Emotions

As the long days of summer begin to wane, parents begin to anticipate and prepare for their children's return to school. What they are often unprepared for, however, are the notes that may soon be sent home by teachers indicating that their child “cannot sit still,” “is having trouble concentrating,” and “is disrupting other students.” Such remarks are certainly concerning, and for many parents, mark the beginning of a journey designed to distinguish normal childhood behavior from a true problem. In these instances, sometimes too quickly, teachers and parents alike are willing to speculate about attention-deficit hyperactivity disorder (ADHD), a neurodevelopmental disorder that can cause hyperactivity, impulsivity, and difficulty with attention and concentration. ADHD, the newer term for ADD, affects between 4 and 12 percent of school-aged children, and is 2 to 3 times more likely to be diagnosed in boys than in girls. Epidemiologically, ADHD has become much more prevalent within our society over the past several years, causing many to consider it epidemic. Needless to say, this has elicited much controversy, not only amongst educators, psychologists, and physicians, but in the general public as well, and has led many to consider ADHD to be over-diagnosed and over-treated. While there may be some truth to this, it is probably more accurate to say that ADHD is too often misdiagnosed—missed in certain situations, and too often confused with other problems. For example, distractibility as a symptom is not specific to ADHD—it may be caused by depression, anxiety disorders, or interpersonal difficulties such as peer conflict and family stress. Furthermore, ADHD often co-occurs with other disorders, making it all the more difficult in some situations to establish an accurate diagnosis. Although these reasons may, in part, account for the increase in the number of cases of ADHD, more clearly articulated diagnostic criteria, as well as increased awareness and a greater willingness to seek treatment, may also explain the rise in numbers. Symptoms Although inattention, hyperactivity, and impulsivity are the hallmarks of ADHD, the disorder can manifest itself differently across individuals. Very often, children with ADHD will be easily distracted and unable to stay focused, making it difficult for them to read and to pay attention in class. They may have trouble staying organized, may be prone to procrastination, and may often have difficulty following through on tasks, making it difficult to both start and complete projects. In children where hyperactivity is also a concern, parents and teachers often report excessive restlessness or fidgety behavior, an inability to sit still, and increased impulsivity (e.g., difficulty taking turns, more interruptive behavior, acting without thinking through the consequences). Furthermore, children with ADHD may have problems with short-term memory, may be more careless and accident prone, and may report more emotional distress and interpersonal difficulties. While this is not an exhaustive list of symptoms, it covers the basics and explains why so many children with ADHD have difficulty in academic settings. However, it is worth noting that the symptoms must cause significant impairment in more than one area of functioning to warrant the diagnosis. Furthermore, the symptoms must be present before the age of seven, and must not be better explained by some other condition such as depression or a learning disability. Assessment Again, because ADHD is so easily confused with other disorders, a thorough assessment is absolutely necessary in establishing an accurate diagnosis. Other explanations, including intellectual giftedness and being bored in class, need to be ruled out. Although clinical interviews and behavioral observations are the cornerstone of a good evaluation, psychological testing, in most cases, is also an integral part of the assessment process. There are a handful of questionnaires that directly assess ADHD symptoms, but an intelligence test to evaluate cognitive strengths and weaknesses is perhaps even more important. Additional tests of memory and neuropsychological functioning are also usually included in a comprehensive test battery. Although many clinicians rely solely on clinical interviews to establish an ADHD diagnosis, conducting a more thorough evaluation would certainly reduce the number of misdiagnosed cases and potentially reduce the controversy around this often misunderstood condition. Treatment While there has been much research into the etiology of ADHD, the cause remains unknown. ADHD seems to run in families, therefore it seems likely that there is some underlying genetic contribution. At the same time, a variety of additional factors, including dyes and preservatives in food, a history of head injury, and premature birth, have all been considered in the onset of ADHD. Because the exact cause remains undetermined, there is no specific cure at this time. While many children seem to outgrow the condition by adolescence, or at least find ways to adaptively work around the symptoms, many adults remain affected. Epidemiologically, it is estimated that as many as 50% of children affected by ADHD will continue to have difficulties as an adult, and more attention is being paid to adults who may never have been diagnosed as children. In terms of treatment, a parent's initial reaction may be to seek a pharmacological answer, although medications remain a controversial subject. Parents may turn to their pediatricians or primary care physicians for answers, but many feel that psychostimulants such as Ritalin, Adderall, and Concerta are over-prescribed, especially in mild cases. And as with any medication, the side effect profile needs to be carefully balanced with the therapeutic gains of the medication. Of course, many parents prefer psychotherapy as an alternative to medication. In this realm, providing parents with education and support may be most critical in enabling them to coach their children through difficult situations. Children also often respond well to behavior therapy, which focuses directly on symptom management and the establishment of effective coping skills. At the same time, children with ADHD often benefit from cognitive therapy aimed at improving self-esteem and minimizing any secondary distress, as well as social skills training to improve interpersonal relationships and minimize the negative impact ADHD often has on peer relationships. Again, although there is no specific cure for ADHD, medication and psychotherapy, which are often used together, are both effective in the reduction of symptoms and distress, and the minimization of impact on the child's life. More broadly speaking, it may also be helpful to consider the fact that ADHD is culturally defined, and as such would cease to be a relevant diagnosis if we lived in a society where learning could actually be tailored to each individual child thereby taking advantage of his or her strengths and weaknesses. Then children would be encouraged to work with their ADHD, rather than fight against or be controlled by it. John S. Schell, Ph.D. Staff Psychologist