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Attention Deficit Hyperactivity Disorder Archive 2004

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Shari Gent, M.S.,
Educational Specialist

Shari Gent, M.S. is an education specialist with eighteen years of teaching experience. She has taught a diversity of students including those with learning handicaps, mental retardation, and autism spectrum disorders in both urban and rural environments. Her special interest is working with children with attention deficit disorder and associated mental health conditions. Shari has appeared on National Public Radio with leading experts in the field of attention deficit disorder. In addition to her professional work, she is a chapter coordinator for Children and Adults with Attention Deficit Disorder (CHADD) and parents a teenager with AD/HD.

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  • FAS/FASE misdiagnosed as ADHD.

Question:

I am noticing a lot of children who are diagnosed with ADHD and information that comes up through parents/guardians which let me know that the children have been prenatally exposed to alcohol. I have questions regarding the misdiagnosis of ADHD for those who may be FAS/FASE, I thought I would ask a couple of people in different fields what their thoughts are on this subject and their experience.

  1. What do you think are the contributors to misdiagnosis of FAS/FASE as ADHD
  2. What do you see as the problems that could arise with that misdiagnosis?
  3. How do you feel that professionals can better identify FASE without making the mistake of going toward an ADHD evaluation?
  4. What kind of effect do you see in FAS/FASE children treated with ADHD medication? Is it beneficial?
  5. What are the marked characteristics that you would look at in distinguishing the two?
  6. What are the overlapping characteristics that make it difficult to diagnose?
  7. Do you feel that behavioral treatments within the schools would differ greatly depending on their diagnosis? Explain.
  8. At what age do you see more FAS/FASE diagnosed? How are they brought to your attention?
  9. What would strategies would you suggest to professionals working with those with FAS/FASE in the schools?
  10. Any other comments to add.

Shannon


Answer:

Dear Shannon: 

Thank you for your thoughtful questions about the relationship between FAS and ADHD. FAS is not an educational diagnosis however, I will address those questions related to education. I'm referring questions related to medicine to Dr. Kay Browne, behavioral pediatrician. 

Understanding the diagnosis of FAS is critical to understanding the relationship between FAS and ADHD. First of all, unlike ADHD, FAS is not a mental health diagnosis described in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV). Fetal Alcohol Syndrome is a physical, mental and neurobehavioral birth defect resulting from maternal use of alcohol during pregnancy. A child can also be affected by paternal alcohol consumption, though only maternal consumption can cause FAS. The father's drinking can lower testosterone levels, decrease healthy sperm, and increase the risk of disorders, particularly behavior problems, in offspring. Preliminary animal studies indicate that alcohol can damage the DNA in male sperm. 

FAS is a lifelong birth defect characterized by abnormal facial features and growth and central nervous system problems. People with FAS suffer from difficulties with learning, memory, attention and judgment. FAS is also a leading cause of mental retardation (NIAAA, Eighth Special Report NIH Publication No. 94-3699), but only 15% of people with FAS have IQ's under 70. 

Many terms have been used to describe the effects of prenatal alcohol exposure. I'm assuming that your abbreviation "FASE" stands for the term "fetal alcohol effects" or FAE, at one time considered to be a milder form of Fetal Alcohol Syndrome. You are not the only one confused by the terminology! In April 2004, a summit conference was held by the medical community to determine appropriate descriptors. Most recently, physicians have come to describe both FAS and FAE under the umbrella term Fetal Alcohol Spectrum Disorder (FASD). The term FAE has been replaced by the terms ARND and ARBD.

  • Fetal Alcohol Syndrome (FAS) is the term used to describe children with all the characteristics of Fetal Alcohol Spectrum. Differences in facial features are a hallmark of FAS. 
  • Alcohol-Related Neurodevelopmental Disorder (ARND) Those with ARND may have functional or mental problems linked to prenatal alcohol exposure but not facial abnormalities. Their difficulties include behavioral and/or cognitive deficits such as learning difficulties, poor school performance and poor impulse control. They may have difficulties with mathematical skills, memory, attention, and/or judgment.
  • Alcohol-Related Birth Defects (ARBD) Children with ARBD may have problems with the heart, kidneys, bones, and/or hearing but the behavioral and cognitive deficits may be mild and facial differences may not be visible.

