Is it really ADHD? Coursera ADHD Class Week 8 – Assessment

More and more kids in the US have ADHD. This has led many to feel that we are over-diagnosing kids that have other issues, or are just a bit slower to mature, with a psychiatric disorder where none exists. Others argue that we are diagnosing and then medicating students whose only “disorder” is being anti-authority. It reminds me a bit of One Flew Over the Cuckoo’s Nest.

In his ADHD Coursera course, Dr. Rostain makes a strong point that the diagnosis criteria are solid and if applied correctly, will not over-diagnose ADHD. A complete evaluation for a child that shows signs of ADHD involves many steps, checks, and a full case history. Unfortunately, in most cases, this complete workup is not done because it is too time-consuming and expensive. Instead, a couple quick surveys filled out by frustrated parents and teachers and your child too can get a prescription for ADHD “study” drugs.

A complete ADHD assessment includes interviewing both the parents and the child and looking at:

  • Identifying key symptoms
  • Tracking the developmental course of those symptoms and the corresponding concerns
  • Conducting clinic-based psychological tests
  • Complete review of prior school and medical records
  • Complete physical and possibly neurodevelopment screening to rule out other causes of disruptive/distracted behavior
  • Vision, hearing, and formal speech and language assessments
  • Individually administered IQ tests, educational achievement tests, and screening for learning disabilities
  • Differentiating ADHD from other disorders
  • Clarifying the developmental “inappropriateness” of those symptoms and concerns
  • Look for other causes of the symptoms including changes or stressful situations at school and/or home
  • Checking on sleep patterns. Lack of sleep mimics ADHD.
  • Evaluating co-morbid conditions
  • Determining the degree of impairment
  • Assessing the family situation and how they are adjusting and accommodating the child’s behavior
  • Identifying strengths and resources of the child and the family
  • Eliciting priorities for change
  • Identifying community resources

Most of the time all of the above is not done. Having gone through the diagnosis process in our family, I know it was much more straightforward. I just noted that I thought ADHD might be an issue, filled out a couple of surveys that were highly subjective, and presto, we had Ritalin. Since then we have let the prescription lapse. It seems that being in a better educational environment is more effective than drugs for producing happy, productive kids. There are many reasons why a child has high-energy and is easily distracted. If a highly gifted student is in a classroom that is moving too slowly, of course she may be distracted and not paying attention. If a profoundly gifted boy has a third grade teacher that is only covering science at the third grade level and he “corrects” her by pointing out inaccuracies in her explanations, is that a psychiatric disorder?

One of the most used surveys to assess ADHD impairment is the Vanderbilt Assessment Scale. Almost all the questions from the teacher survey can be answered positively when a child is highly or profoundly gifted and is in an inappropriate school environment, but does not have ADHD. If independent IQ testing isn’t part of the screening process, a child could be incorrectly diagnosed and medicated when all he or she needs is a more challenging class. Yes, the teacher survey does include questions about whether the child is above average or not in reading, math, and writing but again, if the gifted, bored child isn’t doing the classroom work, the teacher will probably not rank his “academic performance” as above average. This is one of the reasons SENG has started to heavily publicize the issue of misdiagnosis of gifted kids. Two of the top misdiagnoses of gifted and talented children are ADHD and Oppositional Defiant Disorder (ODD). ODD is frequently co-morbid with ADHD and these misdiagnosis are due to a basic level of ignorance among health professionals and teachers about normal social and emotional characteristics of gifted kids. The medical profession pathologizes that which is uncommon, even if it is just a different normal.

Improper regulation of neurotransmitters in ADHD – Coursera ADHD – Week 5

This week’s class gave us a more detailed look at the neurochemistry of ADHD. Much of it focused on monoamines, catecholamine synthesis, chemical structures, and neurobiology of the brain. I’ll attempt to distill the information down to what I, as a parent, find most helpful.

The neurotransmitters dopamine and norepinephrine are deficient or dysregulated in ADHD. On the molecular genetic level, research shows that the genes most likely linked to ADHD also affect dopamine and norepinephrine.

