in auditory and visual attention.
The QEEG has proven to be a very integral aid in the diagnostic process, in that not only does it help to diagnose the presence or absence of difficulties, but it has been found that different types of attention difficulties respond better to different medications and/or medication combinations. The Neurometric QEEG has been used to establish distinctive brain wave patterns known to typically respond better to certain types of medications or medication combinations. If you or your child has been previously diagnosed with an Attention Deficit Disorder before, you may have experienced difficulties with medication levels and types, and many individuals and families have come to us after numerous difficulties and perceived failures with medication. Many have found that the QEEG has provided them with insights into some of the difficulties that they may have been having, and a more successful regimen of medication may be suggested from test results. For more of a discussion of medication issues see the Medications section.
Analysis of Data and the Report
Once all the relevant data has been collected, it is necessary to make sense of it. The information collected needs to be scored. Once the data is scored, the scores often are compared to other people’s performance on the same measures through the use of normative data. The normative data helps us to identify how the individual performed relative to their peers. This is helpful in evaluating how this individual should perform in academic and vocational settings. Another step in the analysis is to evaluate the range of test scores to see where they scored higher and lower not only compared to their peers, but also within their own skill areas. This analysis is important in consideration of ADD, processing deficits, learning disabilities, and cognitive deficits.
Often data collected from mood and personality inventories can help us to understand intellectual functioning, attention and concentration, and learning problems. The converse is also true. Once the analysis of data is complete, it is put in a report form that is often presented to the parents, teachers, and other pertinent individuals or professionals. Due to the different professions that are being addressed, slightly different report formats may be required. One of the most important pieces of the report is the recommendations section. This portion of the report should be designed specifically for the individual and should point to how strengths can be used to reduce the affect of apparent weaknesses and what interventions are suggested to ameliorate weaker areas of performance. Due to the complexity of many of the cases, it is often very helpful for us to become personally involved with the physician, the school and other professionals to make sure that recommendations are being followed and are workable in the environment that the individual inhabits.
There are many different modalities of treatment that have shown success with ADD individuals. Due to the many different apparent subtypes of the disorder, no one type of intervention is appropriate in all cases. Issues to consider in identifying interventions are age, gender, economics, educational setting, family dynamics, brain profiles and co-existing deficits such as learning deficits, perceptual deficits, or emotional problems. Treatments may range from the more common use of medication to individual and family therapy to EEG neurofeedback.
Medication is often the first intervention for ADD that many want to pursue. Many seem to see it as a quick fix, but it can mask more of the ingrained difficulties that may surface and resurface in the form of behavioral problems and poor performance. There are cases when medication is the best option for the client. Our approach is to recommend medication as a last resort or as a "short term" intervention until the client and/or family can learn other mechanisms or other interventions less likely to produce harmful effects from long-term use.
The most common types of medications used to treat ADD are the Stimulant Class medications. Some of the commonly used are Ritalin, Dexadrine, Adderal and Cylert. These medications, while they have different chemical structures act primarily on excitatory neurotransmitters (norepinephrine, adrenaline, and noradrenalin) by mimicking their action and "adding" to the level of neurotransmitters to smooth out the lower levels of neurotransmitters in the brain. There are situations where stimulants are not indicated as a type of treatment: if the person or their family has a history of tic disorders or Tourette’s Syndrome, if their brain profile indicates signs of excess frontal Alpha brain waves, and generally medications should be avoided when children are under the age of five. The period of time that the stimulants act can vary anywhere from four to eight hours, and often there is an immediate effect on the individual after the initial dose.
There is a great deal of confusion about the use of stimulants. People sometimes feel that they are giving their children "Speed" and/or their children may become addicted to the medication. While "Speed" is in the same class as the stimulants, the dosage levels of the prescribed stimulants are drastically lower in many cases. Additionally, while lower levels of stimulants will help to calm an ADD individual, this individual could demonstrate the same effects as individuals who may "overdose," when they take too much medication. This is one reason why children and adults need to be monitored closely by a professional when changing dosage levels and/or during growth spurts.
Antidepressants are another class of medications used to treat individuals with attention problems. Tricyclics are one group of antidepressants. A common drug in this class is known as Imipramine. These drugs work by slowing down the breakdown of norepinephrine in the synapse, thereby increasing the period it can act on the neuron. More recently, another group of antidepressant medications were developed knows as the Seritonin Suppression of Re-uptake (also knows as SSR’s). Drugs in this group, which are commonly used, include Prozac, Zolft, and Paxil. While the use of antidepressants can have an ameliorative effect on depressive symptoms, they may also improve attention problems. Antidepressants may be used in combination with the stimulants or can be used alone. They often take one to three weeks to get to therapeutic levels and it takes time to work out of the body after stopping the medication.