Children with FAS often have a smaller than normal head. Facial characteristics of FAS include short eye slits, elongated mid-face, long and flattened nose and upper lip, thin upper lip and flattened facial bone structure. The illustration below is borrowed from the FASlink website http://www.acbr.com/fas

Facial Characteristics of FAS

The most serious effects of FASD, and those most affecting school performance are:

  • Attention deficits*
  • Memory deficits*
  • Hyperactivity*
  • Difficulty with abstract concepts
  • Inability to manage money
  • Poor problem solving skills*
  • Difficulty learning from consequences*
  • Immature social behavior*
  • Poor emotional control*
  • Overly friendly toward strangers
  • Poor impulse control*
  • Poor judgment*

I have starred those characteristics commonly demonstrated by children with either disorder. A child or teen with ADHD might also demonstrate poor money skills, but this is not a most common characteristic. Some children and teens with ADHD are well able to think abstractly. However, they may have difficulty producing work that demonstrates this. 

As you can see, the two disorders have much in common, particularly when facial abnormalities are not present. Children with FASD have ADHD as part of their diagnosis. In absence of facial abnormality, FASD may not be apparent to school personnel who might be the first to refer a child. Also, unless the parent is willing to disclose a history of alcohol consumption during pregnancy, ARND may be missed. Denial is one of the psychological effects of alcohol addiction. Facial characteristics of FAS are most apparent between the ages of 2 and 10 years. They are often not as obvious immediately following birth, during adolescence or in adulthood. This transient appearance compounds diagnosis. 

Children with FASD and ADHD have many of the same behavioral characteristics and needs. However, although children with FASD often demonstrate a wide range of behaviors from mild to severe, FASD often involves more severe and intractable behaviors and these children often have more difficulty linking cause and effect. In addition, because 15% of children with FASD have mental retardation, more concrete methods may need to be applied. Many experts feel that modifying the environment is easier than modifying the behavior of the child with FASD. The Ministry of Education in British Columbia has published a handbook on teaching children with FAS. It is available at: http://www.acbr.com/fas 

However, according to the National Center on Birth Defects and Developmental Disabilities, behavioral interventions for children with FASD are currently "often non-specific, unsystematic, and/or lack scientific evaluation or validation." Several university settings are involved in research on educational and behavioral strategies. These include:

  • Marcus Institute- Atlanta
  • Georgia University of Washington - Seattle
  • Washington University of Oklahoma Health Sciences Center - Oklahoma City, Oklahoma
  • Children's Research Triangle - Chicago, Illinois 

For more information about FASD, the relationship of FASD to ADHD, and school interventions, refer to the following websites: 

American Academy of Pediatrics 
www.aap.org 

FAS Community Resource Center
www.come-over.to/FASCRC

National Organization on Fetal Alcohol Syndrome
http://www.nofas.org/main/index2.htm 

National Center on Birth Defects and Developmental Disabilities (NCBDDD)
http://www.cdc.gov/ncbddd/fas/fasask.htm 

An informational CD the includes psycho-educational profiles of students with FASD can be purchased at: 

FASlink 
http://www.acbr.com/faslinkcd.htm


  • I may have ADD, where should I go for help?

Question:

I am 17 and I think I have ADD, but I am not totally sure and am too scared to go for help. I have read lots of internet sites and some books, and I fit into all their descriptions of ADD and have most if not all of the symptoms listed. The only thing holding me back from seeking help is that I sometimes doubt my symptoms are serious enough. Do symptoms of ADD have to be present 100% of the time, or can they be a little less problematic on some days, especially when there is interest in what is going on? Do you think I should go for help? Your opinion would be GREATLY appreciated, because I am quite frustrated by the way I am and will glady accept any help offered. Thanks so much! 

