Newsletter: ADHD

May 2014

Past newsletters are posted at www.isbaron.com. Questions/comments should be emailed to ida@isbaron.com

Q. A teacher told me that she thinks my child has Attention Deficit Hyperactivity Disorder (ADHD). I am not sure I agree. What do I need to know?

A number of alternative possibilities have to be considered before an ADHD diagnosis is made. Accurate diagnosis is essential, as an ADHD diagnosis has both short- and long-term negative implications for the child if incorrectly applied. ADHD should not be diagnosed as a convenient way to obtain special educational resources when it is not a true diagnosis. If a child requires extra academic help there are other ways to document free and appropriate Federally mandated academic resource assistance.

The American Psychiatric Association DSM-V specific diagnostic criteria for an ADHD diagnosis are:

Six (6) or more symptoms of inattention persisting for at least 6 months; inconsistent with developmental level; negatively impact social and academic/occupational activities
Six (6) or more symptoms of hyperactivity and impulsivity
Several inattentive or hyperactivity and impulsivity symptoms present prior to age 12 years
Several inattentive or hyperactivity and impulsivity symptoms present in 2 or more settings
Evidence that symptoms interfere or reduce quality of social, academic, or occupational functioning
Symptoms do not occur exclusively during psychotic disorder, and are not better explained by another mental disorder

Importantly, a child can have attention problems without meeting criteria for a diagnostic label of ADHD. Therefore, it is important to distinguish between ADHD and the many other reasons for a similar constellation of inattentive behavior. A diagnosis of ADHD suggests different therapeutic recommendations than would be made for a child who has attention problems due to other reasons.

A professional should be consulted to discuss these alternatives to avoid a mistake in diagnosis. Distinguishing between primary attention deficit and that due to a co-morbid condition is very important. A few examples of co-morbid conditions that strongly influence attention are:

Various medical conditions, either known or as yet undiagnosed
Medications or medical treatments for past or current illnesses
Sleep disorder
Sensory (hearing or visual) impairment
Interpersonal/social circumstances (e.g., bullying; parental separation or divorce; death of a family member or pet)
An interpersonal mismatch between a particular teacher (or other adult) and a child
Specific learning disability or other neuropsychological disorder
Anxiety, depression, or other psychiatric disorder

To help a neuropsychologist determine whether or not ADHD is a correct diagnosis the following information is obtained in addition to psychological test results, integrated, and communicated to you in the interpretive session (see the April 2014 Newsletter):

A careful and thorough history-taking about the child and family
A comparison of the child’s behavior at home and at school; interview of the parents and teachers and/or their completion of standardized behavioral questionnaires.
An evaluation of the different types of attention

Types of Attention

There are different types of attention and each is mediated by different brain regions and each can be evaluated with objective, standardized tests. Each type should be assessed since a child is unlikely to be deficient in all of the types of attention.

Should a child have an evaluation that only concludes that there is an “attention deficit disorder” or ADHD, the results likely will not be as helpful as if you are told exactly which types of attention are intact and which types of attention are weak. Four types of attention commonly tested by neuropsychologists are:

Focused/selective attention

This refers to the ability to pay close attention and be vigilant when monitoring information. For example, can a child perceive a stimulus and orient toward it in order to respond effectively, i.e., carry out an assignment as instructed by a parent or teacher?

Divided attention

This refers to the ability to efficiently work on two things at the same time, and not have either be a distraction and worsen the performance of the other. For example, can a child accurately complete homework assignments while also watching TV or listening to music at the same time?

Sustained attention

This refers to the ability to pay close attention and remain vigilant over time when performing a continuous or repetitive activity. Performance noticeably worsens over time when a child has difficulty sustaining attention. For example, can a child continue to work effectively uninterrupted until the task is completed without requiring short rest breaks?

Alternating/Shifting attention

This refers to the ability to maintain mental flexibility and shift mindset from one activity, stimulus, or object to another that requires a different set of behaviors or responses. For example, can a child shift attention away, or break the mental connection to, what was being done in order to engage in a new activity, stimulus, or object?

Other types of attention are also assessed, and will be mentioned next month (June 2014) in a discussion of Executive Function.

Advance online publication:

Baron, I. S., Weiss, B. A., Litman, F. R., Ahronovich, M. D., & Baker, R. (2014). Latent Mean Differences in Executive Function in At-Risk Preterm Children: The Delay-Deficit Dilemma. Neuropsychology.

In this study of 1,079 participants (668 aged 3 years born 2000–2009 and 411 aged 6 years born 1998–2006) divided into extremely preterm, late preterm and typically developing groups, we concluded that executive deficit identified early in development after preterm birth could for some represent a transient developmental delay likely to resolve at older age or, for others, a more subtle adverse effect likely to persist over the life span. Our longitudinal study at multiple age points should assist in resolving this dilemma, which has important implications for early age neuropsychological screening and intervention.