CHADD
Parent to Parent:
Family Training on ADHD
INTRODUCTION
TO ADHD
SESSION ONE
© 2017 by Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). All Rights
Reserved.
Parent to Parent:
Family Training on
ADHD
Founders
Beth A. Kaplanek, RN, BSN
Beth Kaplanek is a past president of Children and Adults with Attention-
Deficit/Hyperactivity Disorder (CHADD), served as a volunteer for the nonprofit
organization for more than twenty years. Kaplanek on parenting issues and
solutions related to ADHD to both national and international audiences. She is the
mother of an adult with ADHD.
Mary Durheim
Mary Durheim, an educational consultant, is a past national president of CHADD.
Specializing in Section 504 and disability issues, Durheim works with school
districts at the local, state, and national level. A trained mediator, Section 504
hearing officer, and behavior strategist, she is active in numerous county and state
interagency organizations. She is the mother of two adult children with ADHD
Terry Illes, Ph.D.
Terry Illes received his doctoral degree in social psychology from Brigham Young
University in Provo, Utah, and practiced as a school psychologist in the Jordan
School District. He was well known for his expertise working with children with
learning and behavioral problems. Terry was a board member of CHADD. He
spoke to teachers and families across the nation to help them understand the
unique challenges of ADHD.
Linda P. Smith
Linda P. Smith is a former high school English teacher and a parent advocate. As a
CHADD volunteer for almost thirty years, she has served as a national board
member, local CHADD coordinator, and presented workshops on ADHD for
educators, parents, mental health professionals, and healthcare providers. Smith is
the parent of five children and the grandmother of many grandchildren, some
whom have been diagnosed with ADHD.
Acknowledgements:
This program is made possible through the support, expertise, and guidance of a
number of people, including CHADD staff and volunteer experts.
© 2017 by Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). All Rights Reserved.
Contents – Introduction to ADHD
1.1 About ADHD CHADD, National Resource Center 1
on ADHD
1.2 Myths and Misunderstandings CHADD, National Resource Center 7
on ADHD
1.3 What Everyone Should Know about ADHD Stephen P. Hinshaw and Katherine 11
Ellison, Attention
1.4 ADHD and Executive Functioning Russell A. Barkley, PhD, Attention 15
1.5 Executive Dysfunctions the Sleepy Susan D. Rich, MD, Attention 19
Secretary of the Brain
1.6 At a Glance: 3 Areas of Executive Function Understood Website 23
1.7 ADHD & Adoption--Two Journeys Jennifer Klotz and Ruth Hughes, 25
PhD., Attention
1.8 Trauma and ADHD Co-Exist in Foster CHADD, ADHD Weekly Newsletter 29
Children
1.9 The Unsurprising Emotional Nature of Erica D. Musser, PhD, Attention 33
ADHD
1.10 Women and Girls CHADD, National Resource Center 35
on ADHD
1.11 The Secret Lives of Girls with ADHD Ellen Littman, PhD, Attention 38
1.12 The Most Common Misdiagnoses in Child Mind Institute 41
51
Children 53
1.13 ADHD: Other Conditions With Similar WebMD
Symptoms - Topic Overview
1.14 ADHD Symptoms Checklist CHADD
1.15 ADHD and Coexisting Disorders CHADD, National Resource Center 54
on ADHD
1.16 When ADHD is not Alone Roberto Olivardia, PhD, Attention 57
58
1.17 Understanding ADHD and Dyslexia Elsa Cárdenas-Hagan, EdD & Eric 59
Tridas, MD, Attention
1.18 Disruptive Behavior Disorders CHADD, National Resource Center 62
on ADHD
1.19 Autism, Asperger's Syndrome, and ADHD Edward B. Aull, MD, Attention 66
1.20 ADHD, Sleep and Sleep Disorders CHADD, National Resource Center 69
on ADHD
1.21 ADHD and Tics or Tourette Syndrome CHADD, National Resource Center 73
on ADHD
1.22 My Child's Strengths Worksheet CHADD 76
1.23 ADHD: Talking with Your Child Intermountain Health 77
1.24 How to Talk to Your Child About Your Jonathan D. Carroll, MA, Attention 81
Own ADHD
About ADHD More than 75 percent of children
with ADHD continue to experience
Everybody can have difficulty sitting still, paying significant symptoms in adulthood.
attention or controlling impulsive behavior In early adulthood, ADHD may be
once in a while. For some people, however, the associated with depression, mood
problems are so pervasive and persistent that or conduct disorders and substance
they interfere with every aspect of their life: abuse.
home, academic, social and work. Adults with ADHD often cope with
Attention-deficit/hyperactivity disorder difficulties at work and in their
(ADHD) is a neurodevelopmental disorder personal and family lives related to
affecting 11 percent of school-age children ADHD symptoms.
(Visser, et al., 2014.) Symptoms continue into
adulthood in more than three-quarters of ADHD. The current name reflects the importance
cases (Brown, 2013.) ADHD is characterized by of the inattention aspect of the disorder as well
developmentally inappropriate levels of as the other c haracteristics of the disorder such
inattention, impulsivity and hyperactivity. as hyperactivity and impulsivity.
Individuals with ADHD can be very successful Symptoms
in life. However, without identification and Typically, ADHD symptoms arise in early
proper treatment, ADHD may have s erious childhood. According to the DSM-5, several
consequences, including school failure, family symptoms are required to be present before
stress and disruption, depression, p roblems with the age of 12. Many parents report excessive
relationships, substance abuse, delinquency, m otor activity during the toddler years, but
accidental injuries and job failure. Early ADHD symptoms can be hard to distinguish
identification and treatment are e xtremely from the impulsivity, inattentiveness and a ctive
important. behavior that is typical for kids u nder the age of
Medical science first documented c hildren
exhibiting inattentiveness, impulsivity and National
h yperactivity in 1902. Since that time, the Resource
d isorder has been given numerous names, Center
including minimal brain dysfunction, on ADHD
h yperkinetic reaction of childhood, and
a ttention-deficit disorder with or w ithout A Program of CHADD
h yperactivity. With the Diagnostic and Statistical
Manual, Fifth Edition (DSM-5) classification
system, the disorder has been r enamed
a ttention-deficit/hyperactivity disorder or
help4adhd.org 1
four. In making the diagnosis, children should Since that time all forms of attention deficit
have six or more symptoms of the d isorder disorder are officially called “Attention-Deficit/
present; adolescents 17 and older and adults Hyperactivity Disorder,” regardless of whether
should have at least five of the symptoms the individual has symptoms of hyperactivity or
p resent. The DSM-5 lists three presentations of not. Even though these are the official labels, a
ADHD—P redominantly I nattentive, Hyperactive- lot of professionals and lay people still use both
Impulsive and Combined. The symptoms for each terms: ADD and ADHD. Some use those terms to
are adapted and summarized below. designate the old subtypes; others use ADD just
as a shorter way to refer to any presentation.
ADHD predominantly inattentive presentation
• Fails to give close attention to details or Severity of symptoms
makes careless mistakes As ADHD symptoms affect each person to
• Has difficulty sustaining attention varying degrees, the DSM-5 now requires
• Does not appear to listen p rofessionals diagnosing ADHD to include the
• Struggles to follow through with instructions severity of the disorder. How severe the d isorder
• Has difficulty with organization is can change with the presentation during
• Avoids or dislikes tasks requiring sustained a person’s lifetime. Clinicians can designate
mental effort the s everity of ADHD as “mild,” “moderate” or
• Loses things “s evere” under the criteria in the DSM-5.
• Is easily distracted
• Is forgetful in daily activities Mild: Few symptoms beyond the required
n umber for diagnosis are present, and
ADHD predominantly hyperactive-impulsive symptoms result in minor impairment in social,
presentation school or work settings.
Moderate: Symptoms or functional impairment
• Fidgets with hands or feet or squirms in between “mild” and “severe” are present.
chair Severe: Many symptoms are present beyond
the number needed to make a diagnosis;
• Has difficulty remaining seated several symptoms are particularly severe; or
• Runs about or climbs excessively in children; symptoms result in marked impairment in
social, school or work settings. As individuals
extreme restlessness in adults age, their symptoms may lessen, change or
• Difficulty engaging in activities quietly take different forms. Adults who retain some
• Acts as if driven by a motor; adults will often of the symptoms of childhood ADHD, but not
all, can be diagnosed as having ADHD in partial
feel inside as if they are driven by a motor remission.
• Talks excessively ADHD throughout the lifespan
• Blurts out answers before questions have Children with ADHD often experience delays
in independent functioning and may behave
been completed y ounger than their peers. Many children affected
• Difficulty waiting or taking turns
• Interrupts or intrudes upon others
ADHD combined presentation
• The individual meets the criteria for both
inattention and hyperactive-impulsive ADHD
presentations.
These symptoms can change over time, so chil-
dren may fit different presentations as they get
older.
Confusing labels for ADHD
In 1994, the name of the disorder was changed
in a way that is confusing for many people.
help4adhd.org 2
by ADHD can also have mild delays in language, and working memory. Recently, deficits in
motor skills or social development that are not executive function have emerged as key factors
part of ADHD but often co-occur. They tend affecting academic and career s uccess. E xecutive
to have low frustration tolerance, difficulty function is the brain’s ability to prioritize and
controlling their emotions and often experience manage thoughts and actions. This a bility
mood swings. permits individuals to consider the long-term
Children with ADHD are at risk for p otentially c onsequences of their actions and guide
serious problems in adolescence and adulthood: their behavior across time more e ffectively.
academic failure or delays, d riving problems, Individuals who have issues with executive
difficulties with peers and s ocial situations, functioning may have d ifficulties completing
risky sexual behavior, and substance abuse. tasks or may forget important things.
There may be more severe negative behaviors
with co-existing conditions such as oppositional Co-occurring Disorders
defiant disorder or c onduct disorder. Adolescent More than two-thirds of children with ADHD
girls with ADHD are also more prone to eating have at least one other co-existing condition.
disorders than boys. As noted above, ADHD Any disorder can co-exist with ADHD, but
persists from childhood to adolescence in the certain disorders seem to occur more often.
vast majority of cases (50–80 percent), although These d isorders include oppositional defiant
the hyperactivity may lessen over time. and conduct disorders, anxiety, depression,
tic disorders or Tourette syndrome, substance
Teens with ADHD present a special challenge. abuse, sleep disorders and learning d isabilities.
During these years, academic and life demands When co-existing conditions are present,
increase. At the same time, these kids face typical a cademic and behavioral problems, as well as
adolescent issues such as emerging sexuality, emotional issues, may be more complex.
establishing independence, dealing with peer
pressure and the challenges of driving. These co-occurring disorders can c ontinue
More than 75 percent of children with ADHD throughout a person’s life. A thorough d iagnosis
continue to experience significant symptoms and treatment plan that takes into account all of
in adulthood. In early adulthood, ADHD may be the symptoms present is e ssential.
associated with depression, mood or c onduct
disorders and substance abuse. Adults with Causes
ADHD often cope with difficulties at work and in Despite multiple studies, researchers have
their personal and family lives related to ADHD yet to determine the exact causes of ADHD.
symptoms. Many have inconsistent performance H owever, scientists have discovered a strong
at work or in their careers; have difficulties genetic link since ADHD can run in families. More
with day-to-day responsibilities; e xperience than 20 genetic studies have shown evidence
relationship problems; and may have chronic that ADHD is strongly inherited. Yet ADHD is a
feelings of frustration, guilt or blame. complex disorder, which is the result of multiple
Individuals with ADHD may also have difficulties interacting genes. (Cortese, 2012.)
with maintaining attention, executive function
Other factors in the environment may increase
the likelihood of having ADHD:
• exposure to lead or pesticides in early
childhood
• premature birth or low birth weight
• brain injury
Scientists continue to study the exact
relationship of ADHD to environmental factors,
but point out that there is no single cause that
help4adhd.org 3
explains all cases of ADHD and that many factors Determining if a child has ADHD is a complex
may play a part. process. Many biological and psychological
problems can contribute to symptoms s imilar
Previously, scientists believed that maternal to those exhibited by children with ADHD.
stress and smoking during pregnancy could For example, anxiety, depression and c ertain
increase the risk for ADHD, but emerging types of learning disabilities may cause s imilar
e vidence is starting to question this belief s ymptoms. In some cases, these o ther c onditions
(Thapar, 2013.) However, further research is may actually be the primary diagnosis; in o thers,
needed to determine if there is a link or not. these conditions may co-exist with ADHD. A
t horough history should be taken from the
The following factors are NOT known causes, p arents and teachers, and when appropriate,
but can make ADHD symptoms worse for some from the child. Checklists for rating ADHD
children: symptoms and ruling out other disabilities are
often used by clinicians; these instruments
• watching too much television factor in age-appropriate behaviors and show
• eating sugar when symptoms are extreme for the child’s
• family stress (poverty, family conflict) d evelopmental level.
• traumatic experiences For adults, diagnosis also involves gathering
ADHD symptoms, themselves, may contribute to information from multiple sources, which can
family conflict. Even though family stress does include ADHD symptom checklists, standardized
not cause ADHD, it can change the way the ADHD behavior rating scales, a detailed history of
presents itself and result in additional problems past and current functioning, and information
such as antisocial behavior (Langley, Fowler et obtained from family members or significant
al., 2010.) others who know the person well. ADHD cannot
be diagnosed accurately just from brief office
Problems in parenting or parenting styles observations or just by talking to the person. The
may make ADHD better or worse, but these person may not always exhibit the symptoms of
do not cause the disorder. ADHD is clearly ADHD in the office, and the diagnostician needs
a neurodevelopmental disorder. Currently to take a thorough history of the individual’s life.
research is underway to better define the areas A diagnosis of ADHD must include consideration
and pathways that are involved. of the p ossible presence of co-occurring condi-
tions.
Diagnosis As part of the evaluation, a physician should
There is no single test to diagnose ADHD. conduct a thorough examination, including
T herefore, a comprehensive evaluation is assessment of hearing and vision to rule out
necessary to establish a diagnosis, rule other medical problems that may be caus-
out other causes, and determine the presence ing symptoms similar to ADHD. In rare cases,
or absence of co-existing conditions. Such persons with ADHD may also have a thyroid
an evaluation requires time and effort and dysfunction. Diagnosing ADHD in an adult
should include a careful history and a clinical r equires an evaluation of the history of c hildhood
assessment of the individual’s academic, social,
and emotional functioning and developmental
level.
There are several types of professionals who can
diagnose ADHD, including clinical psychologists,
clinical social workers, nurse practitioners,
neurologists, psychiatrists and pediatricians.
Regardless of who does the e valuation, the use
of the DSM-5 diagnostic criteria for ADHD is
n ecessary.
help4adhd.org 4
problems in behavior and academic domains, as decreased a ctivity levels, impulsivity, negative
well as examination of current symptoms and behaviors in social interactions and physical
coping strategies. and verbal hostility (Spencer, 1995; Swanson
1993.) These improvements show up clearly in
Treatment the short term, however, long-term effectiveness
Treatment in children with ADHD is still being studied by r esearchers (H inshaw,
ADHD in children often requires a et al., 2015.) A nonstimulant medication—
c omprehensive approach to treatment that atomoxetine—a ppears to have similar
includes the following: e ffects as the s timulants. Antidepressants,
antihypertensives and other medications
• Parent and child education about diagnosis may decrease impulsivity, hyperactivity and
and treatment a ggression. However, each family must weigh
the pros and cons of taking medication.