Kimberley


Answer:

Dear Kimberley: 

Thank you for your question. I wish that I could provide you with a simple fill-in the blank test to determine if you have ADHD. However, none exists, nor is ADHD like a medical disease that can be diagnosed with a simple blood test. Symptoms vary from one person to the next and even within an individual over their lifespan. For example, many people who as children were diagnosed with ADHD, impulsive-impulsive or combined type, become less hyperactive when they reach puberty and later qualify as inattentive type. Some individuals who required medication at some point in their life may have periods in life when medication is not necessary.

A hallmark of ADHD is inconsistency. Everyone has periods when they have difficulty attending and organizing. However, the person with ADHD experiences longstanding, severe impairment. Also, most people with ADHD do have a few activities in which their impairments are absent. These tend to be those that rely on active involvement such as sports, computer use, video production, or mechanical activities. Some experts believe that symptoms for women can become more severe before or during their menstrual periods.

Since I don't know you personally, I certainly cannot tell you if your concerns are well-founded. However, I strongly urge you to speak with your parents or school counselor about seeing a professional, particularly since your difficulties are troubling to you. Only a diagnosis by a trained clinician will ease or confirm your fears and give you suggestions about what you can do to alleviate the symptoms that concern you. Also, only a trained clinician can suggest a course of action if you have a diagnosis other than ADHD.

Since you are 17 years old, you should be closely involved in all aspects of a potential assessment. You should help your parents interview the possible candidates for conducting the assessment and should participate in interviews, rating scales, and all other aspects of the assessment.

Assessment by a physician in an hour or less office visit is not now considered to be sufficient. Expect to spend a minimum of two visits in a clinical setting. In a previous Ask A Specialist answer, a link was given to guidelines published by the American Academy of Pediatrics (AAP). In addition to pediatricians, other professionals qualified to diagnose ADHD are:

  • Psychiatrists
  • Clinical and school psychologists
  • Clinical social workers
  • Family practitioners
  • Neurologists

To give you some idea of what to expect when you do seek an evaluation, I've listed some basic components of a thorough assessment.

  • A thorough history of your symptoms than includes interviewing both you and your parents
  • Behavior rating scales
  • Teacher reports
  • A review of school records
  • Direct observations
  • Physical exam
  • Academic and intelligence testing

Some professionals also use computerized "performance tests" consisting of computer tasks that involve inhibiting impulses and organizing responses to visual information. These are not required for an accurate diagnosis. Keep in mind that an assessment will require parent and school participation. However, you can be in the driver's seat.

Some excellent resources about teens with ADHD can be found at Chris Dendy's website: www.chrisdendy.com

Chris is the mother of two boys with ADHD and has collaborated with her son to write a book for teens and young adults called, A Bird's Eye View. This book offers down-to-earth tips for coping with issues such as disorganization, forgetfulness, always being late, sleep problems, memorization procrastination, restlessness, medication, writing essays, and algebra. Contributions are written by teens and young adults with ADHD. Another resource is the video, Teen to Teen: the ADD Experience. This is a great video that features teens on a panel of "experts." The experts are interviewed by other teens and adults about their life experiences. You'll be surprised how normal these kids are!

Good luck in putting together your assessment. Remember to make use of your adult resources. Whether or not you have ADHD, it takes courage to discover who you are.


  • What is the best school environment for a shy, anxious, and gifted adolescent girl?

Question:

What is the best school environment for adolescent girls who are shy, anxious, and gifted with attention deficit? What extra support is necessary? 

Jackson


Answer:

Dear Jackson,

Each teenager is different and has different needs.  Interventions should be individualized to fit the student.  Without knowing your student’s situation, it is difficult to give you specific suggestions.

Each teenager is different and has different needs.  Interventions should be individualized to fit the student.  Without knowing your student’s situation, it is difficult to give you specific suggestions.

