How To Assess and Treat ADHD (Children and Adults)

By Steven T. Griggs, Ph.D.

-Intro and ADHD test.
-Definitions and symptoms--"Classic" ADHD: Inattention/Hyperactive-Impulsive. Hyperfocused subtype, Central sensitization subtype, Temporal, Limbic and The Ring subtypes/phenomena. Other cognitive syndromes.
-Hypoarousal states, neuron states (excitatory and inhibitory), self-stimulation seeking.
-ADHD recognized by four official government agencies. Demographics: five percent of the population. Frequency of boys vs. girls, kids vs. adults. Genetic preponderance and geographic propensities. ADHD and gradeschool performance; retention rates.
-ADHD and family composition. ADHD and acting out, substance use, medical bills, behavior problems. Boys vs. girls--different behaviors?
-ADHD and differential diagnoses (ODD, OCD, moods and specifically, bipolar disorder).
-ADHD--first appearance, which symptoms. ADHD and the critical first three years of school (KG, first and second grade). Do kids outgrow this? ADHD vs. "Normal" behaviors.
-Causes of ADHD--Seven categories.:
-Five steps to diagnosing ADHD
1) Clinical Interview.
Choosing the right professional. Preparing for the interview. Physical Exam--What questions to prepare for. Eliminating other possible causes (other illnesses or conditions).
-2) Behavior Rating Scale.
Child version. Adult version. How to score and interpret the scores.
-3) Differential Diagnostic Testing--Getting an Intelligence Test. A primer on differentiating learning disabilities.
-4) Differential Diagnostic Testing--Getting an Achievement Test. Learning Disability diagnosed vs. simple ADHD.
-5) Differential Diagnostic Testing--Neurological Test, Visual evaluation--acuity vs. tracking.
ADHD or Bipolar Disorder? ADHD and intelligence--the myths.
-Tying all the results together. "Workarounds" and the impact on test results.
-Hyperfocused Type.
-The rich and famous. Self-Esteem.
-Treatments (four major ones, numerous minor ones):
-Managing sleep, allergies and diet. Problem substances in foods--23 categories. Diet clean ups. The two-week plan. Diet suggestions.
-1) Psychotherapy/Behavior therapy
Externalizing strategies: 4:1 rule, three contingencies of reinforcement, cueing, modeling, shaping, reinforcement schedules, star charts, punishment vs. rewards, task reducing, self-talk, self-monitoring, mindfulness, journaling, cognitive re-framing.
-2) Family therapy: symptom containment, scheduling behaviors, family rules, assertiveness, empathy, symptom mapping, stress management. Parenting Considerations: Breast feeding, sleep, morning routine management, team vs. one-on-one approaches, manipulation, strategic breaks.
General considerations for psychotherapy and family therapy: slow down, uni-focusing, immediacy and here-and-now processing, managing expectations, identifying recurring problems, external ticklers, managing transitions, using props, creating routines, organizing, homework tips, homework tracking, clarity/consistency, garnering attention, praise/reward criteria, love, enjoyment, task immersion, safe environments, ambient sounds, exercise, inside vs. outside activities, non-labeling, maturity assessment, "screen" time policy, personal assistants, best kinds of teachers and schools, special services/grants/programs, cognitive mapping (two kinds), cognitive monitoring, creativity, structured thinking (12 kinds), structured movement.
-Other proposed ADHD remedies--Things to think about and/or try before going further: Meditation/mindfulness, Brain Highways, Neurofeedback.
-3) Herbs (ten)
Homeopathic approaches (sample of two products but too many ingredients to count). Vitamins/supplements (forty plus...).
-4) Medication
Stimulants (six chemical classes with eleven variations/brand names). Non-stimulants (four chemical classes with six variations/brand names)
-Appendix C: Further reading and related sources (19) and websites to search (13).
-Appen...

• Language: English
• Publisher: Steven T. Griggs, Ph.D.
• Release date: Aug 30, 2014
• ISBN: 9781310979835

Steven T. Griggs, Ph.D.

I'm a psychologist. I write no-fat, how-to ebooks on subjects and conditions I fix everyday in the office. These include relationships, being assertive, struggling with guilt and/or procrastination, children and teenager's behavior, anxiety disorders, anger management, kids and divorce, self-esteem, child visitation, weight control, forgiveness, ADHD, addictions, and my latest, mood disorders. I've written 15 ebooks, and most of them are translated into Spanish. Now, I'm starting to write a book, "The Other Side of the Couch." It's about my daily experiences as an outpatient psychologist and how I see the world through the lense of a shrink...

