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By Dr. Melissa Fiorito-Grafman
Although it is in a child’s nature to be active, energetic, and curious, there comes a point when parents begin to question whether or not such activity exceeds their child’s age group. The term Attention Deficit/Hyperactivity Disorder (AD/HD) has infiltrated the masses and has sparked the interest of many parents who have questions about what is considered typical development vs. atypical. Clinicians and parents alike continue to debate the reasons for the growing number of children (and adults) diagnosed with ADHD. Some have proposed that it is simply “overdiagnosed.” Others assert that parents are too eager to get their kids evaluated as they are motivated to obtain school related services; and let’s be honest, any child (with or without ADHD) would benefit from extra help. On the contrary, some folks emphasize the advancements in research and medicine as contributing to the increase in the number of children diagnosed. Perhaps, it is a little bit of everything. Despite the reasons for its growing popularity or skepticism, ADHD is a chronic condition that affects many children that often persists into adulthood.
Definition, signs & symptoms:
Ok, before we get started, let’s clear the air about the whole ADD vs. ADHD dilemma. It appears that the change from Attention Deficit Disorder (or ADD) to Attention Deficit/Hyperactivity Disorder (ADHD) has many parents confused; and rightly so. One of the most basic reasons why a change (in the name) was implemented was due to advancements in research that repeatedly identified two (not just one as the original ADD label had suggested) distinct behavioral problems/symptoms thought to characterize Attention Deficit Hyperactivity Disorder. These two dimensions are Inattention and Hyperactive-Impulsive behavior. It is important to note that not all children with ADHD present with both dimensions. That is, some parents get confused with the added term Hyperactive because they think “Well, Jane is inattentive, but not hyperactive, so how could she possibly have ADHD?” So, just to be clear, ADHD is just the umbrella term and it comes along with subcategories that are more specific in describing whether or not your child presents with inattention, impulsivity/hyperactivity, or both. Needless to say, don’t get confused about the added term (hyperactivity) to the title, it’s just their to reflect that the disorder has many dimensions and whether or not your child has one, two, or all the dimensions will be addressed in the subcategory of the diagnosis. So, in other words, when given a diagnosis of Attention Deficit Hyperactivity Disorder, the individual is then given a more specific label to reflect the type of ADHD they actually present with, including:
o Pre-dominantly Inattentive Type
o Pre-dominantly Hyperactive-Impulsive Type
o Combined Type (meaning meets criteria for the two above)
Signs and symptoms of inattention may include, but not limited to:
o Difficulty paying close attention to details
o Trouble sustaining attention and/or listening
o Disorganized, losses things, forgetful, distractible
o Can’t seem to finish tasks
Signs and symptoms of hyperactive and impulsive behavior may include, but not limited to:
o Exhibits excessive activity, when not appropriate
o May be observed talking excessively, interrupting or blurting out anything on their mind
o Appears to be intrusive
o Appears to be restless, fidgets, or is moving around excessively
o Doesn’t think before acting
Whether your child has some or all of the aforementioned difficulties, there are many things to consider prior to labeling a child as having ADHD. For example, let’s say your child begins to exhibit such behaviors on the heels of a divorce. Chances are, their behavior can be better explained by a change in the family dynamics rather than ADHD. If in fact it is a true case of ADHD, it is typically the scenario that behaviors have been present prior to the age of 7, has been persistent for more than 6 months, occurs in more than just one setting, consistently disrupts daily functioning, as well as causes problems with interpersonal relationships. In general, though not exclusive, boys present differently than girls when it comes to ADHD. That is, boys are more likely to be hyperactive, whereas girls more inattentive. Many feel that this is the reason the prevalence rate amongst boys is higher, as boys tend to grab the attention of their teachers and parents as their symptoms manifest more frequently as disruptive behaviors, unlike girls who tend to be more inattentive, so their behaviors are often more conspicuous.
Causes & risk factors:
There appears to be both a genetic component (inherited traits) and environmental factors that, either causes and/or contributes to a child’s behavior. For example, whereas a child may be born with a genetic disposition to ADHD, environmental factors may contribute or worsen their behaviors. Researchers have identified several factors that may play a role:
o Heredity: ADHD has a tendency to run in families
o Altered brain function/anatomical brain structures: while the exact cause of ADHD is still unclear, research has suggested that there appears to be less activity in brain structures responsible for attention.
o Exposure to toxins, drug use and smoking in-utero increases the risk of the offspring to have ADHD and other developmental disabilities.
o Childhood exposure to toxins in the environment, such as lead, is at increased risk of developmental and behavioral problems.
Although ADHD doesn’t cause other psychological or developmental problems, per se, children with ADHD are more likely than other children to also have conditions such as:
o Oppositional Defiant Disorder
o Conduct Disorder
o Learning Disabilities
o Tourette Syndrome
NEXT: WHEN TO DO SOMETHING ABOUT IT
When to do something about it?
Although no single test for ADHD exists, there are many things professionals can do to ascertain whether or not your child’s behavior is consistent with such a diagnosis. If your child demonstrates signs and symptoms that you think are consistent with ADHD, and it appears that it is interfering with their daily functioning, there are several ways in which you can address the issue.
Given that you most likely visit the pediatrician every so often for check-ups, your likely to start by first speaking with your child’s doctor. Depending on their impressions, your doctor may refer you to a specialist, such as a developmental-behavioral pediatrician, psychologist/neuropsychologist, psychiatrist or pediatric neurologist. However, some parents go directly to anyone of these professionals; there is no circumscribed way to seek out professional help.
