ADHD: Disability Review

<<BACK to jeffyepstein.com

By Jeff Epstein (jeff_epstein@yahoo.com)

SPED561, Holy Family University

Written 10/20/2004

Learning disabilities, emotional disabilities and ADHD all negatively affect a child's ability to learn. A learning disability is any condition causing a deficit of intellectual processing. An emotional disability is when negative emotions cause behavior that is inconsistent with a learning environment. ADHD is a condition preventing a child from being "fully present" during a learning situation (Silver, 1998, 73). A child may exclusively have a learning disability, emotional disability, or ADHD, or may have any combination thereof.

Definition

[For the most complete definition of ADHD, see the official diagnostic criteria as created by the American Psychiatric Association: DSM-IV. See figure 6-1 on page 166 in the textbook. Despite its being listed in a psychiatric manual, ADHD is still considered a biological disorder].

In general, "ADHD is a disorder that makes an individual unavailable for learning... The official classification system identifies the essential features of ADHD as having developmentally inappropriate degrees of inattention, impulsiveness, and hyperactivity. Although many persons with ADHD show problems in each of these areas, some will have only one or two of these behaviors (Silver, 1998, 73-4)."

Characteristics

Hyperactivity: "Most young children with true hyperactivity display squirmy, fidgety behavior beyond the norm. Some part of the body is always in motion, often purposeless motion (Silver, 1998, 74)." I question how much of those with a high metabolism mimic this behavior.

Inattention/Distractibility: "Children with ADHD will be inattentive because they are distracted... For children and early adolescence, the most frequent challenge is blocking out unimportant stimuli in their environment. By adolescence or adulthood...some have difficulty blocking out their internal thoughts in order to focus on what they should be attending to... Some complain that their minds drift [while] others complain that their minds jump (Silver, 1998, 76)."

Impulsivity: "An individual with impulsivity appears not to be able to reflect before he or she talks or acts. Less, this person doesn't learn from experience, since he or she cannot delay action long enough to recall past experience and consequences (Silver, 1998, 76)." In the words of Dr. Phil: "Ready, fire, aim."

Flavors of ADHD

When it is not known what specific symptoms the individual suffers from, "AD/HD" is the name used.

Type		%	Notes	Referred to as	Inattentive?	Hyperactive/Impulsive?
Combined	CB	55 (to 85)	12% also have LD, 35% also have conduct disorder	ADHD	Yes	Yes
Predominantly Inattentive	IN	27	Has highest percentage of girls: 26%	ADD	Yes	No
Predominantly Hyperactive-Impulsive	HI	18	76% are between four and in six years old	?	No	Yes

[Figure 6-3 on page 170 in our textbook has a summary of impairments associated to ADHD.]

[Figure 6-2 on page 167 in our textbook describes the characteristic differences between HI and IN]

Other characteristics (Hallowell, 1994a):

• "Many adults with ADD have an addictive or compulsive personality that keeps them always hooked on something (298)." "Most clinicians working with the adult ADD populations note higher than usual rates of alcohol abuse, marijuana abuse, cocaine abuse, gambling, and overeating (261)."
• There is "a strong connection between ADD and aggression (268)."
• "[ADD sufferers are] notoriously poor self-observers (294)."
• "People with ADD are at much greater risk of getting into traffic accidents than the general population (145)."
• As many as two thirds of those with ADHD also have a secondary learning or emotional disorder. "Many young children with ADHD (approximately 50%) also have speech and language disorders. Students with complex partial seizures are more at risk for ADHD. Furthermore, some students with mental retardation or autism have symptoms of ADHD... Also, some students with ADHD are gifted (Turnbull, 2004, 175-6)."

Positive Traits Associated with ADHD

" '[They] are highly imaginative and intuitive. They have a "feel for things", a way of seeing right to the heart of matters while others have to reason their way along methodically. As the child who cannot explain how he thought of the solution, or where the idea for the story came from, or why suddenly he produced a painting, or how he knew the shortcut to the answer, but all he can say is, he just knew it, he could feel it. This is the man or woman who makes million-dollar deals ... and pulls them off the next day. This is the child, who, having been reprimanded for blurting something out, is than praised for having blurted out something brilliant. These are children who learned and know and do and go by touch and feel.'

"The...defining characteristics of ADHD...are 'also key descriptors in the biographies of highly creative individuals [including Albert Einstein and Thomas Edison].' ... A surprising strength for students with AD/HD is their ability to hyperfocus. Many people with AD/HD are highly successful because of this skill, although their success may come at the cost of family, friends, and personal health (Turnbull, 2004, 169)."

