ADHD Part 2

Hmmm… I said I would get back to you (my own ADD / ADHD is currently under control and I actually recalled that I would finish my discussion on ADD / ADHD interventions)… so here it is…

…while not a “magical” treatment or even a “new” healing program (this will not make Oprah or the Early Morning Shows), research also clearly indicates hat behavioral interventions are of significant benefit among children with features of disinhibiiton including ADD / ADHD symptoms. In addition to the previously identified environmental and parental interventions, research suggests that introduction of cognitvive behavior therapy (CBT) interventions have promise particularly among children over the age of about ten years. Great thing about CBT … you don’t need to drop $120,000 on an education to learn or use it!

CBT is a step-wise intervention strategy that includes:

(a) increasing self-observer functions by labeling emotions (ie., “it looks like you are feeling…”) (to assist in articulation of negative emotions)

(b) providing cues/assistance in identification of antecedents or triggers for negative emotions (ie., “when did you begin to feel that way? where were you?, etc.) (to assist in identification of trigger zones or antecedents)

(c) learning to identify that behaviors are choices (ie., “what did you choose to do with those negative emotions?”) (to enhance higher level executive contributions to behavior)

(d) assistance in identification of outcomes (ie., “how did that work out for you?”) (to facilitate self-observation and utilization of feedback)

(e) assistance in recognition of the extent to which outcomes influenced triggers (“did those outcomes change the triggers?”) (to avoid vicious cycles in which behaviors have no impact on the triggers).

Existing research indicates that cognitive-behavioral therapy (CBT) – type interventions are among “what works” among high risk children and adolescents involved in juvenile probation. Parental instruction in the use of these techniques is critical to success because the therapists are the parents. So, finally, you get to do something! In addition to formal programming or therapeutic strategies, avoidance of emotional trigger words including “should”, “why”, “have to” and “try” often proves beneficial. These four words (or phrases) are often viewed as parental words that tend to elicit child responses including oppositionality, aggression, withdrawal, etc. See the old stand-by book I’m OK, You’re OK (Thomas Harris) for an explanation (read chapters 1-7). In lieu of these four curse words, insert choices (ie., what might you choose to do?) and questions (ie., what happened? when did it happen? what could you do?, etc.).

So… tired of waiting for the doctors to make things better? Want to get some control over your life and participate in the development and maturation of your child? Please do not “try” these interventions… but you could choose to implement them.

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Dr. Richard Dowell is a Neuropsychologist located in Pennsylvania. Dr. Dowell evaluates upwards of 400 children and adolescents each year. In addition, Dr. Dowell is recognized as one of the top Forensic Neuropsychological witnesses in the North East.

Dr. Dowell can be contacted at DrDowell@NeuropsychologicalServices.net

For more information on Neuropsychology visit NeuropsychologicalServices.net

ADHD Part 1

“My four-year old son was just diagnosed with ADHD. My husband says it’s a lot of “hooey” (which I assume is Pennsylvania Dutch for BS) and that the physician is a drug pusher. His mother (good old mother-in-law) thinks all the drug companies are a bunch of crooks, no better than an organized form of crime. My best friend says it's an epidemic, no one ever heard of ADHD when we were kids. And me? I think… well… I don’t know what to think. What’s the truth?”

The statistics for ADD / ADHD are staggering; 3-10% of all children have symptoms consistent with a diagnosis of ADD / ADHD; 3.5 million children take daily ADHD medications; $3.1 billion was spent on ADHD medications in 2005, an amount that reportedly is four times the number in 2000. So, is it an epidemic? The statistics would say “yes” if an epidemic is defined in terms of a disease or disorder “that appears as new cases in a given human population, during a given period, at a rate that substantially exceeds what is expected, based on recent experience (the number of new cases in the population during a specified period of time is called the "incidence rate").” (taken from Wikipedia). However, is the epidemic real or related to other factors?

Research appears to indicate that improvements in our diagnostic tools (and accuracy), introduction of higher demands within the educational system (“No child left behind”) along with “punishments” for schools that “leave a child behind” and the advent of medications that are both safe and effective (ie., why diagnose a disorder if you cannot treat it) contribute to the dramatic increase in diagnoses of ADD / ADHD.

