Attention Deficit

A Practitioner's Handbook

Santo J. Triolo

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780876308905
• eBook ISBN: 9781134870455
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Most clinicians rely on only an interview to diagnose ADHD in adults. With the recent media "overkill" about ADHD, more and more patients have already read numerous articles and books about the topic making it even harder for practitioners to differentiate between symptoms due to ADHD and symptoms of a hypersensitive patient. As a result, the clinician should no longer rely on just an interview but a more sphoisticated and reliable method.

Attention Deficit: A Practitioner's Handbook offers practical guidance to diagnose ADHD with special consideration to comorbid and differential diagnoses. This volume also challenges practitioners to move beyond current diagnostic criteria and presents arguments for standardized testing in addition to the traditional interview. Insightful commentaries on major points of current controversy in this area of study are also highlighted. Dr. Triolo, author of the Attention Deficit Scales for Adults (ADSA), also discusses theoretical perspectives of ADHD and bridges the gap between the research and clinical practice. A most practical volume that clinicians will appreciate in their library.

Chapter 1

Introduction

Attention deficit hyperactivity disorder (ADHD), the latest in a long string of names to describe this disorder, is at present the diagnosis given to individuals who present significant symptoms of hyperactivity–impulsivity and inattention. These problems are defined by a set of behavioral and cognitive symptoms that impair normal functioning. It is estimated that 3%–7% of the childhood population can be described as having ADHD (Barkley, 1990). It has now been well documented that ADHD persists into adulthood (Nadeau, 1995; Weiss & Hechtman, 1993; Wender, 1995); however, there is controversy with respect to the percentage of children who grow up to continue to have significant problems in adulthood. Schaffer (1994) presented the most conservative data, with the estimation that only 10% of ADHD children experience significant symptomatology in adult life. By contrast, Weinstein (1994) suggested that 79% of children diagnosed as having ADHD will continue to have significant problems in adulthood. The latest reviews (Barkley, 1997; Jackson & Farrugia, 1997) suggest that the best estimates, based on more objective prospective analyses, are somewhere between 30% and 50%. The variance in percentage may be explained partially by error due to different inclusion criteria over the years and by different operational definitions of significant symptomotology.

On the basis of more recent objective analyses, there is reason to believe that ADHD is underdiagnosed in adults because the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV; American Psychiatric Association, 1994) uses symptom cutoffs that are based on childhood sample groups, as opposed to adults (Murphy & Barkley, 1995). Also, there is ample evidence to suggest that there are numerous ADHD adults who were never diagnosed ADHD as children and are now missed by clinicians normally trained to address “adult” problems such as alcoholism, personality disorders, marital conflicts, antisocial behaviors, mood disturbances, and anxiety disorders. Eyestone and Howell (1994) interviewed and tested 202 inmates from an all-male prison population and discovered that over 25% met the criteria for ADHD as adults and had presented significant ADHD symptoms during their childhood years. They identified 22 additional inmates who showed “varying patterns of ADHD symptoms throughout childhood and adulthood, but did not have sufficient symptoms to be diagnosed ADHD” (p. 187) based on the researchers’ testing at the time of the study. Of the 202 inmates, only 40 reported no significant ADHD symptoms. The authors concluded that prisoners represent an untapped population of ADHD adults: people who have not been diagnosed and, consequently, moved away from mainstream functioning.

Similar arguments can be made for the population of drug abusers. There have been several researchers who have noted a high correlation between substance abuse and ADHD (Shekim, Asarnow, Hess, Zaucha, & Wheeler, 1990; Tzelepis, Schubiner, & Warbasse, 1995; Wood, Wender, & Reimherr, 1983). It has been hypothesized that many undiagnosed ADHD adults have turned to drugs as a way to medicate themselves. Again, this population of adults may be representative of a significant number of ADHD adults who have yet to receive appropriate professional help. Clinicians who are trained to work with adults are more likely to focus on typical adult problems, such as antisocial functioning, alcoholism, and mood disturbances, and may not consider ADHD.

BRIEF HISTORICAL PERSPECTIVE

Historical documentation of ADHD and, in particular, adult ADHD, has been presented elsewhere (Barkley, 1990; Jaffe, 1995). Barkley’s (1990) review of this field’s beginnings and historical achievements is quite comprehensive, except perhaps for the omission of his own contribution. He may be too modest to say it, but his work over the years has helped shape the landscape of ADHD research. In addition, Jaffe’s (1995) chapter provides a special historical perspective on adult ADHD research. He documents the acceptance of adult ADHD by the professional community and its growing recognition by the general public.