• Parent training in behavior management M edications may carry the risk of side effects.
techniques Physicians need to monitor their patients who
take m edication for potential side effects, such
• Medication as mood swings, hypertension, d epression and
• School programming and supports effects on growth.
• Child and family therapy to address p ersonal
Behavioral interventions
and/or family stress concerns Behavioral interventions are also a major
component of treatment for children who have
Treatment should be tailored to the unique ADHD. Important strategies include being
needs of each child and family. Research from consistent and using positive reinforcement
the landmark NIMH Multimodal Treatment and teaching problem-solving, communication
Study of ADHD showed s ignificant improvement and self-advocacy skills. Children, especially
in behavior at home and school in children t eenagers, should be actively involved as
with ADHD who received c arefully monitored r espected members of the school
medication in c ombination with behavioral planning and treatment teams.
treatment. These children also showed better School success may require a variety of
relationships with their classmates and family c lassroom accommodations and behavioral
than did children receiving this combination interventions. Most children with ADHD can
of treatment (Hinshaw, et al., 2015.) Further be taught in the regular classroom with minor
research c onfirms that combining behavioral adjustments to the environment. Some c hildren
and s timulant treatments are more effective than may require special education services. These
either treatment alone (Smith & Shapiro, 2015.) services may be provided within the regular
education classroom or may require a special
Medication placement outside of the regular classroom that
meets the child’s unique learning needs.
Psychostimulants are the
most widely used class ADHD treatment for adults
of medication for the Adults with ADHD can benefit by identifying the
m anagement of ADHD areas of their life that are most impaired by their
related symptoms. ADHD and then seeking treatment to address
Approximately 70 to 80 them. Adults with ADHD may benefit from
p ercent of children with t reatment strategies similar to those used to
ADHD r espond p ositively treat ADHD in children, particularly m edication
to psychostimulant and learning to structure their environment.
medications (MTA 1999.) Medications effective for childhood ADHD
Significant a cademic
improvement is shown by students who take
these medications: increases in a ttention and
concentration, compliance and effort on tasks, as
well as amount and accuracy of schoolwork, plus
help4adhd.org 5
c ontinue to be helpful for adults who have ADHD. MTA Cooperative Group. (1999). A 14-month
Various behavioral management techniques can randomized clinical trial of treatment strategies
be useful. Some adults have found that working for attention deficit hyperactivity disorder.
with a coach, either formally or informally, to be A rchives of General Psychiatry, 56, 12.
a helpful addition to their ADHD treatment plans. Hinshaw, S.P. & Arnold, L.E. for the MTA
In addition, mental health counseling can offer C ooperative Group (2015 Jan–Feb). Attention
much-needed support to adults dealing with deficit hyperactivity disorder, multimodal
ADHD in themselves or someone they care about. t reatment, and longitudinal outcome: E vidence,
Since ADHD affects the entire family, receiving paradox, and challenge. WIREs Cognitive Science,
services from ADHD-trained therapists skilled in 6(1):39-52.
Cognitive-Behavioral Therapy can help the adult Owens, E., Cardoos, S.L., Hinshaw, S.P. (2015).
with ADHD learn new techniques to manage Developmental progression and gender
living with ADHD. d ifferences among individuals with ADHD.
in Barkley, Russell A. (Ed.) Attention-deficit
Suggested reading and references hyperactivity disorder: A handbook for d iagnosis
Barkley, R.A. (ed.) (2015.) Attention Deficit and treatment (4th ed.). , (pp. 223–255). New
Hyperactivity Disorders: A Handbook for York, NY: Guilford Press.
Diagnosis and Treatment (4th edition.) New Smith, B.H. & Shapiro, C.J. (2015). Combined
York: Guilford Press. treatments for ADHD in Barkley, R.A. (Ed),
Barkley, R.A. (2010). Attention Deficit (2015). Attention-Deficit H yperactivity D isorder:
Hyperactivity Disorder in Adults: The Latest A Handbook For Diagnosis and Treatment (4th
Assessment and Treatment Strategies. Jones and ed.), (pp. 686–704). New York, NY: Guilford
Bartlett Publishers. Press.
NBrown, T.E. (2013). A New Understanding Thapar, Anita; Cooper, Miriam; et al. (January
of ADHD in Children and Adults: Executive 2013). Practitioner Review: What have we learnt
F unction. Routledge. about the causes of ADHD?, Journal of Child
Cortese, S. (2012). The neurobiology and P sychology and Psychiatry, 54(1):3-16.
genetics of Attention-Deficit/H yperactivity Visser, S.N., Danielson, M.L., Bitsko, R.H., et al.
Disorder (ADHD): What every clinician should (2014). Trends in the Parent-Report of Health
know. European Journal of Paediatric Neurology, Care Provider-Diagnosis and M edication
16(5):422-33. T reatment for ADHD disorder: United States,
Kessler, R.C., et al. (2006.) The prevalence and 2003–2011. Journal of the American Academy of
correlates of adult ADHD in the United States: Child & Adolescent Psychiatry, 53(1):34–46. e2.
Results from the National Comorbidity Survey
Replication. American Journal of Psychiatry,
163(4):716–723.
Find your local CHADD Chapter For further information, please contact
National Resource Center on ADHD:
A Program of CHADD
4601 Presidents Drive, Suite 300
Lanham, MD 20706-4832
1-800-233-4050
www.chadd.org/nrc
This factsheet is supported by Cooperative Agreement Number NU38DD005376 from the Centers for Disease Control and Prevention (CDC). The contents are solely the
responsibility of the authors and do not necessarily represent the official views of CDC. Permission is granted to photocopy and freely distribute this factsheet for
non-commercial, educational purposes only, provided that it is reproduced in its entirety, including the CHADD and NRC names, logos and contact information.
© 2017 Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). All Rights Reserved.
10/12/2017 Myths and Misunderstandings | CHADD
Understanding ADHD | About ADHD | Myths and Misunderstandings
Myths and Misunderstandings
Evidence from research studies continue to dispel the myths and misunderstandings about ADHD. Here are some of the
misconceptions and recent research available to address them:
Myth # 1: ADHD is Not a Real Disorder
Myth # 2: ADHD is a Disorder of Childhood
Myth # 3: ADHD is Over-Diagnosed
Myth # 4: Children with ADHD are Over-medicated
Myth # 5: Poor Parenting Causes ADHD
Myth # 6: Minority Children are Over-Diagnosed with ADHD and are Over-Medicated
Myth # 7: Girls Have Lower Rates and Less Severe ADHD than Boys
Myth # 1: ADHD is Not a Real Disorder
ADHD cases have been described as far back as the textbook published in 1775 by Adam Weikard in German. Since that time, over
10,000 clinical and scientific publications have been published on ADHD (Barkley 2015). Research studies show numerous
differences between those with and without ADHD (Roberts et al. 2015). ADHD impairs major life activities including social,
http://www.chadd.org/understanding-adhd/about-adhd/myths-and-misunderstandings.aspx 1/5 7
10/12/2017 Myths and Misunderstandings | CHADD
emotional, academic and work functioning. It is a lifespan disorder with the majority of children with ADHD continuing to struggle with
symptoms as adults. ADHD also runs in families with a heritability chance of 57% for a child if a parent has ADHD, and a 70%–80%
chance for a twin if the other twin has ADHD (Barkley 2015). Brain scan studies show differences in the development of the brain of
individuals with ADHD, such as cortical thinning in the frontal regions; reduced volume in the inferior frontal gyrus; and reduced gray
matter in the parietal, temporal, and occipital cortices (Matthews et al. 2014).
Myth # 2: ADHD is a Disorder of Childhood
Long-term studies of children diagnosed with ADHD show that ADHD is a lifespan disorder. Recent follow-up studies of children with
ADHD show that ADHD persists from childhood to adolescence in 50%–80% of cases, and into adulthood in 35%–65% of cases
(Owens et al. 2015). A 16-year follow-study of boys diagnosed with ADHD found that 77% continued to have full or subthreshold
DSM-IV ADHD (Biederman et al. 2012). A study of girls ages 6–12 years with childhood ADHD found that 10 years later, they
continued to have higher rates of ADHD and coexisting conditions, including higher rates of suicide attempts and self-injury,
compared to girls without ADHD (Hinshaw et al. 2012).
Myth # 3: ADHD is Over-Diagnosed
The rate of diagnosed ADHD in children has increased approximately 5% every year, according to the National Survey of Children’s
Health, 2003—2011. This has led many to wonder if the condition is being over-diagnosed. But the report based on the 2014
National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome found that children are being carefully diagnosed
by healthcare practitioners. The vast majority (9 out of 10) of the 2,976 children diagnosed with ADHD had been diagnosed by
practitioners using best practice guidelines (Visser et al. 2015). Possible explanations for increased diagnostic rates include
improved awareness about ADHD among healthcare practitioners and parents, more screenings by pediatricians and other primary
care givers, decreased stigma about ADHD, availability of better treatment options, and more cases arising from suspected
environmental causes such prenatal exposure to toxins or high blood lead levels.
Myth # 4: Children with ADHD are Over-medicated
Most evidence from research studies suggest that levels of treating ADHD with medication are either appropriate or that ADHD is
undertreated (Connor 2015). According to the National Survey of Children's Health (NSCH) 2003–2011, of the 5.1 million children
with a current diagnosis of ADHD, 69% (or 3.5 million) were taking medication for ADHD. Data from the National Comorbidity Survey
Adolescent Supplement, which included over 10,000 adolescents aged 13–18, found that only 20.4% of those with ADHD received
stimulants (Merikangas et al. 2013). Data from the National Health and Nutrition Examination Survey report a 7.8% prevalence rate
of ADHD among the 3,042 participants aged 8–15, but only about 48% of them were receiving treatment in the past 12 months
(Merikangas et al. 2010).
Myth # 5: Poor Parenting Causes ADHD
Research studies point to genetic (hereditary) and neurological factors (such as pregnancy and birth complications, brain damage,
toxins and infections) as the main causes of ADHD rather than social factors including poor parenting. Twin studies of children with
ADHD show that the family environments of the children contribute very little to their individual differences in ADHD symptoms
(Barkley, 2015). Although parenting practices do not cause ADHD, they can contribute to worsening of coexisting disorders such as
oppositional defiant disorder (ODD) or conduct disorder (CD), and inconsistent parental discipline as well as low paternal
involvement have been found to be associated with ADHD symptoms (Ellis et al. 2009).
Myth # 6: Minority Children are Over-Diagnosed with ADHD and are Over-Medicated
http://www.chadd.org/understanding-adhd/about-adhd/myths-and-misunderstandings.aspx 2/5 8
10/12/2017 Myths and Misunderstandings | CHADD
Findings from the National Health Interview Survey (NHIS) 2011–2013 show that it is not minority children, but non-Hispanic white
children who had the highest rates of diagnosis according to parent reports. The prevalence rates for non-Hispanic white children is
11.5%, compared to 8.9% for non-Hispanic black children and 6.3% for Hispanic children (Pastor et al. 2015). Analysis from the Early
Childhood Longitudinal Study, Kindergarten Class of 1998–1999 (n=17,100) had also found that minority children were less likely
than white children to receive an ADHD diagnosis (Morgan et al. 2013). This same study found that children with ADHD were much
less likely to use prescription medication for the disorder if they were Hispanic, African American or of other races/ethnicities.
Myth # 7: Girls Have Lower Rates and Less Severe ADHD than Boys
ADHD in girls and women has been recognized only in the past few decades, and more research studies are reporting on the
substantial impairments they experience, often to the same extent as boys. They are at risk for many of the same coexisting
conditions and impairments as males―oppositional defiance disorder, conduct disorder, academic and social impairments, driving
problems, substance abuse and risky sexual behavior. Adolescent girls with ADHD may be more prone than boys to eating
disorders, but by young adulthood this difference is reduced (Owens et al. 2015). A 10-year follow-up study of girls aged 6–12 years
by Hinshaw et al. (2012) found a higher risk for suicide attempts and self-injury by adulthood among the girls. The latest diagnosis
data as reported by parents of children ages 4–17 in the National Health Interview Survey (NHIS) 2011–2013 found a diagnostic rate
of 13.3% for boys and 5.6% for girls. Other large community samples have found a similar gender ratio of 2.3:1.0, but by adulthood,
studies have found that prevalence is nearly the same between genders (Owens et al. 2015).
References
Barkley, Russell A. (2015). History of ADHD. In R. A. Barkley (Ed.), Attention-Deficit Hyperactivity Disorder: A Handbook for
Diagnosis and Treatment, 4th ed. (pp. 356–390). New York, NY: Guilford Press.
Barkley, Russell A. (2015). Etiologies of ADHD. In R. A. Barkley (Ed.), Attention-Deficit Hyperactivity Disorder: A Handbook for
Diagnosis and Treatment, 4th ed. (pp. 356–390). New York, NY: Guilford Press.
Biederman, Joseph et al. (2012). Adult Outcome of Attention-Deficit/Hyperactivity Disorder: A Controlled 16-Year Follow-Up Study.
Journal of Clinical Psychiatry 73(7):941–950.
Ellis, Brandi & Joel Nigg (February 2009). Parenting Practices and Attention-Deficit/Hyperactivity Disorder: New Findings Suggest
Partial Specificity of Effects. Journal of the American Academy of Child & Adolescent Psychiatry 48(2):146–154.
Hinshaw, Stephen P. et al. (2012). Prospective Follow-Up of Girls With Attention-Deficit/Hyperactivity Disorder Into Early Adulthood:
Continuing Impairment Includes Elevated Risk for Suicide Attempts and Self-Injury. Journal of Consulting and Clinical Psychology
80(6):1041–1051.
Matthews, Marguerite et al. (2013). Attention Deficit Hyperactivity Disorder. Current Topics in Behavioral Neurosciences 16:235–266.
Merikangas, Kathleen et al. (2013). Medication Use in US Youth With Mental Disorders. JAMA Pediatrics 167(2):141–148.
Morgan, Paul L. et al. (2013). Racial and Ethnic Disparities in ADHD Diagnosis From Kindergarten to Eighth Grade. Pediatrics
132(1):85–93.
Owens, Elizabeth et al. (2015). Developmental Progression and Gender Differences among Individuals with ADHD. In R. A. Barkley
(Ed.), Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, 4th ed. (pp. 223–255). New York, NY:
Guilford Press.
Pastor, Patricia N. et al. (2015). Association between diagnosed ADHD and selected characteristics among children aged 4–17
years: United States, 2011–2013. NCHS Data Brief, no 201. Hyattsville, MD: National Center for Health Statistics.
http://www.chadd.org/understanding-adhd/about-adhd/myths-and-misunderstandings.aspx 3/5 9
10/12/2017 Myths and Misunderstandings | CHADD
Roberts, Walter et al. (2015). Primary Symptoms, Diagnostic Criteria, Subtyping, and Prevalence of ADHD. In R. A. Barkley (Ed.),
Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, 4th ed. (pp. 51–80). New York, NY: Guilford
Press.