Anti-convulsants, such as Tegretol, are typically used when there is some type of abnormal electrical activity in the brain. This can include seizures or "epileptiform" activity such as EEG spikes or atypical waveforms. In some attention problems, there are periodic "spikes" in the brain wave activity. These spikes and/or atypical waveform patterns may create an interruption of electrical transmission of information. This type of interruption of electrical activity and thus interruption of information processing can often be very frustrating for those observing the individual and the individuals themselves, since this type of activity is often undetectable to most people. This medication often takes time to build up to therapeutic levels in the body.
There has been increasing interest in health supplements. There is
also a great deal of speculation as to how these may affect physical and mental
health. There are many benefits to them, in that they often do not introduce
foreign chemicals into the body that can have harmful effects and do not have
the side effects that may come with medication. While we have seen many
positive effects of these supplements, the jury is still out and the medical
community is often the last to support these as interventions, and in many
cases, research for natural supplements is not as sound as it is for medical
interventions.
In the last year, we have been offering information about the use of Pycnogenol as an additional and/or alternative treatment for ADD. The active effects of pycnogenol are not clearly known for ADD, but generally it acts as a very powerful anti-oxidant that aids at the molecular level of cell generation to decrease free radicals. There are many positive effects of pycnogenol including improved allergy control, increased elasticity in collagen, and has been shown to have a protective action against UVB radiation.
It should be noted that there are two types of Pycnogenol. One type is an extract from grape seeds. The other type is an extract from the bark of the French Maritime Pine Tree. While both extracts have similar chemical structures and are often called by the same name, they are very different in how individuals respond to them. In our personal experience we have seen positive effects of the pine bark supplement on attention, concentration, and impulsivity. While many claim that they have had positive results from the grape seed extract, we have yet to see favorable results. It should be cautioned that while we have had favorable results in approximately 60% - 70% of cases, like any treatment consideration, there is NO GUARANTEE. We are currently examining those groups of individuals who may benefit more from this intervention.
There are many different types of Pycnogenol that are currently being distributed in stores, through mail order and through other means. As with many nutritional products, be cautioned that quality differs greatly. We do not want to discourage you from trying any of these interventions, but want you to be educated. If you are interested in trying Pycnogenol, we provide pine bark derivative in our office through an outside distributor as a service to our clients.
Colloidal minerals are another newer type of health supplement that have shown promise at increasing general physical health. The colloidal products include many different minerals as well as vitamins and other nutrients (some even include pycnogenol). The theory behind colloidal minerals is that the vitamins and minerals are dissolved in a liquid substance (similar to glacier water) and as a result of chemical structures of the colloidal substance, the body is able to more readily absorb the nutrients. Research has demonstrated that many vitamins in capsule or pill form are often only absorbed at a 10% - 50% level, because they do not have the chemical bonding structures to attach to proteins or other metabolites. This means that the remaining unbonded nutrients are flushed out of the body, unused. As with brands of Pycnogenol, there are different levels of quality in vitamins and nutrients, and it is very important to do your own research.
When one is taking quality supplements in colloidal or capsule form, the body may run smoother and more efficiently. Occurrence of illness is greatly decreased, individuals often wake more rested and attention and concentration can improve with less stress. We previously indicated that poor nutrition and allergies cause some attention and emotional problems. This is why there are some cases that attention problems may not be true attention deficits, but may be caused by other weaknesses in the body that affect the ability for the brain to perform at an optimum level. If the body runs smoothly, the mind often follows.
C. Psychotherapeutic Interventions
Short-term individual therapy may be needed after the diagnosis to help the individual understand their attention difficulties and, more importantly, the emotional consequences of their difficulties. There are a number of issues to consider psychologically and without intervention, these individuals can have tendencies toward depression, anxiety, anger outbursts, and other personality difficulties. On the other hand, it is also very important to accentuate the strengths of these individuals, not only to them, but also to their families. As was stated previously, there are many advantages to ADD. One goal in psychotherapy is to empower the individual so that they feel they can reach their goals by their own merit. The length of therapy varies from individual to individual, but generally the earlier the problems are detected, the shorter the intervention.
Group therapy is also often very helpful, in that the individual is able to meet with others like him/her. One can identify with the difficulties of others, and can learn through the example of others. We have found that when children are in the groups, there has been a more powerful outcome when the parents also attended a simultaneous support group that integrated subjects being learned in the children’s group. Group therapy has been shown to be successful for children from the ages of 7 to 17, as well as through adulthood. We have also offered support groups and integrated groups for spouses.