Onset

Some say onset absolutely occurs on the day of birth, where others believe it can be any time during one's life. It is impossible to prove (Cohen, 2004). Some believe they have found a link between the behavior of a mother during pregnancy, mishaps during birth (Ingersoll, 1988, 55), or even genes thought to be involved in ADD. Regardless, "the diagnosis of ADD is generally not considered until school age (health.yahoo.com)."

Prognosis (Turnbull, 2004, 190-1)

Of all students with ADHD, about...

• 80% are likely to still experience it in adolescence.
• 35% drop out of school.
• (as many as) 70% continue to have symptoms as adults.
• half will improve around the age of puberty, and half will go into adolescence with their ADHD (Silver, 1998, 78).
• 30% of children will continue to have ADHD into their adult life (Silver, 1998, 78).

Students with ADHD are more likely ...

• by three times, to fail at least one grade and be suspended or expelled.
• to drop out of college.
• to have received special education services in high school.
• to experience substance abuse, psychological distress, and learning disorders.

Prevalence

• ADHD "is the most common childhood psychiatric disorder and accounts for at least half of all referrals to child mental-health clinics (Ingersoll, 1988, 2)."

• "Approximately three to seven percent of school age children have ADHD (Turnbull, 2004, 175)."

• "...at least one or even two children with ADHD are in every classroom throughout the United States (Barkley, 1995, 18)."

• "The disorder is three to ten times more common in males than females. (health.yahoo.com)."

• "The vast majority...are European American (Turnbull, 2004, 176)."

• Identical twins either both do, or both don't have ADHD, at a much higher frequency than any other sibling type, including fraternal twins (Turnbull, 2004, 174).

• "...anywhere from fifteen to twenty percent of American boys are currently taking Ritalin, or other stimulant drugs to control their behavior in school. The majority begin taking these drugs at six or seven, but the minimum age is creeping lower all the time... The number of Ritalin prescriptions written for two-to-four-year-olds went up nearly 300 percent between 1991 and 1995 (Mercogliano, 2003, i)."

Subjective evaluation

The diagnosis of ADHD is completely subjective.

The National Institute of Health has stated (NIH, 1998, 10), "...after years of clinical research and experience with ADHD, our knowledge about the cause or causes of ADHD remain speculative. Consequently, we have no strategies for the prevention of ADHD. "

"There are no formal tests to establish the diagnosis of ADHD. Unfortunately there are no specific physical examination findings of blood, urine, brain imaging, brainwave, or other neurological findings that establish the diagnosis. [While] there are excellent [tests to identify symptoms, none can] clarify the reason [behind] these behaviors... The only way we currently have for doing this is by the clinical history. It is the information obtained from parents, teachers, in previous records, along with information learned from the person being evaluated, that leads to the diagnosis...

"The most common cause of the symptoms of ADHD is anxiety... The second most common cause is depression... The third most common cause is one of the other neurologically based disorders... The least common cause of hyperactivity, distractibility, and/or impulsivity in any age group is ADHD [emphasis added] (Silver, 1998, 207-8)."

Since children do not have the self-awareness, word power, nor the trust of society, they cannot significantly contribute to their diagnosis.

Controversy (Cohen, 2004)

ADHD is controversial in its evaluation, diagnosis and treatment. The subjectivity of evaluation contributes to a high degree of misdiagnosis; one third to one half of all ADHD cases are potentially misdiagnoses. Most troubling is how the majority of misdiagnoses are simply because the child is a behavior management problem; in other words, their teacher/parent considers them "a pain in the butt" (this is also a problem with Oppositional Defiance Disorder and Conduct Disorder).

There is a general consensus that ADHD does indeed exist, but the high probability of misdiagnosis has created a deep division among those interested in the issue; including parents, teachers, and adults who were labeled--rightly or wrongly--with ADHD during their school years. Contributing to this controversy is the fact that the vast majority of those labeled with this disease, children, are without a voice to explain or defend themselves.

Because there are many negative characteristics associated to ADHD, and the prognosis for a consequence-free future are low, mis-associating the label of ADHD to an individual increases the chance that they will "live to this label", and suffer some of these consequences.

"... Be careful not to drive your child's internal dialogue in a negative direction. For example, you must be extremely careful about hanging labels on your child even if you think those labels are accurate. Labels can be especially dangerous because young people tend to internalize them. Often they then act according to the expectation... The labeling of the child as ADD or slow or clumsy can...implant messages and self-images that will restrict or disable. Such labels will likely dampen a child's interest in acting on opportunities and could also cripple the all-important ability to get beyond failure or disappointment (McGraw, 2004, 174)."