Russell, Abigail E. et al. (2015). Socioeconomic Associations with ADHD: Findings from a Mediation Analysis. PLoS One
10(6):e0128248.
Visser, Susanna N. et al. (September 3, 2015). Diagnostic experiences of children with attention-deficit/hyperactivity disorder.
National Health Statistics Reports; no 81. Hyattsville, MD: National Center for Health Statistics.
Get Involved 4/510
Join CHADD
Attention Magazine
Donate to CHADD
http://www.chadd.org/understanding-adhd/about-adhd/myths-and-misunderstandings.aspx
What Everyone Sho
ABOUT
by Stephen P. Hinshaw and IN A RECENTLY PUBLISHED BOOK—ADHD: What Everyone
Katherine Ellison Needs to Know (Oxford University Press, November 2015)—
we have teamed up to write an authoritative, engaging, and some-
times edgy look at this condition. ADHD has become one of the
most controversial health and mental health issues in the world,
a ecting an estimated 6.4 million youth and nearly 10 million
adults in the United States alone. e book, which constitutes the
ATTN_04_16_Sh
ouldKnow.pdf
26 Attention SHUTTERSTOCK
11
ould Know Search Engine
ADHD
rst mental health title in Oxford’s growing What Everyone We believe that amidst the veritable ood of informa-
Needs to Know series, features a question-and-answer for- tion about ADHD these days—much of it based on com-
mat, straight talk, and de nitive yet accessible information mercial interests and a lack of validated science—a major
on the condition’s blend of neurobiological and psychoso- need exists for sound information presented in matter-of-
cial causes, the major surge in diagnoses over recent years, fact and sometimes humorous format. Indeed, we wrote
what’s needed for accurate diagnosis, and how various this book with the general public in mind; we hope that
treatments do (and in some cases do not) work. its messages will dispel myths and set the record straight.
April 2016 27 12
Below are adaptations of just a few of the Q & As in the book.
1 Isn’t ADHD an excuse for bad parenting, 3 Aren’t we all getting a little “ADHD”
lazy kids, or accommodation-seeking because of how much we’re all using
adults? Facebook and Twitter and checking our
portable devices constantly?
is is a prevalent myth—and one we spend a lot of time
debunking in this book, in interviews, and in our public Everyone in modern society is facing a new world of
talks. Despite the skepticism and the stereotypes, substan- devices, social media, and demands for rapidly shi ing
tial research has shown that ADHD is a strongly heritable attention. It’s quite possible that the evolution of technol-
neurodevelopmental disorder. e quality of one’s parent- ogy is moving faster than our brains’ capacity to adapt. It’s
ing doesn’t create ADHD, although it can certainly in u- no coincidence that reports of ADHD emerged with the
ence how ADHD and a number of accompanying condi- advent of compulsory education in the nineteenth cen-
tions can develop. People with ADHD are not lazy but tury, when for the rst time all children were made to sit
instead compromised in their abilities to regulate e ort still and learn academic skills. As performance pressures
and attention and to control impulses. In particular, prob- mount, ADHD diagnoses tend to rise.
lems with what are called “executive functions” (planning,
maintaining e ort, retaining di erent bits of information Still, it’s important to make a distinction between dis-
in memory) and with developing a sense of intrinsic mo- traction that can be controlled by turning o your email
tivation o en underlie ADHD symptoms. ese issues versus genuine ADHD. Although most of us today are
are deeply rooted in brain chemistry and tend to run in facing environmentally caused problems with distraction,
families. people with ADHD are at a particular disadvantage.
2 Isn’t it just a plot by pharmaceutical firms 4 How fast have US rates of ADHD
that want to sell more medications, been increasing, and why?
especially powerful stimulants?
e short answer is: really fast. U.S. rates of ADHD were
Pharmaceutical rms have worked hard to expand aware- already high at the turn of the millennium, but since 2003,
ness of ADHD as they pursue pro ts in a global market the numbers of diagnosed children and adolescents have
estimated to approach $12 billion. But they didn’t create risen by 41 percent. Today, more than six million youth
the disorder. Moreover, many well-controlled studies have received diagnoses. And the fastest-growing segment
have shown that stimulant medications—the most com- of the population with respect to diagnosis and medica-
mon treatment for ADHD in the United States—can be tion treatment is now adults, particularly women.
quite helpful for many people with the disorder and are
generally safe, when used as prescribed. ese medica- e current numbers are staggering: For all children
tions work by regulating the ow of two key neurotrans- aged 4-17, the rate of diagnosis is now one in nine. For
mitters in the brain, dopamine and norepinephrine. e those over nine years of age, more than one boy in ve
chief e ects of the meds are to increase focus and reduce has received a diagnosis. Among youth with a current
impulsive and dgety behavior. But to teach important diagnosis, nearly 70 percent receive medication. U.S. rates
academic and social skills and improve family function- are signi cantly higher than anywhere else in the world,
ing, combining medicine with psychosocial treatments, although many other nations are beginning to catch up.
especially behavioral and cognitive-behavioral interven-
tion, is usually optimal. 5 What might be causing some of the
In short, our position on medication boils down to this: high rates in the United States?
ere is no “magic bullet,” and medication should be used
with caution, because of potential side e ects and valid An issue of serious concern is the likelihood of overdiag-
concerns about dependency if the pills are used without nosis in some parts of the country. (State-by-state variation
careful monitoring. But you shouldn’t let Big Pharma’s in rates of ADHD diagnosis is staggering.) is danger is
sometimes remarkably aggressive tactics dissuade you, or heightened given that determining whether someone has
your child, from receiving a medication trial, following a ADHD remains a somewhat subjective process, in that, like
careful diagnostic work-up. all mental disorders, there is no blood test or brain scan
that can decisively determine it. Gold-standard clinical pro-
cesses, which include taking thorough medical histories and
gathering rating scales from family members and teachers,
28 Attention 13
can guard against overdiagnosis, but all too o en the diag- ADHD advocates have championed the idea that the
nosis is made in a cursory visit with a nonspecialist. condition is a “gi .” We support the idea of ADHD as a
kind of neuro-variability that in some contexts, and with
6 What danger might there be the right support, might o er advantages. But do look
this gi -horse in the mouth: ADHD is too o en a seri-
of underdiagnosis? ous liability, which prevents creative ideas and energetic
actions from being completed. It needs to be managed
e same quick-and-dirty evaluations that fuel overdiag- throughout a lifetime. Consider the Olympic swimmer
nosis can also lead to missing ADHD when it truly exists. Michael Phelps, who rose to super-stardom only to be
In other words, the clinician who insists that he or she can embarrassed by drug and alcohol problems. Longitu-
detect ADHD in a brief clinical observation may overlook dinal studies show that people with ADHD on average
the fact that children and adults may act quite di er- su er signi cantly more problems with addiction, acci-
ently in a doctor’s o ce than they do at school or in the dents, divorces, and academic and employment setbacks
workplace. is problem is equally concerning, because than their peers—with huge costs to the overall economy
whereas overdiagnosis may lead to overtreatment, under- compounding personal and family su ering. ADHD is
diagnosis means individuals who truly need help aren’t serious business. ●A
getting it.
Stephen Hinshaw, PhD, an international expert on psychopathology
7 I keep hearing that ADHD is a “gift.” and ADHD, is a professor in the department of psychology at the
University of California, Berkeley, and the vice chair of psychology in the
What does that mean? department of psychiatry at the University of California, San Francisco.
Katherine Ellison is a Pulitzer Prize-winning journalist and author who
Celebrities—including the rapper Will.i.am and busi- was diagnosed with ADHD in her late forties.
ness superstars such as Jet Blue founder David Neele-
man—have talked about the advantages of having
ADHD in terms of creativity and energy, and many
ADVENTURES IN
EDUCATION
ADVENTURE SCHOOL for youth with ADD/ADHD and LD
Specializing in a unique combination of academics, adventure, and life skills.
Learn more at academyatsoar.org or call us today at 828-456-3435
April 2016 29 14
ADHD and
by Russell A. Barkley, PhD
WEoften hear that ADHD is a disorder of executive functioning (EF) and that it also in-
volves poor self-regulation. But what do these terms mean? And how are they related?
What do they have to do with ADHD? And with its management? A lot, as I will explain here.
ADHD involves significant deficit disorder).While the official name for the disorder will not be
problems with sustained atten- changed anytime soon in the official manual that grants names to
tion, persistence toward goals, re- mental disorders (Diagnostic and Statistical Manual for Mental Dis-
sisting distractions along the way, orders, 5th Edition, or DSM-5), it is still important that people under-
inhibiting excessive task-irrelevant stand this connection between ADHD and self-regulation deficits.
activity (hyperactivity), and inhib-
iting actions, words, thoughts, and Conflict between the “now” and the “later”
emotions that are either socially
inappropriate for the situation or The incredible value in viewing ADHD as SRDD comes from also
inconsistent with one’s longer term understanding that our brain-based executive functions are what
goals and general welfare. allow us to engage in self-control. Let’s see just how that works by
Since the late 1970s, clinical re- starting with the definition of self-control. The term is often con-
searchers who were studying ADHD sidered to involve at least three components: (1) any action an in-
asserted that the disorder likely in- dividual directs at themselves so as to (2) result in a change in their
volved a serious problem with self- behavior (from what they might otherwise have done) in order to
regulation. Why? Because they had (3) change the likelihood of a future consequence or attainment
already begun documenting through of a goal. In short, it is self-adjusting your own current behavior to
various measures that ADHD was make it more or less likely that you will be better off in the future.
associated with deficits in inhibition,
managing one’s attention, self-talk and When you walk into a coffee shop intending only to buy coffee
rule-following, self-motivation, and and you see a display counter filled with pastries or confections,
eventually even self-awareness. If ADHD you face a situation that may tempt you to buy things now that
involved difficulties in these faculties and these are the hu- are likely to ruin your plans for losing weight this month. This
man mental abilities that are involved in our being able to control exposes the heart of situations that test our self-regulation—they
our own behavior, then logically ADHD ought to be a disorder of pose a conflict between the “now” and the “later,” or more accu-
self-regulation. rately “me now” and “me later.” To deal with this conflict and the
Since then, research has continued to affirm the involvement of immediate temptation you face while you wait for your coffee to
deficits in these and other mental abilities that are essential for our be prepared, you may avert your eyes from the counter, walk to
effective self-regulation. ADHD is actually SRDD (self-regulation a different section of the shop away from the tempting goodies,
engage yourself in mental conversation about why you need to
not buy those products, and even visualize yourself saying no to
8 Attention 15
the clerk who asks you if you want a doughnut with that coffee. Okay, so that is the nature of our self-regulation. How does EF
You may even call up an image of the new, more slender version link up with SR? Simply, EF involves those things you just did to
of yourself you expect to achieve in the near future to help moti- try and manage yourself. You monitored yourself, recalled your
vate you to say no to that doughnut. All of these are self-directed goals, inhibited yourself, visualized your plans and goals, talked
actions you are using to try and alter the likelihood of giving into to yourself, and attempted to self-motivate, among other things.
temptation and therefore increase your chances of meeting your In my theory of EF, each of these is a component of EF and each
goal of weight loss this month. is a type of self-control—something we did to readjust our own
behavior to make a future goal more likely to occur. An EF is a type
This situation calls upon a number of distinct yet interacting of SR, in my view. People use various types of actions they direct
mental abilities to successfully negotiate the situation. You have at themselves to manage themselves for a better future. They use
to be aware that a conflict has arisen when you walked into the at least six different types of self-directed actions (EFs) that form
shop (self-awareness), you have to restrain your urge to order a Swiss Army knife of mind tools for self-control.
the pastry to go with the coffee you have ordered (inhibition),
you redirected your attention away from the tempting dough- Defining executive functioning
nuts (executive attention or attentional management), you spoke
to yourself using your mind’s voice (verbal self-talk or working While this is my view, I must confess that there is no consensus
memory), and you visualized an image of your planned behavior in neuropsychology at this time on the meaning of the term EF,
(saying no) and your eventual goal of what you would look like despite its being used prolifically in journal articles, presentations,
when you successfully attain it (nonverbal working memory, or and books, including those about ADHD. A commonly used
visual imagery). You may also have found yourself thinking about definition is that EF means “those neuropsychological processes
various other ways you could have coped effectively with these needed to sustain problem-solving toward a goal.” I think this is
temptations (problem-solving), and may have given yourself a close, but too vague, as just about any and all mental abilities are
pep talk (“You can do this!”) to enhance the likelihood that
you would follow your plan (self-motivation). used toward our goals. But if we modify this to mean
August 2014 9 16
“those self-directed ac- rather than of knowledge or skills. They are problems with doing
tions needed to sustain what one knows and not of knowing what to do. Mental health
problem-solving toward and education professionals are more expert at conveying knowl-
a goal,” then this nicely edge (what to do)—how to change. They are not as informed
agrees with my view. about ways to help people do what they know; to engineer en-
An EF is a self-directed vironments to facilitate performance, or the where and when to
action (a form of self-control), change. At the core of such problems of performance is the vexing
and it is being used to improve our issue of just how one gets people to behave in ways that they know
future welfare (accomplish a goal). This may be good for them yet which they seem unlikely, unable, or
then limits the term EF to those actions we use unwilling to perform.
to adjust our own behavior (self-direction). I think there are at least
six such actions: inhibition and resistance to distraction (self-re- Conveying more knowledge does not prove as helpful as alter-
straint), self-awareness (self-directed attention), working memory ing things in the setting associated with the performance of that
(self-talk and visual imagery, or seeing to ourselves), planning and behavior at its appropriate place and time. Yet we must accept the
problem-solving (self-directed play), emotional self-control (self- fact that such changes in behavior are likely to be maintained only
directed emotion), and even self-motivation. As these self-directed so long as those environmental adjustments or accommodations
actions develop in childhood, they may be visible to others (talking are as well. To expect otherwise would seem to approach the treat-
to ourselves, for instance), but as we mature the publicly observ- ment of EF deficits with outdated or misguided assumptions that
able features become inhibited or privatized and they eventually are one can cure these deficits with a short-term course of treatment.
internalized, mental, and largely not visible to others. To date that has not been the case.