Parent Training has been shown to be successful when the child is under age ten and more so when the child is under age five. Many parents are hesitant to consider parent training because they are fearful that they may find they have been doing something "wrong" in the past. In our philosophy, there is no "wrong", only opportunities to learn. We try to help the parents understand that although we go through a great deal of training for our jobs, to drive a car, and to learn to do many other things in life, we do not have to go through training to have children and be parents. Many parents learned parenting skills vicariously from their parents, who learned from their parents…, and they either do the same as their parents did, or the opposite. Without intervention, there are often no other options for the parents to choose from. There are no perfect parents, but we hope to be able to make the job easier.
Biofeedback refers to the general method of monitoring some sort of biological process and providing some feedback to us about the how well that biological process is functioning. We have already discussed that QEEG has identified distinctive EEG brain wave abnormalities, which correspond with attention problems. Recently, the use of computers, which can monitor aspects of these brain wave abnormalities, have been employed to provide a method of biofeedback to help the individual learn to control and reverse these abnormalities. Like other methods discussed above, EEG biofeedback or Neurofeedback Therapy is still controversial and not widely accepted as a legitimate intervention for attention difficulties. Nonetheless, there have been a number of research articles, which have been published reporting positive results from this approach. Added to this, the hundreds maybe thousands of anecdotal reports of successful outcomes using this therapy, have helped the use of this noninvasive therapy to become very popular all over the country.
Prognosis: How to Tell the Future
There are many emotions and concerns that occur in the process of diagnosing attention difficulties. Once the individual is diagnosed with an attention deficit, there is a great deal of confusion and often fear as to what the implications ADD/ADHD mean to the long term success of the individual. However, a number of issues may prevent family members from discussing these fears with each other and others. There are often feelings of guilt and responsibility, sadness, loss, as well as other feelings that each may feel independently or similarly. We hope that if you have read thus far, your fears or concerns have been soothed.
How does one go about predicting how an individual with an attention
deficit will turn out? Though it is impossible to be precise, there are several
indicators that have been shown to correlate with this person’s eventual
success-or lack of it as an adult. Some indicators of success are:
· · 1. Socioeconomic status: Often, the higher, the better. These parents may be more aware of problems, may receive better pre- and post-natal care, and may be more likely to seek and be able to afford professional help. These points indicate that if a parent has the means to follow through with proper healthcare, both medical and mental, there is a higher probability of success.
- Intelligence: In many cases, the higher the better. Higher intelligence can help many ADD individuals compensate for their distractibility and impatience, as well as offering more skills with which to cope. When the individual is taught to focus on the positive aspects of learning, success in school can usually come more easily. Offering them strategies and options on how to learn is often the key to success. The more intelligent, the stronger the tendency for the individual to understand their options.
- Aggressiveness: While this is sometimes an emotional consequence of ADD, the less the aggressiveness, the better. Impulsivity can interfere in relationships and contribute to aggressive outbursts. When ADD individuals run into difficulties, frustration will often lead to aggression. If they are able to learn strategies on how to manage their anger and frustration, they may avoid the unpleasant power struggles that can ensue, which will promote a more favorable outcome.
- Hyperactivity: As one can imagine, the lower the activity level, the better. Non-hyperactives are much easier for others to deal with and often make more friends. When children grow up with hyperactivity, there is a higher probability of perceived failures in interactions with others and with outcomes of events. This can result in more negative influences on emotion and personality. It is also much more difficult for these individuals to cope if they have not outgrown their hyperactivity by adolescence or later.
- Social skills: Prognosis is poor for children who have not developed significant social skills by age 10. Once again, social skills can be influenced by emotional factors, and the more psychologically sophisticated the individual, the more able they are to handle variations in social situations.
As for other issues with ADD adults, we have found that there are a variety of different levels of coping styles that they have attained. Many of the individuals who do come in for treatment have been undiagnosed and have had difficulties ranging from many job changes and sporadic relationships to minor concerns and chronic frustrations. There are many more who never seek treatment who may have more significant difficulties but fear recognizing them, as well as the many who have succeeded beyond perceived expectations. Of the cases where the adults have come in for treatment, results have been very favorable, often using a combination of medication and therapy.
Birth - Age 3: There are many ways in which an infant can demonstrate attention difficulties. Often at this age, unless hyperactivity is at an unmanageable level, diagnosis and treatment with medication is avoided due to many of the idiosyncrasies that children exhibit during these ages.