The emphasis here will be on the presentation of two themes that have not been discussed extensively in earlier writings. First, the study of ADHD has received much popular attention, and this may present special challenges to the practitioner. Although media attention advances interest, it may very well be a source of bias that could get in the way of good clinical practice. Second, the history of ADHD is far from linear; it is important to keep in mind that researchers are influenced by the professional trends and perspectives of their time. Periods of progress have been followed by alternate periods of regression. These themes are important to understand, and they have great significance for clinicians who must address the practical matters of taking good care of their patients.

As mentioned earlier, ADHD is the latest of a long list of names that has included minimal brain damage; hyperkineses or hyperkinetic syndrome; hyperactivity; attention deficit disorder (ADD) with or without hyperactivity; and now attention deficit hyperactivity disorder (ADHD). It is important to understand that these names are reflective of limitations in seeing the “elephant” rather than any real changes in the “elephant” itself. The core observations of behaviors and cognitive tendencies have remained relatively stable throughout the years. Back at the last turn of the century, Still’s (1902) description of problem children was remarkably similar to what is observed today. He recognized that these children had problems with moral conduct; they seemed to understand the behaviors that were expected of them, although they did not follow through with their actions. He also observed what was described as volitional inhibitions—an inability to control behaviors. Still recognized that these children were physically different and, in particular, noted their small bone structure and size with respect to age. He correctly recognized that there were more boys than girls with these types of problems and correctly speculated that the problems follow familiar lines. Still was remarkably accurate in noting that these children were unable to attend and focus as well as their peers, an emphasis that was seemingly missed by observers for several decades subsequent to his publication. Also, Still speculated that these problems were due to constitutional factors, a major emphasis in today’s literature. The ADHD patient of today is obviously no different from the patient of almost 100 years ago. Thus, what has changed over time are the interpretations and emphasis of the particular behaviors.

Barkley (1990) suggested that interest in ADHD was sparked by the effects of the 1917–1918 encephalitis epidemic on the survivors. Many of the children who survived presented significant behavioral and cognitive problems similar to the symptoms of ADHD. Consequently, a logical connection was made between ADHD behaviors and brain damage. At first, children with a documented history of brain infection or injury were followed, and their ADHD-like behaviors were documented. As time passed, children who presented with ADHD behaviors were assumed to have experienced some kind of brain trauma, even if none was documented. Perhaps the term minimal brain damage (Strauss & Lehtinen, 1947), a very misleading label, was coined because clear historical documentation of brain trauma was not presented. The association between ADHD and brain trauma remained through the rationalization that the injury was minimal and, therefore, undetectable. However, concurrent and subsequent reviewers continued to argue that this label was misleading (Birch, 1964; Childers, 1935; Herbert, 1964) and, slowly, a new direction toward a more descriptive label was adopted.

By the 1960s much emphasis was given to environmental influences, and there seemed to be a trend toward behavioral observations. The ADHD child’s most obvious problem, to observers, was the “hyperactive” component; consequently, a new label, hyperkinetic reaction of childhood disorder (American Psychiatric Association, 1968) won favor over the minimal brain damage label. To some extent the switch may have been influenced by the growing sensitivity toward the negative consequences of labels. Social consciousness and special emphasis on environmental influences seem to have been more prevalent during the 1960s and 1970s and, just as old genetic and organic origins of intelligence were challenged (Brody & Brody, 1976), similar challenges were introduced in the study of ADHD (Block, 1977). As Barkley (1990) correctly accounted, these challenges included the notions—which we know now to be false—that sugar and other nutritional factors were the cause of ADHD. This challenge also included the use of medication, and this time period marks the beginning of major debates about the merits of various treatments. Arguments that “proper” parenting and teaching are what is missing in ADHD children found their roots during this era. Possibly, the theme that medication treatment is used as a substitute for a lack of motivation on the part of parents and teachers can be traced to the political trends of the time.

