Treatment of ADHD: The Need for Careful Assessment
Primary care providers interact with children diagnosed with one of three subgroups of Attention Deficit Hyperactivity Disorder (ADHD). ADHD-Combined Type means that the individual is hyperactive, inattentive and impulsive. ADHD-Hyperactive-Impulsive Type means that the individual is hyperactive and impulsive. ADHD-Inattentive Type means that the individual is only inattentive.
It is not difficult to evaluate what behaviors are associated with being hyperactive or impulsive. These behaviors are typically in evidence in our offices and exam rooms. This article focuses on what “inattentive” means and makes some recommendations regarding non-psychopharmacologic management and treatment.
The guidelines listed in the Diagnostic and Statistical Manual of Mental Disorders-IV may be used to establish whether a child is inattentive. The system requires a clinician to identify at least six behaviors out of nine in evidence. Those behaviors are as follows:
• Often fails to give close attention to details or makes careless mistakes in school.
• 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 instruction and fails to finish schoolwork or chores.
• Often has difficulty organizing tasks and activities.
• Often avoids dislikes or is reluctant to engage in tasks that require sustained mental effort such as homework or filing homework.
• Often loses things necessary for tasks or activities.
• Often distracted by extraneous stimuli.
• Often forgetful in daily activities.
Key indicators have to do with distraction by external stimuli (sounds or visual) and difficulty sustaining attention. Notice that the last seven behaviors describe difficulty related to the concept of executive function: the ability to conceptualize a task, plan how to carry it out, and complete it in a timely way. Thus, in your assessment, these problems may be viewed as difficulties with organization and planning.
The question arises, how to help a child with primary inattention? While difficulties with inattention may improve when a stimulant is used, often medication may not fully address the organization and time management problems parents bring to our attention. Here we may recommend special education tutoring or working with an ADHD coach or counselor, particularly one who specializes in organizational skills.
Diagnostically these difficulties with organization and time planning may be associated with ADHD or may result from learning disabilities. Often the difficulties are due to both ADHD and learning difficulties. As primary care providers, it falls to us to help parents understand potential causes and how those features dictate effective treatments.
There is clearly an interaction effect. Parents should understand that the symptoms of inattentive ADHD, such as organization and time planning, may also cause academic difficulties. Primary care physicians are often asked about children who are unable to retain what is read or organize their thoughts and write a paper.
Complicated children struggle in school and have serious academic and behavioral troubles. Often these patients receive a psycho educational evaluation at school with findings that while these children have above average intellectual ability, processing speed and working memory scores are well below average. Primary care physicians often start these children on stimulants, and while their focus may improve, academic performance does not.
Further evaluation often reveals that by seventh grade these children have difficulty keeping up with assignments and completing work on time. Careful questioning reveals that they understand the material but do not retain what is read. They may appear to understand lectures but are unable to organize thoughts well enough to write them down. Children have told me, “I stare at the page and nothing comes out.” Additionally, children with poor working memory forget to write assignments down.
A review of the psycho educational evaluation may reveal that educational difficulties may not always be addressed at school conferences.
Primary care providers often conclude that ADHD is the apt diagnosis. They must press further and refer for educational testing which often reveals that patients have difficulties retaining what is read and organizing thoughts. Thus, while some of these patients may have ADHD, they also may have covert learning disabilities.
It is wise under these circumstances to suggest special education tutoring. Schools usually need to be prompted to provide these accommodations.
In my years of practice, many lessons have been learned. Patients are presented to us with organization and time planning problems. Some patients have problems associated with inattentive ADHD. Others have organizational problems a result of learning disabilities, which require special education interventions to begin to improve.
Primary care providers often find school professionals quick to interpret symptoms of inattention and problems with executive function (specifically organization and time planning as ADHD). We need to be aware that such symptoms stem from learning disabilities and require different treatments.
Depression
We care for children with feelings of sadness and emptiness, surprisingly common among patients who have ADHD. Depression may arise as a consequence of chronic frustration and disappointment of trying to manage untreated or poorly managed ADHD. Such cases of depression are said to be secondary to ADHD. Children endure many blows to their self-esteem and have accepted the idea that they are “lazy” and “stupid,” certainly not good enough to succeed socially or professionally.
Often ADHD and depression may be confused. Both disorders bring about mood problems, forgetfulness, an inability to focus and lack of motivation.
There are subtle distinctions between ADHD induced symptoms and those caused by depression.
Children with ADHD have dark moods. Bad feelings tend to be transient. In contrast, mood problems associated with depression are generally pervasive and chronic lasting for long periods.
Those with ADHD often say that they cannot accomplish much because they are overwhelmed and can’t decide what to do first. Teens with depression can become lethargic and unable to initiate activities.
In areas associated with sleep, children with ADHD have problems falling asleep and they say that their minds refuse to turn off. Patients who are depressed fall asleep readily but may wake up repeatedly during the night. At each awakening their minds are filled with negative or anxious thoughts.
Parents and children have told me some secrets of success with respect to non-pharmacological management of ADHD.
Recognize and empathize with expressions and learn social cues. Some parents enroll children in social skills classes to help them learn to read facial expressions. It is assumed that everyone can read expressions, but that is not the case with ADHD children. They have told me they need to recognize when someone is angry, annoyed, impatient or surprised. Classes also teach them to wait their turn and not interrupt. As result of their classes, children become better at making friends and do better in school.
The homework club. Disorganized children miss assignments because they have not been written down and they did not know answers on exams because they lost their notes. Parents may take charge of a daily schedule creating a kitchen table homework club designed to make outlines, offer tips and check assignments. ADHD patients can take control of their schedule, learn logic behind their action and use study strategies from their parents. They learn to check relevant chapters, devise a study plan, gather notes, stick to a study schedule and eat a high protein breakfast on exam day and avoid cafeteria meals.
Teacher as friends. Parents have told me that their children are misunderstood by teachers because they don’t fully explain themselves or stand up when unjustly blamed. Parents explain how their ADHD children need to present their cases logically and explain themselves.
Above all we need to assist parents to approach ADHD as a “difference” not a “deficiency.” Certainly this is something that can be managed so that the children can move past this “difference” and get much more out of life. The key here is empathy, support, wisdom and of course, love.
Additional information and resources for parents of ADD children can be found online at www.additudemag.com .