Ages 3-5: As the ADD child gets older, noncompliance can become more of an issue, creating awkward and frustrating situations for the parents and siblings. Peer problems can emerge as the children engage in often impulsive and unregulated actions in their attempts at interactive play. Phone calls from preschools and kindergarten can begin about the child’s misbehavior, often producing the beginning of "phone phobia" for mother. It also now becomes more obvious that discipline doesn’t work like it does with other children, and as frustrations build, parents may respond with anger totally out of proportion to the actual difficulty. Hostile destructiveness is not uncommon in these children, but they can also break things or take them apart simply out of impulsive curiosity. At this point too, parents may argue more about how to handle the child, causing increased marital friction on a regular basis. One of the keys to success with parenting with ADD children and all others is to offer options and choices to keep from getting involved power struggles that result in all involved feeling failure and or frustration.
Ages 5-12: Now the ADD child enters school, where the demands to sit still and concentrate increase dramatically, and thus school complaints also become more frequent. Retention is frequently considered around this time because the "child is so immature." Learning problems may begin to emerge, since about one-half or more ADD children may also have a learning disability. ADD can often be confused as a learning disability, because if the child is not able to pay attention in school, they do not acquire the skills or information necessary for success. Emotional and interpersonal difficulties result in sporadic and varied friendships that are tumultuous and sometimes stormy. The child may be more of a loner, and acting out can increase, such as lying, fighting, and stealing. If undetected by the age of ten, academic difficulties may mount to the point of decreasing grades and feelings of failure. The demands of the class work and homework tap the attention skills of these children and frustration becomes unbearable.
Adolescence: Up to this point the challenges may seem overwhelming. However, by adolescence, many will begin to outgrow their hyperactivity and/or have learned to manage it. Many people are under the impression that when the hyperactivity disappears, the ADD disappears. This is not true. It is believed that roughly 25-50% of individuals may outgrow or come to successfully manage their ADD, while the remainders maintain some form of attention deficit which still provides obstacles for them. Peer problems continue, and/or the teen may become associated with troubled kids who may be in and out of trouble with the law. In some of our experiences with the legal system, as well as research studies, we have found that up to 50% of the adolescents and adults who have multiple run-ins with the law have some form of attention difficulty. While the prevalence of legal problems used to be higher, changes in treatment and therapies, as well as a better understanding of the disorder have resulted in a higher success rate and fewer legal problems. However, by this time in the child’s life, the family has often been worn out by the numerous problems with their behavior, especially with the all too frequent arguments at home about anything from school to chores. There is now a much greater risk of depression. Finally, as you can surmise, there is evidence that ADD kids are poorer drivers than their non-ADD counterparts.
Adulthood: The question of ADD in adults is not well understood; however, more and more research is appearing. We do know now that more ADD adults exist than was once thought - the problem is not usually outgrown, though it can moderate some. The good news is that the ADD person can now choose what he/she wants to do, and may be able to find an interesting career and/or relationship and difficulties with concentration become less of a handicap. Residual symptoms can continue, however, such as inattention, impulsivity, hyperarousal, and so on, that can hamper the person’s functioning on the job as well as in marriage. Trouble with the law is less likely, but depression and low self-esteem may continue.
This pamphlet presents a great deal of information. Because of the complex nature of this disorder and the overlap of symptoms with many other disorders and normal life, the diagnostic phase is often the most important piece of the whole puzzle. You can see that in order to insure the long-term success of these individuals and families, diagnosis is usually just the beginning, and the willingness of the individual and family to explore the issues further leads to a more favorable outcome for all.
We hope that you have begun to understand that attention deficits are very complex, and we are still probably in the infancy of understanding their origin, weaknesses and assets. Although our current technology has aided greatly in what we know, we are still limited by what we do not know. We know that attention problems are, in most cases, not due to physical brain damage, that there is a strong genetic component, and it can be identified more objectively through QEEG techniques. Poor diet, bad parenting, or allergies do not cause ADD, however, while these factors are not causative, they do strongly influence symptoms. Due to the complexity of the disorder, there are many emotional consequences which contribute to personality development that often require therapeutic intervention through individual, group, and/or family therapy, as well as parent training. In considering attention deficits, we hope that you have been able to see a more positive side of the issue in that there are many gifts and strengths that accompany individuals with ADD. A therapeutic goal is to enhance those strengths to insure the success of each ADD individual and the people in their lives. We hope that this information has helped you realize that with proper identification, treatment and follow-up, the success of those with ADD is greatly enhanced.
If you would like any additional information in this booklet, please contact Dr. Erik Fisher at 770-513-0577.
