Attention Deficit Hyperactivity Disorder (ADHD) - Diagnosis and Treatment
Attention Deficit Hyperactivity Disorder (ADHD) - Diagnosis and Treatment
Steps In Making a Diagnosis
Whatever the specialist's expertise, his or her first task is to gather information that will rule out other possible reasons for the child's behavior. In ruling out other causes, the specialist checks the child's school and medical records. The specialist tries to sense whether the home and classroom environments are stressful or chaotic, and how the child's parents and teachers deal with the child. They may have a doctor look for such problems as emotional disorders, undetectable (petit mal) seizures, and poor vision or hearing. Most schools automatically screen for vision and hearing, so this information is often already on record. A doctor may also look for allergies or nutrition problems like chronic "caffeine highs" that might make the child seem overly active.
Next the specialist gathers information on the child's ongoing behavior in order to compare these behaviors to the symptoms and diagnostic criteria listed in the DSM (Diagnostic and Statistical Manual of Mental Disorders). This involves talking with the child and if possible, observing the child in class and in other settings.
The child's teachers, past and present, are asked to rate their observations of the child's behavior on standardized evaluation forms to compare the child's behaviors to those of other children the same age. Of course, rating scales are subjective--they only capture the teacher's personal perception of the child. Even so, because teachers get to know so many children, their judgment of how a child compares to others is usually accurate.
The specialist interviews the child's teachers, parents, and other people who know the child well, such as school staff and baby-sitters. Parents are asked to describe their child's behavior in a variety of situations. They may also fill out a rating scale to indicate how severe and frequent the behaviors seem to be.
In some cases, the child may be checked for social adjustment and mental health. Tests of intelligence and learning achievement may be given to see if the child has a learning disability and whether the disabilities are in all or only certain parts of the school curriculum.
In looking at the data, the specialist pays special attention to the child's behavior during noisy or unstructured situations, like parties, or during tasks that require sustained attention, like reading, working math problems, or playing a board game. Behavior during free play or while getting individual attention is given less importance in the evaluation. In such situations, most children with ADHD are able to control their behavior and perform well.
The specialist then pieces together a profile of the child's behavior. Which ADHD-like behaviors listed in the DSM does the child show? How often? In what situations? How long has the child been doing them? How old was the child when the problem started? Are the behaviors seriously interfering with the child's friendships, school activities, or home life? Does the child have any other related problems? The answers to these questions help identify whether the child's hyperactivity, impulsivity, and inattention are significant and long-standing. If so, the child may be diagnosed with ADHD.
Adults are diagnosed for ADHD based on their performance at home and at work. When possible, their parents are asked to rate the person's behavior as a child. A spouse or roommate can help rate and evaluate current behaviors. But for the most part, adults are asked to describe their own experiences. One symptom is a sense of frustration. Since people with ADHD are often bright and creative, they often report feeling frustrated that they're not living up to their potential. Many also feel restless and are easily bored. Some say they need to seek novelty and excitement to help channel the whirlwind in their minds. Although it may be impossible to document when these behaviors first started, most adults with ADHD can give examples of being inattentive, impulsive, overly active, impatient, and disorganized most of their lives.
Until recent years, adults were not thought to have ADHD, so many adults with ongoing symptoms have never been diagnosed. People like Henry go for decades knowing that something is wrong, but not knowing what it is. Psychotherapy and medication for anxiety, depression, or manic-depression fail to help much, simply because the ADHD itself is not being addressed. Yet half the children with ADHD continue to have symptoms through adulthood. The recent awareness of adult ADHD means that many people can finally be correctly diagnosed and treated.
A correct diagnosis lets people move forward in their lives. Once the disorder is known, they can begin to receive whatever combination of educational, medical, and emotional help they need.
An effective treatment plan helps people with ADHD and their families at many levels. For adults with ADHD, the treatment plan may include medication, along with practical and emotional support. For children and adolescents, it may include providing an appropriate classroom setting, the right medication, and helping parents to manage their child's behavior.
What Are the Educational Options?
Children with ADHD have a variety of needs. Some children are too hyperactive or inattentive to function in a regular classroom, even with medication and a behavior management plan. Such children may be placed in a special education class for all or part of the day. In some schools, the special education teacher teams with the classroom teacher to meet each child's unique needs. However, most children are able to stay in the regular classroom. Whenever possible, educators prefer to not to segregate children, but to let them learn along with their peers.