But beyond that, there is some equally compelling evidence that the actual incidence of children with ADD / ADHD is on the increase much like the diagnosis of childhood autism, cancers, etc. And the cause? Hmmm. round up the usual suspects, toxic chemical factors, stress associated with our high speed technology lives, poisoning (heavy metals, mercury, lead, etc.) and nutritional deficits. Add in two parents working full-time with children being rushed from home to day-care to stores to … (you get the point), over-stressed families who have moved away from grandparents and extended family support… 133 television stations, video games…

Since we are not in a position to treat our modern lives nor control our children’s exposure to atmospheric toxic substances or heavy metal poisoning beyond normal precautions, parents often feel both helpless and powerless. However, recent work has suggested that a combination of interventions that ARE under your control may just have an impact upon a subset of children presenting with symptoms of ADD / ADHD.

Biological interventions: One such “biologcial” program under the control of parents (I’m excluding medications at this time since parents do not control medications) is the 4-A Healing Program of Dr. Kenneth Bock. The 4-A (which stands for ADD / ADHD, Autism, Allergies and Asthma) Healing Program components include: (a) Nutritional Therapy, (b) Supplementation Therapy, (c) Detoxification Therapy and (d) Medication. While the program may not work for all children with ADD / ADHD symptoms, existing evidnce along with anecdotal reports indicate that a subset of children do show benefits and from a cost-benefit analysis the cost of being wrong (ie., good nutrition, good diet, etc.) is minimal relative to the potential benefits. Will it work for your child? I do not know nor is there any evidence that anyone can identify children who will be responders.

Environmental interventions: Unfortunately there are no magic program or McDonald’s drive-through solutions. But we do know that providing high levels of structure within the home is beneficial … structure the child’s room, desk, backpack, etc… structure the child’s time with schedules… daily schedules (ie., posted on the refrigerator) including homework and play times. Reduce the pace of life… children exposed to frantic paces elevate their own activity levels to match the pace required… and the number one internvetion? SPEND MORE 1:1 TIME WITH YOUR CHILD! This does not mean dropping the child off at soccer practice, but more like 1:1 coloring, drawing, walking, hiking, throwing a baseball, reading, fishing, playing board games. Your time is the best intervention and to the extent that you slow down the pace, your child will match your pace (remember the “mirror neurons”)!

Other avenues? Hmmmm… let me get back to you on that one.

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Dr. Richard Dowell is a Neuropsychologist located in Pennsylvania. Dr. Dowell evaluates upwards of 400 children and adolescents each year. In addition, Dr. Dowell is recognized as one of the top Forensic Neuropsychological witnesses in the North East.

Dr. Dowell can be contacted at DrDowell@NeuropsychologicalServices.net

For more information on Neuropsychology visit NeuropsychologicalServices.net

The ADHD Bell Curve

“My seven year-old son is inattentive, off-task, distractible and has a short attention span. At home, he hops from one activity to another, never picks up anything … sort of an energizer bunny. The school suggested that we have him tested for ADHD. Does he have ADHD?”

“I was told (I love this one because the person who told them is never identified) that if your child was a climber as a toddler, then they have ADHD, that you can tell true ADHD in a child if he cannot fall asleep at night … if he stays up late.”

My first thought?, to be redundant, the doctors and nurses at the hospital should have told you about these things when you brought the baby home from the hospital. Children are inattention, they do not stay on task, they hop from one activity to another. Toddlers climb and infants are not always great sleepers.

The issue is not whether a child demonstrates or does not demonstrate a specific behavior or problem, but whether the frequency, duration and/or intensity of identified behaviors or problems are within the middle of the bell curve (the norm).

An understanding of the bell curve is critical to the concept of diagnosis. Ever heard of the bell curve? Well, this is what we know; all human performances (what people do) follow the normal bell curve. An example, a few people are fast, a few people are slow, but most people fall within the middle. A few people are strong, a few people are weak, but most people fall within the middle. The bell curve can be graphed as performance (horizontal axis) by the number of people (vertical axis) and when we graph these two factors, the graph looks like a bell with the highest number of people falling in the middle (called the mean) and progressively fewer people as one moves towards the extremes or tails.

The task is not to identify whether your child is inattentive (because we know that he is) but how much does his inattention (performance) differ or deviate from the mean or average child of the same age.

