The ABC's of Attention Deficit Disorder

Today I will discuss a commonly misunderstood condition, Attention Deficit Disorder.  There is much confusion, fear and misinformation floating on the web that either stereotypes, catastrophizes or minimizes this condition.  This post will outline the disorder; explain some of its more unusual symptoms and explain how it is diagnosed.

Description and Symptoms:

Attention Deficit Disorder (ADD) is a medical diagnosis associated with significant difficulty in sustained focus, listening and concentration. Additional symptoms often include forgetfulness, a propensity for losing or misplacing personal possessions and an inability to accurately estimate the time it takes to complete a given task. A consistent pattern of difficulties with planning, organizing and executing activities is also evident.  Challenges with visual-spatial processing are frequently exhibited as confusion with geographical directions as well as academic challenges in the areas of math and reading comprehension.

Are these deficits caused by the way an individual thinks? Could permissive parenting styles generate Attention Deficit behaviors?  Is it possible that these symptoms are a response to where we live and work?  Let’s examine these possibilities. 

The Thinking Brain:

The frontal lobe of the brain is also known as the hub for executive functioning.  Executive functioning is the process of how we (1) generate an idea; (2) then formulate a plan; (3) organize that plan into functional steps; and (4) finally execute that plan.  In essence, it is our ability to transform a creative thought into a substantive product.  Normal frontal lobe development occurs from approximately age four through age 20.  Research suggests that symptoms associated with Attention Deficit Disorder may reflect a lagging development of the frontal lobe.  That would explain why some children with ADD seem to “catch up” with their peers in the areas of executive functioning during college.  Attention Deficit Disorder is not related to intelligence.  It is related to how we process information!

Visual-spatial ability is the way our brains can “see” dimensions (think geometry) as well as how we read maps and even comprehend what we read.  Our ability to differentiate left from right and east from north, west and south are also a function of “picturing” spatial relationships within our brain.  Reading skills are very dependent upon visual-spatial acuity. In order to comprehend what we read, we transform words into mental pictures that have meaning.  When the ability to translate words into meaningful pictures is compromised, deficits in understanding what we read are very possible.

While there are not structural differences in the brains of individuals who are diagnosed with Attention Deficit Disorder, clearly how the brain processes incoming information is involved in this diagnosis.

Behavioral Origins:

Is it possible that an individual’s behavior causes Attention Deficit Disorder?  No! The connection with what may seem like unruly behavior and Attention Deficit Disorder is more likely the impact of how mental distraction and disorganization affects behavior. This is often observed when an individual seemingly jumps from one activity to another or forgets important materials needed to complete a given task when compared to their peers.   For example, your child may forget to bring their workbook home (the one they needed) although they do remember to bring home the textbook! 

An adult with Attention Deficit Disorder may return to the market several times while preparing a meal because they “forgot” key ingredients despite being there hours earlier!  These examples more accurately reflect an inability to plan and organize their activities rather than deliberate oppositional or defiant behavior. 

  

Unfortunately, to the frustrated parent these behaviors may appear to be intentional; a behavior that could be remedied with more discipline. An individual with Attention Deficit Disorder often feels frustrated and embarrassed by their behavior. In this situation, firmer discipline is rarely effective. I believe it is important to understand that these seemingly scattered behaviors are the outward expression of what the brain is internally struggling to keep straight. 

Environmental Origins:

What about our environment?  Could it cause Attention Deficit Disorder? Highly unlikely!  Is there a definite correlation between the environment and the exacerbation of ADD? Absolutely!  Recall that individuals with Attention Deficit Disorder struggle with organizing and processing information within their brains.  Living in a cluttered home or attempting to function in a chaotic academic or work environment further stresses their ability to organize yet another system in their lives.  The options are: (1) to spend precious time and emotional energy attempting to organize the chaos prior to tackling their assignments; (2) attempt to ignore the chaos and focus on the task at hand; or (3) become caught up in the chaos and accomplish nothing. 

An individual with Attention Deficit Disorder may valiantly attempt to organize their clutter by purchasing organizational tools such as bins and specifically designed organizers only to get side-tracked when determining which color to buy.  A student may dive into a project and then become

overwhelmed by the thought of how to organize their outline. They may choose to escape this internal chaos by focusing on a video game. In both of these examples, little re-organizing will occur without assistance from family and/or friends.