Children with ADHD often need some special accommodations to help them learn. For example, the teacher may seat the child in an area with few distractions, provide an area where the child can move around and release excess energy, or establish a clearly posted system of rules and reward appropriate behavior. Sometimes just keeping a card or a picture on the desk can serve as a visual reminder to use the right school behavior, like raising a hand instead of shouting out, or staying in a seat instead of wandering around the room. Giving a child like Lisa extra time on tests can make the difference between passing and failing, and gives her a fairer chance to show what she's learned. Reviewing instructions or writing assignments on the board, and even listing the books and materials they will need for the task, may make it possible for disorganized, inattentive children to complete the work.
Many of the strategies of special education are simply good teaching methods. Telling students in advance what they will learn, providing visual aids, and giving written as well as oral instructions are all ways to help students focus and remember the key parts of the lesson.
Students with ADHD often need to learn techniques for monitoring and controlling their own attention and behavior. For example, Mark's teacher taught him several alternatives for when he loses track of what he's supposed to do. He can look for instructions on the blackboard, raise his hand, wait to see if he remembers, or quietly ask another child. The process of finding alternatives to interrupting the teacher has made him more self-sufficient and cooperative. And because he now interrupts less, he is beginning to get more praise than reprimands.
In Lisa's class, the teacher frequently stops to ask students to notice whether they are paying attention to the lesson or if they are thinking about something else. The students record their answer on a chart. As students become more consciously aware of their attention, they begin to see progress and feel good about staying better focused. The process helped make Lisa aware of when she was drifting off, so she could return her attention to the lesson faster. As a result, she became more productive and the quality of her work improved.
Because schools demand that children sit still, wait for a turn, pay attention, and stick with a task, it's no surprise that many children with ADHD have problems in class. Their minds are fully capable of learning, but their hyperactivity and inattention make learning difficult. As a result, many students with ADHD repeat a grade or drop out of school early. Fortunately, with the right combination of appropriate educational practices, medication, and counseling, these outcomes can be avoided.
Right to a Free Public Education
Although parents have the option of taking their child to a private practitioner for evaluation and educational services, most children with ADHD qualify for free services within the public schools. Steps are taken to ensure that each child with ADHD receives an education that meets his or her unique needs. For example, the special education teacher, working with parents, the school psychologist, school administrators, and the classroom teacher, must assess the child's strengths and weaknesses and design an Individualized Educational Program (IEP). The IEP outlines the specific skills the child needs to develop as well as appropriate learning activities that build on the child's strengths. Parents play an important role in the process. They must be included in meetings and given an opportunity to review and approve their child's IEP.
Many children with ADHD or other disabilities are able to receive such special education services under the Individuals with Disabilities Education Act (IDEA). The Act guarantees appropriate services and a public education to children with disabilities from ages 3 to 21. Children who do not qualify for services under IDEA can receive help under an earlier law, the National Rehabilitation Act, Section 504, which defines disabilities more broadly. Qualifying for services under the National Rehabilitation Act is often called "504 eligibility."
Because ADHD is a disability that affects children's ability to learn and interact with others, it can certainly be a disabling condition. Under one law or another, most children can receive the services they need.
Some Coping Strategies for Teens and Adults with ADHD
When necessary, ask the teacher or boss to repeat instructions rather than guess.
Break large assignments or job tasks into small, simple tasks. Set a deadline for each task and reward yourself as you complete each one.
Each day, make a list of what you need to do. Plan the best order for doing each task. Then make a schedule for doing them. Use a calendar or daily planner to keep yourself on track.
Work in a quiet area. Do one thing at a time. Give yourself short breaks.
Write things you need to remember in a notebook with dividers. Write different kinds of information like assignments, appointments, and phone numbers in different sections. Keep the book with you all of the time.
Post notes to yourself to help remind yourself of things you need to do. Tape notes on the bathroom mirror, on the refrigerator, in your school locker, or dashboard of your car -- wherever you're likely to need the reminder.
Store similar things together. For example, keep all your Nintendo disks in one place, and tape cassettes in another. Keep canceled checks in one place, and bills in another.
Create a routine. Get yourself ready for school or work at the same time, in the same way, every day.
Exercise, eat a balanced diet and get enough sleep.
Adopted from: Weinstein, C. "Cognitive Remediation Strategies."Journal of Psychotherapy Practice and Research. 3(1):44-57, 1994.
What Treatments Are Available?
For decades, medications have been used to treat the symptoms of ADHD. Three medications in the class of drugs known as stimulants seem to be the most effective in both children and adults. These are methylphenidate (Ritalin), dextroamphetamine (Dexedrine or Dextrostat), and pemoline (Cylert). For many people, these medicines dramatically reduce their hyperactivity and improve their ability to focus, work, and learn. The medications may also improve physical coordination, such as handwriting and ability in sports. Recent research by NIMH suggests that these medicines may also help children with an accompanying conduct disorder to control their impulsive, destructive behaviors.
