Archive for the ‘ADHD’ Category

ADHD in Adults:  Maybe its not only your kid?

Friday, September 1st, 2006

Barkley (2006) and Wender (2000) carefully looked at data across numerous studies and concluded that ADHD can be found in 2%-7% of the adult population, with 4% being the generally accepted rate.  While the gender ratio in children is about 6 to 1, boys over girls, in adults, the incidence rate has been reported to be 2 to 1 with some suggesting it approaches 1 to 1 (Resnick, 2005).

So what accounts for this dramatic change in how ADHD affects children as compared with adults.  Do boys grow into it or grow out of it? Maybe girls grow up and develop it?  Perhaps, the best way to conceptualize adult ADHD is to utilize concepts associated with executive functioning.  Problems with self-control, delay of gratification, affect regulation, planning, organizing and selecting, dividing, and sustaining attention often impact the ADHD adult’s life.  Maybe it’s the demands on adults, different than those on children that account for the change.

Whether I work with children or adults, I always conduct a careful mental status examination to rule out disorders that can mimic ADHD, e.g., depression, anxiety, and substance abuse.  Other considerations are the possibility of sleep apnea, head trauma, lead toxicity, and seizure disorders as they can mimic ADHD.  Further, there can be co-morbid conditions that mask underlying ADHD.  Women, for example, are frequently treated for depression without detecting the underlying ADHD.  Women with ADHD are more likely to report dysphoria while men are more likely to report conduct problems (Quinn, 2005).  Anxiety, stress and bi-polar disorder can also mask ADHD.  Questions that might need to be asked in an Adult ADHD evaluation include:

  1. Does the person describe difficulties with problems in self-control, and self-regulating behavior?

  2. Does the person have poor working memory and access it inconsistently?

  3. Is the person forgetful – even for pleasant and desirable things or events?

  4. Are there organizational problems?

  5. Does the person have poor persistence in task effort?

  6. Is the person often late and have poor time perception?

  7. Does the person say they are easily bored?

 

Some other areas to think about that may be the result of adult ADHD include:

  1. Reactivity:  does the person over or under react to the environment?

  2. Risk Taking:  does the person not tolerate low stimulation and/or crave novelty?

  3. Is the person prone to temper outbursts, with a quick “on” or a slow “off”?

  4. Is the person struggling to sustain motivation?

  5. How are their social skills and social judgment?

  6. How is their sleep, e.g., restless, or trouble falling or staying asleep?

  7. How is their frustration tolerance?

  8. How forgetful are they?

 

ADHD adults in my practice receive coaching more often than psychotherapy, and often the treatment is intermittent rather than ongoing.  Many of the adults that I see derive benefit from psychostimulants.  All stimulants are either dextro amphetamine or methylphenidate molecules.  The 14 products on the market differ in the delivery system and the length of time that the drug is effective.  Side effect profiles are similar with the most common being a loss of appetite, insomnia, and stomach discomfort.  All stimulants, if effective, are immediately effective (though further titration of dose is often necessary) and have no cumulative therapeutic effect.  Rather, each does is a discrete event.

ADHD adults may require cognitive-behavioral therapy to help them change the negative messages from others in the past to more realistic and positive thoughts.  Neutralizing these old experiences inspires hope as well.  Marital therapy is also often an adjunct component of treatment. 

Treatment plans are often multi-modal and frequently need to change over time.  Adults who think they may have ADHD are encouraged to seek an evaluation and get help with the symptoms with which they may have been struggling for a very long time.

References

Barkley, R.A. (2006). Attention deficit hyperactivity disorder:  A handbook for diagnosis and treatment.  New York:  The Guilford Press.

Resnick, R.J. (2005).  Attention deficit hyperactivity disorder in teens and adults:  They don’t all outgrow it.  Journal of Clinical Psychology:  In Session, 61, 529-534.

Wender, P.H. (2000).  ADHD:  Attention-deficit hyperactivity disorder in adults. New York:  Oxford University Press.

 

September 2006

 

 

 

ADHD:  How Does Intellectual Ability Affect its Impact?

Wednesday, March 1st, 2006

It is widely accepted that there are two sets of behaviors associated with the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) First, there is the Hyperactive-Impulsive component (ADHD-H), and second, there is the Inattentive component (ADHD-I).  A third type is described as the combined type that includes both dimensions.

Children with ADHD are characterized as having poor behavioral inhibition (Barkley, 1997).  Their symptoms include poor planning and anticipation, reduced sensitivity to errors, poor organization, impaired verbal problem-solving and self-directed speech, poor rule-governed behavior, poor self-regulation of emotions, and problems developing, using and monitoring organizational strategies.