However, in general, a student with the characteristics you have described may be eligible for accommodations in the general classroom environment.  I say “may” because the accommodations made possible by Section 504 of the Rehabilitation Act (1973) are designed to prohibit discrimination against individuals with disabilities.  In order to qualify, a student must have or have a record of a serious disability that “substantially limits” one or more life activities.  If your student is “gifted”, a “substantial” limitation becomes more difficult to document.  Determination of eligibility is the responsibility of the school district and can vary from district to district.  Each school district has a Section 504 coordinator.  I would suggest that you contact your school district coordinator for more information if you are interested. You can also request that your student be referred to a student study team if she is experiencing significant difficulty at school.  For more information on what you can expect and on Section 504, please refer to a previous “Ask A Specialist” response to “Anita’s” question that begins “My sixth grade son, who is also …”

Accommodations can include opportunities such as taking tests in a quiet environment, having a set of textbooks at home, or using graph paper to complete mathematics problems.  A wide variety of accommodations are available and each student’s needs are different.  Since your student is a teen, to encourage her to develop independence and take responsibility for her accommodations, she should help determine her accommodations.  She may be interested in filling out a checklist of accommodations.  A checklist is available to download in Chapter 5 of the Self-Advocacy Manual, available at: http://www.ldpride.net/selfadvocacy.htm .  This website contains much other information that may be useful to your teen as she learns to request accommodations and advocate for her needs. 

The special challenges faced by girls with AD/HD have been outlined in a previous Ask A Specialist, beginning “I have an eight year old daughter in the third grade…” Be mindful of the tendency for teenaged girls with AD/HD to develop depression.  Be sure to give her a lot of positive recognition to counter her tendency to be self-critical.  An excellent online resource listed in that article is:  www.addvance.com

An article that might be especially pertinent for you and your student is High School Girls with AD/HD, by Kathleen Nadeau from Attention! Magazine, November/December 2000.  Attention! Magazine is available to the general public and is a benefit of membership in CHADD (Children and Adults with Attention Deficit Disorder.)  

As I mentioned above, a gifted student who has AD/HD will likely face unique challenges.  Giftedness and attention disorders have many behaviors in common.  The list below may be helpful in learning to distinguish between the types of behaviors your teen might demonstrate at any given time: 

Characteristics of Giftedness
Characteristics of Attention 
Deficit Disorder

Reasons well
Strong vocabulary
Excellent memory
Excels in reading comprehension
High energy level
Great sense of humor
Mature judgement
Highly creative
Learns rapidly
Long attention span, but easily bored
Perfectionistic
Highly curious
Grasps abstract concepts, disdains details 
Prefers older companions
Avid reader
Keen observer
Questions authority
Often disinterested in organization
Sensitive
Intense
Wide range of interests 


Vivid imagination

Difficulty organizing thoughts
May talk excessively
Difficulty memorizing facts
Comprehension deficits common
Usually has a high energy level
May be slow to “catch on” to humor
Immature judgement
Often highly creative
Inconsistent performance
Short attention span, easily bored
Easily frustrated
Curious
Problems with careless errors
May have difficulty keeping friends
May have difficulty finishing books
Trouble focusing
Trouble following directions
Disorganized
Often over-reacts
Low motivation
Difficulty focusing on one interest or over focuses

Often imaginative, preoccupied

For additional online resources on the gifted child with AD/HD and other disabilities (ADHD, Asperger's, Tourette, etc.), refer to: 

Subscription address: lyris@gtworld.org 
Send message: subscribe gt-special 
Post messages to: http://www.gtworld.org

The Gifted Student with AD/HD: Between Two Worlds
http://www.ncpamd.com/Gifted_ADD.htm

Gifted and AD/HD: What Do We Know?
http://www.gifted.uconn.edu/kaufkalb.html

Personal story of a gifted 12-year-old girl with AD/HD
http://www.schwablearning.org/articles.asp?r=276


  • Where can I get help for my son who has ADHD?

Question:

I am really feeling like I am losing my son. My son was diagnosed with ADHD two years ago when he was ten. He has been taking Concerta now for about year and a half. This had been working for him. He is in seventh grade this year and wanted to try to attend school without the medication. The first month and half of school was horrible. He was constantly in trouble and was failing 3 out the 5 academic courses. I have since put him back on the medication. The behavioral problems at school have decreased but he still is failing to hand in his homework and is stilling failing most of his classes.