It turns out that not all children who are average fall exactly on the mean so we need to establish a “tape measure” to determine how much a child deviates from the mean. This measure of deviation from the mean (or “gold standard”) is called the standard deviation. About 2/3 children fall within about one standard deviation above or below the mean. This group of children is called the “middle of the bell curve” or average range.

So, does your child have clinically significant features of inattention? It depends on how much his behavior or problems differ from the mean. Behaviors that deviate from the norm by more than two standard deviations (less than about 5% of the children) are generally labeled as having features that are clinically significant or important. While the presence of clinically significant or important features of inattention (more prevalent than about 95% of children) is important to know, it still does not nail down an ADHD diagnosis.

My point? Objective measurements of behaviors or problems with subsequent comparison to age norms (bell curves by age) is the first step in understanding whether a behavior is a clinically significant issue. In the absence of standardized observations and normative comparisons, the diagnostic process boils down to the “mean” and “standard deviation” that that the professional has in his or her head based on clinical experiences. Maybe part of our confusion regarding diagnostic processes is because each clinician develops his or her own norms (means) including normal ranges (standard deviations) without recognition of their inherent bias.

Do your child’s behavior problems fall within the norm? Does your child still drive you crazy even if it’s not clinically significant? Hmmmm…the doctors and nurses should also have told you about that part too!

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Dr. Richard Dowell is a Neuropsychologist located in Pennsylvania. Dr. Dowell evaluates upwards of 400 children and adolescents each year. In addition, Dr. Dowell is recognized as one of the top Forensic Neuropsychological witnesses in the North East.

Dr. Dowell can be contacted at DrDowell@NeuropsychologicalServices.net

For more information on Neuropsychology visit NeuropsychologicalServices.net

Einstein’s Relativity

“I am a foster parent. My (foster) child appears angry with periods of rage and depression along with acting out, aggression… he can’t sleep at night, can’t sit still… and has basically no friends because he plays too rough. His family background is a mess… father is incarcerated, mother has a long drug history with multiple paramours, alcohol abuse, domestic violence. We have been told that he as ADHD, ODD and bi-polar disorder. He has "failed" trials on three different psychostimulants and now is taking some kind of cocktail that includes three medications at one time. Are his problems biological or environmental?” Hmmmm…

… this may take a minute to formulate a theoretical background… but please be patient with me… Einstein’s “Theory of Relativity” boiled down to its child-like essence goes something like this. As a boy, young Einstein would sit along the railroad tracks and watch the trains go by. In his book, Relativity, he recalls wondering what would happen if someone threw a ball up in the air while riding on a moving train. What would it look like? Well, if you were on the moving train the ball would travel in an arc … and one could actually construct a mathematical equation that would define the arc. But, if you were sitting beside the train tracks, the ball would travel straight up and down in a line and you could construct a mathematic equation that would define the line. Both are mathematical truths! So, which is true? Does the ball travel in an arc or line? The answer… it depends on the relative position of the observer.

Hmmmm… what does that have to do with neuropsychology in general or your child, in particular? Is a symptom/problem related to a physiological disorder (mass) or a psychological disorder (energy)? The answer? Yes… it is both… any symptom/problem will have both physiological (brain/body) and psychological (energy/spiritual) components. The implication is that a holistic approach that seeks to understand both physiological and psychological contributions to symptoms is critical… and that interventions must necessarily consider both physiological and psychological factors. The physician who treats only the body is a fool as equally as the psychologist who only treats the psyche… the mind and body are simply two aspects or perspectives of the same person… and treatments must consider both avenues.

What does this have to do with your child? It means that your activities, relationship, home environment, emotional tone, etc. are as critical to your child’s healing as the medication. Oftentimes we look to wizards (ie., physicians, psychologist, etc.) to treat the body and feel powerless or impotent to affect outcomes. Your efforts are central to healing!!!

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Dr. Richard Dowell is a Neuropsychologist located in Pennsylvania. Dr. Dowell evaluates upwards of 400 children and adolescents each year. In addition, Dr. Dowell is recognized as one of the top Forensic Neuropsychological witnesses in the North East.

