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GENERAL COMMENTS:
Diagnosis is not a "checklist" of symptoms but a diagnosis of impact.
Attention Deficit Disorder does
not necessarily reflect an inability to pay attention. Usually
involves problems with allocation and flexibility of attention.
Individual diversity makes ADD children and adults clinically and diagnostically elusive.
Symptom severity falls
along a continuum from mild to severe-degree of impact for each individual
will be affected by a variety of factors.
Approximately 70-80% of children diagnosed with ADD will carry symptoms into adulthood to some
degree.
Prognosis of each child is shaped by intrinsic resiliency and the type of emotional and educational
"protection"
he has available.
Remember that inattention is multidimensional - has many facets and faces and will respond to
environmental demands.
Specific diagnosis categories are still undergoing changes and revisions to better clarify
what we see
clinically.
Symptoms may be noticable in all of us at different times and to varying degrees. Diagnosis
needs to
account for:
Longevity of symptoms
Severity of symptoms
Impact of symptoms on child's
academic and social success
GENERAL SYMPTOMOLOGY:
1) POOR CONCENTRATION
A) Cognitive fatigue
B) Inability to regulate task rythm
C) Poor task persistence
2) DISTRACTIBILITY
A) Sensory: visual, auditory, and tactile (body sensations)
B) Flight of ideas:
internal distractibility (daydreamy)
C) Social: Child has trouble filtering out activities of peers
D) Insatiability-Future
Oriented: Child is constantly looking ahead to what is coming or happening next
NOTE: Keep in mind that there
is a fine line between visual distractibility and graphic creativity!
3) IMPULSIVITY
A) Behavioral: poor
reflective ability; doesn't learn from experience; disinhibition; poor social
boundaries
B) Verbal: blurts out
answers; off topic comments and questions; topic jumps in conversation;
poor awareness of non-verbal social cues
C)
Cognitive: poor work quality; rushes through tasks; little regard for accuracy
4) PERFORMANCE INCONSISTENCY
A) Poor regulation of attention
B) Poor task rythm
C) Performance and productivity are very unreliable -
leads to poor self confidence
D) Outgrowth of mental fatigue - trouble with consistent mobilization of mental effort
- the child finds
that effort requires too much effort!
5) POOR SELF-MONITORING
A) Often has trouble
keeping track of how he's doing
6) HYPERACTIVITY
A) Dysfunctional activity level typically falls along
continuum from hypoactivity to fidgeting to motor
driven activity - is actually a dysfunction of motor tempo or pacing.
Must assess the purposefulness
of the activity and not merely the level of activity itself.
B) May interfere with
productivity and output and therefore affect cognitive tempo (finishing tasks too
quickly or slowly). Effective students
are usually well-paced.
C) May only be evident in certain situations.
D) No longer the sole diagnostic criteria
- may only be important descriptively.
E) May decrease as child gets older or be more appropriately channeled.
CLASSROOM / HOME OBSERVATIONS:
1) Don't be fooled by the child's ability to focus attention to excess while doing certain tasks.
2) Need to assess the
nature of the task, the interest level to the child, and how much focused
attention does the task require. Legos, Nintendo,
fishing, and T.V. are usually high interest, low focus
tasks that the child may excel at.
3) ADD kids (and adults!)
require optimal conditions to sustain effort and attention.
4) Usually works better one to one.
5)Good day/bad day
syndrome.
6) Diagnostic question for teachers: "Is he/she completing work independently at an age appropriate
level?"
7) Doesn't respond consistently to "drastic" consequences.
8) Poor time management-judgment-procrastinates.
9) May over or under react to situations.
10) Usually functions on the extremes of "life's continuum"
- this difficulty arises from the inability
to balance attention, emotions, and responses.
11) Not all ADD children
exhibit behavioral/tempermental dysfunction. If distractibility is primarily
internal and the child tends to underreact,
he may present as very easy going, laid back, etc.. This is
probably a very under-diagnosed population!
12) Primary
task of parents and educators should be to preserve the child's PRIDE and protect him
from HUMILIATION.
CAUSES OF ATTENTION DEFICITS:
1) Brain Injury: 3 - 5 %
2) Neurotransmitter Imbalance: thought to involve Dopamine, Norepinephrine, Serotonin. Imbalance
felt to occur primarily in frontal lobe region which controls the executive functions of impulse
control, sequential
thinking, and planning and organizing.