I am afraid that the medication is not enough. He needs some special attention at school. I am unable to help him with his homework because he seems to resist my assistance. The school my son attends does not have any one on the staff that is trained in ADHD. My question is where can I get him the help he needs? I live in Grass Valley, California. I have looked for doctors, counselors or a psychiatrist that specializes in children with ADHD. I need help. I know that continuing to fail at school is not helping his self-esteem. I just don't know how to help him. I have tried to help him organize his notebook, homework and to study for his tests but I am just not getting through to him.

Can you help?????? Desperate Mom


Answer:

Dear Desperate,

Carefully monitored medication is the most effective treatment for ADHD, and does help students attend. However, no medication can teach organization and study skills. A combination of medication, psycho-social, and educational interventions have the best outcome for most students with ADHD. As a parent, you can help your son by: 

Continuing to educate yourself and you son about ADHD
Communicating with his teachers about the educational implications of ADHD
Advocating for the services that your son needs
Working with his teachers to help him learn organization skills

At school, your son could be eligible for Section 504 accommodations under the category "other health impaired." Depending on the severity of his impairment, he may also be eligible for special education and an Individual Education Plan (IEP). As a parent, you can ask him to be evaluated for Section 504 and/or special education services if you feel this would be helpful. Section 504 accommodations allow him to remain in the general classroom without the stigma often attached to special education. With accommodations, your son can have shortened assignments, a list of assignments in advance, and other supports that give him access to the curriculum. You may be interested in taking our online course about Section 504 to help you determine which type of service is best. The training is available at:

http://www.dcn-cde.ca.gov/504/504_index.htm

You and your family would probably benefit from the support of other families experiencing similar challenges. I have frequently referred to the organization Children and Adults with Attention Deficit Disorder (CHADD). CHADD provides information, resources and support for supporting children who have attention disorders. Although it doesn't appear that they have an in-person group in Grass Valley, membership in CHADD entitles you to join online discussion groups and real time chats with the experts and to have access to articles like the one above. For more information, visit:http://www.chadd.org

Another organization you might want to be aware of is the Kitty Petty ADD/LD Institute. This group maintains a list of professionals recommended by their members. If you are looking for a counselor, psychiatrist, pediatrician or coach, their list may be helpful. The KP Institute is online at:http://www.kpinst.org

As you continually educate yourself about ADHD, you will want to help your son understand his difficulties and learn to advocate for himself. Although 95% of students with ADHD do not graduate from college, those that do are successful because they understand their attention problems and know when and how to ask for help. Chris Zeigler-Dendy is a mother, educator, and mental health professional who has raised a son with ADHD. She has written extensively about parenting and educating teens. She also conducts teen panels where students from middle school through early college share their experiences and has captured one of these on a video, "Teen to Teen: The ADD Experience" which might be enlightening for you and your son to watch. She and her son, Alex, have written a book with students from one of these panels entitled, "A Birds Eye View of Life with ADD and ADHD: Advice from Young Survivors" which is an excellent resource for educating teens about attention problems. Her products are available at:http://www.chrisdendy.com

You and your son will need to communicate with his teachers about his needs. Sadly, many teachers need to be convinced that kids with ADHD are not just lazy. Many families have found that giving teachers a portfolio of information on attention deficit disorder and ways that ADHD interferes with success in school is helpful. Consider scheduling a conference with each of your son's teachers early in the year to discuss his accommodations and to share information about ADHD. Avoid power struggles with teachers at all costs. Instead, support your son to share with the teachers how he learns best. Follow this link to an article titled, "Executive Function" that I've found to be informative for teachers.

When you have secured appropriate services, you will need to work closely with your son's teachers to improve his organizational skills. Even after he enters high school, you will probably need to call teachers to keep up with his progress. Be sure to involve your son in determining accommodations and train him to eventually take over the job of communicating with teachers. Set up a system with his teachers for communicating about homework. Homework can be posted on a website. If your son tends to lose work, he could e-mail his assignments directly to the teacher. Your son may be able to take around an assignment sheet to be checked by his teachers.

Don't give up yet! Remember, what's lost can be found. Many parents have had similar experiences. The link below leads to a story about an amazing family. Perhaps their story will give you hope... "From Police Calls to College Halls".