Attention Deficit/Hyperactivity Disorder

By Daniel B. Nagelberg, Ph.D.
Coastal Psychology, LLC

Coastal Psychology, LLC is a group practice started by Daniel B. Nagelberg, Ph.D. in December of 1986. Currently, there are four psychologists and a psychotherpist in the group who, collectively, treat a variety of psychological disorders in children, adolescents, and adults. All of our psychologists also specialize in diagnostic evaluations (also known as psychological testing). In recent years, poor academic performance among children, adolescents, and college students is the most common problem that presents to our clinic. The referral almost always involves problems with attention, difficulty focusing, and inability to stay on task; these are hallmarks of Attention Deficit/Hyperactivity Disorder (ADHD). Thus, we are frequently asked to evaluate whether or not the student has ADHD.

In our culture, it is much more socially acceptable to be diagnosed with ADHD than other problems (such as depression, anxiety, psychosis, low IQ, and many others) that may interfere significantly with the ability to concentrate and stay on task. Next time, I will discuss how many of these psychological disorders mimic (or at least contribute to) problems associated with ADHD which is why, in part, so many people are currently diagnosed and treated for ADHD. The current article will focus on the basics of ADHD: what is it, how is it diagnosed, and how is it treated.

Attention Deficit/Hyperactivity Disorder is the current term that is used to describe a syndrome, or group of symptoms, associated with inattention and/or hyperactivity and impulsivity. Formerly, we used the terms "ADD with hyperactivity" or "ADD without hyperactivity" in describing what is now called ADHD, Predominantly Hyperactive-Impulsive Type and ADHD, Predominantly Inattentive Type (when both sets of symptoms are present, we call it ADHD, Combined Type). When hyperactivity is not part of the problem, many people are a bit offended and quick to correct me ("ADD, not ADHD"). However, this is just a small misunderstanding of how the terms have changed through the years (one can easily enjoy the humor, therefore, of one local insurance company that will not pay for a diagnsois of Hyperkinetic Syndrome - an old term used before ADHD was coined - but will pay for the diagnosis of ADHD!).

ADHD is a developmental disorder that involves a persistent pattern of inattention and/or hyperactivity-impulsivity. Though the patient may be diagnosed in adolescence or adulthood, some, if not all, of the symptoms must be present prior to the age of seven. By definition, therefore, a person does not suddenly develop ADHD as an adolescent or adult (much has been written about "Adult ADD" though I would maintain many adults are misdiagnosed as having ADHD, when, in fact, other etiological factors better account for their problems with attention). The symptoms must also interfere significantly with everyday functioning whether that be at school, at work, or with social relationships. A student who earns A's and is described as "fidgety" or perhaps inattentive ("spacey") may have ADHD symptoms but the symptoms are not likely severe enough to warrant pharmacologic treatment.

There is no single diagnostic test for ADHD. Rather, an appropriate psychological evaluation gathers information ("data") from a variety of sources including the history (usually provided by a parent), behavior rating scales completed by both parents and teachers, behavioral observations, formal psychometric testing (which may include measures of both cognitive and personality/emotional functioning), and what are called Continuous Performance Tests (computer-assisted tests of attention, impulsivity, and vigilance). Like any other behavioral or medical disorder, ADHD symptoms may vary from mild to very severe. Thus, some

patients, those with severe symptoms, are easy to diagnose while others, who may have mild symptoms, are much more difficult to diagnose. Frequently, I hear the term "borderline," that is, a parent comes in and says their child was tested previously and diagnosed with "borderline ADHD." That is not a very useful term

or diagnosis but I take it to mean the child had mild symptoms of ADHD but it simply was not clear that he/she actually met the full criteria for the disorder. As a professional in the field, I feel an obligation to carefully distinguish those students who actually have ADHD and those who do not. Otherwise, every student who may be having "difficulty with attention" and not doing well in school would be diagnosed with ADHD. Remember, we ALL have difficulty with attention at times. We ALL have difficulty focusing when we have other things (worries, concerns) on our minds. We ALL get distracted at times and fail to finish a task. Also, most young children, especially under the age of six, are easily described as hyperactive and impulsive.

There are three "arms" to treatment that I typically discuss with parents of students who are diagnosed with ADHD. These include (1) pharmacotherapy (i.e., medication), counseling and behavior management, and (3) educational modifications. Medication, when effective, can have a dramatic effect on children's behavior and performance, especially those with symptoms of hyperactivity and impulsivity. The most popular medicines include Methylphenidate (e.g., Ritalin), extended duration Methylphenidate (e.g, Concerta), Amphetamine (e.g., Adderall), extended duration Amphetamine (e.g., Adderall XR), and a new non-stimulant medication, Atomoxetine (Strattera). Like many other medications, there is a certain amount of "trial and error" to determine which medication, at which dosage, is most effective for a particular person. Some people are confused by the effects of stimulant medication. They fear stimulants will "stimulate" the child and make him/her even more "hyper" or distractible. They have heard stimulants work the opposite with children than with adults, that there is a "paradoxical effect." The better way of understanding how stimulant medication works, whether with children or adults, is that it helps with self-control. That is, it facilitates inhibitory behavior and decreases excitatory behavior. Thus, the student will be less hyperactive, less impulsive, and less distractible (they can therefore focus better).

Psychological counseling/behavior management refers to a therapeutic approach which engages both the student (identified patient) and parents in better understanding the dynamics of the problematic behaviors and what can be done to modify or change the behaviors. Sometimes, a child (and certainly an adult) can learn to compensate for their symptoms. How often have I heard of children diagnosed with ADHD but who can play video games for hours on end, without being bored or distracted? The reason for this is that they are MOTIVATED by the excitement, pace, and challenge of video games. School cannot possibly compete with the multimedia, fast paced, and stimulating environment in which our children are raised (case in point is how most of us grew up watching television....we sat watched a show with the rest of the family whereas now kids "surf" the channels and frequently "watch" several shows simultaneously). What this means is we have to find ways to make learning interesting. I do not mean fun because school is never going to be "fun" for most kids. A motivated teacher, with a dynamic personality, can do much more for a child than a teacher with an advanced degree who is burned out and better suited in some other type of occupation.

Educational modifications require cooperation among the student, parents, and teachers. When there is a diagnosis of ADHD, appropriate educational modifications are allowed under public law. These may include extra time on major and standardized tests, taking the tests in a quiet, isolated ("low distraction") area, moving the student so that he/she sits near the teacher or front of the classroom, breaking an assignment into smaller "chunks" of material, allowing the student some degree of "movement" in the classroom, etc. With appropriate educational modifications, many children can compensate for their symptoms. Of course, the most effective treatment may involve a combination of medication, counseling and behavior management, and educational modifications.

Parents with children (as well as adults) who are diagnosed with ADHD or have concerns about ADHD should educate themselves about the condition. The following are a few useful web sites you may want to visit and learn more about ADHD.