Virginia Douglas has been credited for the movement away from hyperactivity and the rediscovery of attention factors involved with ADHD (Barkley, 1990). Through a series of objective observations, Douglas (1972) discovered that the level of activity alone could not differentiate ADHD children from non-ADHD children as well as behaviors associated with attentional components. Because of these efforts, subsequent research on components such as the ability to use time efficiently, screen away distracting stimuli, concentrate on tasks, and sustain focus with minimal external reinforcers became the prominent subject matter of research studies (Douglas, 1983). This shift away from simply looking at activity levels and toward the assessment of cognitive deficits, at least indirectly, may be responsible for the consideration of ADHD as a lifelong condition. Although ADHD children can eventually learn to compensate and reduce their level of overt activity as they get older, the core underlying cognitive deficits remain. Sensitivity to these deficits may have helped clinicians recognize that adults can continue to have problems (Kane, Mikalac, Benjamin, & Barkley, 1990; Morrison, 1979, 1980; Wood, 1986).

The shift away from hyperactivity toward attention deficit disorder was accepted into mainstream diagnostics in 1980 with the publication of the DSM–III (American Psychiatric Association, 1980). The new diagnostic name was attention deficit disorder. This new diagnostic label had two subcategories: with or without hyperactivity. Also, it was the first indication in mainstream diagnostics that children do not outgrow this disorder. A third category was introduced: attention deficit disorder, residual type. Full commitment to the diagnosis of adults as having this disorder apparently was withheld, but at least recognition was given to lingering symptoms beyond the childhood and adolescent years.

Adult treatment for ADHD began much as the treatment for children, with the use of stimulant medication by the presentation of case studies. Arnold and his associates (Arnold, Strobl, & Weisenberg, 1972) presented the results of dextroamphetamines treatment on a 22-year-old male patient. This patient had never previously been diagnosed as a child, but retrospective reports indicated that behavioral difficulties observed in adulthood originated in early childhood. The dependent variables included concentration, anxiety, depression, and self-esteem. In a single-subject double-blind procedure, the patient was observed on two different days on either dextroamphetamines or a placebo in each. Data were collected before administration of the drug and three other times: 2, 5, and 8 hr after the administration of the drug. In a repeated-measures design, significant increases in concentration and decreases in anxiety were reported, compared to placebo conditions. Also, the authors noted an increase in depression and no significant changes in self-esteem.

Later in 1975, David Wood and Paul Wender treated two women who presented ongoing symptoms and history of ADHD with methylphenidate, the now-preferred stimulant medication in the treatment of ADHD; the positive results motivated them to conduct an expanded double-blind study (Wood, Reimherr, Wender, & Johnson, 1976). They found that their patients responded positively to the stimulant medication, and these preliminary results encouraged them to further study the use of stimulant medication treatment on adults with ADHD (Wender, 1995; Wood, 1986).

From the mid-1970s to the early 1980s, much advancement in the field of ADHD took place. Barkley’s (1981) publication of Hyperactive Children: A Handbook for Diagnosis and Treatment perhaps solidified him as a leading researcher in the field. He certainly helped set the pace for the move away from subjective analyses to quantitative objective study. One could argue that this period marked the most advancements and, since that time, there may have been some regressive trends.

In 1987, the next DSM edition (DSM–III–R) was published (American Psychiatric Association, 1987). The new diagnostic label was attention deficit hyperactivity disorder (ADHD). It was argued that

in a field trial of several hundred children of the DSM–III–R criteria of attention deficit hyperactivity disorder, oppositional defiant disorder and conduct disorder, a clinical diagnosis of DSM–III category of attention deficit disorder without hyperactivity was hardly ever made. This suggests that with the revised and more inclusive criteria for attention deficit hyperactivity disorder there may be little need for this category. (APA, 1987, p. 411)

The key notation here is that the field trial included only children. Although by this time it had been recognized that ADHD is a lifelong condition for a significant number of patients, adults were excluded. Ironically, the “residual type” was dropped from this publication and replaced by the “undifferentiated type.” This change in terminology, although perhaps a matter of semantics only, indirectly recognized and validated the diagnosis of ADHD in adults. Residual refers to a remnant of ADHD; undifferentiated is reflective of the fact that an ADHD diagnosis applies, although not all of the symptoms for the other ADHD categories are presented.

The latest edition of the DSM, the DSM–IV seems to be a compromise ...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Preface
• Acknowledgments
• Chapter 1 Introduction
• Chapter 2 Theory
• Chapter 3 DSM–IV Criteria: Critique for the Diagnosis of Adults
• Chapter 4 Diagnosis
• Chapter 5 Case Studies
• Chapter 6 Psychotherapeutic Treatment of ADHD Adults
• Chapter 7 Pharmacotherapy
• Chapter 8 Future Advancements
• Index