CA Dept. of Education

Home

Attention Deficit Hyperactivity Disorder Archive 2012

bc  

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.

Submit A Question

Click a topic below to expand the full question and answer.

  • Upcoming new DSM-V Criteria for AD/HD

Question:

I’ve heard the qualifications for a diagnosis of AD/HD may be changing. Is this true? What’s up for the future?

Concerned teacher


Answer:

There are a number of changes occurring in the diagnosis of ADHD. These will be introduced in the Diagnostic and Statistical Manual, Fifth Edition (DSM-5), to be published by the American Psychiatric Association in May, 2013. The new manual will be released at the APA conference in San Francisco this May 18-22. Until then, the currently used Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR) remains the standard for assessment.

The DSM-5 is the compendium of diagnostic criteria for mental disorders used by psychiatrists, psychologists, neurologists, social workers and other mental health clinicians. The DSM, first published in 1951 and periodically updated since, helps to insure consistency in diagnosis between clinicians. Revisions are designed by workgroups consisting of global experts in various diagnoses. The manual is organized by chapters based on specific characteristics. The chapters are organized by categories that reflect potentially common etiology within larger disorder groups. In organizing and delineating diagnoses, creators of the DSM-5 have placed the highest priority on clinical usefulness and additional priority on continuity from one edition to the next. Revisions are based on existing research.

During the past few years, many controversial reforms in the diagnosis of ADHD have been proposed, but according to the APA document “Highlights of Changes form DSM-IV-TR to DSM-5”, little change will take place in the basic 18 symptoms that have formed the core of the diagnosis in the DSM-IV-TR. Symptoms will continue to be divided into the two domains of inattention and hyperactivity/impulsivity. Six symptoms in one domain will continue to be a qualification for diagnosis. However, “subtypes” have been replaced with “ presentation specifiers” that map directly to the prior subtypes. Also, the need for symptoms to be present in two or more environments will be strengthened to specify “several symptoms” in each setting.

Some significant changes have been made in response to scientific advances in the study of the brain. ADHD will no longer be included in the category of Disruptive Behavior Disorders. Now that ADHD is known to be present throughout the lifespan, it will no longer be listed in the chapter “Disorders Usually First Diagnosed in Childhood. “ Instead, in recognition of recent information about the neurological basis for ADHD, it will be listed in the neurodevelopmental disorders chapter.

Several other changes will be made to highlight the lifespan nature of ADHD. Criteria for onset will now be prior to age 12 rather than age 7. Because adult symptoms are different from childhood symptoms, the wording has been revised and examples have been added that apply to adults as well as children. Because adult presentation is different, often with less hyperactivity, the cutoff for adult diagnosis will be five rather than six symptoms.

Finally, individuals with autism spectrum disorder will also be eligible for ADHD diagnosis.

For addition information, please refer to the American Psychiatric Association DSM-5 information website:

www.dsm5.org


  • Update on Interactive Metronome

Question:

Our adult son, age 30, feels he may have AD/HD and would like further information. Where do we start for testing?

Thank you,
Lynn


Answer:

Hello, Lynn-

You are posing a timely question. There has been a lot of interest lately in adult AD/HD. Approximately 2-5% of the adult population has AD/HD. Although adult AD/HD has been recognized since the early 1990’s, criteria specific to adults have not been formulated until recently, complicating assessment.

The fifth edition of the Diagnostic and Statistical Manual (DSM-5), the handbook for diagnosing mental health conditions is scheduled for publication in May, 2013. Many psychiatrists, in particular Dr. Russell Barkley, have advocated including additional criteria for adult AD/HD. Previously, the criteria was oriented around the behavior of young children, ages 8-12 years. Criteria has included descriptions of childish behaviors such as “often runs about or climbs excessively.” The current proposed revisions include some significant changes that use language acknowledging differences in symptoms in young children and adults but do not list separate criteria. With these changes coming soon, hopefully, your son will receive a more accurate diagnosis than he might have a few years ago.

To obtain an assessment, your son will need to visit a licensed mental health professional such as a psychiatrist, neurologist, psychologist, or clinical social worker. Only a psychiatrist or neurologist is licensed to prescribe medication. Your son will want to find a professional who has had experience in diagnosing and treating adults with AD/HD. One way to find such a professional is to have your son speak with his primary care physician. He or she may be able to use a screening questionnaire to determine if your son’s concerns warrant further assessment.

