What Causes ADHD?
ADHD is a medical condition that is characterized by symptoms of inattention.
Problems with impulse control and hyperactivity are also commonly shown but are not necessary for a diagnosis of ADHD.
Medical evidence:
1. PET, SPECT, and QEEG studies have consistently demonstrated that patients diagnosed with ADHD demonstrate abnormal patterns of brain activity in those regions of the brain responsible for attention, concentration, social problem-solving, and behavioral/mood control.
2. ADHD is a condition with a high degree of “heritability” (.75 in twin studies).
Over 50% of adults with ADHD will have at least one child with ADHD
About 33% of children with ADHD will have one sibling with ADHD
3. Genetic studies of patients with ADHD reveal abnormalities on chromosomes involved in the development of dopamine receptors and dopamine reuptake transporters (e.g. Chromosome 11).
4. PET studies have indicated that dopaminergic brain cells in patients with ADHD tend to “reabsorb” 70% more dopamine (interfering with neural transmission) and receptors appear to “take in” dopamine approximately 16% slower. These two factors may be responsible for the “cortical slowing” demonstrated on the QEEG studies published by our clinic and other clinical research centers.
5. Medicines like Concerta, Metadate, and Ritalin, all work by blocking the “reuptake” of the neurotransmitter, dopamine, allowing increased availability of this chemical in the brain which promotes improved attention, concentration, behavioral control and mood. Adderall-XR stimulates increased release of dopamine, as well as the neurotransmitter, norepinephrine and blocks the “reuptake” of both neurotransmitters. Strattera is relatively specific to norephinephrine and blocks the reabsorption of this neurotransmitter. The goal of each of these medications is to treat the cortical underarousal that is commonly found in patients with ADHD.
Common Functional Problems: WITHOUT TREATMENT
| Health/Injury: | Teens have 4X the number of serious injuries; 3X as many auto accidents ADHD patients require more than twice the health care as peers |
| Academic: | ADHD patients perform poorer than peers on achievement tests Are more likely to be retained in a grade Have 3 fewer years of education Are more likely to not graduate from high school |
| Substance Abuse: | ADHD patients tend to start smoking cigarettes at an earlier age and smoke more Are more likely to continue smoking as adults and have greater difficulty quitting Are more likely to begin drinking/using illegal drugs at an earlier age and demonstrate drug/alcohol problems as adults Comprehensive Treatment for ADHD led to an 85% reduction in risk for substance abuse disorders |
| Sexual Behavior: | ADHD teens are more likely to have sexual intercourse at an early age Are more likely to have more sexual partners Are more likely to become pregnant (38% vs 4%) Are more likely to contract STD’s (17% vs 4%) |
| Social Behavior/Self-Esteem: | Problems in peer and family relationships, emotional control, social problem-solving, and self-esteem are noted in over 50% of children with ADHD. |
Strategies For Parents
Ask for an evaluation by a physician or psychologist if you are seeing (or hearing) that your child (4+) has problems paying attention, completing school work, controlling their actions or their mood and don’t seem to improve (over six months) despite your best effort.
Realize that a child can have difficulties paying attention for a variety of medical reasons, other than ADHD including: anemia, hypoglycemia, diabetes, thyroid disorders, sleep disorders, allergies, dietary insufficiencies of zinc and magnesium, visual problems (acuity, tracking, & convergence) and hearing problems. Make sure that your child is evaluated thoroughly by a physician before concluding a diagnosis of ADHD.
If your child is diagnosed with one of these other conditions, treat that medical problem first. If “ADHD” symptoms persist, then pursue medical treatment for ADHD. Inform the CSE Chairperson in your school district that your child has been diagnosed with ADHD and request an evaluation in order to determine the need for an Individual Education Plan (I.E.P.) or 504 Accommodation Plan. Part of most plans will include at least weekly communication between teacher and parents regarding the child’s progress.
Initiate and maintain a relationship with a health care provider who commonly treats (and has been successful) in treating patients with ADHD. Parent counseling, social-skills training, EEG biofeedback, and school interventions have all been useful in promoting the success of patients with ADHD. Individual psychotherapy, “cognitive-behavioral” therapy, and traditional group therapies have not been demonstrated to be helpful.
Tips for Parenting your “ADHD Child”
(Source: V.J. Monastra.(2004). Parenting Children with ADHD: 10 Lessons That Medicines Can’t Teach. Washington, D.C.: American Psychological Association’s Magination Press.
At home, establish a weekly “planning time” to decide what skills you’d like your child to “work on”. Select about six.