Dr. Dowell can be contacted at DrDowell@NeuropsychologicalServices.net

For more information on Neuropsychology visit NeuropsychologicalServices.net

Defiant Johnny

“Johnny is oppositional and defiant! He doesn’t listen… and when you tell him “no” or to do something, he explodes… he screams, hits, kicks… he used to bite… but now he generally just throws things and yells at me. We’ve been at this since he could walk (unspoken: “… and we are very tired”). I can’t even leave him at school (the respite center for most parents)… they call a couple times each week with more complaints… he doesn’t stay in his seat, he doesn’t listen, he hits other kids… plays too rough on the playground. He saw a couple counselors but nothing helps.” This scenario, in various terms by various parents, plays out during the initial screening about 200-300 times each year in our clinic (from among 400 referrals). Interesting (to us), but frustrating to the parents, Johnny sits stoically during the recitation of his “crimes” with nary a complaint nor hint of the symptoms that are tearing this parent (and usually family) apart. Occasionally a parent may go so far as to prod the child into a negative response simply to show that they (the parent) are not lying. Other parents support their argument with a recitation of the teachers, service providers, family, etc. that have been ravaged by their child’s behaviors and concluded the ominous diagnostic verdict, “Your child has oppositional defiant disorder.”

A child who is oppositional and defiant has “oppositional defiant disorder?!?” As professionals, we may need to guard the diagnostic secret that all we do is say “disorder” after the child’s symptoms! Given this line of reasoning, secondary diagnoses for this child could include “scream disorder and kick disorder.” Labeling the child’s symptoms as “oppositional defiant” does not advance understanding of the etiology of symptoms nor potential treatment avenues. Unfortunately, this scenario plays out millions of times each day for children across the country with similar conclusions. The primary cost of this labeling approach to diagnoses is that it tends to result in termination of the search for the underlying etiology or cause for the presenting symptoms. The solution… complete an evaluation or assessment to search for factors that may contribute to the symptoms.

Existing research irrespective of diagnosis indicates that outcomes are related to three factors including: (1) abilities (ie., “hardware” or central nervous system-based processing capacities), (2) skills (ie., acquired responses based on the environment including academic skills, daily living skills, social skills, etc.) and (3) coping resources (ie., “software” packages written by a child in response to the world in which they live). Given this background, a logical extension is that failures of positive outcome (ie., oppositional defiant behaviors) must similarly be related to limitations or deficits related to abilities, skills and coping resources.

What about Johnny? Test results showed strengths across measures of verbal (language), perceptual-motor, learning/memory and higher level reasoning abilities. In contrast, deficits were observed across measures of lower level executive or “conductor” functions including: (a) inhibition (b) rhythm/background tone and (c) “select” (ie., multi-tasking, shifting mental sets, etc.) functions. Deficits in inhibition (or disinhibition) were reflected across external stimuli (ie., short attention span, distractible, etc.), motor responses (ie., hyperactive, hurried, fidgeting, messy, etc.), behavior (ie., rule violations), mood/emotions (ie., irritable, anger, temper tantrums, etc.) and arousal level (ie., difficulties falling asleep, constant motion, broken sleep, etc.). Poor rhythm/background tone was reflected in low frustration tolerance and difficulties adapting to change. Deficient “select” functions were reflected in difficulties with respect to multi-tasking (ie., performing two tasks at once or in rapid/alternating succession) with a high frequency of off-task behaviors (ie., failure to complete assignments, requirements for re-direction and difficulties completing assignments on time). The conclusion…. Johnny’s collection of symptoms/problems (his “ODD”) was related to a breakdown in abilities that warranted a similarly biologically-based (central nervous system) intervention program foundation. Research suggests that an estimated 90% of children with this profile (who also meet ADHD criteria) show benefits to psychostimulant medications.

My Lazy Kid

“Teachers have been telling me that my child is lazy and that if only she just worked harder, was more motivated, etc., then she could do very well. We have responded by setting aside daily study times, requiring her to complete all homework before going out to play, providing her with stars for success, taking away all video games and grounding her for poor grades. Our interventions have resulted in study times that take all night, angry outbursts, depression (“I just wish I was dead”), loss of friends, no free time and… poor grades. Help!” The parent saying these words generally looks the part of the beleaguered parent with the wear and tear of endless nights of battles over homework and being the target of child anger being etched in their face.