Ritalin helped Henry focus on and complete tasks for the first time. Dexedrine helped Mark to sit quietly, focus his attention, and participate in class so he could learn. He also became less impulsive and aggressive. Along with these changes in his behavior, Mark began to make and keep friends.
Unfortunately, when people see such immediate improvement, they often think medication is all that's needed. But these medicines don't cure the disorder, they only temporarily control the symptoms. Although the drugs help people pay better attention and complete their work, they can't increase knowledge or improve academic skills. The drugs alone can't help people feel better about themselves or cope with problems. These require other kinds of treatment and support.
For lasting improvement, numerous clinicians recommend that medications should be used along with treatments that aid in these other areas. There are no quick cures. Many experts believe that the most significant, long-lasting gains appear when medication is combined with behavioral therapy, emotional counseling, and practical support. Some studies suggest that the combination of medicine and therapy may be more effective than drugs alone. NIMH is conducting a large study to check this.
Use of Stimulant Drugs
Stimulant drugs, such as Ritalin, Cylert, and Dexedrine, when used with medical supervision, are usually considered quite safe. Although they can be addictive to teenagers and adults if misused, these medications are not addictive in children. They seldom make children "high" or jittery. Nor do they sedate the child. Rather, the stimulants help children control their hyperactivity, inattention, and other behaviors.
Different doctors use the medications in slightly different ways. Cylert is available in one form, which naturally lasts 5 to 10 hours. Ritalin and Dexedrine come in short-term tablets that last about 3 hours, as well as longer-term preparations that last through the school day. The short-term dose is often more practical for children who need medication only during the school day or for special situations, like attending church or a prom, or studying for an important exam. The sustained-release dosage frees the child from the inconvenience or embarrassment of going to the office or school nurse every day for a pill. The doctor can help decide which preparation to use, and whether a child needs to take the medicine during school hours only or in the evenings and on weekends, too.
Nine out of 10 children improve on one of the three stimulant drugs. So if one doesn't help, the others should be tried. Usually a medication should be tried for a week to see if it helps. If necessary, however, the doctor will also try adjusting the dosage before switching to a different drug.
Other types of medication may be used if stimulants don't work or if the ADHD occurs with another disorder. Antidepressants and other medications may be used to help control accompanying depression or anxiety. In some cases, antihistamines may be tried. Clonidine, a drug normally used to treat hypertension, may be helpful in people with both ADHD and Tourette's syndrome. Although stimulants tend to be more effective, clonidine may be tried when stimulants don't work or can't be used. Clonidine can be administered either by pill or by skin patch and has different side effects than stimulants. The doctor works closely with each patient to find the most appropriate medication.
Sometimes, a child's ADHD symptoms seem to worsen, leading parents to wonder why. They can be assured that a drug that helps rarely stops working. However, they should work with the doctor to check that the child is getting the right dosage. Parents should also make sure that the child is actually getting the prescribed daily dosage at home or at school--it's easy to forget. They also need to know that new or exaggerated behaviors may also crop up when a child is under stress. The challenges that all children face, like changing schools or entering puberty, may be even more stressful for a child with ADHD.
Some doctors recommend that children be taken off a medication now and then to see if the child still needs it. They recommend temporarily stopping the drug during school breaks and summer vacations, when focused attention and calm behavior are usually not as crucial. These "drug holidays" work well if the child can still participate at camp or other activities without medication.
Children on medications should have regular checkups. Parents should also talk regularly with the child's teachers and doctor about how the child is doing. This is especially important when a medication is first started, re-started, or when the dosage is changed.
The Medication Debate
As useful as these drugs are, Ritalin and the other stimulants have sparked a great deal of controversy. Most doctors feel the potential side effects should be carefully weighed against the benefits before prescribing the drugs. While on these medications, some children may lose weight, have less appetite, and temporarily grow more slowly. Others may have problems falling asleep. Some doctors believe that stimulants may also make the symptoms of Tourette's syndrome worse, although recent research suggests this may not be true. Other doctors say if they carefully watch the child's height, weight, and overall development, the benefits of medication far outweigh the potential side effects. Side effects that do occur can often be handled by reducing the dosage.
It's natural for parents to be concerned about whether taking a medicine is in their child's best interests. Parents need to be clear about the benefits and potential risks of using these drugs. The child's pediatrician or psychiatrist can provide advice and answer questions.