Divide your child’s day into four parts (before school; at school; before dinner; and after dinner). Establish what tasks your child needs to accomplish during each period (e.g. get washed, dressed, eat breakfast before school; cooperate with the teacher and complete school work; complete an afternoon chore and part of homework before dinner; finish homework, get ready for bed and go to bed without a major battle).
Reward and punishment typically backfire with kids that have ADHD. I’ve often observed that there seems to be no reward too big or punish- punishment too great to consistently work with these children. Here are the basics of the motivational strategies taught at our clinic.
In life, your child will need to work for what he or she wants. There should be very few “freebies” at home. Your child needs to earn t.v., computer, video, phone, organized sports, and other privileges by obeying parental rules and taking care of their responsibilities without whining, griping, avoiding, yelling, etc. Until they complete their morning, school(etc) responsibilities, their life is “on hold”. The child needs to complete their tasks (as well as “make up” for excessive whining, yelling, screaming, throwing, etc) before play. As important, you need to realize that by giving away “freebies” you are pretty much eliminating the kinds of motivators that you will need to teach your child life-skills.
In life, if you make someone’s life more difficult, then you need to make it easier in some way. Translation, if your child yells and gripes for 40 minutes over doing their homework, then finally “gives in” and completes it, before they proceed to have some fun, they need to apologize and do something to make your life a bit easier.
In life, if you “mess up” you need to “make up”. We all can lose our cool and get angry, sarcastic, or mean. If your child does this, then they need to apologize and “make up”.
Yelling does not accomplish anything. Children need to be taught how to solve problems with you and their peers. This is a primary focus of parenting classes and social skills programs.
Nutrition Does Matter. Protein is the foundation of attention and concentration. Children who eat the USDA recommended amounts of protein at breakfast and lunch are in a much better position to do their school work than kids who don’t. For little kids (under 7) 10-15 grams at each meal would be great. For older children, try to encourage them to eat about 15-20. Teenagers would do well to consume between 20 to 30 grams at breakfast and at lunch. A simple guide follows:
Your child will get about 7 grams of protein from each of the following foods:
1 egg (just the white… in case your child doesn’t like the yolk)
1 ounce of beef, chicken, pork, poultry, or fish (you’d be surprised how many kids like chicken nuggets or tuna for breakfast)
1 glass of milk (8 ounces)
1 ounce of cheese (typically 1 slice)
2 tablespoons of peanut butter.
Strategies For Teachers
Prior to Diagnosis:
You are probably in the best position to determine whether a child’s attention, concentration, effort on school tasks, and classroom behavior are unusual for your grade. If you are observing an unusually high frequency of inattentive, impulsive or hyperactive behaviors that continue for six months despite class-wide interventions (use of agenda; Color Chart with mild reinforcers), prompts and reminders by you (and class aides), placement of the child near you, and notes to parents, my recommendation is that you meet with the parents, share your observations, and suggest that they review this information with their child’s physician.
THIS IS NOT THE SAME AS SAYING YOU SUSPECT THAT THE CHILD HAS ADHD.
However, you are in a unique position to share with parents what happens when their child is asked to attend to instruction, and concentrate and complete tasks that require sustained mental effort. You can also share that there are a number of medical conditions that can contribute to problems attending (e.g. visual problems, hearing problems, anemia, hypoglycemia, ADHD, etc.) and that the best person to evaluate the situation is the child’s physician.
After Diagnosis:
Once a child has been determined to have ADHD, the CSE needs to conduct both an evaluation for learning disabilities and a functional assessment. The LD evaluation is needed because learning disabilities occur in approximately 50% of children diagnosed with ADHD. The functional assessment (i.e. evaluation of the ways that ADHD is adversely affecting educational performance) is needed because ADHD is known to limit alertness and adversely affect educational performance.
Both state and federal educational laws are clear in asserting that patients with ADHD qualify for assistance because of impairment in educational performance. This impairment is due to difficulty in sustaining alertness throughout the day. The presence of a specific learning disability is not required in order for children to receive assistance.
Common Interventions:
Primary/Intermediate:
Monitoring of the student’s “homework” book or agenda
Monitoring of the student’s “packing” their book bag at the end of the day
Reduction in the number of “repetitive” writing assignments (e.g. copying spelling words; writing multiple sentences for each spelling word; copying material from books, boards)
Providing the student (and parent) with advance notice on assignments for the next week. Because children with ADHD become overwhelmed, easily upset, and mentally fatigued in the evening, it can be beneficial to provide the student with next week’s spelling list or assignments in social studies or English on a Friday, so that they can get a “head start” on homework.