The entire mechanism of motivation and attention is complex and involves multiple brain areas and neurochemicals. Although it was not covered in detail, the transmitter serotonin is also thought to modulate brain function and affect the symptoms of ADHD. Because the system is so complex, researchers feel that the issue with ADHD might be more a dysregulation of the neurotransmitter system where the release of chemicals is out of sync than a systematic deficiency of dopamine or norepinephrine. That being said, most ADHD drugs work by increasing their production and/or slowing their re-uptake to extend their effect.

One of the lecture slides was a great venn diagram showing serotonin, norepinephrine, and dopamine functionality. The diagram here, from the World of Caffeine website, is a more complex version of the one used in class. It shows how the three monoamines balance to create optimal attention, motivation, mood, and cognitive function.

World of Caffeine also has a nice summary of how caffeine affects the neurotransmitters. Caffeine is frequently the ADHD stimulant medication of choice for adults with ADHD symptoms.

Outside of the formal lecture, responses to the office hours questions were also posted this week. Amid general course and detailed brain anatomy information, were a few answers about kids and ADHD that stood out:

  • ADHD diagnoses decrease with age due most likely to several factors including the disorder naturally improving with age in some individuals.
  • The current definition of ADHD and system of diagnosis will not over identify children if clinicians are careful in their assessments and look for other explanations for problems with impulse control and attention regulation other than ADHD. However, too often our healthcare system doesn’t allow adequate time for evaluations. This can also lead to missed diagnosis.
  • Exercise and diet cannot prevent the onset of ADHD but they can help improve the symptoms. Dr. Rostain recommends the book Spark by Dr. John J. Ratey for anyone interesting in learning more about using exercise to improve ADHD.
  • ADHD is linked to poor sleep. It is possible the same brain difficulties that lead to ADHD symptoms also interfere with sleep regulation.
  • Although autism and ADHD  are entirely different entities, the same genes are involved.
  • Psychosocial stress increases ADHD risk and insufficient sleep diminishes focusing and productivity for everyone.
  • Brain training can build focus, attention, and cognitive processing but there is limited data on which programs are most effective because the field is very new.
  • There is no correlation between ADHD and IQ other than as a group, children with ADHD have a slightly lower average IQ of 95 rather than the 100 of the general population. This little fact, to me, says that if a child who is highly or exceptionally gifted has symptoms that look like ADHD, extra care should be taken in trying to determine what is actually going on. It might be ADHD but it might just as easily be normal behavior for a stressed, high-energy, gifted child.

In a few of the office hours answers students were referred to Judith Warner’s recent article on ADHD in Time. The gist of the article seems is that ADHD is a true medical condition and if we get too worried about over diagnosis we run the risk of having insurance companies or congress deny effective treatment options to vulnerable kids. She states that it is a developmental disorder not a symptom of social pathology.

Yes, ADHD is a real problem and is classified as a developmental disorder. Yet, carefully treating kids negative affected by it does not preclude an in-depth discussion on modern childhood. It is a disorder triggered or amplified by certain environmental conditions. This makes it all the more important to closely examine what has happened to childhood over the last 20 years to see how we may have turned on the ADHD genes.

Stimulants for ADHD don’t improve long-term outcomes – Coursera – ADHD – Week 4

I am now 1/3 of the way through the class and overall I’ve really enjoyed it. The course description estimated the workload at 2-4 hours per week and that has been correct. The TA’s have done a good job responding to questions about the weekly quizzes and making changes when there is a consensus that a question had confusing wording. This week they are adding another unique feature for a Massive Open Online Course (MOOC) — office hours!  We can submit questions to the professor and Friday he will answer as many as he can.

This week we explored the neuro-imaging of ADHD. Although there are differences seen in PET and fMRI scans in adults with ADHD versus adults without ADHD, neuro-imaging cannot be used to diagnose ADHD. Looking at ADHD from a parenting or educator lens, here is the information I found most relevant.

First, while maximum brain volume is typically reached by age 16 for all children, those diagnosed with ADHD show about a 3-year lag in brain development. This is most likely one of the reasons they seem less mature than their classmates. Once their brains are fully developed at about age 16, people who have ADHD still show smaller and less active orbital-prefrontal cortexes, basal ganglias, and cerebellums. The size difference of these regions compared to a more typical brain is directly correlated with how sever the ADHD symptoms are in a given person. Individuals diagnosed with ADHD also show lower levels of dopamine transporters in the brain’s reward center. Although the lecture didn’t cover it, I suspect that an impaired reward system is one of the reasons some ADHD individuals are susceptible to drug abuse and addition.