An alternative approach to manage a chaotic environment may be to extract themselves from the chaos and hyper-focus on the task at hand. The mental exhaustion required to complete the original task amid the chaos depletes the energy required to then reorganize their environment.  This may be incorrectly identified as laziness, when it may be emotional and mental exhaustion! 

The least healthy approach is to get lost in the chaos.  This may look like halfhearted attempts to organize the environment followed by halfhearted attempts to focus on their work with little impact on either situation.  Generally this approach is followed by surrender on both fronts. Therefore, we may conclude that Attention Deficit Disorder is definitely affected but certainly not caused by the environment.

Interactions Between the Brain, Behavior and Environment:

Attention Deficit Disorder is a neurological disorder that originates in the brain that challenges the processing of information as well as affecting sustained attention and concentration. Often loved ones first observe behaviors that may prompt concern.  Environmental factors, especially chaos and clutter certainly may exaggerate symptoms and further compromise functioning.  But neither behavior nor the environment causes ADD.  Who then is qualified to diagnose Attention Deficit Disorder?

The Diagnostic Process:

In most states, a medical professional is qualified to diagnose Attention Deficit Disorder.  However, many physicians refer their patients to a psychologist who will administer tests and evaluate relevant family history prior to making a recommendation of this diagnosis.  Research suggests that there may be a genetic transmission of Attention Deficit Disorder.  Most recent research also suggests that maternal smoking and alcohol consumption during the second trimester of pregnancy may also be correlated with Attention Deficit Disorder in children. These are several reasons that a comprehensive familial history is important when evaluating this diagnosis. It is also important to rule out the possibility of depression and anxiety. These emotional conditions may also impact an individual's ability to focus and process information and thus may mimic symptoms of Attention Deficit Disorder.  A psychologist is also qualified to assess as well as rule out emotional issues that may confuse the diagnostic picture.

CONCLUSION:

An adolescent or an adult cannot suddenly develop Attention Deficit Disorder!  While this diagnosis may not be determined until adolescence or even adulthood, symptoms must have been present prior to age seven to meet diagnostic criteria. Frontal lobe development, family history, behavioral observations, academic and home environments, and possible emotional issues must be considered prior to confirming this diagnosis. If you or your loved one seems to be struggling despite conscientious efforts to succeed, consider an evaluation for Attention Deficit Disorder.  A variety of treatment options are now available that may make the road to success more clear and more readily attainable!

Are Children Who Underachieve Lazy? - Part Two

Part One of this post raised the question of whether underachievement was an indicator of laziness in children.  As previously discussed, this is not necessarily a causal relationship and many different factors, like potential physical health problems, should be examined.  Assuming those possibilities have been ruled out, what are the next steps in determining the source of what appears to be laziness?

One course of action obviously is to discuss your concerns with your child’s teacher(s).  While often a useful addition to your investigation, teachers’ perspectives may be limited in two ways: 1) they have precious amounts of time to spread among an entire group of students and cannot specifically monitor your child throughout the day; and 2) your child’s behavior may differ dramatically between school and home. Let’s dive in to why that may occur.

Most children understand their role as a student and apply their energy to learning while at school.  However, for children who are struggling to keep up in class, their fears of exposure and possible ridicule are significant emotional stressors that may shift their attention from learning.  When they finally arrive home it is often difficult to contain those emotions so parents often witness behaviors that are not displayed at school.  If there is a significant disparity in your child’s behavior between what teachers observe at school and what you observe at home, you may want to consider additional diagnostic evaluation.

Assume you’ve decided to have your child evaluated, how do you begin?  At this point, there are several questions to ask yourself: (1) Will you involve the school? (2) Who is qualified to assess my child? and (3) What do I look for in selecting an assessor?

School-Based Assessment or Private Assessment:

There are potentially two paths from which to choose when you are ready to have an assessment: 1) School-based assessment, or 2) Private assessment. If time is an important consideration for you, a private assessment would be more streamlined compared to the school-based assessment process.  Generally, school-based assessments are subjected to district guidelines for the filing and approval processes.  The only constraint in a private assessment is assessor and client availability.  If your child meets the requirements for a school-based assessment, an assessor will be assigned to your child.  In a private assessment, you have the autonomy to select an assessor who meets you own standards for education, professional standing and personal compatibility. Regardless of which path you choose, know that assessment results are valid for three years. So, the effort and costs incurred in this process will not become an annual event!