Book preview

How To Assess and Treat ADHD

(Children and Adults)

Steven T. Griggs, Ph.D.

Copyright ©2014 by Steven T. Griggs, Ph.D.

All rights reserved. No part of this book may be used or reproduced in any manner whatsoever without written permission, except in the case of brief quotations embodied in critical articles or reviews. Please do not participate in or encourage the piracy of copyrighted materials in violation of the author’s rights. Purchase only authorized editions.

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Table of Contents

Disclaimer

Introduction

What is ADHD?

ADHD Symptoms

Symptoms of Inattention

Symptoms of Hyperactivity/Impulsivity

Other subtypes

My way of thinking about ADHD

ADHD Facts

When Do ADHD Symptoms Emerge?

Causes of ADHD

Five Steps to Diagnosing ADHD

Clinical Interview

Behavior Rating Scale

Interpretation

Differential Diagnostic Testing—Intelligence Test

Differential Diagnostic Testing—Achievement Test

Differential Diagnostic Testing—Neurological Test

Subtle stuff

More Refinement

First Things First

Sleep

Allergies

Diet

Treatment

Behavioral

Psychotherapies

Family Therapy

General Parenting Considerations

General Tips and Strategies

General Psychological Considerations

Psychologically Specific Suggestions

Impulsivity/Hyperactivity Strategies

Other ADHD Treatments

Meditation

Brain Highways

Neurofeedback

Herbs and Supplements

Medication

Afterthoughts

Appendix A (Behavioral Rating Scale for Kids)

Appendix B (Behavioral Rating Scale for Adults)

Appendix C (Further Reading and Other Internet Resources)

Appendix D (Quotes)

About The Author

DISCLAIMER

This ebook is written to assist those who wish to learn about assessing and treating ADHD, in children and adults. The information is written in ordinary English and presented in a manner that is not too technical (clinical), even though some terms and concepts are necessary. It is intended for adults of reasonably sound mental states who wish to learn about ADHD, evaluate themselves or others and take steps to improve the condition, using concepts and techniques that are well known, in the standard literature or that have been adapted and/or modified by this author through years of outpatient clinical experience.

The material in this ebook conforms to the general standards of the psychiatric and psychological professions in the United States. It is designed to assist people in general and is not meant to be a substitute for professional intervention. The tests in this ebook have been empirically validated by external sources, but not as presented in this form (adapted for ebook formats). Therefore, they are not to be used by themselves as diagnostic instruments. All information presented is to be coordinated with trained professionals, who by way of their training and licenses, are qualified to render a final diagnosis. All treatment descriptions/suggestions/recommendations, including information about herbs/medications are to be validated and coordinated with a mental health professional.

The author of this ebook does not claim the enclosed information will cure ADHD or its many symptoms or other manifestations, only that it will give the general reader a better sense of the range of ideas, concepts, terms and approaches in this area. Hence it is assumed that the reader has some normal or average competence and ability to read, think about and understand materials of this nature, and will seek professional help if necessary.

INTRODUCTION

I’ve been a practicing outpatient child and adult psychologist for a long time. I see the same eight issues every day. These include addictions, relationships, self-esteem, anxiety, depression, work problems, anger management, and child behaviors. This latter category, specifically, child behaviors, refers to acting out, academic difficulties and parent-child dynamics. ADHD is often underlying acting out, having problems in school and getting along with parents. In fact, of all the kid problems I encounter, ADHD is the most common one and is often the "presenting complaint; that is, the problem that caused parents to call me in the first place.

In adults with ADHD, problems occur in these same areas. School could also be the problem if the adult with ADHD still in school, but more often it is in the work arena that problems arise. Adults with ADHD frequently have relationship problems, and are more likely to suffer addictions, self-esteem problems (as do kids), anger management difficulties, etc.

STOP

If you are interested in assessing yourself, spouse or child, you should next take a behavioral rating scale while you are still naïve about this subject. Take the test in either Appendix A (for children up to age eighteen) or Appendix B (for adults). If you are an adult and wish to assess your child, go to Appendix A and take the test, thinking about your child when answering each question. More than one adult can each take the test for any child. So, both parents and an uncle, for example, can each fill out the test for the same child. I encourage more than one person to take the test, and in a later section, I'll tell you how to combine the scores for interpretation. Similarly, if you are taking the test to rate yourself as an adult, you can take the test in Appendix B, only considering yourself, or you can do that plus have other adults also take the test, thinking only of you, from their perspective. The combined adult scores will then be used to interpret the results. I'll tell you how to do all this, later.