In my theory of ADHD, those with it have great difficulties
with using their EFs (self-directed actions) for purposes of self- However, here are some very useful strategies or principles of
regulation and attaining their goals because they are delayed in the treating ADHD that come out of this theory that ADHD is SRDD
development or have experienced injury to those brain networks which is EFDD.
that create the EFs and self-regulation. We can now understand
that ADHD involves more than just the obvious symptoms of in- 1. If behavior is not being effectively controlled by internally
attention/distractibility and impulsivity/hyperactivity, as listed in represented information (ideas being held in mind; working
the DSM-5. ADHD therefore involves deficits in self-restraint, self- memory), help that person by “externalizing” that informa-
awareness, self-speech, self-sensing and imagery, self-control of tion. Find ways to physically represent that information in the
emotion, self-motivation, and self-directed play for planning and problem setting at the point of performance (where and when
problem solving. These difficulties are delays or deficiencies in the this information should be used). For instance, using sticky
development of these important mental abilities, and not absolute notes, cards, signs, or other physical cues and reminders placed
losses of these abilities as might occur after a severe brain injury. precisely in that situation and at that time when something is to
Therefore, what distinguishes someone with ADHD from some- be done can go a long way toward making up for the working
one without it is that they appear to be less mature (are age-inap- memory deficits.
propriate) in their ability to engage in self-regulation (EF) toward
specific goals and the future more generally. To help someone with 2. ADHD creates time blindness. Those with ADHD cannot or-
ADHD, he or she must be helped to either correct these delays/ ganize their behavior both within and across time, leaving them
deficits or at least compensate for them (make accommodations with serious problems with time, timing, and timeliness of behav-
to them) if they are to be more effective or successful in managing ior, such that they are to time what nearsightedness is to vision.
themselves, getting to their tasks and goals, and preparing for their They create a temporal myopia in which the individual’s behavior
future more generally. We have no ways to permanently correct the is governed more than normal by events close to or within the
neurological problems, but medications may do so to a large extent “now” and immediate context, rather than by internal informa-
and temporarily while being taken. Mostly we have strategies to help tion that pertains to longer term, future events. This helps us to
people compensate for the EF deficits and so reduce the likelihood understand why adults with EF deficits make the decisions they
they may be impaired in their major life activities from those deficits. do, short-sighted as they seem to be to others around them.
If one has little regard for future events, then much of one’s
Principles of treating ADHD behavior will be aimed at maximizing the moment and its im-
mediate rewards and escaping from immediate hardships or
Disorders of EF or self-regulation, like ADHD, are not easily man- aversive circumstances without concern for the delayed conse-
aged. That is because they create disorders mainly of performance quences of those actions. To help with this timing problem, time
itself must be “externalized” or represented in situations where
time is important. This can be done for short-term projects by
10 Attention 17
placing various timing devices in the situation where the work ● engaging in self-affirming statements of
must be done. For longer-term projects, it can be addressed self-efficacy prior to and during such tasks
breaking these projects into many smaller parts that can be done
frequently or daily making each “baby step” toward the goal far ● experiencing positive emotions, and
easier to do than when one is contemplating the entire project ● consuming (sipping) glucose-rich beverages
to be done across a long time span.
3. Add more consequences and accountability to the problem (like sports drinks) during the task.
situation. ADHD creates a deficit in self-motivation. That is 5. Take your ADHD medication consistently, as
the very type of motivation that one needs to support or drive
goal-directed behavior toward the goal. What to do? As above, prescribed. To date, ADHD medications are the
“externalize” the motivation. Add more external and artificial only treatments that can result in improvement or
immediate consequences to that situation where one must do normalization of the underlying neurological and
work in the absence of immediate natural consequences. even genetic substrates of the EF deficits—even if
this improvement is only temporary while the drug
For instance, the provision of artificial rewards, such as to- is acting in the body. This is no different than using
kens, may be needed throughout the performance of a task or insulin for diabetes. It does not permanently correct the
other goal-directed behavior when there is otherwise little or underlying neurological problem but can temporarily
no such immediate consequences associated with that perfor- do so or at least improve it while the drug is in the body.
mance. Such artificial reward programs become for the person The ADHD stimulants or the nonstimulants like atom-
with EF deficits what prosthetic devices such as mechanical oxetine or guanfacine XR can improve or even temporar-
limbs are to amputees. The artificial consequences allow them to ily normalize the neural substrates in the brain’s prefrontal
perform more effectively in some tasks and settings with which regions and related networks that likely underlie these defi-
they otherwise would have considerable difficulty. This can also cits. For instance, research shows that clinical improvement
be done by making the person more accountable to others and in behavior occurs in as many as 75–92% of those with ADHD
doing so more often across the work period (closer supervision, and results in a temporary normalization of behavior in ap-
more frequent checking-in with the supervisor, more frequent proximately 50–60% of these cases, on average.
unannounced spot-checks by the supervisor). The motivational
disability created by the EF deficits makes such motivational ADHD is a disorder of self-regulation. Self-regulation requires
“prostheses” nearly essential for most people with such deficits. that a person have intact executive functions. The EFs are specific
4. Boost the EF fuel tank. Engaging in EF and SR takes effort and types of self-regulation or self-directed actions that people use to
that effort or “fuel” tank has a limited capacity. Having ADHD manage themselves effectively in order to sustain their actions (and
probably leads to more such effort being expended to do rou- problem-solving) toward their goals and the future. ADHD is both
tine tasks than typical people have to expend and may even be SRDD (self-regulation deficit disorder) and also EFDD. By under-
associated with a smaller fuel tank of effort. The more EF one standing this relationship among these terms, we can understand
has to use the more effort must be expended to do the task, that people with ADHD have difficulties using the mental forms
and thus the more one is depleting that tank or resource. This of self-directed actions we all use to manage ourselves effectively
results in an individual being less capable of SR in immediately so as to attain our goals and see to our long-term welfare. To deal
subsequent situations and thus more likely to experience failures with the problems ADHD creates, we will need to understand that
in self-control in that next situation. it involves EF deficits and that such deficits can be temporarily
Such temporary depletion of the fuel tank may be further ex- improved or normalized with ADHD medications and also com-
acerbated by excess stress, excessive use of alcohol or other drugs, pensated for by modifying the environment and making other ac-
illness, or even low levels of blood glucose.Yet, research shows that commodations so as to both buttress and facilitate the individual’s
doing certain things can help to replenish that fuel tank, such as: use of their own self-control. ●A
● routine physical exercise
● taking ten-minute breaks periodically during situations that Russell A. Barkley, PhD, is a clinical professor of psychiatry and pediatrics
heavily tax self-control at the Medical University of South Carolina in Charleston. He is the recipient
● relaxing or meditating for at least three minutes after or occa- of various career achievement awards from the American Psychological
sionally during such exerting activities Association and American Academy of Pediatrics. He is the author of
● visualizing the rewards or outcomes while involved in EF/SR tasks twenty-one books, more than two hundred fifty articles and book chapters,
● arranging for periodic small rewards throughout the tasks or and seven videos concerning ADHD and related disorders. His most recent
SR-demanding settings books are Taking Charge of ADHD (2013; Guilford Press, Guilford.com),
Taking Charge of Adult ADHD (2010), and Executive Functions: What
They Are, How They Work, and Why They Evolved (2012). His websites
are russellbarkley.org and ADHDLectures.com.
August 2014 11 18
Executive Dysfunctions
the Sleepy Secretary of
by Susan D. Rich, MD, MPH
As a child psychiatrist, parents NEUROPSYCHOLOGISTS DESCRIBE EXECUTIVE FUNCTIONS (EFs) as
often ask me to interpret reports initiation, attention, working memory, organization, processing speed, filtering
of highly qualified, multiple- information, and a variety of many other highly technical terms. Metaphorically,
degreed neuropsychologists. the EFs represent the “secretary” or “executive assistant” to the brain’s “chief
I have been challenged executive officer” or true intellect. (For younger children, the “school secretary”
to accurately demystify and “principal” may be described instead.) Breaking it down for patients and their
complex results in ways that families, the analogy of a secretary versus CEO depicts differences between the EFs
appropriately predict prognosis and the general intelligence. Vitally important to support the “boss” of the brain—
for bright children with representing abilities in higher level problem solving, critical thinking, abstract
executive functioning issues and reasoning, judging, understanding consequences, and predicting outcomes—the
ADHD, without demoralizing EFs cannot replace the general intellect.
them or making them feel
their child is disabled. The In this scenario, secretarial functions include fil- The sleepy secretary
past several years have taught ing, organizing the office, scheduling appointments, When children (or adults) have executive functioning
me to simplify the language sorting the mail, and other tasks that make the CEO’s issues, the part of the brain in an area of the prefron-
in terms that are optimistic, job a lot easier. Secretaries remember who just called tal cortex (just behind the eyebrows and forehead) is
goal-directed, and functionally on the phone long enough (i.e., working memory) to hypoactive or “sleepy.” Using this analogy, a person
relevant to my patients. This direct the call to the correct person in an ancillary de- with ADHD and/or executive functioning issues has
“Cliff Notes interpretation” partment (i.e., processing) and to screen both visitors a “sleepy secretary”—one that was out partying most
of neuropsychological testing and callers (or extraneous noises, voices, information, of the night and came into work with little sleep and
enables an abbreviated thoughts) from reaching the CEO when s/he is busy. no coffee. Kids with “high engines” or hyperactivity
explanation tailored to the A good secretary is an efficient note-taker (uses short- are innately wired to rouse their sleepy secretary by
patient yet appropriate for hand in order to capture important information) and movement (foot tapping, fidgeting, doodling, wig-
private practice psychiatry an acceptable editor (corrects typos and punctuation gling, standing up, or otherwise being in perpetual
settings. The approach is errors, dots the i’s and crosses the t’s). Although s/he motion). This allows them to stay more alert and at-
based on a premise that these may not grasp the ramifications of a multibillion dol- tentive despite the drowsy secretary. Impulsivity is the
conditions fall within a broad lar project, s/he is adept at looking at the details of a child’s way of being an active participant in a discus-
spectrum of normal human contract without being overwhelmed by the minutia. sion, classroom, family event, social activity, or other
brain function, much like the occasion while not fully connected to the “rhythm” of
idea of multiple intelligences A wonderfully gifted secretary is productive even the other people they are around. They tend to blurt
within the classroom. The goal when multitasking—while covering the phone line out answers, butt into conversations, ask inappropri-
is to explain the differences and front desk, s/he types a dictation or creates a ate or off-topic questions, and jump into a situation
in brain function without memo. S/he is able to prioritize the work on her desk before thinking about the consequences. Kids with
pathologizing the problem or in order to know what must get done ASAP and what
stigmatizing the person. To can wait until after lunch or tomorrow. Secretaries
preface this discussion, it is make to-do lists and follow them until completion,
not written in formal “medical- not too proud to make coffee if it puts the boss in a
ease” but instead to help create better mood in the morning, and show up on time,
a scaffolding for discussions willing to work, and motivated to get any job done.
about diagnosis, treatment S/he finds value in the work for the sake of having a
planning, and progress. – SDR job, is not too egotistical to make her boss look good,
and understands that hard work and perseverance
Susan D. Rich, are the keys to success in overcoming challenges. Re-
MD, MPH, sponsible for housekeeping functions of the brain, a
is a board-certified fabulously poised secretary often makes the boss look
child, adolescent, efficient, organized, productive, task-oriented and on
and adult psychiatrist time—in turn, improving the boss’s performance.
based in Maryland.
16 Attention 19
and
ADHD
sleepy secretaries are often difficult to awaken in the morning, who experience side
leading to power struggles with their parents due to being effects from medications
late to school and grumpy at home. as well as those with ADHD and
anxiety, depression, or other co-occurring disor-
The burnt-out boss ders are referred to child psychiatrists. Many parents of children with
A complication to the sleepy secretary is the sleepy boss. For garden-variety ADHD and mild executive functioning issues never
kids who aren’t getting good sleep, their CEO or whole brain consider taking their child to a child psychiatrist. Their children are
also comes to work sleepy—they stayed too late at the same office treated by a pediatrician, often with stimulant medication. They may
party their secretary closed down the night before. It turns out that not be identified until middle school or high school, when it becomes
many kids with ADHD don’t sleep well because their brains secrete harder to secure a 504 plan for academic accommodations. For some,
melatonin later in the evening than those without ADHD symptoms. stimulant medications may exacerbate underlying anxiety disorders,
In these cases, adrenaline then kicks in around the time they should be leading to obsessions, compulsions, crying episodes, poor frustration
going to bed to hyper-arouse and re-energize the“low engine,”overrid- tolerance, and motor or vocal tics. Stimulants can also trigger changes
ing the effects of melatonin even when it is finally released. Not only is in mood, irritability, sleep problems, poor appetite, and lethargy. Psy-
the secretary going to be less alert and less productive, but the boss will chotic episodes are infrequently triggered by rapidly increasing the
also be functioning at a minimal level of productivity. S/he will be un- dose of a stimulant or restarting at a previously therapeutic dose after
able to compensate for the sleepy secretary if s/he too is less awake and months off a stimulant medication.
alert. Chronic sleep deprivation in these kids may seem a lot like going
to work or school with a hangover or after a blackout the night before. The meditating secretary
Meditation and medication have a lot more in common even than
The burnt-out secretary one may think at first glance. Often I remark that they only have one
Most often, I see bright young women with EF issues and/or ADHD letter different. Mindlessness as a goal of meditation is the act of let-
in my practice beginning in late middle school to high school or col- ting go of all extraneous thought except what the teacher’s voice is
lege who are burnt out, sleep deprived, and depressed from working saying, what one is reading, or the conversation one is having with a
their CEO into exhaustion. In these cases, the young women are eager friend. In order to actively connect to the moment, one can focus on
to please, academically driven, and motivated to excel. Their anxiety one’s breath while letting go of all thoughts. In this analogy, a person
propels them toward perfectionism, and their intellect is able to com- is taught to fill his or her head with air like a balloon while breathing
pensate somewhat for the hypoaroused prefrontal cortex. Since the in deeply through the nose, collect all thoughts/worries/discomfort
secretary is less efficient and not doing her job promptly and on time, within the breath, then breathe out through the mouth—imagining
the CEO then steps in to answer the phone, schedule meetings, type letting all the thoughts/worries/discomforts expel with the breath.
memos and file the paperwork. These are all tasks the CEO can do but The person is taught to actively notice the thoughts/worries/discom-
that make his or her job more difficult, slowing down productivity fort but to let go of them gently with each breath.
and decreasing optimal functioning.
Over time, this method of meditation can improve focus, con-
Ultimately, chronic sleep deprivation results from the CEO forc- centration, attention, efficiency, productivity, and performance. It is a
ing them both to burn the midnight oil in order to make up for in- technique used by highly trained athletes to“get in the zone,”by actors
efficiency and procrastination earlier in the day. On the other hand, and politicians to overcome stage fright, by patients with high blood
even the most talented, self-motivated secretary cannot do the CEO’s pressure and heart disease to lower their stress levels, and by yogis and
job—making huge business decisions, consolidating massive amounts
of information, recognizing the bigger picture, and creating strategies
for improving the company’s assets. The other caveat is that, within a
single person’s brain, there is no way to fire one’s secretary any more
than a CEO would fire his mother if she worked for him. So, the highly
intelligent person with faulty EFs begins to recognize trouble when
the expectations and academic demands of school begin to exceed the
CEO’s ability to do his/her job plus the secretary’s. Very often, this oc-
curs in late middle school to high school or the first few years of college.
The medicated secretary
Medication serves to artificially arouse the hypoactive prefrontal cor-
tex by acting like a cup of coffee for the sleepy secretary. Children
August 2012 17 20
18 Attention magicians to control their autonomic functions in order to accomplish miracu-
lous, death-defying feats. Children with ADHD and EF issues, as well as anxiety
and other emotional issues, can train themselves to meditate in order to keep their
secretaries focused, alert, actively engaged in learning, and slow down their engine
long enough to think twice about what they want to say in class or the answer
they want to choose on a test. It is a way in which we as humans can tune into
our own unique rhythm that brings us in closer harmony with those around us.