If your son does not feel comfortable speaking with his physician or does not have a regular primary care physician, he could consider other sources of referrals.

  • Contact your state psychiatric or psychological association.
  • Explore the websites of nonprofit organizations devoted to AD/HD. Both Children and Adults with Attention Deficit Disorder (CHADD) and Attention Deficit Disorder Association (ADDA) listed in the Resources, contain advice about diagnosing AD/HD in adults. Local CHADD chapters often offer group support for adults with AD/HD and also often have a list of local professionals who specialize in this population. ADDA has a list of professionals by area on their website.
  • Attend a CHADD meeting for adults and ask for personal recommendations from members.
  • Contact a local university hospital or psychology department .

Knowing what to expect ahead of time will help your son feel more comfortable. Assessment of adults for AD/HD typically consist of the following:

  • Use of rating scales filled out by him and sometimes someone who knew him as a child
  • A personal interview
  • A review of previous records, such as school or job reports that might document possible impairment
  • A general physical exam when medication is being considered
  • Psychological assessment of general cognitive ability and academic assessment
  • Possible tests of attention, inhibition and memory

To be prepared, your son may want to gather and bring with him:

  • School records from both college and high school, if these are still available
  • Medical records and records from mental health professionals
  • Driving, job evaluations, and any criminal records or other documentation of problems related to possible ADHD
  • Contact information for people who know him well and would be willing to speak frankly about possible symptoms
  • List of family history of mental health difficulties
  • Description of problems in childhood and adolescence that may be relevant

Your son may want to visit and interview several professionals before making the decision to choose one. Encourage your son to formulate some questions ahead of time to evaluate whether he wants to continue with particular professional. Some questions Dr. Barkley suggests are:

  • What percentage of your practice is made up of adults with AD/HD?
  • How long have you been treating adults with AD/HD?
  • What was your area of medical specialty? Are you board certified?
  • How long does it take to get an appointment?
  • What types of insurance do you accept? What are your fees?
  • Following diagnosis, do you provide treatment? If not, where are patients typically referred?
  • Can you refer me to nearby resources such as coaches and support groups?

Best wishes to you and your son in exploring this diagnosis. For additional information, please refer to these resources:

Books

Barkley, R. & Benton, C. (2010) Taking Charge of Adult ADHD. New York, New York: The Guilford Press.
Hallowell, E. & Ratey, J. (2011) Driven to Distraction, Revised. New York, New York: Random House
Pera,G. (2008) Is It You, Me or My Adult ADHD? San Francisco, CA: Alarm Press

Websites

Attention Deficit Disorder Association (ADDA). http://www.add.org/
Children and Adults with Attention Deficit Disorder. http://www.chadd.org/
Russell Barkley. www.russellbarkley.org


  • Bullying and Students with Special Needs

Dear Ask A Specialist Readers,

Did you know that children with disabilities are at an increased risk of being bullied?  Any number of factors:  physical vulnerability, social skill challenges, or intolerant environments, may increase the risk. Research suggests that some children with disabilities may even bully others as well.

On April 3, 2012 the U.S. Education Secretary, Arne Duncan, and Health and Human Services (HHS) Secretary, Kathleen Sebelius, unveiled the revitalized Stop Bullying website: www.stopbullying.gov.

The Stop Bullying Website:

“The site encourages children, parents, educators, and communities to take action to stop and prevent bullying, and provides a map with detailed information on state laws and policies, interactive webisodes and videos for young people, practical strategies for schools and communities to ensure safe environments, and suggestions on how parents can talk about this sensitive subject with their children. The site also explores the dangers of cyberbullying and steps youngsters and parents can take to fight it.”

Special Resources to Help Children with Disabilities:

This website also provides special resources to help children with disabilities who are bullied or who bully others. The website illustrates how IEPs or Section 504 plans can be useful in designing specialized approaches for preventing and responding to bullying.  Additionally, the website discusses how civil rights laws protect students with disabilities against harassment. That is, when bullying is directed at a child because of his or her disability and it creates a hostile environment at school, bullying behavior may cross the line and become “disability harassment.”  Under Section 504 of the Rehabilitation Act of 1973 and Title II of the Americans with Disabilities Act of 1990, the school must address the harassment.

