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.