Another debate is whether Ritalin and other stimulant drugs are prescribed unnecessarily for too many children. Remember that many things, including anxiety, depression, allergies, seizures, or problems with the home or school environment can make children seem overactive, impulsive, or inattentive. Critics argue that many children who do not have a true attention disorder are medicated as a way to control their disruptive behaviors.
Medication and Self-Esteem
When a child's schoolwork and behavior improve soon after starting medication, the child, parents, and teachers tend to applaud the drug for causing the sudden change. But these changes are actually the child's own strengths and natural abilities coming out from behind a cloud. Giving credit to the medication can make the child feel incompetent. The medication only makes these changes possible. The child must supply the effort and ability. To help children feel good about themselves, parents and teachers need to praise the child, not the drug.
It's also important to help children and teenagers feel comfortable about a medication they must take every day. They may feel that because they take medicine they are different from their classmates or that there's something seriously wrong with them. CH.A.D.D. (which stands for Children and Adults with Attention Deficit Disorders), a leading organization for people with attention disorders, suggests several ways that parents and teachers can help children view the medication in a positive way:
- Compare the pills to eyeglasses, braces, and allergy medications used by other children in their class. Explain that their medicine is simply a tool to help them focus and pay attention.
- Point out that they're lucky their problem can be helped. Encourage them to identify ways the medicine makes it easier to do things that are important to them, like make friends, succeed at school, and play.
Myths About Stimulant Medication
Myth: Stimulants can lead to drug addiction later in life.
Fact: Stimulants help many children focus and be more successful at school, home, and play. Avoiding negative experiences now may actually help prevent addictions and other emotional problems later.
Myth: Responding well to a stimulant drug proves a person has ADHD.
Fact: Stimulants allow many people to focus and pay better attention, whether or not they have ADHD. The improvement is just more noticeable in people with ADHD.
Myth: Medication should be stopped when the child reaches adolescence.
Fact: Not so! About 80 percent of those who needed medication as children still need it as teenagers. Fifty percent need medication as adults.
Treatments To Help People With ADHD and Their Families Learn To Cope
Life can be hard for children with ADHD. They're the ones who are so often in trouble at school, can't finish a game, and lose friends. They may spend agonizing hours each night struggling to keep their mind on their homework, then forget to bring it to school.
It's not easy coping with these frustrations day after day. Some children release their frustration by acting contrary, starting fights, or destroying property. Some turn the frustration into body ailments, like the child who gets a stomachache each day before school. Others hold their needs and fears inside, so that no one sees how badly they feel.
It's also difficult having a sister, brother, or classmate who gets angry, grabs your toys, and loses your things. Children who live with or share a classroom with a child who has ADHD get frustrated, too. They may feel neglected as their parents or teachers try to cope with the hyperactive child. They may resent their brother or sister never finishing chores, or being pushed around by a classmate. They want to love their sibling and get along with their classmate, but sometimes it's so hard!It's especially hard being the parent of a child who is full of uncontrolled activity, leaves messes, throws tantrums, and doesn't listen or follow instructions. Parents often feel powerless and at a loss. The usual methods of discipline, like reasoning and scolding, don't work with this child, because the child doesn't really choose to act in these ways. It's just that their self-control comes and goes. Out of sheer frustration, parents sometimes find themselves spanking, ridiculing, or screaming at the child, even though they know it's not appropriate. Their response leaves everyone more upset than before. Then they blame themselves for not being better parents. Once children are diagnosed and receiving treatment, some of the emotional upset within the family may fade.
Medication can help to control some of the behavior problems that may have lead to family turmoil. But more often, there are other aspects of the problem that medication can't touch. Even though ADHD primarily affects a person's behavior, having the disorder has broad emotional repercussions. For some children, being scolded is the only attention they ever get. They have few experiences that build their sense of worth and competence. If they're hyperactive, they're often told they're bad and punished for being disruptive. If they are too disorganized and unfocused to complete tasks, others may call them lazy. If they impulsively grab toys, butt in, or shove classmates, they may lose friends. And if they have a related conduct disorder, they may get in trouble at school or with the law. Facing the daily frustrations that can come with having ADHD can make people fear that they are strange, abnormal, or stupid.
Often, the cycle of frustration, blame, and anger has gone on so long that it will take some time to undo. Both parents and their children may need special help to develop techniques for managing the patterns of behavior. In such cases, mental health professionals can counsel the child and the family, helping them to develop new skills, attitudes, and ways of relating to each other. In individual counseling, the therapist helps children or adults with ADHD learn to feel better about themselves. They learn to recognize that having a disability does not reflect who they are as a person. The therapist can also help people with ADHD identify and build on their strengths, cope with daily problems, and control their attention and aggression. In group counseling, people learn that they are not alone in their frustration and that others want to help. Sometimes only the individual with ADHD needs counseling support. But in many cases, because the problem affects the family as well as the person with ADHD, the entire family may need help. The therapist assists the family in finding better ways to handle the disruptive behaviors and promote change. If the child is young, most of the therapist's work is with the parents, teaching them techniques for coping with and improving their child's behavior.