Act Now!

We know that bullying can negatively impact a student’s ability to learn and threaten their physical and emotional safety at school. We know, too, that the best way to address bullying is to stop it before it starts. The Stop Bullying website and the other websites listed in the Resources provide a number of actions school staff can take to make schools safer and prevent bullying.

We here at Ask A Specialist encourage you to do your part to help all students be safe at school.

Submitted by Ann England, Assistant Director, Diagnostic Center, Northern California on behalf of all the Ask A Specialist Contributors

RESOURCES:

  • Positive Behavioral Interventions and Supports

  • Update on Interactive Metronome

Question:

Dear Shari,

Have you heard of the interactive metronome? How does it work? I have two kids, ages 6 and 9 with AD/HD. Can it help them?

Edward


Answer:

Hello Edward,

Thank you for the interesting question. Several years ago, another reader posed a similar question about the Interactive Metronome (IM) which I addressed. I will provide an update now, but the basic background information hasn’t changed. Please look back to 2007 Archives, “Is Interactive Metronome Worth a Shot” at the link below for basic information:

http://www.askaspecialist.ca.gov/archives/ADHD/2007.html

Just to summarize, implementation of IM for AD/HD children is based on the assumption that deficits in attention and concentration are related to motor planning and timing. In addition, stimulant medication improves motor planning and timing, possibly leading to the conclusion that interventions like IM that improve motor timing and planning would help students with AD/HD. Whether there is a connection between poor motor coordination and inattentive symptoms of AD/HD is controversial.

If you would like to see how IM looks and works, check out this You Tube video:

http://www.youtube.com/watch?v=S1407F_Tw-Y

Since my first response appeared, two additional studies on the effect of IM on learning and behavior were published. One addresses improved reading achievement; the other improved AD/HD symptoms. The second study, completed in 2010, found favorable results with improving signal detection and by implication, attentional focus, in boys, aged 6-11 years, with AD/HD and appeared in a peer-reviewed journal. Unfortunately, more studies are needed before this intervention can be considered “tried and true.” By comparison, consider that hundreds of studies, involving over 6,000 individuals have been conducted to determine the effects of stimulant medication.

When choosing interventions for you children, consider if these have been well researched and that findings have been published not by the advocate of the treatment, but by recognized experts in the field. Often alternative treatments are simply supported by testimonials of individuals claiming to have benefited from the treatment or by single case studies. An excellent source for guidelines when considering any treatment is the article, “Complementary and Alternative Treatments for AD/HD” by the National Resource Center on AD/HD (see Resources.)

In conclusion, I would like to suggest that IM continues to fall in the category of “promising” for treatment of AD/HD and might be considered as “complementary” but not in place of multimodal treatment. Consultation with your children’s treating physician is recommended before beginning any alternative treatment.

Resources:

Interactive Metronome website: www.interactivemetronome.com

Leisman,G. & Melillo, R. Effects of Motor Sequence Training on Attentional Performance in ADHD Children.

National Resource Center on AD/HD. Complementary and Alternative Treatments for AD/HD. What We Know #6. www.help4adhd.org


  • Isn’t AD/HD just a disorder that involves being forgetful and fidgeting?

Question:

Hello, Shari

I have a twelve year-old son who has been diagnosed with AD/HD. Unfortunately, losing papers at school and failing to do homework is the least of his problems. He is chronically under-achieving, but his temper outbursts at home really disrupt the whole family. His outbursts seem totally out of proportion to the issues. Thinking that he must have something else besides AD/HD, I took him to a local clinic for an assessment. They said the problem is just severe AD/HD. How can this be? Isn’t AD/HD just a disorder that involves being forgetful and fidgeting? I’m just not sure where to go from here. He’s already being treated with AD/HD medication.

Sylvia


Answer:

Dear Sylvia,

Sounds like you have a difficult situation at home. Perhaps having further understanding of the emotional issues involved in AD/HD may be helpful.

A diagnosis of AD/HD is based on criteria in a handbook called the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) published by the American Psychiatric Association (APA.) DSM-IV-TR was first published eleven years ago and was a revision of the DSM-IV, published in 1994. Since publication, many advances have been made in understanding the neurology of AD/HD.