For now, take this test BEFORE reading any further. If you know too much about ADHD beforehand, it will bias your responses to the questionnaire. So, stay dumb for a minute and take the test. When you are finished, score it and tuck away the results. We’ll come back and interpret them later. If you don’t care about this part, read on.

WHAT IS ADHD?

These letters stand for Attention Deficit Hyperactive Disorder. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV),

"The essential feature … is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development. Some hyperactive-impulsive or inattentive symptoms that cause impairment must have been present before age 7 years (12 years in the DSM V) although many individuals are diagnosed after the symptoms have been present for a number of years. Some impairment from the symptoms must be present in at least two settings (e.g., at home and at school or work). There must be clear evidence of interference with developmentally appropriate social, academic, or occupational functioning."

(The DSM IV, and more recently the DSM V are the Bibles of the mental health profession. These books describe the systematic classification or knowledge about any given condition--nosology--of all known mental disorders and/or mental conditions.) The DSM V, the most recent incarnation of this genre of book, goes on to say that ADHD must not be due to other diagnoses or conditions, such as childhood developmental delay, schizophrenia, mood or anxiety disorders, etc.

ADHD has been called attention-deficit disorder (ADD) and hyperactivity. But ADHD is the preferred term because it describes both primary aspects of the condition: inattention and hyperactive-impulsive behavior. This is the classic nosology. While many children who have ADHD tend more toward one category than the other, most children have some combination of inattention and hyperactive-impulsive behavior. Signs and symptoms of ADHD become more apparent during activities that require focused mental effort, particularly on low-stimulation tasks. While most children diagnosed with ADHD show signs and symptoms early, some appear to be very hyperactive even in infancy, even in utero. Here's The List of symptoms outlined in the DSM, divided into the two classic categories.

ADHD SYMPTOMS

Symptoms of Inattention:

1) Often fails to pay close attention to details or makes careless mistakes in schoolwork or other activities.

2) Messy work.

3) Careless mistakes. Appears to rush through tasks.

4) Often has trouble sustaining attention during tasks or play. Can be easily distracted by irrelevant stimuli.

5) Seems not to listen even when spoken to directly.

6) Has difficulty following through on instructions and often fails to finish schoolwork, chores or other tasks.

7) Acting as if their mind is elsewhere.

8) Going from one uncompleted activity to another, leaving a string of messes (not because of not understanding the tasks). Work or school materials are often scattered about the work or school areas, are carelessly handled and/or damaged.

9) Often has problems organizing tasks or activities. Frequently loses needed items, such as books, pencils, toys or tools.

10) Poor time management. Fails to estimate time needed to arrive at a destination or complete work. Fails to utilize time resources when available.

11) Needing higher stimulation activities. Tasks that require sustained attention and are of a low stimulus value are perceived as unpleasant (boring).

12) Uncharacteristically poor memory in relation to overall intelligence.

Symptoms of Hyperactivity and/or Impulsivity:

1) Frequent verbal interruptions. Blurts out the answers before questions have been completely asked.

2) Abrupt shifts in conversation subjects or not listening or not keeping one’s mind on conversations.

3) Not following details or rules of games or activities.

4) Often forgetful in daily activities.

5) Fidgets or squirms frequently. Plays with hands or cannot refrain from moving feet.

6) Often leaves his or her seat in the classroom or in work or other situations when remaining seated is expected.

7) Often runs or climbs excessively when not appropriate (on the furniture indoors) or, if an adolescent, might constantly feel restless.

8) Grabs objects from others.

9) Frequently has difficulty playing quietly.

10) Always seems on the go. Driven from within.

11) Talks excessively. Over-excited, overly-animated or talks too loudly (expresses enthusiasm with volume.) Pressured speech (can’t get a word in edgewise).

12) Difficulty delaying responses.

13) Frequently has difficulty waiting for his or her turn.

14) Has trouble making transitions; that is, stopping one thing and starting another in a timely manner when asked.

The DSM’s classic delineation of ADHD is based upon these two lists of symptoms. The DSM describes "subtypes. The first subtype is primarily inattentive. The second subtype is primarily hyperactive/impulsive. The third subtype is a combination of subtypes one and two. All three of the subtypes are subsumed under the one acronym, ADHD. So, keep in mind these lists of symptoms while I digress. I’ll cover the three classic subtypes more under the Clinical Interview section, below.