The accommodated secretary
Highly intelligent, hard-working kids can adapt and compensate for mild to mod-
erate executive functioning issues by training their secretary to sleep well, show
up on time, stay alert, create lists and complete the items, and drill, drill, drill the
information into their brains. They learn other important coping skills such as or-
ganizational strategies (using color-coded binders and recopied notes,for example),
reminders, calendars, phone alarms for appointments, and structure for staying on
task. Making one’s bed before leaving the house is a way to feel more productive ev-
ery morning and less distracted when coming home to do schoolwork. Simply put,
a bedroom looks much tidier if the bed is made and the clothes are put in a laundry
bin. Other ways of organizing include putting shelves in the closet with odds and
ends that would otherwise clutter the room—putting papers and mementos in
labeled shoeboxes that can be cleaned out and purged periodically.
A child psychiatrist’s approach
My approach is to first get the child or adolescent sleeping the adequate number
of hours required for his or her age. Most parents are unaware that post-pubes-
cent youngsters still need about nine-and-a-quarter hours of sleep. Children in
the tween stages (ages ten to thirteen) need around nine-and-a-half to ten hours.
It still baffles me when parents seem confused as to why their elementary to
high school aged children have meltdowns, irritability, and two-year-old temper
tantrums. They seem shocked to learn that the child getting eight hours or less of
sleep per night is grumpy because he or she isn’t sleep-
ing enough—or are napping, which serves to worsen
sleep dysregulation.
Normally, I suggest a thirty-day trial of my strat-
egy of getting adequate sleep, unplugging from
electronics for two hours consistently after school
to focus on homework and studying, and avoiding
napping which can further exacerbate the sleep cycle
dysregulation. Once children or adolescents are get-
ting an adequate amount of consolidated sleep for
their age, they often require less medication, respond
better to accommodations, and are more apt to com-
plete their homework in a timely manner.
There is evidence that children encouraged by
statements like, “You are really smart, you should be
able to do it,” perform more poorly on standardized
testing than their matched counterparts who are
praised for their determination and “stick-to-it-
iveness.” As my grandmother always told me, “There
is nothing you can’t do if you put your mind to it!”
My motto is, “What separates a smart person from
a successful student is hard work and perseverance.”
I encourage my patients to minimize distractions of
electronics and social media, discipline themselves
to study efficiently (using learned tools and coping
strategies), and reframe homework completion
as satisfying productivity instead of busywork.
I encourage parents of children and adolescents to
avoid micromanaging homework in order to foster
independent learning in the child, and to praise
the child for diligence, fastidiousness (for example,
making his/her bed in the morning), and the
accomplishment of effort rather than grades.
21
Most analogies and metaphors
come from our own life experiences.
Over my childhood, adolescence and
young adulthood, I watched my stepmother
work her way up from the typing pool to
become a purchasing agent and then a buyer
for a large manufacturer of yachts. Growing up
in the South, my father wanted me to follow in
her footsteps as a secretary and was dismayed
when I brought home the only B on my report
card in typing. He believed I wouldn’t get a job
with a B in typing. When I countered that the
purpose of typing class was to be able to type
my own term papers in college, he retorted
that college would educate me beyond my
intelligence and I would never get married if I
went that route. Despite my twenty-eight years
of education, each time I jam my photo copier/
scanner/printer/fax machine, I’m reminded why
I didn’t become a secretary. At the same time,
I’m glad I learned how to type and developed
my own executive functioning skills to help my
CEO be efficient and successful! – SDR
Distractions from career goals
My patients often hear me say,“In times of catastrophe,
I want as many people with ADHD on my side to solve
the problem—they act quickly, run on adrenaline, and
think outside the box—all great qualities of emergen-
cy response teams and entrepreneurs!” Truth be told,
many kids with ADHD in my practice are children of
entrepreneurs and emergency room physicians. Dur-
ing discussions of family history, the successful par-
ent with ADHD will frequently admit to having taken
medication in the past or currently. Genetically speak-
ing, the apple doesn’t fall far from the tree!
Twenty to thirty years ago, it was much easier for
the intelligent student to compensate for a “sleepy
secretary.” There were certainly far fewer distrac-
tions—television, cell phones, video games, social
media, and other forms of electronics that feed pro-
crastination, loss of productivity, and inefficiency in
even the most intelligent adolescents. Smart, hard-
working students could more easily overcome EF is-
sues and ADHD by determination and postponing
gratification.
The instantaneous gratification of cell phones,
video games, instant messaging, texting, video chat-
ting, and other forms of media limits one’s drive and
motivation for careers requiring years of intensive
study. Helping youngsters find their hidden passion,
meaning in life, and purpose on the planet is always
a goal of my work with patients with EF issues and/or
ADHD—to motivate, inspire, encourage, and believe
they can reach their realistic goals in life.
In that spirit, the sleepy secretary analogy
serves to promote the philosophy that a belief in
oneself, working hard, and persevering despite
academic adversity diminishes moments of frus-
tration and can help improve one’s self-esteem,
motivation, and confidence. ●
August 2012 19 22
23
24
ADHD &
Two Journeys
by Jennifer Klotz and Ruth Hughes, PhD
25
Hughes family photos:
A portrait photo of
Ruth and Chris; Chris
after skydiving during
a trip to South Africa;
proud mother and son
at Chris’s high-school
graduation.
COURTESY OF RUTH HUGHES
Ruth’s
Adoption Story
dszc / istock October 12, 1987 was Christopher Columbus Day and the met a stranger he didn’t like.
most important day of my life. With family and friends I In first grade Chris began to fall behind his peers in reading and
descended upon Reagan National Airport to meet my son,
Christopher Ujjal Hughes, who was journeying from India to the arithmetic, and he had his first evaluation for ADHD. Despite be-
Americas. Chris had been born prematurely in Calcutta, weighing ing a clinical psychologist, I was certain the only problem was a
only three pounds and six ounces three months earlier. On that day we little immaturity—just a little denial on my part. But he was rapidly
started a journey that has been incredibly enriching, challenging, lov- diagnosed and began treatment. Immediately his ability to learn
ing, frustrating, and humbling. It was my journey into motherhood, at school was vastly improved, as was his classroom behavior. But
adoption and ADHD, and it eventually led me to CHADD. I had no improvement did not mean the symptoms of ADHD disappeared.
information about his birthparents or the circumstances of his birth.
Through the years we have had our share of academic and behav-
At age two it was clear that Chris was ahead on some milestones, ioral challenges. The number of near disasters is legion—fires, acci-
behind on others, and missing others altogether. He was first diag- dents, wild parties, and calls from the principal were not unknown in
nosed with a speech delay and treated by a speech therapist. Within a my household. IEPs and 504 plans, visits to the psychiatrist, therapy,
year he was talking nonstop. Of course he also never stopped moving. and support groups were part of the mix. But there was also lots of
Even in his sleep the bed would move across the room, because doing love, exuberance, and excitement.
anything quietly wasn’t his thing. He never even made it to the zero
percent level of the U.S. growth chart until he was six. Today Chris is a twenty-three-year-old young man and, at five
feet ten inches, no longer the smallest kid around. He has two years
Despite several years in preschool, kindergarten was a major of college under his belt and is now preparing to go to Thailand
challenge. Sitting, listening, and taking turns were not Chris’s for six months to volunteer at an orphanage for children with dis-
strong points. But he was engaging, inquisitive, happy, and never abilities. He is caring, loving, level-headed and, of course, still has
ADHD with all its challenges.
Ruth Hughes, PhD, is CHADD’s Interim CEO. Jennifer Klotz is CHADD’s Training Coordinator. October 2010 27
26
Klotz family photos: Two photos of Matt
enjoying outdoor activities; Kate’s
high-school graduation photo; and
Jennifer with Matt and Kate.
Our family has had many difficulties as well as many happy
times. Over the years, I have used a variety of treatments and inter-
ventions for my children.We consulted a treating child psychiatrist
for medication management. We also have used the services of
weekly counseling, including social workers and psychologists.
I worked very closely with my children’s schools. My daughter
never had an official IEP or 504 plan, but her teachers did make
accommodations for her throughout her school years. My
son attended a pre-kindergarten program at the local public
school. By the first day of kindergarten, I had an IEP for him,
which has continued into middle school. We also used a
variety of behavior management techniques at home.
Parenting is challenging,and even more so with the add-
ed layers of transracial adoption and special needs.We have
a complicated family. Over the years, I have found support
through adoptive parent groups as well as CHADD’s support
groups.I found it so much easier to parent my children when I had
the support of other families like mine. I attended monthly educational
and support groups, as well as social events. It was important for my
children to know that there were other families just like theirs.
My son Matt is now thirteen and in the seventh grade and con-
tinues to succeed in school with an IEP. My daughter Kate has now
graduated from high school and is eighteen years old. ADHD has not
disappeared. She is now working and thinking about college.
COURTESY OF JENNIFER KLOTZ
watcha / istock, bonotom studioAdoption and ADHD
Jennifer’s
November is National Adoption Awareness Month. This is a
Adoption Story time to bring about awareness of adoptive families in the United
States. Children join families through private and public adop-
am the parent of two children who joined my family tion, as well as domestic and international adoption. There are
through adoption.Both of my children have the diagnosis of ADHD. about 120,000 adoptions each year, and a significant number of
They are from two different biological families. My daughter was those children will eventually be diagnosed with ADHD. Research
adopted domestically and placed with me at twelve weeks old. My son has consistently shown that adopted children are two to three
was also adopted domestically and placed with me at twelve days old. times more likely to be diagnosed with ADHD than their peers
Medical history obtained by the adoption agency revealed that there without ADHD. With the ADHD prevalence rate at seven to eight
were family members in my daughter’s biological family with the di- percent of all children, studies of adopted children find rates from
agnosis of ADHD. My son’s biological family is much the same. My fifteen to thirty percent.
daughter was evaluated and diagnosed with ADHD at the age of seven
and my son at the age of four. Is there a connection between ADHD and children who have
joined their families through adoption? ADHD is highly heritable
and runs in families. Impulsive teens live in the moment. If left
untreated, teenagers are at greater risk for making poor choices,
including substance abuse and pregnancy. Russell Barkley and his
colleagues have found earlier initiation of sexual activity, less use
of contraceptives, and a significantly higher rate of teen pregnancy
among adolescents with ADHD, particularly those with hyperac-
tivity, compared to their non-ADHD peers. An individual with the
diagnosis of ADHD may have more challenges and difficulties rais-
ing a child and be more likely to allow that child to be adopted.
28 Attention
27
Many children who are placed for adoption have special needs in
addition to ADHD. Those special needs can be physical, emotional,
or mental. A child may have a history of abuse or neglect, test posi-
tive for HIV, have prenatal exposure to drugs or alcohol, and have
learning disabilities or any of the many conditions that may lead to
current or future problems. Research has also shown that that some
environmental variables such as prenatal exposure to drugs, alcohol,
cigarettes, low birth weight, and lead poisoning may place a child at
higher risk for ADHD. And a child who was adopted from an or-
phanage may be a greater risk for ADHD due to malnutrition, lack of
nurturing, and other environmental factors. Often adoptive parents
do not know about these risk factors at adoption.
Adopted children are two In addition,all adoptive
children have questions
to three times more likely and uncertainties about
to be diagnosed with ADHD being adopted. Will my
than their peers without parents keep me if I’m bad?
ADHD. With the ADHD Why did my birthparents
give me up? Who am I real-
prevalence rate at seven ly? Both of our families are
to eight percent of all multicultural, and it is not
children, studies of adopted unusual for adoptees to
children find rates from look nothing like anyone
else in the family. All of
fifteen to thirty percent. these issues must be dealt
with. In Ruth’s household,
Chris repeatedly wanted to take their dog, Buddy, back to the pound
because he was bad. And each time mom would explain that adoption
was forever. When his English teacher asked the class to make a birth
certificate, Chris had a major meltdown and ended up in the principal’s
office.“How am I supposed to know who my birthparents are?”he yelled
at his mother.For some children these problems are much more serious;
they have attachment disorders, arising from a failure to form normal
attachments to primary caregiving figures in early childhood.
Those of us with family members who are adopted and also have
ADHD have a special bond. We have very complex families with
many challenges, but we also feel blessed. We have chosen these
children to be part of our lives. Once the ADHD is diagnosed, the
need for information, treatment and support is similar to so many
other families with some extra surprises thrown in. The evaluation
and treatment process must deal with more unknowns and take into
consideration the possible traumas and circumstances that may have
taken place prior to the adoption. Support from other parents is cru-
cial—both ADHD support groups and adoption support groups.
Information and effective parenting strategies are essential. It is not
surprising that both of our family journeys brought us to CHADD
and to working closely with CHADD’s Parent to Parent program.
It is where we are meant to be. ●A
October 2010 29
28
10/11/2017 ADHD Weekly Article
Understanding ADHD | About ADHD | ADHD Weekly | Article
ADHD Weekly Newsletter
Trauma and ADHD Co-Exist in Foster Children
Join the discussion.
Did you know that children in foster care are three times as likely to have
ADHD than other children? And almost 9 out of 10 foster children have
experienced a traumatic event at least once, while many have
experienced traumatic domestic conditions.
Some children enter foster care because their birth family’s environment
may have been unstable or even violent, creating for those children not
just one traumatic event, but an ongoing climate of trauma. For young
children, such conditions can affect the neurodevelopment of their
brains.
“Traumatic…experience in adults alters the organized brain, but in infants and children it organizes the developing brain,”
according to researchers Bruce Perry, MD, PhD, and Ronnie Pollard, MD.
Treating foster children
Meeting the needs of children in the foster care system, and helping them to either return to their families or be adopted into
new, loving families is a struggle, especially when the symptoms of ADHD and trauma can not only be similar but may also
aggravate each another.
Lisa Dominguez, LCSW-C, the director of Clinical Services for the Center for Adoption Support and Education (C.A.S.E.),
says her agency sees many children with an ADHD diagnosis. Frequently, she says, the child is struggling with a
http://www.chadd.org/Understanding-ADHD/About-ADHD/ADHD-Weekly/Article.aspx?id=401 1/629
10/11/2017 ADHD Weekly Article
combination of ADHD and trauma symptoms. Or, she adds, the child has been misdiagnosed with ADHD when the
difficulties—hyperactivity, inattention, behavioral issues—are actually related to trauma symptoms.
Ms. Dominguez says working with caregivers, educators, and prospective parents to better understand the intersection of
trauma and ADHD is an important step in helping children recover from trauma and become successful later in life.
How kids wind up in foster care
Very often children who have a diagnosis of ADHD have inherited the condition from their
parents. Adults with undiagnosed or poorly managed ADHD are at greater risk for
underemployment or unemployment, difficulties in their social lives and with spouses or
partners, may have co-occurring substance abuse disorder and may also have undiagnosed
co-occurring mental health conditions that interfere with daily life. These challenges can lead
to problems in parenting or in some situations, create unsafe living situations for their
children.