In addition, the old criteria were based on studies of children. Since that time, AD/HD has been found to be a lifelong condition. Consequently, the APA is in the process of formulating an updated handbook, the DSM-V, which will be published in the next few years. The new criteria for AD/HD hopefully will reflect recent scientific advances. Because the criteria being used do not yet reflect the state of the science, many lay people are not aware of some of the changes that have taken place.

One characteristic of AD/HD that is not reflected in the DSM-IV-TR is that individuals with AD/HD generally experience executive function difficulties. Executive functioning can be defined as “a set of processes that all have to do with managing oneself and one's resources in order to achieve a goal. It is an umbrella term for the neurologically-based skills involving mental control and self-regulation.These mental processes govern our behavior and actions.” (Kouper-Kahn, J. & Dietsel, L.) Examples of executive functions include:

  • Inhibiting behavior at the appropriate time
  • Shifting from one activity or experience to another
  • Emotional control
  • Initiating tasks
  • Using working memory
  • Planning
  • Organizing
  • Self-monitoring progress

Dr. Russell Barkley, a well-known researcher and expert in the area of AD/HD, finds a direct link between emotional control and AD/HD. Emotions can become dysfunctional in their intensity and in their inhibition or control. Studies have shown that the person with AD/HD is quicker to show emotion and his or her emotions are stronger than typical individuals. This may be socially acceptable, or at least forgivable if the emotions are positive such as affection, excitement or enthusiasm. Where this presents a problem for the person with AD/HD, according to Dr. Barkley, is when the individual experiences negative emotions such as frustration and anger. Strong expression of negative emotions in our society generally leads to negative consequences for that individual.

Emotions and executive function are directly linked to motivation. In order to focus on a goal, one must be able to inhibit the desire to do something that would produce a more immediate reward. To achieve a goal, such as completing a homework assignment, when there are no immediate rewards, one must be able to imagine and remind oneself of the positive emotion one will feel at completion. Your son may be having difficulty with school because of problems in modulating his emotions and in other executive functions. He then becomes discouraged and acts out at home where he feels safe.

I do not know your son and so am unable to suggest specific interventions for your family, but some basic principles apply. First of all, behavior is communication. Your son is likely trying to tell you something when he acts out. Secondly, be proactive. Know what pushes his buttons and try to direct him to express his feelings in a more positive way. Consider professional support such as family therapy, to open up lines of communication so you have a clearer understanding about what your son is attempting to communicate and how to respond.

Finally, the most important goal for your family is to keep everyone safe. Broken doors can be repaired, but physical injuries are more difficult to heal. With the help of a professional, consider formulating an action plan ahead of time so that your family knows what to do when your son becomes angry. Any person in the middle of a rage is overpowered by the intensity of their emotion and is unable to reason clearly. Avoid confronting your son when he tantrums. One option for some families is to leave the area where the child is raging. Also, with a professional, think about what sort of consequences are appropriate when your son expresses anger in an acceptable way and when all else fails and he destroys property. Restitutions is often an appropriate consequence. Your son may also benefit from anger management training with a professional.

Resources:

Barkley, R. (2011) A New Look at ADHD: Treatment for Multiple Mental Health Disorders and Emotional Regulation. Eau Claire, WI: CMI Education

Cooper-Kahn, J. & Dietzel, L. (2008) Late, Lost, and Unprepared. Bethesda, MD: Woodbine House

National Center for Learning Disabilities (NCLD) (2008). Executive Function Fact Sheet.
Found online at: http://www.ldonline.org/article/24880


  • Prognosis for student with AD/HD

Question:

Hello, Shari

I have a 5th grade boy diagnosed with AD/HD. After trying several medications, he is on Strattera now and it is working very well (though costly). What is the prognosis for people with ADHD? Will my son be on medication his entire life? Will it get better? He is very bright - but the movement, dips and dives in mood, and impulsive behavior are challenging when he's off the meds.

Kim G.


Answer:

Dear Kim,

AD/HD occurs in a range of severity, from mild to severe. In addition to the severity of AD/HD, intelligence and social development have a positive effect on prognosis. Children with above average cognitive ability are often better able to compensate for their weaknesses over time.