When thinking about ADHD, I often wonder about how a child or adult would score on an intelligence test that loads heavily on those areas of functioning that are most affected by ADHD. One such intelligence test is the Cognitive Assessment System, which utilizes the PASS theory of intelligence.  Briefly, the PASS theory (Naglieri & Das, 2005) is rooted in the work of A.R. Luria, and was used by Naglieri and Das (1997) as a blue-print for defining core components of human intelligence that are assessed in the Cognitive Assessment System (CAS) (Naglieri & DAS, 1997).  There are four basic cognitive processes that the CAS examines:  Planning is a cognitive process that provides cognitive control, use of knowledge, intentionality, and self-regulation.  Planning is critical to all activities where the person has to determine how to solve a problem, which includes self-monitoring and impulse control as well as generation, evaluation, and execution of strategies for problem solving.  Attention is a cognitive process that provides focused, selective cognitive activity over time and resistance to distraction.  Attention is involved when a person selectively focuses on particular stimuli and inhibits responses to competing stimuli.  The process provides focused and selective attention over time.  Focused attention involves directed concentration toward a particular activity and selective attention is important for the inhibition of responses to distracting stimuli.  Simultaneous Processing is a cognitive process used to integrate stimuli into groups.  An essential aspect of simultaneous processing is the conceptualization of interrelated elements into a whole, which is why this process is often tested using visual spatial tasks.  Successive Processing is a cognitive process used when stimuli are arranged in a specific serial order to form a chain-like progression.  This process is required when information must follow a strictly defined order where each element is only related to those that precede it and these stimuli are not interrelated.  There have been several studies that have examined the performance of children with ADHD from the PASS perspective.

Naglieri summarized the research on samples of children with ADHD-Hyperactive Type.   These studies have indicated that children with ADHD-H earn average scores on all measures of PASS except Planning.  These findings are particularly noteworthy because they are in contrast to profiles reported for children with reading disabilities, who are low on Successive processing, and children who have anxiety disorders, who show no PASS weakness.  Children with ADHD-I, as expected, typically perform poorest on Attention. Two important issues should be considered when a diagnosis of ADHD-H or ADHD-I is made, based in part on a disorder in cognitive processing.  First, it is important to differentiate between children who have a relative weakness in basic processing (e.g., Planning – 95; Attention = 115; Simultaneous – 115; Successive = 115) from those who have a true cognitive weakness (e.g., Planning = 80; Attention = 115; Simultaneous = 115; Successive = 115) in cognitive processing.

Second, children with a cognitive weakness in Planning (possibly ADHD-H) or Attention (possibly AHDH-I) could qualify for special educational services for having a specific learning disability.  Current IDEA (2004) law defines a specific learning disability as “a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, which disorder may manifest itself in the imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations”. ADHD children with a planning and/or attention cognitive weakness who have impaired academic functioning should be considered eligible for special educational services, when those weakness negatively impact their abilities in the above noted areas.

In summary, utilizing the PASS theory to and the CAS to uncover weaknesses in one or more  basic psychological processes allows for a better understanding and more targeted way to educate and treat individuals with attention deficits.  Psychologists who are working with ADHD persons need to be aware of the cognitive issues briefly outlined herein, in order to optimally care for children with ADHD.

References Barkley, R.A. (1997).  ADHD and the Nature of Self-Control.  New York: Guilford Naglieri, J.A., & Das, J.P. (1997).  Cognitive Assessment System.  Itasca, IL:  Riverside. Naglieri, J.A. & Das, J.P. (2005).  Planning, attention, simultaneous, successive (PASS) theory:  A revision of the concept of intelligence.  In D.P. Flanagan & P.L. Harrison (eds.), Contemporary Intellectual Assessment:  Theories, Tests, and Issues, New York: Guilford.

 

March 2006

 

Executive Functioning

Sunday, April 4th, 2004

I have long been interested in how Executive Functioning, or the ability to plan, organize, problem-solve, strategize, and inhibit undesirable responses, impacts both children and adults.

We need to credit Stuss and Benson (1986) for giving us possibly the most comprehensive definition of Executive Functioning. They detailed issues such as Planning and Sequencing, Paying attention to several different components at once, Grasping the gist of a situation, Resisting distraction and interference, Inhibiting inappropriate response tendencies, and Sustaining behavioral output for a sustained period of time. Harris (1991) discussed self-regulation, set-maintenance, selecting, prioritizing, organizing time and space, selective inhibition, cognitive flexibility, and output efficiency. Russell Barkley (1997) gave us a simple but truly elegant definition: “Those self-directed actions of the individual that are being used to self-regulate”. Personally I like: POPSI: Plan, Organize, Problem-solve, Strategize, and Inhibit undesirable responses. Regardless of how you want to think about executive functioning, almost all will agree it has enormous influence on how we function in life.