One area of brain anatomy and function covered in-depth for the first time this week is the role of the anterior cingulate cortex. Individuals with ADHD have less activity in the anterior cingulate cortex than more neuro-typical people and this can significantly impair their performance. The anterior cingulate cortex is an essential part of the cognitive and emotional executive attention system and has a role in emotion, motivation, timing, focused attention, willed motor control, working memory, pain, error detection, reward, monitoring, and feedback-mediated decision-making. One of these, working memory, is explicitly tested for in IQ tests such as the Stanford-Binet and some researchers feel that working memory is more important than IQ when predicting overall achievement. A child may be highly gifted but not perform as expected if their working memory (and attention for that matter) is less than ideal. Although some high-energy gifted kids are incorrectly diagnosed with ADHD, there is most likely another group of gifted kids that are not recognized as being gifted or having ADHD because their performance is average and their behavior isn’t annoying enough for the adults to suspect ADHD.

So what effect do drugs, especially methylphenidate, have on brain function and anatomy as viewed with neuro-imaging? They definitely increase brain activity while they are in the system, however, they do not change brain structure. The medications can help a child improve their classroom behavior, performance, and teacher and peer interactions in the short-term. Yet psychostimulants do not seem to create long-term changes in outcomes for peer relationships, social skills, academic skills, or school achievement. This little tidbit, buried at the top of page 146 of the 1999 Surgeon General’s report on ADHD, assigned for our week 5 reading, sent me on a search for more studies and more information.

If ADHD medicine is only a short-term fix, why are we drugging our kids’s developing brains? Aren’t there other ways to change their behavior?  And if their symptoms are so bad, why is it common to just prescribe drugs without also helping them with behavioral techniques? The combined treatment of drugs plus behavior modification has better results than just treatment with drugs alone. The drugs may make a child more attentive, less impulsive, and less disruptive but they have no effect on academic achievement. Just because a child is sitting still, better at completing homework, and easier to handle in class, does not mean that child is actually learning more. The lack of long-term improvement with the use of stimulant medication, combined with study results that indicate that they may increase depression in some children and have negative long-term cardiovascular implications, makes me question why they are prescribed so freely in the US. This in-depth, long-term view is beyond the scope of the Coursera class which is more focused on the basics of how ADHD is viewed, diagnosed, and treated by doctors today.

People with ADHD can have a more difficult time completing tasks and attending to directions, especially if they are not interested in or are bored by the subject matter. Our current view has classified ADHD as a disorder because of this impairment. What if evolutionarily speaking, this isn’t the case? What if ADHD tendencies are a different way for a perfectly normal brain to function and the ADHD brain is optimized in some other way that isn’t compatible with our current education system?

The most interesting part of the lecture this week, for me, was something I noticed on a brain scan that wasn’t directly addressed. The brain scan from a study on anterior cingulate cortex dysfunction in ADHD, left me with a strong desire for more research. In it we see differences in brain activity during a counting stroop task for individuals with “normal” brains vs individuals with diagnosed ADHD. The “normal” brain on the left shows the anterior cingulate (green rectangle) lit up with bright yellow and red activity while the ADHD brain on the right shows nothing going on in the anterior cingulated cortex but lots of activity in the frontal stratal, insular and thalamic network. The lecture highlighted the fact that ADHD individuals had to work harder and were slower at solving the task than were other individuals because they were solving the task with a less than ideal brain region. This begs the question, what are the ADHD individuals thinking about and what connections are they making? Clearly there is a lot of something going on in their brains, by colored area alone there is actually more activity than in the “normal” brain. Just because they can’t perform as well on the counting stroop task does not mean that this activity should be deemed suboptimal. See the images yourself on page 1547 of the study.

We know that studies of scans of men’s and women’s brains clearly show that men and women process information differently and use different areas of their brains to solve the same problems. We also know that men’s brains are, on average, larger than women’s brains. This does not mean that men are smarter or that one sex uses the more correct areas of their brains. Perhaps the same is true in people with ADHD. Individuals whose brains are more wired with ADHD tendencies may struggle with tasks that are easier for people with more typically wired brains but does this really mean that ADHD is a disorder?