Use a “class-wide” Color Chart System and provide parents with a daily report on the child’s performance so that parents can reinforce at home (e.g. if the child “gave the teacher a hard time about doing a particular task”, then the child can be required to do something to “make up” with his teacher and complete the task or equivalent before play time)
Collaborate with the case manager/resource room teacher to provide weekly progress notes on any missing assignments. Avoidance of tasks requiring sustained mental effort is one of the primary symptoms of ADHD. It is essential that parents and teachers collaborate to “close the loop” and make sure that avoiding work does not pay.
When possible, provide student with advance notice on the next weeks assignments so that they can get a head start.
Middle/High School:
Provide the student with an agenda to record assignments
Encourage the student to become skilled at word processing via a computer or “Alpha Smart/Dream Writer”. Student’s with ADHD often write too little or illegibly because the act of writing has been adversely affected by ADHD. By viewing their writing sample on a screen and reducing the amount of effort needed to produce a letter, students with ADHD are often able to improve the quality and quantity of their writing.
Assist the student in developing note taking and study skills. If the student demonstrates an inability to sustain concentration while listening or reading, collaborate with his case manager or resource room teacher to provide notes and study guides. The key is to accommodate and remediate.
Avoid debates with the student. ADHD is a condition associated with impairment of the frontal lobes. Don’t attempt to reason with a student with ADHD who is clearly upset. If they are becoming disruptive in the class, suggest that they regroup at their seat, in the back of the class, or at the nurses or counselors office (or other approved locations). Students with ADHD will typically calm within a few minutes unless engaged.
In general, it is important that you realize that ADHD is a medical condition that requires a combination of medical, psychological, nutritional and educational interventions. If a student with ADHD continues to be disruptive and upset each week, their parents, physician, psychologist or counselor needs to be informed so that treatment can be adjusted. Neither you nor the child will benefit from persistent outbursts in the class.
Strategies For Physicians
Suggestions for Clinical Practice
- Do not limit your evaluation to a review of behavioral symptoms. Even the most detailed and comprehensive review of symptoms will not help you rule out if the child’s inattention, impulsivity, or hyperactivity is due to allergies, anemia, hypoglycemia, diabetes, thyroid disorder, sleep apnea, dietary insufficiencies of zinc, magnesium, or Vitamin B. Medical evaluation of each of these conditions seems advisable. In our case review of over 12,000 patients, we have found that at least one of these conditions was contributing to “ADHD symptoms” in approximately 5% of our sample.
- Don’t ignore the obvious. If a child is struggling to attend and concentrate at school, insist on an evaluation for learning disabilities in reading, mathematics and written expression prior to beginning medication. In addition, in patients displaying problems in reading decoding and comprehension, request a thorough visual examination. There is mounting scientific evidence that children with “ADHD symptoms” have a greater incidence of impaired visual tracking and convergence than peers.
- Screen patients for illegal psychoactives beginning at least in the middle school. Due to the high rate of substance abuse among pre-teens and teenagers, and the risk for drug interactions, and the adverse effects of such drugs on treatment outcome, blood screening for illegal psychoactives is routinely requested at our clinic, prior to initiating any treatment.
- Respect the importance of nutrition in sustaining attention and maintaining behavioral and emotional control. The relationship between dietary intake and the biosynthesis of neurotransmitters is well known. Without protein in the morning and at lunch, children, teens and adults will be unable to concentrate. At our clinic, we encourage children (under 10) to consume 10-15 grams of protein at breakfast and at lunch (pre-teens: 15-20 grams; teens and young adults: 20-30 grams). Those patients who followed these guidelines demonstrated fewer side effects, and required a lower dose of stimulants than matched controls (Monastra, V.J. (2004). EEG Biofeedback treatment for ADHD: An analysis of behavioral, neuropsychological, and electrophysiological response over a two year follow-up period. Presented at the Annual Conference of the Association for Applied Psychophysiology and Biofeedback. Colorado Springs, CO.).
- Consider using continuous performance tests and QEEG examination (in addition to rating scales) to assist in identification of an optimal dose of medication. Because many factors can contribute to less than optimal response to a particular dose of medication (e.g. learning disability, insufficient diet, lack of sufficient academic support at school, absence of an effective behavioral intervention plan at school or home), we use CPT’s and QEEG’s in order to determine when a medication is sufficient to help a child achieve “normal” scores on tests of attention and behavioral control, and produce levels of cortical arousal on a QEEG that are consistent with age. Children who are being treated with medications for ADHD but continue to display significantly high frequency of core ADHD symptoms, despite age appropriate performance these tests, commonly do so because of factors other than inadequate dose of medication.