Hmmm….. First, a quiz. Which would be easier? To put in forty-five minutes of study time, go out and play, be the recipient of parental praise and have extended free time… or… take four hours to complete a homework assignment while having your parents relentlessly harass you, lose privileges, have your videogames taken away, lose friends and have no free time to play? I’m thinking that it would be much easier to just do the work in the shortest amount of time and receive the benefits… and so would every child. Present to each child in school (through about age 12 years) a request that “Who ever wants an “A” in all their classes for this year, just raise your hand” and you will see 100% compliance or agreement. If the ante was raised slightly, “Who ever wants an “A” in all their classes for this year, raise your hand and walk around the track one time (400 meters)” and you may see a slight reduction in compliance. How about “Raise your hand, walk around the track one time and run the 100 yard dash in under 11 seconds” and you will begin to lose some more hands.

The point?…. everyone wants success, but at some point the child may not have the tools to achieve that success. For the child that is working four hours while screaming and crying, losing privileges and enduring parental harassment, these conditions are obviously more readily available than success by studying 45 minutes. I see about 350 children each year… and during the past 20 years, I believe that I have seen about three “lazy” children (and each of these were adolescents with psychopathic features). The rest? The rest were children with undiagnosed learning disorders that have variously included deficits in attention, visual-spatial processing, visual-motor integration, auditory processing disorders… or children that were the victims of significant life stressors, neglect, deprivation, etc. that undermined their capacity to translate abilities into “real world” performance on a consistent basis.

Your child has been labeled “lazy”? Consider the probability that your child has an undiagnosed learning disorder or other stress-related disorder. The solution… consider having a formal evaluation completed to rule out this potential.

Pharmaceutical Guinea Pigs

You enter your physician’s office… once again you are greeted by a smiling nurse that escorts you quickly into an examination room where moments later the physician enters the room. She nods pleasantly and greets you with a smile. You inform her that you are experiencing abdominal pain. The smile does not leave her face as she begins to write vigorously on a prescription pad. After a few minutes, you are greeted with the product of her efforts…. a prescription for gall bladder surgery. You gulp… “Surgery???” you ask imploring a different response, “… but how do you know?… couldn’t it be something different?” Your physician smiles and unveils the explanation, “We have found that statistically speaking, the highest base rate disorder to account for your somatic distress is a gall bladder problem and the definitive treatment for gall bladder problems is surgery… so we’ll do the surgery first… if you still have the symptoms one month after surgery, then we may consider doing some testing.” Ludicrous?!? I hope you are nodding “yes”.

Unfortunately, many parents who present their children to professionals (physicians, psychologists, etc.) with symptoms of inattention and hyperactivity receive psychostimulant therapy since statistically speaking it is the most common childhood disorder associated with inattention and the definitive treatment for inattention is psychostimulants. The parents are subsequently informed that if the child fails the psychostimulant trial (ie., meaning the child develops insomnia, crying spells, shakiness, emotional lability, tremors, tics, etc.), then an evaluation may be considered. Ludicrous?!?! I hope you are still nodding. Managed care organizations (HMO) and insurance carriers support this approach by encouraging treatment of children but denying or limiting insurance coverage for evaluations. In other words, you (the consumer) are actually paying for and supporting the strategy of using medications to rule out or rule in a diagnosis. While the American Medical Association and its various branches decry this strategy, the reality is that medications, and psychostimulants in particular, are commonly used as a tool in diagnosing attention deficit and attention deficit hyperactivity disorders (ie. “Let’s give this a try… if its ADD/ADHD, then the medication will work…”). The Solution… ask “…and what will happen if it does not work?… adverse symptoms? delays in treatment? child perceptions of being a guinea pig. Parents need to be empowered to say “no” to medical testing on their children and request evaluations prior to treatment.

Hmmm… let’s open up the skull and see if there is a tumor or just nothing.

Time: A Marker for Change Part 2

OK… I was not dodging the first part of the last question (even though it may resonate with my life and I would probably feel better dodging it). “My child always did well in elementary school… but since about 5th or 6th grade, his performance has really deteriorated… he is disorganized, does everything at the last minute, makes repeated careless mistakes. I’ve been told that a lot of kids have difficulties at that age due to the transition into middle school along with the hormones kicking in. Is this just a maturity thing? Will it just get better with time?”

