ADHD Evaluation and Therapy

• What is ADHD?
• What is ADHD (in plain English)?
• What else can cause behaviors that mimic ADHD?
• What are the components of an ADHD evaluation?
• How is ADHD treated?
• Resources
• Some of my favorite strategies for managing ADHD symptoms

Let’s start with two definitions to clear up the problem with the acronyms. ADD and ADHD essentially refer to the same condition in different versions of the Diagnostic and Statistical Manual (DSM), a diagnostic dictionary that lists all mental health diagnoses.

• ADHD Attention Deficit-Hyperactivity Disorder (the DSM-IV term)
• ADD Attention Deficit Disorder (the DSM-III term)

Both of the subtypes in the DSM-IV are defined by nine behaviors with a minimum of six being required to make the diagnosis.  As can be seen from the symptom lists that follow, the language remains heavily skewed towards children/teens.  Further, it remains highly subjective.  While there has been some excellent research in recent years that has begun to document neurological differences in those with ADHD, no diagnostic "tests" have yet been approved for making the diagnosis.  Some vigilance tests such as the TOVA hold some promise as does Lubar's research on EEG patterns, and Amen's research with SPECT scans.  For now, though, ADHD remains defined by the 18 symptoms on these two lists.  

Inattentive Symptoms

• often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
• often has difficulty sustaining attention in tasks or play activities
• often does not seem to listen when spoken to directly
• often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
• often has difficulty organizing tasks and activities
• often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
• often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
• is often easily distracted by extraneous stimuli (sights or sounds or objects unrelated to the task at hand)
• is often forgetful in daily activities

Hyperactive/Impulsive Symptoms

• often fidgets with hands or feet or squirms in seat
• often leaves seat in classroom or in other situations in which remaining seated is expected
• often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
• often has difficulty playing or engaging in leisure activities quietly
• is often "on the go" or often acts as if "driven by a motor"
• often talks excessively
• often blurts out answers before questions have been completed
• often has difficulty awaiting turns
• often interrupts or intrudes on others (e.g., butts into conversations or games)

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What is ADHD (in plain English)?

The research points to ADHD being a genetic condition that effects how the brain works. It is not the result of "bad parenting" (though parenting a child with ADHD can be a real challenge at times!) Unlike some conditions like diabetes, there is no such thing as "adult onset ADHD." By definition, the symptoms are evident early in childhood. The severity of the symptoms varies from person to person. For the easiest overview, I would suggest Dr. Daniel Amen's book, Healing ADD and his website at www.amenclinics.com. For ongoing reading, take a look at some of the back issues of Dr. Russell Barkley's ADHD Report in my waiting room.

One core problem with ADHD traces to the "executive control center" of the brain located right behind the eyes. This area, called the prefrontal cortex or pfc, is responsible for helping plan and carry out various activities. For reasons not yet well understood, this part of the brain becomes underactive during periods of concentration, just the opposite of what is expected. This problem seems to be associated with too little dopamine, one of the brain's key neurotransmitters. Researchers believe that stimulant medications like Ritalin, Concerta, Strattera and Adderall help keep more dopamine available in the pfc. Think of trucks bringing shipments to a loading dock where ferries will take the shipments across a river to other trucks waiting on the other side. Dopamine provides the function of those ferries, helping get information from one part of the neural highway to the next. Too little dopamine means the information doesn't get where it needs to as reliably.

The pfc also helps filter information coming in to the brain, as well as helping evaluate ideas before we act on them ("think twice before speaking once"). People with ADHD symptoms, particularly the hyperactive/impulsive kind, don't seem to learn from past experiences. Actually, they do -- they know the right thing to do, but accessing that wisdom is more difficult because of the reduced activity in the pfc.

There is a myth that children with ADHD can't focus. They can, but not as easily unless the activity is sufficiently stimulating to compensate for the problems with the pfc. When they do find something that holds their interest, another problem often emerges: they lose track of time and have trouble letting go of it to move on to the next activity.

People with ADHD often learn much better in a "hands-on" kind of way. They do not do as well learning with their ears. They learn better with their eyes and hands. This helps explain why sitting in class is often such a problem: unless the lecture content is something the student really likes, the pfc is going to make concentrating much more difficult because of its reduced activity level.