- One of the most important findings from the MTA Study (MTA Cooperative Group, 1999), was that significant functional problems persist despite effective pharmacological treatment. Parent training, social skills programs, and EEG biofeedback have all been supported by controlled group studies and merit inclusion in the treatment of patients with ADHD.
Strategies For Counselors
Keys for Successful Patient Care
1. ADHD is not like other psychiatric disorders. It was not caused by trauma, neglect, inadequate parenting, or social isolation. Applying therapeutic strategies based on existing models of psychopathology simply fails to produce resolution of the core symptoms of ADHD or promote improved social functioning.
2. Like other medical conditions that can affect attention, concentration, mood, and behavioral control (e.g. diabetes, hypoglycemia, anemia), the underlying medical causes of ADHD must be addressed as part of any effective treatment program. Prior to treating a patient for ADHD, make sure that they have been thoroughly evaluated for other medical conditions that can cause symptoms of inattention, restlessness, and impulsivity (e.g. anemia, hypoglycemia, diabetes, thyroid disorders, sleep apnea, dietary insufficiencies of zinc, magnesium). In pre-teens and teenagers it is highly advisable to insist on a screening for illegal psychoactives.
3. To date, certain types of stimulant medications (e.g. Ritalin-LA, Concerta, Metadate-CD, Adderall-XR), antihypertensive medications (e.g. clonidine and guanfacine), tricylclic antidepressants (e.g. Imipramine) and norepinephrine specific reuptake inhibitors (Strattera) have been demonstrated to be effective in treating the core symptoms of ADHD. The only type of non-pharmacological treatment that has been shown to produce significant improvement in the core symptoms of ADHD is EEG biofeedback. Without utilizing one of these types of treatments, there is no scientific evidence that your patient’s symptoms of inattention, impulsivity or hyperactivity will improve.
4. If school is going well, life gets a lot easier for kids with ADHD. Consequently, make sure that your patients with ADHD are receiving accommodations and support as mandated by the Individual’s with Disabilities Education Act (I.D.E.A.) and Section 504 of the Rehabilitation Act of 1973 (504 Plans).
5. I once heard it said that “pills don’t build skills”. From my perspective, Skill-building is at the core of effective counseling for patients with ADHD. Kids with this condition need to learn a number of skills including:
how to engage in meaningful and enjoyable conversations with others,
how to “pick out” important information when they listen and read,
how to organize their possessions,
how to work for what they want,
how to control impulsive expressions of anger, sadness, and fear,
how to express disappointment in an appropriate manner
how to overcome fears and anxiety and
how to solve social problems with others.
Play therapy may be useful in establishing rapport with a child whose disorder is caused by trauma or neglect. However, ongoing “play therapy” or “cognitive behavior therapy” is unsupported when applied to treating patients with ADHD. To be frank, kids with ADHD do not need an adult buddy to hang out with them and play chess or video games. These kids need parents, teachers, and therapists who will involve them in social skills groups (e.g. those modeled after the MTA groups developed by Dr.William Pelham) and encourage their parents to participate in parent training programs specifically developed for caretakers of children with ADHD (such as the program developed and evaluated at our clinic).
Coaching for Adults with ADHD
ADHD is a medical condition, much more like diabetes than depression. It is not caused by traumatic life experiences like the loss of a loved one, physical or psychological abuse or emotional neglect. Consequently, traditional psychotherapy often fails to help adults with ADHD improve their lives. Like a diabetic patient, it is important for an adult with ADHD to understand the medical causes of their medical condition…. To learn how medications work and which one might be best for them…. To appreciate the role of nutrition and fitness in improving attention, mood and functioning. Sometimes, adults with ADHD can “do it on their own”. Other times, the advice of a personal trainer or “coach” is needed to help them take steps to simplify their lives and overcome the day to day problems that are part of ADHD.
At our clinic, we are here to help you, if you need a “coach”. We’ll begin by asking you to provide us with some essential background information… like how were you diagnosed with ADHD, what doctors or health care providers are involved in your treatment, and ask your permission so that we can collaborate with them in your care. We’ll also ask you to complete several questionnaires designed to give us a better idea of how your ADHD is interfering in your life.
Once we receive this information, one of our coaches will contact you to arrange an individual consultation, either at our clinic or by telephone. Our coaches hold either a doctorate degree in psychology or master’s degrees in social work and have extensive experience helping adults with ADHD. During this initial consultation, we will talk about what you want to change and develop strategies to “make it happen”. Afterwards, your coach will be in daily contact with you to help if you get stuck. Typically this is done via email; however, phone consultation is available should you so desire. Fees for this type of service vary depending on your need but typically cost less per month than a single “psychotherapy” session.