Coming up the course will explore the neuroplasticity of the brain and interventions shown through neuro-imaging to improve brain functions in individuals with ADHD. Given the lack of proven long-term positive outcomes with drug therapy, I am looking forward to good data on behavioral interventions.

 

 

 

Checking out Coursera – ADHD Class – Week 2

Week two the Coursera class on ADHD Through the Lifespan taught by Dr. Anthony L. Rostain, M.D., M.A. of the University of Pennsylvania is focusing on the causes of ADHD. The lecture was well put together and very informative. The reading is from Brain Facts, a free publication from the Society for Neuroscience.

I am getting more enthusiastic about the course now that we are starting to tackle some of the science of ADHD. Although diagnosing ADHD can be an exercise in subjective opinion more that unbiased reality, ADHD does have a biological basis. The problem is that it is a complex genetic disorder where various factors alter the neural pathways. It doesn’t follow simple Mendelian inheritance rules although it is one of the most inheritable psychiatric diagnoses. The mean heritability of ADHD is 0.75 this is almost the same as the mean heritability of height and greater than the heritability of asthma, high blood pressure, breast cancer, or alcoholism. As an aside, autistic-like traits are 0.82-0.87 inherited which is something to keep in mind with the increase in autism diagnoses over the last 10 years.

The best data tells us that 65-75% of ADHD is due to genetics and 25-35% is due to acquired central nervous system injuries. If a parent has ADHD, their child has a 40-54% chance of having ADHD. The chance of a child being diagnosed with ADHD skyrockets when both a genetic factor and an environmental factor are both present. Specific genes associated with ADHD are serotonin and dopamine receptors and transporters, and synaptosomal-associated protein 25. The different types of ADHD may be associated with different genotypes and specific ADHD medications may be more or less effective, depending on which genes are contributing to ADHD in a specific individual.

Taking all this together, I believe there are some strong implications for public policy and preventative parent education programs. For example, after heredity, the largest cause of ADHD is low birth rate. In fact, low birth rate by itself is associated with ADHD as much or more than fetal alcohol syndrome, lead exposure, and the mother smoking during pregnancy, combined. Parents with low birth weight children should be educated on ADHD while they are still in the hospital. They need to know that if one parent has ADHD and their child has a low birth weight, there is an increased likelihood that child may eventually be diagnosed with ADHD. They must also be given ideas and tools for how to help their child learn impulse control and organization skills.

It is interesting to note the increase in ADHD, especially in boys, seems to parallel the decrease in recess, walking to school, and physically active gym classes. We know that serotonin and dopamine are positively affected by exercise and exercise can alleviate ADHD symptoms. I am hoping that Dr. Rostain includes exercise as a treatment option. Many parents, especially of very young children with ADHD, are looking for ways to help their children without medication. Again, if parents are aware of the genetic+environment risk factors for ADHD, they will hopefully be more proactive in helping their kids get effective, regular exercise.

Just like with autism, early intervention and extra effort can lead to improved outcomes for individuals with ADHD. It seems it is far better to help kids proactively develop good habits and coping skills instead of letting untreated or acknowledged ADHD symptoms derail their academic and social lives.

 

Does Michael Jordan Make You Insecure?

Last week’s TIME magazine, dated July 9, 2012, has a multi-page article on Salman Khan and Khan Academy. Our family has used Khan Academy videos to supplement school work for over a year. As Khan Academy has expanded their offerings to include more subjects, exercises, and tracking we have played with the idea of using Khan Academy as the primary material for some subjects.

The entire idea of letting kids learn at their own pace seems to still be controversial. I’m not sure why this is. We as a nation have a huge hangup about difference in academic potential that we do not have when it comes to sports. In sports we love the stand-out players and eagerly pour extra time and resources into those players that we think have the potential to be great. We never worry about whether by helping one athlete succeed we are forcing another to fail. In fact, we frequently feel that having a star player on a team working to their full potential inspires the other players to work harder and reach a higher level than they would otherwise.

American education however, is treated too often as a zero sum game. We feel that resources are so limited that by helping one group of students succeed, especially if they are exceptionally bright, we short-change another group. The TIME magazine article, when addressing the reluctance of educators to let students learn each at their own pace states that, “In the worst case scenario, high-achieving students race ahead while low performers languish.”