In the early years it was thought that people "outgrew" ADHD sometime during adolescence. Newer research makes it clear that this is not the case neurologically. What does seem to happen is that people learn additional coping strategies as they move through adolescence into adulthood that help them manage their symptoms better. In addition, some of the more blatant symptoms of physical restlessness and hyperactivity seem to subside and are experienced more as an internal restlessness. 

Resources:

The last two decades have seen a wonderful emergence of a wide variety of resources for children and adults. These include books, newsletters, on-line chat rooms, websites, support groups, etc. See Resources.

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Many other conditions and factors present with similar symptoms, so the diagnosis is best made by both inclusion and exclusion. Some of other possibilities include the following:

• depression
• anxiety
• allergies
• medication side effects
• obsessive-compulsive disorder
• bipolar disorders
• family stress
• dissociation and trauma
• learning problems

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For children and teens:

A careful evaluation includes taking a careful family history, gathering impressions from parents and teacher(s) about the child's behavior in different settings (often using rating scales), reviewing report cards and achievement test scores (preferably over a period of several years), and conducting IQ/achievement testing.  This last part is by far the most time consuming part of the process, typically requiring six or seven hours over several sessions. Given the additional cost involved, it is reasonable to ask whether that degree of testing is routinely required.  The reason that I strongly recommend this part of the process is because a majority of children and teenagers that I evaluate for suspected ADHD also have academic difficulties and/or learning problems which exist independent of the ADHD symptoms.  

Following the testing, I prepare a draft of the report and meet with the parents (and older teens) to discuss the results of the evaluation and my recommendations. After the parents have had an opportunity to review the draft, I give the parents a final copy with additional copies as needed for the school, pediatrician, etc.

For adults:

A careful evaluation includes essentially the same history components as those described above because the diagnosis is typically evident by the age of seven. A close review of the conduct section of report cards often helps provide clues to ADHD symptoms during the school years. While I seldom do such extensive IQ/achievement testing with adults, there are situations where it can be very helpful. With adults I include additional self-report, pencil-and-paper questionnaires to help rule out other conditions which can mimic ADHD. 

As with children and teens, I prepare a draft of the results to discuss with the client. Additional copies of the final version are provided as needed for a physician or psychiatrist in the event a medication trial is going to be initiated.

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How is ADHD treated? 

For a number of years now the research has been quite convincing that the best treatment strategy for most people who are diagnosed with ADHD includes a mixture of both cognitive/behavior management strategies and medication. Having said that, there is also some encouraging research coming from the work of Joel Lubar, Ph.D. which suggests that biofeedback training may prove very effective for some people in reducing ADHD symptoms without the use of medication. The cognitive and behavior management strategies (i.e., how you organize space and time where you live and work) are aimed at helping to organize the person's environment and use of time in a variety of ways. (Later in this section I'll list a number of my favorite strategies.) 

Unlike a bacterial infection where an antibiotic eliminates the infection, medication does not "cure" ADHD. What it does do is help reduce the intensity of the symptoms for the duration of the particular medication being used. Since at present only physicians are allowed to prescribe medication, I coordinate my work with the client's pediatrician, internist, or psychiatrist. 

When my evaluation points to a diagnosis of ADHD, I typically recommend a trial run on medication. I make it clear to parents and adult clients that even if the child/adult has an excellent response to medication, this is not a requirement that they continue its use. Rather, it provides a baseline of what is possible in the way of improvement. At that point, some choose to explore Neurofeedback Training, the term used to describe Lubar's treatment approach. If the symptoms are mild on the ADHD continuum, some parents and adult clients opt to focus first on the cognitive/behavior management strategies. However, if these strategies still leave a child or teenager with significant ADHD symptoms that are interfering with academics or peer and family relationships, I'm very clear in my position that I believe it is very unfair to the child not to use medication has an adjunct. Particularly for those with more of the hyperactive or impulsive symptoms, the frequent negative feedback that they get from teachers and parents has a cumulative adverse effect on their developing sense of self-worth and self-esteem. Fairly regularly I find students being referred in the fifth grade who have begun to show mild symptoms of depression or who have begun to tune out in class or act like the class clown. 

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Some of my favorite strategies for managing ADHD symptoms:

• When dealing with tasks that involve repetition, develop a single routine for accomplishing that task. For example,

  Select one place to keep keys, book bags, and other school materials.
  Have one place to record phone messages.
  Have one assignment notebook in which you keep a record of all class assignments.
  Select one place where you leave materials that you want to take with you when you head for class.