The first part… “is this just a maturity thing?”. The answer is most likely “yes”, “no” or “yes and no” (which philosophically-speaking should cover all states of the universe). Helpful? Let me expand. The collection of “coaching” functions including organization, planning, utilization of feedback to adapt responses (along with assumption of an “observer role” to perceive the world through the eyes of others, internalization of social rules and inhibition of lower level emotions), has been related to the frontal lobe. Studies indicate that this frontal lobe or “social” part of each of us shows a trend for progressive development or maturation throughout childhood. Existing social institutions (ala Erik Erikson) have evolved to mirror this maturation process. During the first few years of life, the frontal lobes play a very limited role…ergo the egocentric (“terrible”) under-socialized two year-old tramples social rules in service of self. At about age 3-4, children complete toilet training. Completion of toilet training reflects initiation of frontal lobe processing (and inhibition of lower level behaviors). At about 5-6 years of age, children start kindergarten. Initiation of formal schooling parallels a phase of rapid growth or maturation of the frontal lobes. At about age 12 years, children begin to change classes in school and manage social interactions independently. This time frame corresponds to a phase when the frontal lobe development has progressed beyond 50% development. This frontal lobe development also corresponds with reduced parental input (as the “external hard drive frontal lobes”). At about age 16 years, we (and other drivers) hope that the frontal lobe development has developed to at least about 85% to sustain executive driving skills and by age 21 years of age, frontal lobe processing should approximate the adult level or about 100%.

Children at age 12-13 years show very dramatic differences in rate of growth secondary to hormonally-drive growth spurts. As a result, children in this age range often show dramatic variations in the extent to which the frontal lobes are maturing. Children who are later maturing (with respect to the frontal lobes) often present with features of disorganization (ie., desk, backpack, outlines for writing, study notes, etc.), poor planning (ie., spur of the moment), failure to use feedback to adapt (ie., repeatedly make same mistakes), poor observer functions (ie., difficulties understanding how others may see the world, difficulties with peers, etc.) and limited control of basic emotions with resulting dramatic mood swings, irritability, acting out and rule violations. While “maturity” or growth results in changes, it is the quality of the environment (ie., parenting) that channels the growth into effective processing. Therefore, while maturity may result in positive changes, the positive changes are not a given unless the parents are able to establish and develop a good “frontal” lobe environment that includes: (a) high levels of organization (ie., desk, backpack, room, etc.), (b) high levels of planning (ie., schedule, daily planner, daily study times, etc.) and (c) consistent and predictable feedback (ie., require child to correct tests, study after tests to learn areas of weakness, well-defined rules and consequences, consistent and predictable consequences, etc.). Stability during this stage of instability is critical to positive growth.

Time: A Marker for Change

“My child always did well in elementary school… but since about 5th or 6th grade, his performance has really deteriorated… he is disorganized, does everything at the last minute, makes repeated careless mistakes. I’ve been told that a lot of kids have difficulties at that age due to the transition into middle school along with the hormones kicking in. Is this just a maturity thing? Will it just get better with time?” The last two questions posed by beleaguered parents take on the quality of a hopeful plea.

Last things first. “Will it get better with time?” Check out your garden… some weeds crop up. Will the weeds get better with time? How about the rusty fender on your car… will the rust go away over time? Unfortunately, nothing changes as a result of or due to time. Time is a marker for change, but time actually causes nothing. So, the belief (or perhaps wish) of parents that “time” will make things better is unfortunately not true. What actions you take across time, however, definitely have the potential to make things better. Unfortunately, some actions have the potential to have no effect and some actions have the potential to make things worse. Actions, like treatments, need to address the specific underlying problem or issue. Weeding the garden will enhance the quality of the garden, but has no known effect upon the rust in your car’s fender. Likewise, the actions of trimming away the rusty fender, sanding, painting, etc. may enhance our fender, the garden weeds tend to show limited effect (unless you pour the solvent on the weeds). Getting the point?! An effective intervention (or parental action) must address the underlying problem or issue. The solution… treatments, interventions or parental actions must begin with a comprehensive assessment of the problem and factors contributing to the problem.