How is this a worst case scenario? The sports equivalent would be, “The best high school players of high school “X” all receive full college sports scholarships while the worst players become fat and unhealthy.”  If that happened we would never view it as a worst case scenario. We would applaud and complement the school on the high achievements of their best players and perhaps investigate how we could better server the lower level players.

The article also states that some educators see a risk in letting kids work at their own pace. The risk is, “that two students will reach graduation with very different skill sets. One may have mastered everything from calculus on down while the other made it only as far as algebra.” What exactly do they think is happening now? What do they think is the real harm in some kids knowing calculus and others only algebra? In college and in life people have different interests and bodies of knowledge. If people love what they do, they can achieve success in nearly any occupation. We all know folks without college degrees that are more financially success than some with college degrees. Our country needs to be concerned with equality and fairness in opportunities and stop feeling so insecure about the fact that some of us are more intellectual than others of us.

Guilt

Last night, I did the dishes, all the dishes, not just the sharp knives and breakable hand washables, for the first time this summer. So we made it not quite a month with the kids taking on the daily responsibility for the dishes.

The kids were tired, watching a movie, and one of them had a friend over for the night. I didn’t want to push them to work when they were comfortably watching a movie with their friends.

I felt guilty interfering with their evening relaxation and taking time away from their friends.

Hmm, what is wrong with this picture? I fear I have been contributing more to our growing nation of indulged children than I thought. Time to step back again and let them have the kitchen, while I settle on the couch with a good book.

Finding a Free Online History Course

The options for quality, free courses and course materials are growing daily, seemingly exponentially. I’ve been on a quest over the last couple weeks to find not just quality materials but full courses that will challenge, captivate and not frustrate my gifted 10-year-old.

I’m looking for complete courses because I know I’m not organized enough and really have no interest in creating my own syllabus, assignments, quizzes, and exams. Luckily there are good options out there. One of the best places to start is the (Free) Online High School Courses & Curriculum Materials page on Hoagies’ Gifted website. Hoagies’ is an excellent place to start when researching most anything concerning gifted kids. Through their site I found the history class my son is currently using.

The history class is a high school AP History class, one of the University of California College Prep Open Access courses. It uses The American Pageant by Thomas Andrew Bailey, David M. Kennedy, and Lizabeth Cohen and America: Past and Present by Divine as its primary texts. Both are available on Amazon (new or used). We already had a copy of The American Pageant that he had been working his way through and this early in the course not having America: Past and Present has not been an issue. I doubt he will need a hard copy at all since much of the text is online and included in the course materials.

Why do I really like this course? It has a great mix of videos, online text, pictures, and original documents. Activities and writing assignments are directly tied to all of the above in a way that encourages the student to keep learning. The videos are relatively short, very engaging and stand well on their own, even for younger students who aren’t ready for a full AP History course. Topics covered in the course are laid out by units, lessons, and subject matter and it is easy to jump to a specific time in history, watch the videos, and work though the materials. This feature makes the course work well not just as a stand-alone AP class but also as an easy way to supplement other history courses and materials.

The only thing I do not like about the course is that it requires Flash so it cannot be used on an iPad. Perhaps in the future they will rewrite it as an iTune U class.

Although I don’t know if my 10-year-old will really be ready to take an AP History exam at the end of the class, it doesn’t matter. He is learning far more than he would in a regular elementary school or middle school history class. He is enjoying the depth and the detail and I am enjoying the fact that all this enrichment comes with little effort on my part. Shhhh 😉

Explain

Recently I switched my seven-year-old from a regular elementary school first grade class to homeschooling. We are using a combination of online learning, textbooks, regular books, videos, and museum visits for course materials.

For now the main online material he is using is the math program ALEKS. My older children also use ALEKS and have for the last 3 years. It offers a fairly comprehensive set of K-12 math courses. Students are fed problems and given assessments at their own pace. Their ability to progress is entirely dependent on how well they perform. At times they have completed an entire year’s lesson in just a couple days. Other times, when the math level contained concepts they had not previously encountered, their progress slowed to covering one grade level over the course of a calendar year.