Several intervention approaches are available and different therapists tend to prefer one approach or another. Knowing something about the various types of interventions makes it easier for families to choose a therapist that is right for their needs.
Psychotherapy works to help people with ADHD to like and accept themselves despite their disorder. In psychotherapy, patients talk with the therapist about upsetting thoughts and feelings, explore self-defeating patterns of behavior, and learn alternative ways to handle their emotions. As they talk, the therapist tries to help them understand how they can change. However, people dealing with ADHD usually want to gain control of their symptomatic behaviors more directly. If so, more direct kinds of intervention are needed.
Cognitive-behavioral therapy helps people work on immediate issues. Rather than helping people understand their feelings and actions, it supports them directly in changing their behavior. The support might be practical assistance, like helping Henry learn to think through tasks and organize his work. Or the support might be to encourage new behaviors by giving praise or rewards each time the person acts in the desired way. A cognitive-behavioral therapist might use such techniques to help a belligerent child like Mark learn to control his fighting, or an impulsive teenager like Lisa to think before she speaks.
Social skills training can also help children learn new behaviors. In social skills training, the therapist discusses and models appropriate behaviors like waiting for a turn, sharing toys, asking for help, or responding to teasing, then gives children a chance to practice. For example, a child might learn to "read" other people's facial expression and tone of voice, in order to respond more appropriately. Social skills training helped Lisa learn to join in group activities, make appropriate comments, and ask for help. A child like Mark might learn to see how his behavior affects others and develop new ways to respond when angry or pushed.
Support groups connect people who have common concerns. Many adults with ADHD and parents of children with ADHD find it useful to join a local or national support group. Many groups deal with issues of children's disorders, and even ADHD specifically. The national associations listed at the back of this booklet can explain how to contact a local chapter. Members of support groups share frustrations and successes, referrals to qualified specialists, and information about what works, as well as their hopes for themselves and their children. There is strength in numbers--and sharing experiences with others who have similar problems helps people know that they aren't alone.
Parenting skills training, offered by therapists or in special classes, gives parents tools and techniques for managing their child's behavior. One such technique is the use of "time out" when the child becomes too unruly or out of control. During time outs, the child is removed from the agitating situation and sits alone quietly for a short time to calm down. Parents may also be taught to give the child "quality time" each day, in which they share a pleasurable or relaxed activity. During this time together, the parent looks for opportunities to notice and point out what the child does well, and praise his or her strengths and abilities.
An effective way to modify a child's behavior is through a system of rewards and penalties. The parents (or teacher) identify a few desirable behaviors that they want to encourage in the child--such as asking for a toy instead of grabbing it, or completing a simple task. The child is told exactly what is expected in order to earn the reward. The child receives the reward when he performs the desired behavior and a mild penalty when he doesn't. A reward can be small, perhaps a token that can be exchanged for special privileges, but it should be something the child wants and is eager to earn. The penalty might be removal of a token or a brief "time out." The goal, over time, is to help children learn to control their own behavior and to choose the more desired behavior. The technique works well with all children, although children with ADHD may need more frequent rewards.
In addition, parents may learn to structure situations in ways that will allow their child to succeed. This may include allowing only one or two playmates at a time, so that their child doesn't get overstimulated. Or if their child has trouble completing tasks, they may learn to help the child divide a large task into small steps, then praise the child as each step is completed.
Parents may also learn to use stress management methods, such as meditation, relaxation techniques, and exercise to increase their own tolerance for frustration, so that they can respond more calmly to their child's behavior.
Understandably, parents who are eager to help their children want to explore every possible option. Many newly touted treatments sound reasonable. Many even come with glowing reports. A few are pure quackery. Some are even developed by reputable doctors or specialists--but when tested scientifically, cannot be proven to help.
Here are a few types of treatment that have not been scientifically shown to be effective in treating the majority of children or adults with ADHD:
- restricted diets
- allergy treatments
- medicines to correct problems in the inner ear
- chiropractic adjustment and bone re-alignment
- treatment for yeast infection
- eye training
- special colored glasses
A few success stories can't substitute for scientific evidence. Until sound, scientific testing shows a treatment to be effective, families risk spending time, money, and hope on fads and false promises.
Source: National Institutes of Health
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