• People with ADHD often have trouble finding one specific item from amongst a group (the fancy phrase is poor "figure-ground" skills). For example, I have difficulty finding a particular cold medication on the shelves at the drugstore. To reduce problems associated with this kind of visual "scanning," store things in the same place when possible. Many people find that open shelving makes it easier for them to locate objects rather than having to open a series of drawers.



• When dealing with instructions or other information presented orally, develop a routine for writing down the critical information. For example, I keep a yellow notepad on which I record all phone call messages. When I have handled the call, I put a check in the left margin. When I have handled everything on the page, I draw a large diagonal slash across the page. I do the same kind of thing with smaller lists of tasks to be completed on a weekend day.



• Divide large tasks into smaller ones. Because people with ADHD often have more trouble completing projects, the trick is to make each project small enough that it becomes manageable within the time available. For example, if the task is "writing a term paper", this can be translated into a series of much smaller tasks, each of which may require only an hour or two (or less).

Develop a list of possible topics.
Talk with someone about the pros and cons of each topic.
Spend 30 minutes at the library doing preliminary research on a partial bibliography.
Schedule small blocks of time to begin reading specific articles, taking notes as you go. (If you take your notes on a computer, this becomes an excellent way to begin gathering material that can be cut and pasted later into the actual paper.)
Schedule specific blocks of time to work on the first draft of the paper.


• One of the common problems that many people with ADHD have is remembering to remember. For example, I may remember while driving to work that I need to make a phone call, and then forget to do it for the rest of the day. An important tool for dealing with this kind of problem is to convert those thoughts into a written list (i.e. the visual list rather than an auditory one.) While difficult to do consistently, I have found it very helpful at night to make a short list of things which I want to be sure get done the next day. That list stays with me on my desk where I refer to it several times day.



• One of the benefits of keeping this kind of short, specific list, is that at the end of the day there is a simple way of noticing how much really was accomplished. Because most of us always have too much to do for any given day, it is easy to reach the end of the day and focus on the things we did not get done rather than the things we did. This kind of list can be useful by providing a way to notice the things we keep putting on the list that we do not get done. I find there are two primary reasons that this happens. First, the task is too big for the available time in that day. The solution is to divide the task into smaller pieces. Then put just one of the smaller pieces on the list of tasks to be done that day. Second, these kinds of unfinished items sometimes represent "shoulds" or "have to’s" that the person would rather not do. As a result, they don’t! Deal with these by taking a closer look at whether or not you really "want" to do that task. If not, take it off the list.



• Inconsistent attention to small details is another hallmark of ADHD. When doing written math calculations, this often shows up in such ways as misreading the computation sign, or misreading some aspect of a word problem. Take a moment to re-read word problems after you have solved them. Double check the computation sign. Similarly, check for (missing) units of measure such as $, decimal points, or sq.ft., and the correct placement of decimal points.



• The same concepts apply when dealing with tests involving multiple choice, fill in the blank, and even essay questions. It is a good practice to re-read essay questions periodically while composing your answer. Pay attention to whether the question has several components rather than just one. With multiple choice questions pay attention to small words which may change the meaning of the question. For example, "Which are the following is not one of the causes of the American Revolution". With questions requiring only a single word or two as the answer, be sure to check for verb tense, singular or plural noun, etc.



• Fine-tuning strategies for dealing with ADHD is an ongoing process. Over time you may find it useful to review a variety of issues. For example, most people find that they do best with a certain sequence when studying at night for several courses. While generally the recommendation is to do the hardest work first, some people find that they procrastinate less if they begin with a short assignment that is easy. For some, beginning with a quick "success" provides the motivation to continue with the harder work.



• It is also useful to notice which times of the day are most productive for you in this regard. Staying on top of the workload is sometimes a matter of finding ways to use small blocks of time that occur throughout the day which would otherwise be lost. Notice which kinds of tasks lend themselves to these shorter time periods that many others tend to fritter away.



• There’s an old rule of thumb (the "80-20" rule) which says that 80% of the work gets done in 20% of the time. The other 20% of the work takes the remaining 80% of the time. Developing strategies that add just a couple of productive hours to the week can go a long way towards shrinking the amount of time that the remaining 20% of the work consumes.