3) Environmental Toxins: Lead, Fetal Alcohol Syndrome
4) Dietary Subtances:
Small percentage, widespread effects not proven
5) Genetic: Probably most common cause, may account for up to 70 - 80%
of diagnosis.
NOTE: The cause of the dysfunction does not always have significant impact on the treatment methods
utilized.
DIFFERENTIAL DIAGNOSIS:
Involves the need to rule out other problems that could be mimicking attentional dysfunction.
1) MEDICATION SIDE
EFFECTS
2) ALLERGIC DISORDERS
3) ANEMIA/IRON DEFICIENCY
4) LOW LEVEL LEAD TOXICITY
5) THYROID DYSFUNCTION
6) SEIZURE DISORDER
7) HEARING/VISION LOSS
8) TOURETTE'S SYNDROME
9) DEPRESSION / MOOD DISORDERS / ANXIETY
DISORDERS /
BIPOLAR DISORDER
10) LEARNING DISABILITIES
11) WEAK LANGUAGE PROCESSING
12) FAMILIAL STRESS
ASSESSMENT:
1) Thorough History: Medical; Educational; Family; Social
2) Physical Exam - to rule out medical problems
3) Neurological
Exam - to assess soft neurological signs that may be having subtle impact on learning.
Also need to evaluate for underlying
central nervous system condition, e.g. tumor.
4) Documentation of Symptoms: Home; School; Testing/Evaluation setting.
5) Neurodevelopemental Testing: Designed by Melvin Levine to specifically assess attentional
flexibility and stability,
memory, organization, etc.
NOTE: Diagnosis is complex and multidimensional but need not be a long, drawn out
process!
SECONDARY PROBLEMS:
1) Memory dysfunction
2) Language dysfunction
3) Poor self-esteem
4) Depression/Anxiety
5) Learning Disorders
TREATMENT / MANAGEMENT OF ADD:
General Comments:
1) Most effective approach is multi-modal to address the whole spectrum of the problem.
2)
Due to the long-range nature of the problems, the treatment also needs to be long term.
3) Remember that symptoms of
ADD are BIOLOGICALLY-BASED HANDICAP and NOT purposeful
behavior. Because of this, the most effective approach is problem
solving - NOT punishing.
4) Focus of treatment should be on strengthening of strengths and bypassing weaker areas -
just as
adults do in their career.
5) Treatment needs to be tailored to individual child - there is no "magic
recipe" of interventions - not
every child with ADD will need counseling, tutoring, medication, etc.
6) Treatment
decisions should account for "quality of life" issues. These factors may be less overt for
some individuals
but no less important!
MULTI-MODAL TREATMENTS:
1)DEMYSTIFICATION
A) Insight! Insight! Insight!
B) If I don't know what it is how do I know what to do with it?
2) TUTORING
A) Need for communication with school
B) May need medication to benefit from tutoring
C) Tutor should be viewed as child's ally
3) PSYCHOTHERAPY
A) Not a panacea
B) Need to address
the nature of the diagnosis
C) Therapist needs to recognize ineffective approach and "change the script"
D) Recognize secondary dysfunction as secondary - e.g. Poor self-esteem
4) REFERRAL TO PSYCHIATRIST
A)
If ADD coexists with other disorders - e.g. Bipolar Disorder
5) SPECIAL EDUCATION / 504 SERVICES AND ACCOMMODATIONS
6) EDUCATIONAL BYPASS STRATEGIES
7) BEHAVIORAL MODIFICATION
A) Helps everyone focus on positive
B) Needs to account for the nature of the symptoms
8) STIMULANT MEDICATION
A) Ritalin
B) Adderall
- can last 6-10 hours - may avoid noon dosing
C) Adderall XR - lasts 12 hours
D) Concerta - lasts 12 hours - tablet
is not crushable, so it may reduce abuse potential
E) Dexedrine
F) Cylert - must be taken 7 days a week
9) ANTIDEPRESSANTS
A) Wellbutrin - may also treat ADD symptoms
B) Effexor - may also treat ADD symptoms
C) Norpramine/Tofranil
D) Selective Seratonin Reuptake Inhibitors (SSRI's)- may not address ADD symptoms
directly,
but will improve coexisting depression and anxiety. Can be used in combination
with stimulants: Prozac; Paxil; Zoloft;
Celexa
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