Some of the reasons a child might enter the foster care system can relate to the mental
stability of parents. In many cases, child welfare agencies are called in to remove the child
from an unstable home environment. Statistics from the Administration for Children and Families, Children’s Bureau, June
2016 Report:
There has been abuse, including physical (13 percent), or sexual abuse (4 percent).
There has been neglect (61 percent), such as basic physical needs are not met, the child is left alone for a long period of
time or needed medical care is not provided. When a child goes without basic needs, this is cause for the courts to
remove the child from the home. Neglect can also include lack of food or clean living environment
The family has inadequate housing or living circumstances to raise a child (10 percent).
A parent has been sentenced to prison and there are no other family members to care for the children (8 percent).
There is drug abuse or addiction in the child's home (32 percent; often occurring along with neglect).
The child's parents or guardians have died or cannot be located and there are no other family members available to care
for the child (1 percent).
The parent experiences an illness that prevents him from caring for his children or otherwise coping with child care and
there are no other family members who can help (14 percent).
Occasionally, a child might enter foster care if a parent chooses to relinquish parenting rights and voluntarily places a
child in the foster care system (1 percent). Although there are cases where a child’s disability or behavior may prompt
such a decision, there are other reasons why a parent might find this to be the better choice in difficult circumstances.
All these circumstances can be traumatic for a child, as well as the act of being removed from her home. Frequently
children feel a sense of guilt or shame, wondering if they are somehow the reason for the separation from their parents,
even though it is not true.
“Given these kids were [placed] for adoption or into foster care, it is likely that they may carry genes for ADHD, as well as
other mental illnesses (bipolar disorder, addiction, depression, etc.),” says Roberto Olivardia, PhD, a clinical psychologist
and lecturer in Psychology for the Department of Psychiatry at Harvard Medical School. Dr. Olivardia is a member of the
CHADD Professional Advisory Board. “That, coupled with an environmental expression of those genes, can make for a
complex profile.”
http://www.chadd.org/Understanding-ADHD/About-ADHD/ADHD-Weekly/Article.aspx?id=401 2/630
10/11/2017 ADHD Weekly Article
Medication management alone for ADHD would not be effective, he says. The focus should be on a comprehensive
treatment plan taking into account co-occurring conditions, previous abuse, and social and economic factors that have
affected the child.
Trauma often seen as ADHD in foster care
In 2016, there were more than 427,000 children in foster care; 53,549 were adopted through public child care agencies.
More than a quarter of children in foster care have been diagnosed with ADHD. It’s estimated that 90 percent of children
who are in foster care have experienced one or more traumatic events; many have endured persistent trauma in their lives.
Although these numbers show how common the co-occurrence of ADHD and trauma is, when professionals and caregivers
work with a young child, Ms. Dominguez says they can attribute shared symptoms to the wrong disorder.
“Everyone always assumes it’s ADHD first,” she says. “The ADHD is being treated and the trauma is not. Often the trauma
piece is being missed.” Without addressing the trauma, treatment of ADHD may not succeed, she says.
Symptoms of impulsivity and hypervigilance related to trauma can be mistaken for hyperactivity related to ADHD, while
disassociation or freezing-up — symptoms of trauma — could look like inattention. Many children grieve the separation
from their families, blame themselves and are fearful of either never seeing their parents again or that they will be
separated from their foster or adoptive parents in the future. This grief and fear can be expressed in disruptive behaviors.
These are symptoms of trauma, she says, and need to be recognized and treated as such.
Helping children in foster care
Children usually experience multiple placements before they are able to return to their families of origin or are adopted into
new families. Ms. Dominguez says this makes continuity of care and development of attachment difficult. Children need to
establish trusting relationships with new adults before treatment for trauma can be effective.
Foster parents, adoptive parents, and caregivers need to be trained to understand how trauma affects a child, along with
parent education on ADHD. C.A.S.E. works with public social services in several Maryland and Northern Virginia
jurisdictions to help children and caregivers deal with the effects of trauma. Ms. Dominguez refers to this as “trauma-
informed parenting.”
“Some children present with extremely challenging behaviors,” Ms. Dominguez says. Often adults respond to a child’s
behaviors with discipline, rather than recognize those challenging behaviors as stemming from trauma and/or co-occurring
ADHD. “By parenting from a trauma-informed perspective, we see what the child is trying to communicate to us instead.”
The first step to helping children in foster care, Ms. Dominguez says, is to make sure the child receives a good assessment
from a clinician who understands ADHD, trauma, and the disturbances in a child’s life that occur before and/or during foster
care. Any treatment plan that addresses only ADHD or only trauma cannot succeed. Here are some steps adults can take
to help children experiencing trauma symptoms and ADHD:
A thorough assessment for trauma, ADHD, and other co-occurring conditions. Knowing what a child is dealing with, from
medical and social histories, is imperative to designing proper treatment for that child.
http://www.chadd.org/Understanding-ADHD/About-ADHD/ADHD-Weekly/Article.aspx?id=401 3/631
10/11/2017 ADHD Weekly Article
Design a treatment plan and team to work with the child. This would include parent training, along with behavioral
management techniques, and, when appropriate, medication management.
Work with parents and caregivers to develop realistic expectations for their children in addition to parent training for
trauma, ADHD and co-occurring conditions. Therapy and family support is an important part of the process. Children and
parents come to learn what are triggers for poor behavior, how they are related to past traumas and how ADHD is
involved in the children’s responses. Once those triggers are known, parents can work with children to develop healthier
responses.
“Parents and caregivers need to really understand that good trauma treatment has to go hand-in-hand with skills building
and traditional ADHD treatment,” Ms. Dominguez says.
Moving from foster care to families
When a child cannot return to her family of origin, the goal is adoption in a loving family. It can sometimes take years for a
child to be adopted, either by her foster parents or new parents. Most foster children are constantly fearful of a possible
reversal of placement or adoption, which can be devastating.
“People belong in a family,” Ms. Dominguez says. “That’s where children need to grow up. That’s the lifelong connection;
it’s knowing you have someone to call if you need something, someone to call when you have great news.”
C.A.S.E. counsels prospective parents to have realistic expectations for their child, who has come to them struggling with a
lifetime of separation, trauma, ADHD, and other possibly co-occurring conditions. Building and sustaining a trusting
relationship with the child is key to helping the child deal with past trauma, and to ensure a successful placement.
“Parenting children with a trauma history requires a different style of parenting,” Ms. Dominguez advises. “It takes time and
support. You need to surround yourself with people who understand the unique needs and challenges of children who have
experienced trauma and neglect. I think so many parents want to keep the past in the past. But we need to honor the past
and understand how your child’s early beginning impacts what happens now.”
Where to look for help
Center for Adoption Support and Education
The National Child Traumatic Stress Network
Treatment for Childhood ADHD
Are you a foster or adoptive parent? How can parents help children cope with traumatic conditions?
This article appeared in ADHD Weekly on September 28, 2017.
Follow
http://www.chadd.org/Understanding-ADHD/About-ADHD/ADHD-Weekly/Article.aspx?id=401 4/632
by Erica D. Musser, PhD
THE CORE SYMPTOMS OF ADHD, The
including inattention, hyperac- (Un)Surprising
tivity, and impulsivity, can sig-
ni cantly impair a child’s academic, family,
and social functioning. roughout the
past several decades, de cits in important
cognitive functions—those termed execu-
tive functions, like inhibition and working memory—have been considered
the hallmark characteristics that explain the core symptoms and associated
impairments of ADHD. Recent research suggests, however, that factors relat-
ed to emotion may also play an important role in understanding the impair-
ments experienced by children (and adults) with ADHD.
Many parents and teachers can attest to the emotional nature of many of
the behaviors that seem to be part and parcel of ADHD. For example, a child
may get so frustrated during homework time that she throws her books to
the oor. Or, a child may get so excited that recess is scheduled as the next
activity that he runs to the front of the room ready to rush out the door to
start kickball, only to have his teacher punish him for leaving his seat. Clini-
cians and researchers are nally beginning to recognize what parents and
teachers have known all along: ADHD is not simply a disorder of behavior
and cognition, but also emotion.
ere are several di erent parts to emotions. Current research has focused
on identifying exactly which aspects of emotion are disrupted among chil-
dren with ADHD. ese aspects of emotion may include:
● Emotion recognition in both the self and in others. For example, the of the main character in a second lm clip, but to SHUTTERSTOCK
child with ADHD may have di culty in recognizing that he or she is feeling “keep it a secret” by not expressing the emotion (or
sad or in recognizing that someone else is scared and not angry. to suppress the emotion). e results suggest that
not only do children with ADHD have more dif-
● Emotional empathy, or the ability to “put oneself in another person’s
shoes” emotionally. For example, a child with ADHD may not be able to culty managing their emotions behaviorally, but
understand why his classmate is so upset that he lost his cookie. also biologically, as heart rate is a known marker of
the emotional response. is suggests that children
● Emotion reactivity, or the amount of uctuation in emotions. For exam- with ADHD may nd it more di cult to control
ple, some children with ADHD may have very little emotional changeability, their emotions than other children. Some children
seeming to have a rather inactive emotional life, while other children with with ADHD may also nd it di cult to identify
ADHD may go from happy to sad to angry in seemingly a matter of minutes. what emotion they themselves are experiencing or
what emotions other important people in their lives
● Emotion regulation, or the ability to manage or control ones’ emotions are experiencing.
so that they are not too intense, are not of the wrong type, and do not last
too long. For example, a child with ADHD may nd it more di cult to hide Taking a new approach
his or her frustration from teasing siblings.
From these examples, it is easy to see how these
Recent research has suggested that children with ADHD seem to have the emotional processes can detrimentally in uence
biggest di culties in their emotion reactivity and emotion regulation (and to everything from academic success to family life to
a lesser degree in their emotion recognition abilities). forming and maintaining friendships. e impact
of these di culties on children’s functioning has
In a study conducted by my research team, for example, children with prompted clinicians who work with children with
and without ADHD were asked to watch several emotional lm clips while ADHD to take a new approach in treating the dis-
we collected heart rate data using electrocardiograms (EKGs). Children order by working directly with children and their
were asked to mimic the emotion of the main character in one lm clip (or families to improve their emotional skills.
to express the emotion). en, children were asked to identify the emotion
16 Attention 33
ese interventions may involve training children with ADHD to recog-
nize emotions in themselves and others through the use of emotional stories
and pictures or old standards like teaching children to “count to ten” before
they get angry, while giving them alternative ideas for how to respond to
such situations.
Tips for parents
Emotional Children learn how to manage their emotions from their parents and other
important adults in their lives. us, it is important that parents (and oth-
ers) model appropriate emotion management. Here are some tips you can
use to help your children build stronger skills:
Nature of 1 Be patient; be a model for your child. All children develop at their own
pace, which means that not all children will develop emotion skills at the
same time. While it may
ADHD be tempting to engage in
a shouting match with a
frustrated child, modeling
your own emotion regula-
tion skills will help your
child to recognize that ap-
propriate strategies are suc-
cessful for you. So, before
you get angry, take a deep
breath and count to ten.
2 Label feelings; help your child recognize his or her emotions. Children
aren’t born with the proper words to describe what they are feeling. In
young children, frustration, anger, and fear are almost always expressed with
a tantrum rather than words. Labeling your child’s feelings and encouraging
him or her to do the same helps the child to build empathy, emotion recogni-
tion, and emotion regulation skills. If your child doesn’t have the right word
to describe how he or she is feeling, suggest one. For example, “I see you are
struggling with that writing assignment. at must feel frustrating.”
While we know that both stimulant medications 3 Give your child a choice or two, but not too many. Giving your child the
and behavioral parent training are gold-standard, choice between two or three age-appropriate options, like what to have
evidence-based treatments for ADHD, neither for snack or what to do a er dinner, not only promotes independence, but
focuses speci cally on improving emotional func- also allows children to learn to manage their disappointment or frustration
tioning among children with ADHD. Interestingly, when things don’t quite go their way. Just be careful not to give too many op-
while both stimulant medications and behavioral tions, as this can be overwhelming for some children.
parent training have been demonstrated to improve
academic and family functioning, neither have been 4 Have fun with it. ere are many games that promote emotion and
shown to reliability improve social functioning self-regulation. Classics like Simon Says, Red Light/Green Light, and
among children with ADHD. Because of this, clini- Red Rover all help children build their self-regulation skills while having fun.
cians have begun developing new and improved Activities like games also provide opportunities to discuss behaviors that go
methods for building emotion recognition and reg- along with being a “good winner” and “good loser.” ●A
ulation skills among children with ADHD as these
emotional processes may be key to improving social Erica Musser, PhD, is assistant professor of psychology at Florida International University.
functioning in children with ADHD. Her research examines how emotional factors influence the development of ADHD as well as
other behavior disorders. You can learn more about her work at http://emusse2.wix.com/
abc-erica-lab.
April 2016 17 34
10/11/2017 Women and Girls | CHADD
Understanding ADHD | For Adults | Living with ADHD: A Lifespan Disorder | Women and Girls
Women and Girls
Knowledge of ADHD in women at this time is extremely limited as few studies have been conducted on this population. Women have
only recently begun to be diagnosed and treated for ADHD, and today, most of what we know about this population is based on the
clinical experience of mental health professionals who have specialized in treating women.
Impact of ADHD in women
ADHD in young girls is often overlooked, the reasons for which remain unclear, and many females are not diagnosed until they are
adults. Frequently, a woman comes to recognize her own ADHD after one of her children has received a diagnosis. As she learns
more about ADHD, she begins to see many similar patterns in herself.
Some women seek treatment for ADHD because their lives are out of control―their finances may be in chaos; their paperwork and
record-keeping are often poorly managed; they may struggle unsuccessfully to keep up with the demands of their jobs; and they may
feel even less able to keep up with the daily tasks of meals, laundry and life management. Other women are more successful in
hiding their ADHD, struggling valiantly to keep up with increasingly difficult demands by working into the night and spending their free
time trying to "get organized." But whether a woman's life is clearly in chaos or whether she is able to hide her struggles, she often
describes herself as feeling overwhelmed and exhausted.
While research of ADHD in women continues to lag behind that in adult males, many clinicians are finding significant concerns and
co-existing conditions in women with ADHD. Compulsive overeating, alcohol abuse and chronic sleep deprivation may be present in
women with ADHD.
Women with ADHD often experience dysphoria (unpleasant mood), major depression and anxiety disorders, with rates of depressive
and anxiety disorders similar to those in men with ADHD. However, women with ADHD appear to experience more psychological
distress and have lower self-image than men with ADHD.
Compared to women without ADHD, women diagnosed with ADHD in adulthood are more likely to have depressive symptoms, are
more stressed and anxious, have more external locus of control (tendency to attribute success and difficulties to external factors
such as chance), have lower self-esteem and are engaged more in coping strategies that are emotion-oriented (use self-protective
measures to reduce stress) than task-oriented (take action to solve problems).