Whereas all of the aforementioned professionals can diagnose ADHD and are likely to use questionnaires and interviews to learn more about your child’s behavior, all of which are the basic essentials when diagnosing this disorder, pediatric neuropsychologists can provide additional services that may help parents understand how their child’s behavior and symptoms manifest through the use of standardized measures.
Although a pediatric neuropsychologist cannot prescribe medication (as can a medical doctor), what makes this professional unique, in comparison, is that they are trained and qualified to administer and interpret standardized tests that assess brain functions (i.e., intelligence, memory, language, attention/concentration, etc.). The neuropsychologist may work in many different settings and, in addition to providing evaluation services, may have different roles in the care of your child. In some cases, the pediatric neuropsychologist is a case manger who follows the child over time to adjust the recommendations to the child’s changing needs. He or she may also provide treatment, such as cognitive rehabilitation or psychotherapy.
Neuropsychological testing is extremely helpful in better understanding pre-existing or newly onset cognitive, learning, social, and/or behavioral problems. The results from testing are often a crucial component in developing a treatment plan or educational intervention strategies for your child. In an effort to provide the most comprehensive services, a child or pediatric neuropsychologist typically consults with schools, as well as works with other pediatric specialists in behavioral neurology, developmental pediatrics, pediatric neurology, child psychiatry, pediatricians, occupational therapists and speech and language therapists.
What is a neuropsychological evaluation?
A neuropsychological evaluation is a comprehensive assessment of cognitive and behavioral functions using a set of standardized tests and procedures. Testing involves paper and pencil and hands-on activities, answering questions, and sometimes using a computer. In addition to standardized testing, a detailed clinical interview and developmental history is conducted with the parents/caregiver’s. Parents are also usually asked to fill out questionnaires about their child’s development and behavior. Furthermore, in most cases, information is also obtained from teachers and other professionals who work with the child. The neuropsychologist may also wish to observe your child in a less controlled environment (i.e., testing), such as in a school setting. The evaluation can take approximately 6-8 hours of face-to-face contact and can be scheduled in one or several appointments, all of which depend on the child.
Once this process is completed, the practitioner will devise a report. Although reports vary among practitioner, they typically include historical information obtained during the clinical interview, behavioral observations made during the evaluation, as well as a detailed explanation of the various mental functions assessed and subsequent results from testing. The report will typically highlight the child’s strengths and weaknesses. Clinical impressions are also made, sometimes providing a definitive diagnosis, while other times deferring (i.e., when a diagnosis cannot be made for some given reason). Recommendations are also provided.
What will the results tell me & how will it help?
Comparing your child’s test scores to scores of children of similar ages, the neuropsychologist can create a profile of your child’s strengths and weaknesses; the results of which help those involved with your child’s care.
o Testing may help explain why your child is having school problems. Let’s say your child appears to be having trouble reading. Through testing, a neuropsychologist will be able to discern whether or not reading difficulties are due to an attention problem, a language disorder, an auditory processing problem, or reading disability.
o Testing will also help the neuropsychologist tailor interventions based upon how your child thinks, learns, and processes information. If such strategies are (then) implemented at home and school, your child may have a better chance of performing to their potential.
o Testing can also detect the effects of developmental, neurological, and medical problems, such as epilepsy, autism, attention deficit hyperactivity disorder (ADHD), dyslexia, or a genetic disorder.
o Testing may confirm or clarify a diagnosis
o Provide a profile of strengths and weaknesses to guide treatment and educational planning
o Serve as a baseline and document changes in functioning over time
o Testing can result in referrals to other specialists depending on your child’s needs (i.e., cognitive remediation therapist, neurologist, psychologists, psychiatrists, vocational counselors, etc.).
Treatments and medication:
Treatments for ADHD can include medication, counseling, therapy, special accommodations in school and home, family and community support, alternative medicine, and lifestyle and home remedies, just to name a few. A more substantial review of treatments can be found at http://www.mayoclinic.com/health/adhd
In sum, despite the treatment methods preferred, at the very least, is imperative that early intervention be implemented in remediation of developmental disorders such as ADHD, LD, and autism spectrum disorders. By implementing therapeutic services early on, it gives the developing brain a better chance of gaining mastery of the desired skills over time. Intervening early on not only increases the chances for a better outcome in terms of remediation, it also can minimize the negative cycle of academic and personal struggles that are all too commonplace for children with ADHD. One of the first steps toward early intervention can be a clinical neuropsychological assessment (as described above).
Dr. Melissa Fiorito-Grafman is a licensed psychologist in the state of New Jersey and New York. She completed her residency training at New York University Langone Medical Center-The Rusk Institute of Rehabilitation Medicine, which is an accredited program by the American Psychological Association. Thereafter, she completed a two-year fellowship specializing in Pediatric/Adult Neurospychology. Dr. Grafman’s education and training is unique in that it has afforded her the opportunity to serve children, adolescents, young adults, and families at the individual and group therapy level, as well as providing psycho-educational and neuropsychological assessment. Dr. Grafman currently maintains a private practice in Ridgewood and Closter, New Jersey. If you would like to discuss the contents of the articles on this site or have questions about services, you can contact Dr. Melissa Fiorito-Grafman directly at the Center for Neuropsychology & Psychotherapy, LLC in Ridgewood & Closter, New Jersey at (201) 252-2528 or www.neuropsychandtherapy.com
Expert advice on the signs and symptoms of this oft-misdiagnosed disease.