A key issue regarding the diagnosis and treatment of ADHD is the differential diagnosis of ADHD and anxiety (or depression). For example, an extremely difficult upbringing can trigger a core insecurity within a child. A child suffering core insecurity commonly has difficulty sustaining attention, concentration, and organization, is hyperactive (or in a case of depression, lethargic) and easily distractible. In most cases, these symptoms are an indication of anxiety rather than ADHD.

Further, there is no definitive test that can diagnose anxiety, ADHD, nor differentiate between the two. To diagnose ADHD, it is most important to determine the prevalence of these symptoms in the absence of anxiety. When both the symptoms of ADHD and anxiety are demonstrated -- although dual-diagnosis is an option, in this case it is safest to choose anxiety alone. For a child living in an anxiety-riddled home, differentiation is unlikely.

A true ADHD evaluation and diagnosis incorporates both the official test ("DSM-IV"), along with a complete emotional and psychological profile, including family life. Historically, these profiles have been minimal or subjective, due to carelessness, callousness, insurance issues, or simple constraints on finances, time and energy.

There are other reasons contributing to the increased chance of misdiagnosis. The DSM-IV test has a controversial set of rating scales ("Conner Scales") that attempt objective differentiation. Psychologists with a bias for these rating scales will tend to diagnose ADHD more than anxiety. Most unfortunately, there is also a correlation between the desire for pharmaceutical companies to sell products such as Ritalin, and the higher prevalence of ADHD.

Treatment and Accommodation

ADHD can be treated with or without psychotropic drugs. Some believe drugs are critical and should be primary to treatment, while others believe drugs are harmful and only postpone symptoms that must inevitably be dealt with. For those who are misdiagnosed with ADHD, drugs are obviously and completely unnecessary.

• "Ideally, the student should be on the appropriate medication at the right dose, so that she or he is not hyperactive, distractible or impulsive. If this approach is not possible, the above classroom adaptations often will help (Silver, 1998, 258)." This Book, The Misunderstood Child, has four times more space allotted to information on treatment of ADHD with drugs, versus without (23 versus six pages).

• "While medication is usually effective, it is not the whole answer. And those people for whom medication does not work must rely entirely on non-medication approaches ... In addition, sometimes the medication loses its effectiveness over time. However, whatever new habits you build into your life, whatever new strategies you may develop to deal with the business of everyday life, these last a lifetime. They are more durable than the effects of medication (Hallowell, 1994a, 141)."

• "Emotional problems...are increasingly seen as a disease of the body that can be 'cured' with pills, just like a physical ailment... Thus, the field of psychiatry has begun to enter the brave new world of Aldous Huxley, were the only therapy is drug therapy... While such a biopsychiatric approach was formerly limited to adult psychiatry, is rapidly taking over the child branch of the field as well... The bottom line is that fewer clinicians all the time are asking why a child...might be chronically angry or anxious, have difficulty concentrating, or be impulsive or aggressive to the point of being unable to make friends or function in a cooperative setting. Anyone who has spent time with children knows they are highly emotional beings, anything but predictable... To reduce a child's imbalance to a matter of faulty brain chemistry defies human reason. It's a shortcut to conformity. Though conveniently mechanical, it is unscientific, too (Mercogliano, 2003, 43)."

For the long-term, it seems that a mixture of drugs and non-drug treatment is the best option. Drugs are beneficial in that they can be used for short-term symptom management. At the same time, longer-term nonmedical treatments can be implemented, especially talk therapy, with the goal of weaning off the drugs, and providing skills to manage symptoms manually.

Non-drug treatment

Accommodating for ADHD in the classroom, regardless whether a child takes drugs or not, includes trying to increase motivation, creating a fail-safe environment, and being as clear as possible with expectations. The ultimate goal for non-drug intervention is to develop self-efficacy -- belief in one's personal capabilities and ability to achieve with effort -- and an understanding of their own strength and needs (Turnbull, 2004, 185).

Increasing Motivation (Turnbull, 2004, 183)

There are seven keywords to increasing motivation:

• Relevance: It is easier to learn when the lesson somehow applies to their own life.
• Novelty: The techniques with which lessons are taught should be new and fresh; not repetitive.
• Variety: As many senses as possible should be stimulated when teaching the lesson. For example, computer software teaching math concepts may be more successful when it uses colors, rather than just black-and-white.
• Choice: Give students a variety of assignments to choose from.
• Activity: Physical movement, regardless the lesson, is always beneficial.
• Challenge: Curriculum should not be watered down. High standards breed high performance.
• Feedback: Feedback for desirable behaviors should be immediate.