School-Based Assessment:

One possibility for an assessment could be through the school system.  If the school agrees with your concerns, there are specific district procedures that you will be required to follow.  Understand that a comprehensive psychological assessment differs from an assessment that a school conducts as part of an educational evaluation.  The focus of an educational assessment is your child’s potential for learning.  Generally, the parents must seek out a psychological assessment independent of the school environment. Exceptions may arise if the school has a licensed clinical psychologist on staff. Based upon the testing results your child may be entitled to special accommodations within the school’s academic environment. The results of educational assessments are shared during a parent-assessor-teacher conference or an Individual Education Plan (IEP) meeting set by the school district.

Refer to your State’s Education Code for more details about school-based assessments.

Private Assessment:

If this is your preference, the process is fairly simple: you contact the professional and he or she will advise you of their approach and fee structure.

How do you find a professional assessor?  A common route is to ask for recommendations from your child’s pediatrician, your family practice physician or nurse practitioner, and possibly administrators at your child’s school.  Other parents are also a great source of information.

Choosing A Professional:

Even if a professional is highly recommended, be certain to ask about their qualifications. Begin by looking at the initials after the assessor’s name.  Does the assessor hold either a Master’s Degree (M.A.) or a Doctorate Degree (PhD, PsyD)? Master level assessors are certified to administer certain tests depending on where they conduct them (school or college) and for what purpose (career guidance and some learning difficulties).   Psychologists who hold either a Doctor of Philosophy (PhD) degree or a Doctor of Psychology (PsyD) are qualified to administer all types of testing.  An independent licensed assessor in California would be a clinical psychologist.  Individuals who have a Doctorate in Education although they are not licensed by the State specifically for testing may also offer testing.

The following excerpt from the chapter “Get Smart About Tests” by Rocklin Publications offers a nice summary of which professionals can administer what tests:

“The professionals who administer standardized educational and psychological tests often are psychologists, but other professionals, such as counselors or vocational and educational specialists, as well as classroom teachers, are permitted to administer some tests. The classroom teacher, for example, typically will be the one who administers the proficiency tests your child will take in school. (Most tests administered by teachers, such as quizzes and classroom tests, are developed by the teachers themselves and are a different breed than the standardized educational and psychological tests that take years to develop.) A career or vocational counselor may give career interest inventories and certain aptitude tests in order to help a student choose the right career path. And an educational specialist may administer certain educational tests to determine whether a learning problem exists or to determine which remedial approach works best for a particular student.
   Because standardized educational and psychological tests are such sophisticated instruments, anyone who administers them must be properly trained and have experience administering and interpreting tests. This is important because the person using tests needs to be familiar with the technical and statistical properties of the tests to make sure they are right for the child being evaluated. Just as it would be unwise to have an untrained and inexperienced person perform and interpret medical tests, it would be equally unwise, and unethical, to have an untrained and inexperienced person administer and interpret educational or psychological tests.
    The psychologists, educational specialists, and counseling professionals who administer tests are highly trained. Many will have a doctoral degree—a Ph.D. (Doctor of Philosophy), a Psy.D. (Doctor of Psychology), or an Ed.D. (Doctor of Education)—but a good many also will have a specialist degree, such as an Ed.S. (Educational Specialist), or a master’s degree, such as an M.A. (Master of Arts), an M.S. (Master of Science), or an M.Ed. (Master of Education). You may be wondering whether medical doctors, such as M.D.s (Doctor of Medicine) and D.O.s (Doctor of Osteopathy) administer tests psychological or educational tests. Typically they do not.
    Having one of these degrees does not necessarily mean a person is qualified to administer and interpret psychological and educational tests. They also must be licensed or certified through state licensing boards. And in order to become licensed or certified, most professionals must have appropriate training and experience as well as pass a rigorous written exam and oftentimes an oral exam.”  http://www.rocklinpub.com/whocanadministereducational&psychologicaltests.

A key point to remember is just as all children are not alike,

neither are all mental health professionals. This excerpt suggests that professional licensing may also be important to consider before choosing an assessor.  If a professional is licensed by the State, they are issued a license number and that information is accessible to the public.

Once you have determined that your choice will be to contract a licensed clinical psychologist in private practice, what happens next? We’ll explore that step in Part Three of this post.