My Child is Inattentive and Hyperactive

“My child is inattentive and hyperactive!” I hear this as a presenting complaint about two hundred times each year (from among our clinic’s 400 referrals each year). My first response (after my unspoken… “And?!?!… you had to have been told something about children and this behavior before becoming pregnant?”) is to tell parents that all children (and adults) are inattentive and hyperactive. The question is, “How much does the inattention (or hyperactivity) differ from the norm?”. Einstein aptly informed us that “all is relative” and that a behavior cannot be understood independent of the observer. A parent who exhibits significant symptoms of inattention and hyperactivity may perceive similar child symptoms as the norm. A parent who resides within a chaotic, unpredictable and inconsistent home environment may not recognize features of inattention as a problem. The symptoms defined as the “norm” in one home or “not a problem” in another home may be perceived as disruptive, disabling or catastrophic to the parent whose world corresponds to a Franklin Covey Day Planner. The central role played by the parent (observer) in the diagnostic process is obviously problematic since the presence of a diagnosis is potentially more dependent upon the parent than the child.

The solution to the dilemma introduced by observer bias is the use of standardized tests to assess processing capacities/abilities and deficits/impairments. Standardized tests are measures (or tests) that are presented to children (or adults) using a standardized (consistent, predictable, etc.) method with specific (standardized) instructions to maximize consistency among observers (testers). The diagnostic task is to identify whether the presenting symptoms/complaints (ie., inattention, hyperactivity, etc.) are part of the normal bell curve (within the norm for children the same age) or are outside of the normal bell curve relative to the child’s peers.

All human behavior or performances tend to be normally distributed such a low number of people exhibit a high level of performance, a low number of people exhibit a low level of performance and most people fall in the middle. As an example, a few people are very fast, a few people are very slow, but most people fall in the middle. A few people are very strong, a few people are very weak, but most people fall in the middle. Standardized tests are simply measures of behavior or performance and, as a result, performance on tests is normally distributed with a few children scoring high and low, and a large number of children scoring in the middle. Within the standardized testing method, observations obtained on a single child are compared to this normal bell curve. The task is to identify the extent to which the child’s behavior deviates from the norm. Definitions (often referred to as “cutoff scores”) regarding what constitutes abnormal behavior or the presence of a disorder differ. However, most clinicians tend to classify scores that deviate from the norm by over two standard deviations (ie., observed among less than five percent of children) as abnormal or of sufficient severity to warrant a “disorder” diagnosis.

So… is “my child is inattentive and hyperactive?” The answer is “yes”… and so are you. “Does my child’s inattention and hyperactivity deviate from the norm sufficiently to be an impairment relative to the demands of the normal environment (home or school)?” The answer is “I don’t know” and it is very unlikely that any other single observer will have the answer to that question (including physicians, psychologists, etc. are also biased observers). The solution… complete an evaluation that utilizes standardized measures.

A Dennis the Menace Incarnation

Johnny is a six year-old boy who appears to have missed his calling for the leading role in the remake of “Dennis the Menace”. He is blond-haired with two teeth missing. When I introduce myself, he steps behind his mother allowing one eye to remain trained on me. He follows his mother and me into the office, sits quietly while his legs swing rather quickly under his chair. He tells me that he has no idea why he is here today (although mother swears they had a thirty minute talk about the visit on the trip to the office), but later relents to suggest that his mother wanted him to come here because he doesn’t “listen”. Mother subsequently describes a child history of significant inattention at home that includes not following instructions (ie., he may recall only one step in an instructional set), not attending when she calls him name and becoming overwhelmed in high stimulation (noise) conditions. Mother indicates that problems intensified when Johnny entered kindergarten. In addition, the teacher reports an increase in social withdrawal and limited peer interactions on the playground. However, mother suggests and the kindergarten teacher concurs that perhaps symptoms are due to immaturity. Mother reports that the situation deteriorates in first grade. Johnny is off-task when the teacher is talking, he turns and looks at the papers of other children, he cannot answer questions posed by the teacher, he looks puzzled during class sharing/discussions and he constantly draws or plays with small items in his desk. Mother reports that she took Johnny to see the family physician with a handful of checklists in which the Inattention boxes had been checked by the teacher. Do you know him? Classic ADD, right?