Fail-safe environment (Silver, 1998, 257-8)

The environment in which an ADHD student learns should be one that does not exacerbate or contribute to symptoms. For example:

• Hyperactivity. Allow the student to stand up when working. Use them to send notes to the office. Allow them to briefly leave the room when they need to vent.

• Distractibility. "The teacher might shorten tasks by breaking one task into smaller parts the student can complete at different times. He or she might give fewer and/or briefer homework assignments. The student might benefit from working with other students to try to increase the interest and novelty of the tasks.

The student who is distracted by sounds might sit in the quietest area of the class, away from windows, doors, or air conditioners. I might be best to have him sit next to the teacher's desk."

• Impulsivity. "Efforts might be focused on helping the student learned to wait. She might be encouraged to use a piece of paper on the desk to write down what she needs to say or to do onto a teacher is free."

There could be a gesture the teacher could use to alert the student, in private and from across the room, that a particular behavior needs to stop.

Make Expectations Clear (Hallowell, 1994a, 83-91)

There are many ways to ensure that expectations are clear, and the student is ready to fulfill them. Some examples:

• Ask the student what they need to be successful.
• Create as much structure, limits, and boundaries as possible. Follow through with consequences in a non-punitive, consistent, predictable, and prompt fashion.
• Have as predictable a schedule, for both at school and at home.
• Provide consistent reminders, previews, repetition and direction.
• Monitor progress often, and provide consistent feedback, particularly for positive behavior.
• Trained them skills to ensure they are capable of the filling expectations, including outlining, tests taking skills, time-management, and how to break down a larger task into smaller, more digestible ones.

For Those Misdiagnosed ... (Mercogliano, 2003)

As stated in section "Subjective Evaluation", the least common cause for the symptoms associated to ADHD, is ADHD. The most common causes are anxiety and depression. A misdiagnosed child may be experiencing anxiety during many -- if not all -- of the school years. In the book, Teaching the Restless, it is proposed that this process of finding emotional closure should -- and can only -- take place before any learning occurs ("the head will follow the heart every time"). This is true even if traditional learning is postponed by a number of years. It is the theory of this book that, if true emotional closure can be reached, a person will be many times more successful in both school and all of life, than if they had gone through life with the unresolved emotions.

Treatment with Psychotropic Drugs (Silver, 1998, 259-82)

"There is no established protocol for treating ADHD with medication (259)... I try the stimulant medication's first... If these medications cannot help, or side effects create problems that cannot be clinically resolved, I try a second group called tricyclic antidepressants... If these medications cannot help or help to control only some of behaviors, I might try a combination... Usually, 85% of correctly diagnosed children, adolescents, and adults with ADHD will respond to one or the other group or to a combination of the groups.

"...ADHD is caused by a deficiency of a specific neurotransmitter, norepinephrine. The goal of medication use is to increase the level of this neurotransmitter at the nerve interfaces in the areas of the brain involved. At this time there are two different mechanisms for accomplishing this increase. I like to think of the analogy of the lake without enough water in it. There are two ways you can increase the level of the water in the lake. First, you could pour more water into the lake. The second way would be to build a damn. No more water is flowing into the lake than before; but the water flows out more slowly. Thus, the level of water goes up

"[Stimulant medication's] appear to work by stimulating the nerve endings to produce more norepinephrine. [Tricyclic antidepressants work] like the dam, [decreasing] the breakdown or metabolism of the neurotransmitter, thus causing whatever is produced to stay around longer (261-2)."

Stimulants (264-277)

• Examples: Ritalin, Dexedrine, Dextro-Stat, Cylert, Adderall
• Side effects: Loss of appetite, sleep difficulties, stomachache, headache, tics, emotional lability or spacey behavior.

Tricyclic Antidepressants (277-282)

• Examples: Tofranil, Norpramine, Pamelar, Wellputrin, Catapres, Tenex
• Side Effects: Slight shifts in the electoral conduction pattern of the heart, sedation, use must be tapered off, may not address all symptoms, remains in bloodstream requiring monitoring of liver.