Are there other subtypes? Fortunately or unfortunately, just to muddy the diagnostic waters, there are other professionals who offer further ADHD descriptions. Some add a fourth subtype, the Hyper-focused Subtype. This is characterized by the inability to turn off thinking, to let things go. There are problems shifting attention. This subtype is about cognitive inflexibility. Transitions are not just more difficult as in classic ADHD symptoms, but way more difficult. People with this subtype can be excessive worriers, often over-analyzing and blowing things out of proportion (which tend to be confused with Obsessive Compulsive Disorder symptoms, see below). They don’t often like change and can worry a lot. Physiologists think that in this state there is an over-abundance of blood flowing to the prefrontal cortex, an area of the brain just behind the forehead.

Other researchers write about a fifth subtype, ADD + Central Sensitization. This is characterized by the inability to filter out sensory information. A sixth subtype allegedly is ADD + Interpersonal Deficits. This is the inability to read and to respond effectively to social cues (which tend to be confused with Asperger's Syndrome symptoms).

Other researchers say there are and additional three subtypes beyond the classic three (Inattentive, Hyperactive/Impulsive and Combined Subtypes), but these three are different subtypes than the extra three just described. Their other three subtypes include the concepts of Temporal, Limbic and The Ring. The Temporal Subtype of ADHD (the areas of the brain just under the temples, on both sides) is characterized by additional symptoms of irritability and aggressiveness. These subjects are prone to mood disorders. People who have the Limbic Subtype (midbrain, right under the frontal areas) are thought to also have more thoughts of worthlessness and hopelessness. They also tend to have mood problems, but are also negative and pessimistic. The sixth subtype is described by the term, The Ring (a generally large area all around the sides of the brain, forming roughly a circle or ring). These people also have irritability and aggression, plus are overly sensitive, argumentative and often oppositional. They can be hyper-verbal. Symptoms of this subtype can be confused with those of bi-polar disorder, a major psychiatric condition.

Each of these latter two (non-classic) camps claims to have some diagnostic justification; that is, some test(s) that show the distinctions between their ADHD subtypes. Usually the tests are either EEG-based (brain waves that look like thousands of little squiggly lines on very long lines of paper, or computer screen space…) or image-based. Imaging usually involves SPECT scans. These are three dimensional pictures of blood flow in different parts of the brain.

There is also a relatively new condition that resembles ADHD, but has yet to be thoroughly researched. This condition has been labelled Sluggish Cognitive Tempo or SCT. In contrast with classic ADHD symptoms, people with this condition appear to be more spacey and dreamy, like they are in a mental fog. They tend to stare off into the distance, appear to be sleepier, and of course, not be adequately attentive to the tasks at hand. They are not hyperactive; rather, they are hypoactive, seeming to be more lazy or low energy, slow-moving and sluggish. One major researcher described them as acting like little absent-minded professors. Initial research suggests they may have more depression, social anxiety, shyness and/or memory problems. Symptoms typically develop later in childhood and do not seem to decline with age. Boys and girls seem to be equally prone to this condition. SCT does not seem to respond as well to medication, as does the ADHD group. Both SCT and ADHD groups seem equally prone to learning disorders, but the SCT group may be more prone to math problems. SCT is not in the Diagnostic and Statistical Manuals because it is too new. Stay tuned…

The idea is to correlate activity or inactivity in one or more parts of the brain with one or more symptoms. We know what most parts of the brain do, so when that part is over-or-under active, we guess that the symptoms and behaviors associated with that part of the brain are going to be over-or-under produced. (A discussion of brain morphology and associated behaviors would take me too far afield from the course of this monograph, but this is the direction research is taking.)

Here’s my way of thinking about ADHD. The ADHD brain is in a state of hypo-arousal, especially the forebrain (the front part of the brain right behind and above the eyes). That means the forebrain is underpowered and underactive. Unfortunately, this is the executive part of the brain, that part that makes decisions, plans ahead, checks impulses, and so on. As you might guess, the ADHD behaviors (listed in the two classic categories above) tied to that area will not function normally because the brain cells that connect to other cells are sleepy. The problem behaviors listed above (think classic lists of Inattentive or Hyperactive/Impulsive symptoms) largely (though not exclusively) are related to or outright generated from this area of the brain. If this part of the brain is lackadaisical, so will be the control over these behaviors. In this sense, ADHD is a disorder of self-regulation, particularly with respect to future behaviors, which ADHD’ers notoriously fail to consider. In general, the forebrain fails to control impulses, attention and so on, and then symptoms of ADHD emerge.

If you want to expand this way of looking at the brain to include the other (non-classic) subtypes, then