The statistics can be disheartening for individuals who do not receive treatment. Students who receive medical, psychosocial, behavioral and educational treatment, have the best chance of a positive outcome. Maintaining interventions over a long period of time will also improve your son’s chances.

That said, the good news is that research studies indicate between 25 and 35% (Barkley) of children with AD/HD will eventually outgrow the disorder. In 2007, the National Institute of Mental Health(NIMH) completed a landmark study comparing brain development of children with AD/HD and healthy children and found that the brains of children with AD/HD develop in the same way as the healthy brain, but later (see link in Resources.) Dr. Russell Barkley, a prominent researcher in the area of AD/HD, refers to a 30% delay in social-emotional and self-sufficiency functioning for individuals with AD/HD. The NIMH study found that the brains of individuals with AD/HD continue to develop over a longer period of time than normal and reach maturity when the individual reaches his or her thirties.

The general trend as a child matures is improvement in symptoms. In addition, symptoms seem to change over time. One of the first changes you may see with your son is a decrease in hyperactivity that generally occurs when a child enters puberty. Eighty five percent of children with AD/HD continue to experience symptoms as teens. They are at higher risk for automobile accidents, accidents in general, being involved in a teen pregnancy, substance abuse, and problems with the law. One study indicates that 54% of AD/HD teens have been arrested at least once by the time they reach age 21. The risk of substance abuse seems to be directly related to whether the teen receives medical treatment for AD/HD. Without medical treatment, the young adult with AD/HD is nearly twice as likely to abuse a substance. However, with teens who are treated, that figure drops to at or below the level for non-AD/HD students. Nearly 70% of individuals with AD/HD develop co-existing mental health conditions such as oppositional defiant disorder (50+%), conduct problems and anti-social difficulties (25-40%) learning disabilities (25-40%), depression (25-30%) and low self-esteem.

One major impact for individuals with AD/HD is poor educational outcome. Sadly, although many young people may mature later, by the time they reach maturity in their 30’s, their opportunity for education has slipped by. Most are undereducated in relationship to their intellectual ability. A recent study at the University of California, Davis MIND Institute (Schweitzer, 2010) indicated that students with AD/HD are more likely to drop out or delay high school graduation than those with other mental health disorders. The rate for high school incompletion for students with AD/HD, combined type, is 33.2%, compared to 15.2 % for those with no psychiatric diagnosis. For those who do go on to college, those with AD/HD have a graduation rate of just 5% compared to the typical rate of 35% (Milwaukee Young Adult Study, Barkley, et.al., 2008)

As adults, many individuals with AD/HD may have symptoms that no longer meet criteria for AD/HD. These criteria were primarily based on studies of children and adolescents. New criteria due out in 2013 may include criteria specific to adults. Although may adults do not meet the present criteria, the persistence of impairment at age 27 is estimated to be 65-85% (Barkley, 2008) As adults, individuals with AD/HD are more likely to be underemployed, to experience divorce, to have auto accidents, and to have committed a violent crime or to have antisocial difficulties.

These are grim statistics, however many of the studies are based on individuals seen in a clinic setting where the disability tends to be most severe. In addition, positive parenting, medical treatment, and appropriate school support can minimize the negative outcomes. Most of the negative outcomes are not a direct result of the primary problems of inattention, hyperactivity and impulsivity, but the secondary behavioral, social and academic difficulties. Young people who manage to get along with their peers and have good family relationships as well as those with higher intellectual functioning are more likely to experience a better outcome.

As a parent, the best attitude is to understand that your child may develop differently than is typical. For example, individuals with AD/HD may do best if driving is delayed a year or two and often become independent from their families at a later age. If you are ready for these differences and are able to accept your child for who he is, you will be in a position to be flexible, positive and supportive. These parenting attributes will lead to a positive relationship that can maximize the outcome for your child.

 

RESOURCES:

Barkley, Russell. Fact Sheets; ADHD: Nature, Course, Outcomes, and Comorbidity http://www.russellbarkley.org/

Cassels, C. High School Incompletion Rates Highest in Teens with ADHD. Journal of Psychiatric Research, published online July 16, 2010.

National Institute of Mental Health (2007), press release. http://www.nimh.nih.gov/science-news/2007/brain-matures-a-few-years-late-in-adhd-but-follows-normal-pattern.shtml

Rabiner, D. www.helpforadd.com/long-term-outcomes/