Studies show that ADHD in a family member causes stress for the entire family. However, stress levels may be higher for women
than men because they bear more responsibility for home and children. In addition, recent research suggests that husbands of
women with ADHD are less tolerant of their spouse's ADHD patterns than wives of men with ADHD. Chronic stress takes its toll on
http://www.chadd.org/Understanding-ADHD/For-Adults/Living-with-ADHD-A-Lifespan-Disorder/Women-and-Girls.aspx 1/535
10/11/2017 Women and Girls | CHADD
women with ADHD, affecting them both physically and psychologically. Women who suffer chronic stress like that associated with
ADHD are more at risk for diseases related to chronic stress such as fibromyalgia.
Thus, it is becoming increasingly clear that the lack of appropriate identification and treatment of ADHD in women is a significant
public health concern.
The challenge of receiving appropriate treatment
ADHD is a condition that affects multiple aspects of mood, cognitive abilities, behaviors, and daily life. Effective treatment for ADHD
in adult women may involve a multimodal approach that includes medication, psychotherapy, stress management, as well as ADHD
coaching and/or professional organizing.
Even those women fortunate enough to receive an accurate ADHD diagnosis often face the subsequent challenge of finding a
professional who can provide appropriate treatment. There are very few clinicians experienced in treating adult ADHD and even
fewer who are familiar with the unique issues faced by women with ADHD. As a result, most clinicians use standard
psychotherapeutic approaches. Although these approaches can be helpful in providing insight into emotional and interpersonal
issues, they do not help a woman with ADHD learn to better manage her ADHD on a daily basis or learn strategies to lead a more
productive and satisfying life.
ADHD-focused therapies are being developed to address a broad range of issues including self-esteem, interpersonal and family
issues, daily health habits, daily stress level, and life management skills. Such interventions are often referred to as "neurocognitive
psychotherapy," which combines cognitive behavior therapy with cognitive rehabilitation techniques. Cognitive behavior therapy
focuses on the psychological issues of ADHD (for example, self-esteem, self-acceptance, self-blame) while the cognitive
rehabilitation approach focuses on life management skills for improving cognitive functions (remembering, reasoning, understanding,
problem solving, evaluating, and using judgment), learning compensatory strategies, and restructuring the environment.
Medication management in women with ADHD
Medication issues are often more complicated for women with ADHD than for men. Any medication approach needs to take into
consideration all aspects of the woman's life, including the treatment of coexisting conditions. Women with ADHD are more likely to
suffer from coexisting anxiety and/or depression as well as a range of other conditions including learning disabilities. Since alcohol
and drug use disorders are common in women with ADHD and may be present at an early age, a careful history of substance use is
important.
Medication may be further complicated by hormone fluctuations across the menstrual cycle and across the lifespan (e.g., puberty,
perimenopause, and menopause) with an increase in ADHD symptoms whenever estrogen levels fall. In some cases, hormone
replacement may need to be integrated into the medication regimen used to treat ADHD.
For more information on medication management in adults with ADHD, see Medication Management.
Other treatment approaches
Women with ADHD may benefit from one or more of the following treatment approaches:
1. Parent training. In most families, the primary parent is the mother. Mothers are expected to be the household and family manager
—roles that require focus, organization and planning, as well as the ability to juggle multiple responsibilities. ADHD, however,
typically interferes with these abilities, making the job of mother much more difficult for women with ADHD.
Furthermore, because ADHD is hereditary, a woman with ADHD is more likely than a woman without the disorder to have a child with
ADHD, further increasing her parenting challenges. Women may need training in parenting and household management geared
toward adults with ADHD. The evidence-based parent management programs found to be effective in children with ADHD are also
http://www.chadd.org/Understanding-ADHD/For-Adults/Living-with-ADHD-A-Lifespan-Disorder/Women-and-Girls.aspx 2/536
10/11/2017 Women and Girls | CHADD
recommended for parents with ADHD. However, research on these parent training approaches has indicated that parent training may
be less effective if the mother has high levels of ADHD symptoms. Thus, it may be necessary to incorporate adult ADHD life
management strategies into parent training programs for mothers with ADHD.
2. Group therapy. Social problems for females with ADHD develop early and appear to increase with age. Women with ADHD have
greater self-esteem problems than men with ADHD, and often feel shame when comparing themselves to women without ADHD.
Because many women with ADHD feel shame and rejection, psychotherapy groups specifically designed for women with ADHD may
provide a therapeutic experience―a place where they can feel understood and accepted by other women and a safe place to begin
their journey toward accepting themselves more and learning to better manage their lives.
3. ADHD coaching. ADHD coaching, a new profession, has developed in response to the need among some adults with ADHD for
structure, support and focus. Coaching often takes place by telephone or e-mail. For more information on coaching, see Coaching.
4. Professional organizing. As contemporary lives have become increasingly complicated, the organizer profession has grown to
meet the demand. Women with ADHD typically struggle with very high levels of disorganization in many areas of their lives. Some
women are able to maintain organization at work, but at the expense of an organized home. For others, disorganization is
widespread, which increases the challenges and difficulties of ADHD. A professional organizer can provide hands-on assistance in
sorting, discarding, filing, and storing items in a home or office, helping to set up systems that are easier to maintain. For more
information on organization, see Organizing and Time Management.
5. Career guidance. Just as women with ADHD may need specific guidance as a parent with ADHD, they may also greatly benefit
from career guidance, which can help them take advantage of their strengths and minimize the impact of ADHD on workplace
performance. Many professional and office jobs involve the very tasks and responsibilities that are most challenging for a person with
ADHD, including paying attention to detail, scheduling, paperwork, and maintaining an organized workspace. Sometimes a career or
job change is necessary to reduce the intense daily stress often experienced in the workplace by most individuals with ADHD. A
career counselor who is familiar with ADHD can provide very valuable guidance. For more information, see Workplace Issues.
Ways that women with ADHD can help themselves
It is helpful for a women with ADHD to work initially with a professional to develop better life and stress management strategies.
However, the following strategies can be used at home, without the guidance of a therapist, coach or organizer to reduce the impact
of ADHD:
Understand and accept your ADHD challenges instead of judging and blaming yourself.
Identify the sources of stress in your daily life and systematically make life changes to lower your stress level.
Simplify your life.
Seek structure and support from family and friends.
Get expert parenting advice.
Create an ADHD-friendly family that cooperates and supports one another.
Schedule daily time outs for yourself.
Develop healthy self-care habits, such as getting adequate sleep and exercise and having good nutrition.
Focus on the things you love.
Individuals with ADHD have different needs and challenges, depending on their gender, age and environment. Unrecognized and
untreated, ADHD may have substantial mental health and education implications. It is important that women with ADHD receive an
accurate diagnosis that addresses both symptoms and other important issues with functioning and impairment, which will help
determine appropriate treatment and strategies for the individual woman with ADHD.
Follow
http://www.chadd.org/Understanding-ADHD/For-Adults/Living-with-ADHD-A-Lifespan-Disorder/Women-and-Girls.aspx 3/537
With abundant information available on ADHD,
we may have a false sense that we know more about the experience
of girls than we really do. At last, there is ever-increasing
acknowledgement that the manifestations of ADHD
differ by gender. And yet, we are only beginning to
appreciate the far more crucial factor—that the
impact of ADHD differs significantly by gender. In
fact, much about the lives of girls with ADHD is
secret in that their inner world has been virtually
unknown to us. Although our ability to access
windows into their experience is in its infancy, we can
try to make sense of the glimpses we have.
We can best understand the lens through which girls with ADHD are
viewed by tracing its developmental history. Early referrals to psychiatric
clinics were motivated by the difficulty of managing hyperactive, impulsive,
willful children, the great majority of whom were young white boys. The
research utilizing that clinic data formed the basis for the diagnostic criteria
for ADHD, which reflected the assumption that the disorder primarily af-
fected boys. Only the minority of girls exhibiting behavior most similar to
hyperactive boys could potentially be diagnosed. That initial conception
continues to be over-represented in the research and the media; today,
ADHD remains grouped with the Disruptive Behavior Disorders of
Childhood in the DSM-IV-TR. Still, the presumption is that the diag-
nostic criteria pertain as accurately to girls as to boys. But do they?
Our knowledge of girls with ADHD was limited to those now
described as the predominantly hyperactive-impulsive type or com-
bined type. In 1980, new diagnostic criteria allowed for the possibil-
ity of inattention without hyperactivity. Suddenly, the more easily
overlooked inattentive girls, whose behavior least resembled that of
The hyperactive boys, could be diagnosed. Since then, we’ve witnessed
an extraordinary increase in female diagnoses, which is reshap-
ing the landscape of the disorder. However, despite nearly equal
numbers of women and men with the disorder, clinics continue to
report a higher prevalence of women than girls. We’re reminded
that there remains a referral bias, in that girls are less frequently
Secret Lives referred, and a diagnostic bias, in that the diagnostic criteria still
exclude many girls.
A licensed clinical psychologist, Ellen Littman, PhD,
was educated at Brown and Yale Universities, LIU, and
of Girls the Albert Einstein College of Medicine. Involved with
the ADHD field for twenty-five years, she has a private
practice just north of New York City. Dr. Littman
focuses on a high-IQ adult and adolescent ADHD
population. Her specialty is women and girls with ADHD, and she
With ADHD has expertise treating families that have multiple members with
ADHD. Nationally recognized in the field, she is coauthor
of the book Understanding Girls with ADHD (Advantage
Books, 2000), and a contributing author of the books
Gender Issues and ADHD (Advantage Books, 2002) and
Understanding Women with ADHD (Advantage Books,
2002). She is widely published, lectures internationally,
and provides training to professionals.
18 Attention 38
By Ellen Littman, PhD
Sex differences in neurodevelopment, such as faster maturation
of the female brain, and in neuroanatomy, such as size differences in
brain structures, account for some of the differential manifestations of
symptoms. However, gender differences in hormones and societal role
expectations may contribute to the differential impact. For example, at
an early age, girls begin to internalize gender role expectations. Society
still supports the feminine obligations to accommodate others’ needs,
be passively compliant, work cooperatively, and be neat and organized.
Young women with ADHD often feel compelled to strive for these ide-
als despite the fact that they call upon precisely those executive func-
tions that perform unreliably. Conforming is far from instinctive for
these girls, and they can feel like impostors. Consumed with shame,
they judge themselves harshly relative to their peers.
shutterstock, istock Peer interactions and rejection activity, irritability, and impulsivity. Monthly estrogen fluctuations cause
For girls, peer interactions become powerful determinations of self- a premenstrual syndrome involving decreased frustration tolerance and
worth. Unfortunately, ADHD symptoms can thwart their ability to feelings of negativity, which exacerbate ADHD symptoms. These impair-
comply with the unique demands of girls’ socialization. Daunted by ing symptoms can be the trigger for seeking help, although it may result
the rapid verbal interplay due to slowed processing, they may retreat, in being misdiagnosed solely with a mood disorder or PMDD, rather
ashamed of missing the punchlines. When they can’t recognize their than recognizing the depression as comorbid to underlying ADHD.
impact or read social cues accurately, they can be ambushed by harsh
negative feedback. Because their impulse-driven feelings predominate, This exacerbation of impulsivity in adolescence is particularly pro-
they may appear oblivious to others’ feelings, and be judged as selfish. nounced for girls with the combined type. They can be charismatic,
Craving acceptance, most girls struggle to compensate for their difficul- hyper-talkative, and hyper-social. They can also be intense and emotion-
ties so as to avoid dreaded peer rejection. While boys often externalize ally volatile, defiantly competing for social dominance. Self-proclaimed
their frustrations and blame others, girls try to hide their differences and leaders, these girls often overestimate their social competence; in fact,
appear to conform. To this end, internalizing their feelings becomes the their rebellious stance and relational aggression can provoke peer re-
defense mechanism of choice to keep their shameful confusion a secret. jection. They tend toward addictive behaviors offering immediate
gratification in terms of self-medication and peer acceptance. The lure
While most girls with ADHD appear to internalize aspects of their of substance use is seductive: nicotine and caffeine aid concentration;
suffering, it may be that inattentive girls resort to this coping skill the alcohol and marijuana alleviate restlessness, temporarily evading stress.
most. Introverted and easily overwhelmed, they tend to feel unfairly Bingeing on high-sugar or high-carbohydrate foods increases serotonin,
criticized and alienated from peers. Demoralized by underachievement, offering temporary calm, but leading to weight struggles and sometimes
these passive daydreamers are reluctant to participate in class and sur- bulimia. Other impulsive stimulation-seeking behavior involves risk-
render quickly when frustrated. Easily irritated, they cope with their hy- taking, including driving too fast, pranks, and vandalism. Hungry for
persensitivities through avoidance. For these girls, a high IQ is a mixed acceptance, they frequently engage in high-risk sexual behaviors and
blessing:“twice-exceptional” girls perform well in school, which boosts tolerate unhealthy relationships. Less likely to consider the consequences
their self-esteem. However, believing that intellect carries an inherent of unprotected sex, they are at greater risk for promiscuity, STDs, and
expectation of success, they are even more confused and ashamed of unplanned pregnancy than their counterparts who do not have ADHD.
their difficulties, and even more driven to hide their struggles.
For some girls, ADHD and chronic peer rejection predict a wide
These girls have the capabilities to compensate for their cognitive chal- range of future adjustment problems, which dovetails with the fact that
lenges,but they come at a high emotional cost.Investing tremendous time about half of these girls will have at least one other diagnosable disorder
and energy in their public persona, they rely on obsessional behaviors by young adulthood. With a high likelihood of comorbid anxiety and/
for organization and structure. However, the hypervigilance necessary or depression complicating the picture, persistent criticism and rejec-
for constant self-monitoring is fueled by intense anxiety. Hyperfocusing tion can feel overwhelming and inescapable. These negative interac-
on a seamless facade can become dangerous perfectionism. Regardless of tions become daily traumatic experiences, and their cumulative impact
how successfully they compensate, they still feel burdened and exhausted. cannot be overestimated. Plagued by a sense of demoralization and de-
Ironically, the result of coping well is that their plight remains secret, but spair, it is not surprising that most young women with ADHD struggle
no less damaging; these girls are diagnosed the latest, if at all. with low self-esteem. Without intervention, this sense of helplessness
and hopelessness greatly increases the risk of negative outcomes.
Emerging research has revealed that hormones further complicate
the lives of females with ADHD. We now know that the brain is a target
organ for estrogen, where it impacts cognition, mood, and sleep. For
many girls, behavioral issues blossom around puberty, as estrogen levels
increase. This pattern contrasts with many boys, whose overt hyperac-
tivity decreased so significantly after puberty that, for decades, it was
thought that they“outgrew”their ADHD.Yet another reminder of the di-
agnostic gender bias is the requirement that symptoms be present before
age seven. Since girls’ symptoms have been shown to increase with their
estrogen levels, it is unlikely that most girls will meet that criteria. With
increasing estrogen, adolescents experience mood swings, emotional re-
December 2012 19 39
Girls with ADHD and self-harm ter’s ADHD. In spite of diagnostic issues, it begins with early interven- thinkstock
Stephen Hinshaw, PhD, has been in the vanguard of research on girls tion. Often, parents or teachers begin to suspect ADHD, but conclude
with ADHD. He is the lead author of a recent ten-year follow-up study that the child is not “having trouble,” so they don’t seek help at that
utilizing the largest racially and socioeconomically diverse subject pool time. Often, they wait until there’s a problem academically or socially,
of girls to date. Of 140 females 17-24 years old, 93 had been diagnosed or only seek help when they’re interested in school accommodations
with combined-type ADHD and 47 with inattentive-type ADHD as or medication. This is a mistake. While we may wish it were otherwise,
children, although over forty percent no longer met the criteria for ADHD does not limit itself to one aspect of life.