• Notice the kind of environment in which you study best. Because people with ADHD tend to be visual and reading is visually boring, be careful to avoid places that have lots of visually distracting activity such as a television. I find that many people with ADHD often like to study with music. They tend to become restless if the room is too quiet.



• To quote from Hallowell and Ratey’s book, "Know that it is OK to do two things at once." I finally realized a few years ago I listen much better at workshops when I have something to do with my hands. Being strongly visual, I find that paying sustained attention to the speaker is difficult. I listen better – and retain more of what I hear – when my eyes can be focused on what my hands are doing. As a result, for several years now I have developed the pattern of bringing some of my model railroad structures with me to workshops. Painting them requires little conscious thought (this is critical – the activity cannot compete with your freedom to let your ears listen), and keeps my eyes and hands sufficiently occupied so that my ears can listen for long periods of time to the speaker.



• O.H.I.O. Only handle it once. When it comes to paperwork, develop strategies for dealing with it the first time your hands touch the paper. For example, I open my mail with a wastebasket next to me. As much as possible I avoid giving paper the chance to be put on my desk. For people with ADHD, it is a good idea to avoid having a "to do" box. Papers that wind up in stacks are put there with good intentions, but rarely tend to be acted on. For example, when you get back from class, put handouts in their final destination: a folder, a notebook, or the wastebasket. One man I knew used a rule of "Friday at 5:00 p.m." If he hadn’t dealt with it by then, it went in the wastebasket! He had come to realize that he made time for the really important things; the unimportant ones piled up on his desk. So each Friday he cleared away whatever had not been important enough to make time for. This way he started each week with a clean desk. (I do this about once every two months.)



• Structure, structure, structure. This is not meant to turn you into a time and motion expert. It does mean to pay attention to those numerous aspects of day-to-day life which can be handled in less time (and with much less time spent looking for things) by developing ways to organize both time and things. For example, on the computer I keep separate subdirectories for different kinds of files. I have one for letters, another for reports, another for forms, etc. This makes finding them much easier since each subdirectory is smaller. Now that Windows allows for long filenames, use names which are descriptive to make it easier to find the file later. You can also use the "document summary" feature to help find files. In the summary, list a few key words. Then ask the word processor to search for the key word in each file’s document summary.



• In the same way that your classes have a specific beginning and ending time, notice the tasks in your life to which you can attach specific times. For example, clearly differentiate between play time and study time. Give yourself time to play or take study breaks with a specific time for returning to studying. Experiment with making deadlines and writing them down (i.e., visual). Like the short daily list of tasks which you want to complete that day, notice which deadlines you have trouble keeping.



• Keep a notepad with you (e.g. a small 3" x 5" pad or an 8.5" x 11" yellow pad) that you can use for writing down notes that you do not want to trust to auditory memory. Again, people with ADHD do much better with visual input than auditory. Writing down your reminders eliminates the tendency to remember to do something when you are in a place where it is impossible to do it. Many times I think about the need to call someone when it is too late in the evening. If I do not write it down, the next time I remember it is likely to be at the same time the following evening. I use a yellow writing pad to record phone messages -- and only that pad. When I return the call I put a check mark in the margin. When I've returned all the calls on that page, I draw a big diagonal line across the page. That way I don't spend any time scanning individual items to be sure I've taken care of every call on that page. By using a 50 page pad I also have a way of retrieving critical information weeks or months later in the event that I need it again.  



• Be gentle with yourself when you bump into your ADHD. Adults and teenagers with ADHD are often quite critical of themselves and tend to be their own worst enemies in this way.



• If a problem "remembering to remember" would cause a problem for a friend (such as returning a borrowed CD), consider setting a deadline with the person. Let them know that after the deadline they are free to remind you that you had intended to bring the item back. For example, if I promise a report to someone by the end of the week, I tell them that if they have not received it by then to give me a call. That way, the other person does not politely wait (while becoming increasingly annoyed at the delay) if I have forgotten to mail the report. I assure them that I will not take offense; that I am simply someone who occasionally – despite my good intentions – misses a small but important detail.



• Because people with ADHD have a wonderful ability to become hyper-focused, it can be helpful to use an alarm clock to keep track of time. I keep a small clock next to my computer screen as one way of keeping track of the time because I can get "lost" in my work. If I need to call someone at a particular time, I set the alarm for that time so that my tendency to get hyper-focused will not embarrass me. In this regard, a digital alarm can make an important difference because it will ring at the precise time.



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