I began my interest in executive functioning with my training in neuropsychology and my work with ADHD Children in the early 1980′s.

In the late 1980′s, when I began working with many autistic spectrum disordered children, I began seeing how important executive functioning was in their lives, in particular, with high functioning autistic spectrum disordered children and Aspergers Disorder children. In the 1990′s, I became interested in variations in learning, and so often executive functioning played a role here as well. When I began doing Executive Coaching in 2001, I realized that many adults had very well developed executive functioning skills, but there were other things missing.

With the WISC IV revisions of 2003, and the beginning move away from the ability-achievement discrepancy model, I became confident that executive functioning would now move into the mainstream of educators’ thinking. This is so important because without it, the long established ability-achievement discrepancy model relies upon a faulty premise, that is, a wait to fail mentality.

The WISC IV has an increased emphasis on Fluid Reasoning and Working Memory, and a more clear mandate to look at how the child got the answer. This will eventually force educators to begin to look at the pre-referral side of special education. The WISC IV abandoned a Verbal IQ and a Performance IQ, and now looks at 4 Indexes: Verbal Comprehension Index, Perceptual Reasoning Index, Working Memory and Processing Speed Index. These four indices contribute to a Full Scale IQ Score. And so, now that David Wechsler is adopting executive functioning constructs as central to assessing intelligence, I believe executive functioning will come into the mainstream of educators’ thinking.

This all became crystal clear to me when my son, Jacob, went through the college application process this past year, and despite being an all around outstanding young man with high SAT’s, a 95 point GPA, excellent scores on all five of his AP exams, and being named as an honorable mention linebacker on the local football team (NCN Westchester), he certainly showed me how a very smart kid can have some deficits in executive functioning. I recalled that in the NY Times this past summer (08/26/03) Martha Denckla, M.D., was quoted “What fascinates me is kids who go off to school with perfect SAT’s and then flunk out because there is too little structure for their scattered minds. She says, “On your own” is a death knell for these kids.” I have tried to prepare my son, but we will see.

April 2004

Writing Strategies

Monday, March 1st, 2004

Writing is the window into what your child knows. Enhancing writing strategies can help to promote your child’s self-image to include that of being a good student. I’ve outlined a few ideas below:

  • Encourage your children to organize their thoughts before beginning a written assignment.
  • Write at least two drafts.
  • Have your child proofread and check for:
    1. Answering the purpose of the assignment
    2. Legibility
    3. Neatness
    4. Spelling
    5. Complete sentences, and
    6. Punctuation errors.
  • Help your child to see tests as an opportunity to “show off” what they have learned, rather than something to be feared.
  • Help your children predict test questions as they study for tests.
  • Encourage your child to space learning over several sessions instead of cramming the night before. Five hours of studying, spread over a week is better than studying five hours the night before the test: cramming for tests increases anxiety and often does not produce higher grades.
  • Avoid acting as a tutor for your child. If a child needs a tutor in a particular subject, see if the local high school can provide you with a student tutor through the National Honor Society.

03/04

 

ADHD Kids: What Happens When We Take Away Recess?

Thursday, April 3rd, 2003

A recently published study published in the School Psychology Quarterly (Fall 2003) showed that levels of inappropriate behavior were substantially higher on days when ADHD boys with a diagnosis of ADHD did not have recess, compared with days when they did have recess. Just what I’ve been telling school administrators for 20 years!!!!

The results did show that inappropriate behavior generally increased over time for all participants, that is, also the typical peer groups that were matched to each student with a diagnosis of ADHD, on days when there was no recess. However, this progressive increase of inappropriate behavior over time did not occur on days when the participants did have recess. This effect of preventing further inappropriate behavior, rather than resulting in an immediate decrease in inappropriate behavior, may partially contribute to teachers’ informal reports that they do not observe any immediate benefits associated with recess.

The results of this study are consistent with previous findings that have shown children become less attentive as a function of time of classroom confinement (Pellegrini et al., 1995) and that, in general, children are more on task and fidget less when they had recess, compared with when they did not have recess.

Of greatest importance is to remember that just about all children with a diagnosis of ADHD will benefit from recess in regards to their classroom behavior.

Ridgeway. A. and Northrup, J., et al., (2003) Effects of recess on classroom behavior, School Psychology Quarterly, New York Guilford

Pellegrini, A. (1995) School recess and playground behavior, Educational and Developmental roles, Albany, NY SUNY Press

April 2003

Dr. Alan Tepp currently practices in the areas of child psychology, adolescent psychology, adult psychology, couples and marital therapy, and forensic psychology, serving Northern Westchester and the surrounding areas with offices in Mt. Kisco NY, Fishkill, NY and Ridgefield, CT. To learn more, contact Dr. Tepp today to see how he can help you or a family member.