Appendix

Quotes from Dr. Phil: Tuesday, September 28, 2004

• [Today] we’re talking about children with the diagnosis of ADD and hyperactivity. Notice I said "diagnosis", because I think [it is] used way too much. It's what I call a "wastebasket diagnosis": When were not sure what's going on, let's just throw everything in this particular pile.
• What's the first line of treatment? It's drugs. The kids hate them, the schools love them, and parents are stuck in the middle.
• I think we over-medicate unbelievably. There is this tendency for the medical community to use what tools they have, but there are tremendous side effects to these drugs as well... This is not a magic solution to the problem... Medications are only about 50% effective, and decrease in effectiveness over time... It’s not a long-term solution.
• I think one of the most important things that those in the health care delivery system have to deal with, is what's referred to as differential diagnosis. If you treat the wrong thing, or you fail to treat the needed area, then you're not going to get the results that you want.
• Parents with a child having ADHD are three times more likely to divorce.
• My next guest is a father who refused to put his child on drugs because he is hyperactive [he has not been diagnosed with ADD or ADHD]. [This father says the CYFD and the police got involved, and his son was removed from his home, when] the school reported him for child abuse, because he wouldn't prescribe the medication [as they requested and recommended]...

...I am astounded that the government, by your description, would step up and demand a specific medication for an undiagnosed disorder, when there are alternative explanations for his behaviors.

• [Recommended non-drug treatment steps]:

1. Step up as a parent

[Speaking to parents]: You don't have a unified front, and you fight in front of him about this. [Mom], you yell and scream at him, and you're at your wits end. You also give into his tantrums, and feel guilty when you discipline him, [and you acknowledge you don't provide as much structure as you should]. Would it surprise you that, as parents, how you to act and behave in front of that child, and with that child, is also an explanation for his symptoms? Even if your son truly has ADD, you must do these things.

2. Feed the child better foods

If you him are hyper-vigilant about what you feed your child, you can stop certain behaviors... We're not just talking here about food allergies. Were talking about foods that interact poorly with a child's brain at a neurological level, particularly if they... have the disorder. [Processed foods, high carbohydrates, sugared and fried foods all] will aggravate the situation...

3. Biofeedback and other specialized non-drug training so the child can control his own behavior.

Children can actually learn to control their own brain patterns and activity to the point that it can affect their ADD... biofeedback training [is a tool to aid in this process].

Dr. William Glasser
From the report “Reality Therapy and Choice Theory”, as downloaded from wglasser.com

All of these choices, ranging from profound psychosis to mild depression, are described in detail in the official book of mental illnesses called the DSM IV. As described in Choice Theory and more extensively in Reality Therapy II, Glasser believes these diagnoses are not mental illnesses but almost always descriptions of behavioral choices. They are only mental illnesses if they are associated with tangible brain damage, as in Alzheimer's Disease. Therapy, therefore, is literally teaching clients to make more effective choices as they deal with the people they need in their lives. It is not yet known why one client will choose one "mental illness" over another, but certainly being exposed to people who make such choices - and learning from them - may be an important factor. But, knowing why the specific behavior is chosen is not necessary for successful therapy. The therapist focuses on helping clients improve their present relationships. If he or she is successful, the client will begin to choose more effective behaviors. For example, if he/she is choosing to depress, he/she will stop making this choice and therapy will have been successful.

References

Answers to Distraction: the authors of Driven to Distraction in response of the most frequently asked questions about Attention Deficit Disorder. Hallowell, Ratey, Pantheon Books, 1994 (a).

Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder: NIH Consensus Statement. National Institute of Health, Nov. 16-18, 1998, 16, no. 2

Dr. Sidney Cohen, Ph.D. Psychologist, Cherry Hill, NJ, Private interview, September 15, 2004. Dr. Cohen has attended three to four major (at least one day long) continuing education workshops on ADHD, and estimates he sees seven to eight cases a week, resulting in "several hundred ADHD cases a year".

Exceptional Lives: Special Education in Today's Schools, Fourth Edition. Turnbull, Turnbull, Shank, Smith, Pearson Merrill Prentice Hall, 2004

Family First. Dr. Phil McGraw, Free Press, 2004.

The Misunderstood Child: Understanding and Coping With Your Child's Learning Disabilities, Third Edition. Larry B. Silver, M.D., Times Books, Random House, 1998

Taking Charge of ADHD: The Complete, Authoritative Guide for Parents (rev ed.). Barkley, R. A., New York: Guilford, 2000

Teaching the Restless: One School's Remarkable No-Ritalin Approach to Helping Children Learn and Succeed. Chris Mercogliano, Beacon 150, 2003.

Your Hyperactive Child: a Parents Guide to Coping with Attention Deficit Disorder. Ingersoll, A Main Street Book, 1988