ADHD at the time of this follow-up. They found that these young
women experienced significantly more severe psychiatric symptoms Supporting and empowering girls with ADHD
and significantly greater functional impairment than control subjects Finding a mental health professional who has significant experience
on a wide range of measures. with girls with ADHD is the first step toward helping all family mem-
bers to have a comprehensive understanding of ADHD. Even a young
Most troubling was the fact that the girls with combined-type child can recognize some unique aspects of her functioning, in the
ADHD were significantly more likely to manifest self-injurious be- context that different people have different kinds of brains. Parents
can learn about the struggle for self-regulation: By understanding the
haviors and suicide attempts than the inattentive or control group brain’s need for optimal arousal, they will know when to offer more
subjects. Half of the combined-type subgroup had engaged in self- stimulation and when to help decrease stimulation. Parents can learn
injurious behaviors, and almost a fifth had attempted suicide. Since to create ADHD-friendly home environments, understanding the
these tendencies characterized the girls with combined-type ADHD importance of predictability, structure, consistency, and clear expec-
and not those with inattentive-type ADHD, it suggests that impul- tations and consequences. They can help create quiet space where she
sivity may play a role in compelling these young women to act on feels safe to regroup–-and then respect those boundaries.
their internalized pain.
Parents can learn to modulate their emotional responses. Girls with
These findings are a wake-up call, underscoring the fact that, even ADHD can be frustrating, and how that frustration is communicated
as girls with ADHD mature and appear less symptomatic, they con- determines whether they emerge feeling hopeless or hopeful about
tinue to suffer secretly. While the findings do not suggest any causal their ability to succeed in the future. Parents can strive to present a
relationships, they expand the continuum of potential outcomes for calm united front that will support their daughters in reestablishing
girls, particularly if they were sufficiently symptomatic to be diag- emotional equilibrium. Parents can also help their daughters find an
nosed as children. Since inattentive girls compose only a third of the area of strength in which they can excel. Parents can learn to help their
ADHD subjects, and since the majority of girls with ADHD seem daughters reframe the way they define themselves; encouraging them
to have the inattentive type, it is reasonable to postulate that these to consider more realistic perspectives that are a better fit can reduce
findings do not represent the experience of the majority of girls with stress tremendously. It has been shown that girls’ beliefs in their ability
ADHD. While we can conclude that the girls once diagnosed with to succeed academically offer significant protection from risk factors;
combined-type ADHD became increasingly impaired and ultimately regardless of performance, this message can instill sorely needed confi-
self-destructive, we are left with questions as to whether their ultimate dence about their potential. This suggests that one of the most powerful
diagnosis was ADHD. Nonetheless, these findings clearly highlight the interventions that parents can offer is a consistent sense of hope.
importance of long-term vigilance in monitoring and treating girls as
they negotiate the complex transition into adulthood. When girls are missed by the diagnostic checklists,they aren’t included
in subject pools for new research, their numbers and experiences are not
None of these outcomes are inevitable. It is true that, unrecog- accurately documented, and they continue to live secret lives. Today, an
nized and untreated, girls can experience significant symptoms, im- astoundingly small percentage of research focuses on females and, in ex-
pairment, and comorbidity across contexts. Yet there are a multitude isting studies, the smaller percentage of subjects are the inattentive type.
of things that parents can do to mitigate the impact of their daugh- Until we find ways to access the internalized experience of all girls, they
will continue to wander about in a world that feels less predictable and
less secure than that of their peers.Reactive rather than proactive,they lose
confidence in the judgment and abilities that so often betray them. These
self-attributions, rather than the ADHD challenges themselves, seem to
underlie the psychological distress that can undermine them.
It is critical that researchers explore why ADHD exacts a greater toll
on the psychological functioning of girls than boys. It may be that the
perfect storm of increasingly internalized symptoms, escalating estrogen
involvement, and mounting shame and demoralization in response to
societal expectations combine to create a unique trajectory of stressors for
females. As girls enter adulthood, their situation is further complicated
by anxiety and depression, if not additional comorbid issues. Especially
in light of the continuing gender bias, it is essential that parents, teachers,
pediatricians, and mental health professionals become familiarized with
the more subtle presentation of inattentive girls, as well as with the daunt-
ing risks facing impulsive girls. In all cases, our heightened awareness and
sensitivity to their inner lives will enable us to better support them in their
challenges by creating treatments that target their unique needs. These
girls need to know that, rather than being silenced by their shame, we
want to empower them to be heard—and that we’re listening. ●A
20 Attention 40
10/11/2017 The Most Common Misdiagnoses in Children | Child Mind Institute
Search All+
Topics A-Z
DIAGNOSIS
e Most Common Misdiagnoses in Children
EN ESPAÑOL
When symptoms have multiple causes, mistakes are made
Linda Spiro, PsyD
W hen you have a headache, you know there are many possible causes,
ranging from the mild to the very serious. When you see your doctor,
she will likely ask you detailed questions about how long the
headaches have been taking place, what type of pain you are feeling, when they
occur, and what other symptoms you’re experiencing. Without a thorough
assessment and examination, it would be absurd for your doctor to diagnose you
with a brain tumor or the u, both of which can give you a headache. And, of
course, the treatment for a brain tumor and a virus would look very di erent.
“Common symptoms occur for a variety of 1/1841
reasons, and can re ect several di erent
https://childmind.org/article/the-most-common-misdiagnoses-in-children/
10/11/2017 The Most Common Misdiagnoses in Children | Child Mind Institute
diagnoses.”
e same thing is true of mental illness: many common symptoms occur for a
variety of reasons, and can re ect several di erent diagnoses. at’s why a good
mental health professional will give your child a thorough evaluation based on a
broad range of information before coming up with a diagnosis. It’s crucial to
understand what’s really behind a given behavior because, just as in medicine, the
diagnosis your child receives can drastically change the appropriate treatment.
ADHD medications, for example, won’t work if a child’s inattention or disruptive
behavior is caused by anxiety, not ADHD. And, just like a medical doctor, when a
treatment doesn’t work, whether it’s therapeutic or pharmaceutical, one of the
things a good clinician will do is reexamine the diagnosis.
Here we take a look at some of the common psychiatric symptoms that are easily
misinterpreted in children and teenagers, leading to misdiagnosis. For each
symptom, we explain the diagnosis it is commonly linked to, and what some of the
alternate causes for what that behavior might be. ( is list is only meant to be used
as a guide, and it is important to always consult with a trained diagnostician before
beginning treatment or assigning a label to your child.)
1. Ina ention
e common diagnosis: ADHD
e symptom of inattention is o en rst observed by teachers, who may notice a
student who is unusually easily distracted, is prone to daydreaming, and has
di culty completing homework assignments and following directions. While all
children, especially those who are very young, tend to have shorter attention
spans than adults, some children have much more trouble focusing than others.
https://childmind.org/article/the-most-common-misdiagnoses-in-children/ 2/1842
10/11/2017 The Most Common Misdiagnoses in Children | Child Mind Institute
Inattention that is outside the typical range is one of the three key symptoms of
ADHD, along with impulsivity, and hyperactivity. So when a child seems unusually
distracted ADHD tends to be the rst thing parents and clinicians suspect.
However, there are many other possibilities that can be contributing to
inattention.
“ e kid who is inattentive could be inattentive because he has ADHD,” notes
psychologist Steven Kurtz. “Or he could be inattentive because he is worried about
his grandmother who’s sick in the hospital, or because he’s being bullied on the
playground and the next period is recess.”
Related: Is It ADHD or Immaturity?
Other Possibilities:
Obsessive-Compulsive Disorder:
Many children with OCD are distracted by their obsessions and compulsions, and
when the OCD is severe enough, they can spend the majority of their day
obsessing. is can interfere with their lives in many ways, including paying
attention in school. And since children with OCD are o en ashamed of their
symptoms, they may go to great lengths to hide their compulsions. It is not
uncommon to see children keep their rituals under control while they are at
school, only to be overwhelmed by them when they get home. erefore, a teacher
may notice a student having di culty focusing and assume he has an attention
problem, since his OCD is not apparent to her.
“A kid may be sitting in class having an obsession about needing to x something,
to avoid something terrible happening. en the teacher calls on him,” says Dr.
Jerry Bubrick, the senior director of the Anxiety and Mood Disorder Center at the
https://childmind.org/article/the-most-common-misdiagnoses-in-children/ 3/1843
10/11/2017 The Most Common Misdiagnoses in Children | Child Mind Institute
Child Mind Institute. “When he doesn’t know the answer to the question, it looks
like he wasn’t paying attention, but it’s really because he was obsessing.”
Post-Traumatic Stress Disorder:
Children can also appear to be su ering from inattention when they have been
impacted by a trauma. “Many of the symptoms of PTSD look like ADHD,” explains
Dr. Jamie Howard, the director of the Trauma Response and Education Service at
the Child Mind Institute. “Symptoms common in PTSD, such as di culty
concentrating, exaggerated startle response, and hypervigilance can make it seem
like a child is jumpy and spacy.”
Learning Disorder:
When a child seems to be looking everywhere but at the pages of the book she is
supposed to be reading, another possible cause is that she has a learning disorder.
Undiagnosed dyslexia can not only make a youngster dget with frustration, she
may be ashamed that she doesn’t seem to be able to do what the other kids can do,
and intent on covering that fact up. Feeling like a failure is a big impediment to
concentration, and anything that might relieve the feeling a welcome distraction.
“Fi y percent of kids who have learning disabilities have inattention,” notes Dr.
Nancy Rappaport, a Harvard Medical School professor who specializes in mental
health care in school settings. “For these kids, we need to intervene to support
their learning de cits, otherwise treating them with stimulants will be a bust.”
e trickiest cases, Dr. Rapport adds, are really smart kids who have successfully
compensated for their learning disabilities for years, by working extra hard.
“ ey’ve been able to hide their weakness until they get older and there’s just too
much heavy li ing. ey’re o en diagnosed with ADHD or depression, unless
someone catches the learning problem.
https://childmind.org/article/the-most-common-misdiagnoses-in-children/ 4/1844
10/11/2017 The Most Common Misdiagnoses in Children | Child Mind Institute
2. Repetitive distressing thoughts
e common diagnosis: PTSD
Intrusive thoughts and memories that a child can’t control are one of the key
symptoms of PTSD. Clinicians think of PTSD as a damaged “ ght or ight”
response in a child who has had a disturbing experience, whether it was an
upsetting event or a pattern of domestic violence or abuse. e experience is in the
past, but the child keeps reliving the anxiety.
is can take place in the form of ashbacks, thinking about the event over and
over, or experiencing frightening thoughts that get “stuck.”
Other possibilities:
OCD:
“In both OCD and PTSD, you can experience thoughts that intrude, thoughts that
you don’t want to be thinking about,” said Dr. Howard. “ ese thoughts come into
your head, without your volition and without your control. In both cases, they
cause you distress, and you have to work to manage them.” But there is a major
di erence between the repetitive thoughts in OCD and PTSD, Dr. Howard notes:
“With OCD it will be a concept the causes you distress, but with PSTD it’s an actual
memory of something that happened.”
3. Restricted speech
e common diagnosis: Autism
Autism is a developmental disorder that causes a child to have impairments in
communication. Children with autism may have a delay in (or complete lack of )
the development of spoken language. e most obvious signs of autism are usually
noticed between 2 and 3 years of age. Although many children on the spectrum do
speak, they may use language in unusual ways, avoid eye contact, and prefer to be
https://childmind.org/article/the-most-common-misdiagnoses-in-children/ 5/1845
10/11/2017 The Most Common Misdiagnoses in Children | Child Mind Institute
alone. Autism may rst be noticed by school professionals, who become aware that
the child is not interacting socially with his peers in an appropriate way.
Related: Why Autism Diagnoses Are O en Delayed
Other Possibilities:
Selective Mutism:
Selective mutism is an anxiety disorder in which children do not speak in
particular social situations. Many children with selective mutism are talkative at
home, but there may be a complete lack of speech in other settings, such as in
school. ey may not communicate with peers or teachers at all, which can lead to
school professionals being concerned about their social development. ese social
di culties may lead some school personnel to jump to the conclusion that they are
on the autism spectrum.
“You can have di culty with communication for a lot of reasons,” notes Dr. Kurtz.
“ e thing to look for is the consistency across situations. Kids with SM will be
quite social and quite fabulous chatterboxes in some settings, otherwise they
probably don’t have SM.”
When it comes to making a diagnosis, it is important to make the distinction
between a skills de cit and a performance de cit. Children with selective mutism
have a performance de cit because they have the ability to speak but cannot
demonstrate it in every setting, while children on the spectrum have skills de cits,
so can’t demonstrate certain skills regardless of the setting.
Children with selective mutism may also display other symptoms that may lead to
alarm bells being sounded for autism. Some kids with SM appear very “shut down”
https://childmind.org/article/the-most-common-misdiagnoses-in-children/ 6/1846
10/11/2017 The Most Common Misdiagnoses in Children | Child Mind Institute
in their a ect. “Because the kid’s trying, whether he knows it or not, to convince
people to back o , he’s also going to have poor eye contact like a kid on the
spectrum, at a ect like a kid on the spectrum,” said Dr. Kurtz. “He’s not going to
look like a kid whose only issue is that he is stuck in terms of being able to talk.”
4. Sadness, fatigue, and di culties thinking clearly
e common diagnosis: Depression
It is easy for most people to recognize the symptoms of depression: feelings of
sadness, decreased interest in usual pleasurable activities, fatigue, weight changes,
and di culty concentrating. While it is normal for everyone to feel “down in the
dumps” sometimes, children experiencing sadness or irritability that lasts for
more than two weeks and impairs their ability to function may be thought of as
experiencing a depressive episode.
Other Possibilities:
Hypothyroidism:
Hypothyroidism happens when your thyroid (a gland in your neck) is not
secreting enough of certain important hormones. e symptoms of
hypothyroidism look very similar to those of depression, and include fatigue,
weight gain, feelings of sadness, and di culty thinking clearly. However, the
treatment for hypothyroidism is very di erent: children with hypothyroidism are
treated using a thyroid replacement hormone.
Anxiety Disorder:
Certain anxiety disorders, such as OCD, can be extremely impairing and scary to
the person experiencing them. Children with OCD can have obsessions about
invoking harm to their loved ones, as well as other violent or sexual images. While
these obsessions are not true to what the child actually wants to happen, he has
di culty getting them out of his head. ere are times when depressed mood is
https://childmind.org/article/the-most-common-misdiagnoses-in-children/ 7/1847
The words you are searching are inside this book. To get more targeted content, please make full-text search by clicking here.
Introduction to ADHD Resources
Discover the best professional documents and content resources in AnyFlip Document Base.
Search