Mother reports that Johnny was started on Strattera (since its not a “stimulant”). After a month of no benefits, the medication is discontinued and replaced with a more potent psychostimulant (fill in the brand name). Mother reports that since taking the psychostimulant, Johnny is restless, has trouble falling asleep and appears to be more “fragile”. Mother indicates that the dose of the medication is increased since the physician suggests that perhaps his symptoms are intensifying in the school setting. Johnny reportedly responds with insomnia, crying, agitation and irritability. Johnny is seen by a counselor who discusses issues of low self esteem with mother. Mother reports feeling overwhelmed and anxious… she is failing her child. Which brings us to today’s clinic visit….

…findings of our comprehensive neuropsychological evaluation reveal that Johnny has a receptive language disorder. While statistics on the frequency or base rate of this disorder are unclear, research suggests that perhaps 4-8% of children with “classic ADD” symptoms may have receptive language disorders. For Johnny, the English language is like a second language (recall taking Spanish in high school?). He cannot decode speech sounds at the rate necessary for comprehension and, as result, he cannot follow instructional sets, cannot comprehend the discussion of the teacher and cannot decode the rapid-fire playground speech of his peers (with resulting social withdrawal). Reading, which is dependent upon integrating speech sounds with letters is labored for Johnny (and no fun) and, as a result, he learns words based on the visual configurations (which appears to reflect “impulsive” guessing). On the playground, Johnny retreats since he cannot keep pace with the conversation rate and slang of his peers.

Application of a symptom-based diagnosis (which Johnny fits all ADD criteria) resulted in termination of the search for the underlying cause with resulting delays in introduction of intervention strategies, social isolation, loss of self-confidence, dislike of reading, treatment using medications for a disorder that he did not “have” and counseling sessions after school. . The solution… demand evaluations that search for the underlying cause while ruling out other alternative or possible causes.

Symptom-based diagnostic models

You enter your physician’s office holding your head from a throbbing headache. The nurse cordially smiles at you and takes you to an examining room. Minutes later (hey… this is my dream… I can keep the wait short)… the physician enters the office. You inform him or her that you have a headache. Your physician gives you a long look, sighs then pronounces the diagnosis “You have a headache disorder!” Nonplussed, huh? Thinking that perhaps its not too late to get your co-payment back?

Unfortunately, each day millions of parents take their child into offices of physicians, psychologists, therapists, etc. proclaiming that their child has a deficit in attention and is hyperactive and are told by well-meaning professionals, “Your children has an attention deficit hyperactivity disorder!” Nonplussed? I hope so. Attention deficit hyperactivity disorder is a symptom-based diagnosis much like a “headache disorder” would be a symptom-based diagnosis. The unfortunate aspect of this scenario is that labeling the symptom (ie., “headache disorder”) does not explain the underlying cause or etiology of the symptom. Headaches are non-specific symptoms and may be related to underlying etiologies ranging from muscle tension, cervical neck strain, migraines, cluster headaches, increased intracranial pressure, hemorrhagic strokes to brain to tumors. As a patient-consumer you (and your physician) want to know the underlying cause of the headache so that subsequent treatment may be directed towards the cause, not simply the symptom, of the headache. Similarly, inattention, distractibility, off-task behaviors, restlessness, etc. are non-specific symptoms. A review of the DSM-IV-TR (Diagnostic and Statistical Manual – IV Text Revision) and other diagnostic manuals reveals that this cluster of symptoms is consistent with multiple diagnoses ranging from anxiety, depression, Tourette’s Syndrome, post-traumatic stress disorder, neurologic disorders, pervasive developmental disorders to learning disabilities.

The unfortunate effects of this symptom-based diagnostic model of “ADHD” include: (a) the simplistic labeling of symptoms (ADHD) with resulting termination of the search for an underlying cause, (b) evaluations that are limited to symptom counting, (c) a delay in the development of effective intervention plans among children with more pervasive developmental disorders or other deficits, (d) utilization of the child’s response to medication as a tool for confirming the accuracy of the diagnosis and (e) the “mis-diagnosis” of children with resulting public perceptions that oftentimes effective medications (ie., psychostimulants) are of no value or counter-productive. The solution… hmmm…

See you next week.