How a student approaches ALEKS gives some interesting insights into their comfort and ability with basic problem solving. Not math problem solving, life problem solving. What do you do when you don’t know the answer, when you aren’t even sure how to find the answer? Do you stare at it? Look for additional resources? Ask someone? Bang your head against a wall? Take notes and write down detailed steps? Quit?

When ALEKS introduces a new topic it starts by showing a problem. If the student knows the answer to the problem they have the ability to answer that problem, answer a few more similar problems correctly and then move on to the next topic. This prevents students from spending endless hours working problems within their current level of knowledge.

Where it gets interesting is if a student does not already understand a topic. They have the option of clicking ‘Explain’ which brings up a text and diagram description of the problem and its solution. Some students do not even want to click on ‘Explain’ because they don’t want to fail the problem or they are uncomfortable showing their ignorance, even to a computer. If they do click ‘Explain’ they may not understand the explanation. While sometime the explanation is confusing, other times it seems that the students are just not very good at walking themselves through the explanation, step-by-step.

Working with my young student today it became clear that he is not used to taking the time to work through explanations and untangle problems on his own. He doesn’t like to click ‘Explain’ and when he does, he has a tendency to skim read the explanation and then declare, “I don’t get it. I can’t do it.”

Thus far in his education he has had the luxury of having subjects and concepts clearly explained to him by his teachers. He has been given clear and detailed directions. He has been able to easily and correctly complete assignments by just going through the motions. He has not had to puzzle over concepts. He has been given problems with distinct answers: true/false, multiple choice, fill in the blanks from the above lists of words. If it became difficult or he didn’t understand he could always ask for help or just quit. His ability to easily understand teachers’ explanations combined with the “one right answer” syndrome has made him into a lazy learner. I don’t think he is alone in this. The current test mania environment within the public schools emphasizes knowing the right answer, not knowing how to think and problem solve. Hopefully homeschooling will help him become more comfortable in the space between knowing and not yet knowing. Especially in the 21st century, knowing how to find answers and all their nuances is at least as important as knowing today’s correct answer. Explain.

 

Gifted Kids and Online Learning

Today Ann Treacy with the Blandin Foundation wrote about an update to S. F. 1528: Teachers 21st Century Tools. This bill explicitly encourages students to take online courses and would change the Minnesota Graduation Requirements to include one digital learning course credit.

The bill lays out that the enrolling district must apply the same graduation requirements to all students whether they are traditional classroom students or online learners and must continue to provide nonacademic services to online learning students. The bill also explicitly states that while a licensed Minnesota teacher must supervise the delivery of the instruction to the online learning student, the instruction may include curriculum developed by persons other than a teacher holding a Minnesota license.

This bill seems to open the door for schools and teachers to become far more flexible in meeting the needs of gifted students. Under the bill 50% of the student’s schedule can be online courses and they can be different from the student’s current grade level. In theory, this could give gifted students who are ready to work above grade level in some subjects the opportunity to work at their ability level in all subjects. Students could work with their physical classmates at grade level for some subjects and with their virtual, online classmates and instructors above grade level for other subjects.

The availability of quality online educational programs is skyrocketing and because many of them are self-paced, they can be excellent for gifted students. Ones we have used for homeschooling our gifted kids include Khan Academy, ALEKS, and iTunes U.

All three kids use Aleks for their main math course, supplemented by parent and teachers when they get stuck. Aleks has enabled them to work at their natural pace, frequently completing 2 or 3 grade levels in a single academic year. This type of individualized pacing is virtual impossible in a regular classroom with 25 to 35 kids.

My 10-year-old is taking a biology course through iTunes U. iTunes U courses can include audio, video, textbooks, syllabi, handouts, and quizzes — providing very comprehensive treatments of course subjects. iTunes U courses have been developed by Stanford, Yale, Oxford, UC Berkeley, and the NY Public Library among others. My student finds the iTunes U course more interesting and fulfilling than science at his STEM (Science, Technology, Engineering, and Mathematics) elementary school. iTunes U lets him work at his own pace and the materials are much more detailed than those typically found in 5th grade classrooms. Even in his STEM school, the need to teach to the entire class prevented the teachers from covering subjects with the depth he hungered for.

Online learning can be one of the most effective and economical tools to help all students to reach their full potential.   As funding of gifted education programs continues to far fall below what is needed, it is a positive step for the state to explicitly recognize the value of online learning.