Does
my child really have ADHD?
EEG studies are
also beginning to differential between different types of ADHD. In
fact, A. Clark found two distinct EEG clusters of children with
inattentive ADD. One characterized by an increase in high amplitude
theta with deficits in delta and beta waves, while the other was
characterized by an increased in slow wave activities (delta and
theta) along with deficiencies of fast wave activity (beta). So, in
these two groups we see ADD symptoms with both cortical hypoarousal
and with a pattern consistent with a maturational lag. This
suggests that ADHD should be re-conceptualized not in terms of
observed behaviors per se’, but rather in terms of the type of
central nervous system abnormality underlying the behavioral
manifestations. Doing this, might add significantly to predictive
validity of the diagnostic system which is currently weak.
In fact, if you
look at the DSM-IV Criteria for ADHD you wouldn’t see any symptoms
for problems in regulating emotions. But, as a practitioner with
over twenty years experience working with individuals with ADHD, I
fully concur with Thomas Brown, Ph.D. of Yale Medical School when he
asserts that both researchers and clinicians report chronic problems
in emotional regulation as characteristic of many individuals with
ADHD. In fact, he views the crux of ADHD to involve inconsistency
in initiating and sustaining the arousal necessary to regulate
organization, energy, alertness, planning, memory and mood
Models of ADHD
Barkley’s model of
ADHD is the one most parents are familiar with due to his
association with C.H.A.D.D.. He posits five major components of
executive function impairment in ADHD. These include self-regulation
of affect, motivation and arousal, reconstitution or behavior
analysis for planning and synthesis. According to Brown
The fact is that
all information processing has an emotional basis in that emotion is
the fuel source that drives cognitive activity. As Kenneth Dodge
indicated emotion is the is the energy source that drives, directs,
amplifies or attenuates cognition.
Brain imaging has
even revealed a “gating” of emotion that reduces affective
interference when we are engaged in more valued or complex cognitive
tasks.
Damaging effect of
ADHD
From the practical
perspective, perhaps the most damaging impact of ADHD is the social
ineptness associated with it. People with ADHD often experience
chronic problems in social relationships. They are viewed by others
as too much in a rush, clueless, too intense, and too aloof or
isolated. These characteristics may be experienced as hurtful by
others in the person’s life and their reactions to these
characteristics are, in turn, experienced as painful by the
individual with ADHD. Often others interacting with an individual
with ADHD fail to comprehend that despite a normal level of
cognitive intelligence (as measured by IQ testing), these people
have significant impairments in the area of emotional intelligence.
The practical result, however, is that the individual with ADHD has
strained relationships with teachers and mentors, strained
employer-employee relationships, strained relationships with friends
and strained family relationships.
Impairment in
social intelligence
By impairment in
social intelligence I refer to difficulty discriminating between
different emotions and a consequent deficit in the ability to
monitor either their own emotions or the emotions of others. Thus,
they cannot effectively use this emotional information to think
about and guide their action choices. In order to understand and
appropriately coach the ADHD individual in your life, you need to
understand that a good fund of information and a good ability to
reason about impersonal things, does not correlate with a good
ability to understand and reason about emotional things. The fact
is different neural circuits in the brain are involved in mediation
of this emotional cognition.
Impairment in
communication
Children with ADHD
and those who have conduct disorders do not interpret emotions in
others as accurately as non disabled individuals.
Like other children
on the autistic spectrum, children wtih ADHD evidence pragmatic
language problems. For example, they talk too much in unstructured
settings and conversely may speak too little when expected to. They
have problems introducing, maintaining and changing topics of
conversation, as well as difficulty being specific, accurate and
concise when conveying information. In fact, Tannock et al found
pragmatic speech deficits in sixty percent of ADHD boys.
Continuum of
impairment
Among individuals
with ADHD there is a wide variation in emotional intelligence. Many
ADHD individuals evidenced impaired emotional intelligence.
Others, such as those with Asperger’s Disorder or Autism may
evidence impaired emotional intelligence even though they do not
have ADHD. But, there seems to be a certain continuum or continuity
among these disorders.
Asperger’s Disorder
evidences normal verbal ability during early development, but an
inability to empathize and interact with peers. There is a lack of
social and emotional reciprocity This is combined with unusual
interests and narrow focus on those interests to the exclusion of
other interests. In addition to odd speech patterns and literal
language we also observe poor non-verbal communication.
With Non-Verbal LD
as defined by Byron Rourke we see deficits in visualization,
perceptual organization, conceptual organization, the ability to
grasp the overall picture and problems with summarizing and
integrating information.
When comparing
these ADHD and Non-Verbal LD with Aspergers we note that
individuals with Asperger Syndrome have virtually all the
characteristics of Non Verbal LD. Both have problems with behavior
and adaptive functioning, both have IQ test profiles where the
verbal quotient is greater than the performance quotient and similar
neuropsychological profiles with impaired right hemisphere
functioning.
Right hemisphere
impairment
The right
hemisphere of our brain is the less understood hemisphere in terms
of function. But, we do know that the right hemisphere permits us to
assemble a whole “gestalt” or complete view of the situation. It
permits us to correlate the tone of voice, pitch, rate of speech
with the facial expression, gestures and body stance to enable us to
differentiate a lie from the truth or a joke from a serous
statement. We know that multiple research studies have pointed to
right hemisphere impairments in individuals with ADHD. We know also
that right hemisphere impairments underlie many of the impairments
in executive functioning that we see in both Non Verbal Learning
Disabilities and ADHD. Still, emotional intelligence is complex and
difficult to assess and to treat.
Comorbid conditions
Not only is ADHD a
complex disorder within itself, but, is it one that is frequently
complicated by comorbid conditions. It is estimated that
approximately sixty percent of ADHD i8ndividuals also have one or
more psychiatric or learning disorders. In fact, it is six times
more likely for an individual with ADHD to have another disorder
than it is for someone without ADHD! A full seventy percent of
children with ADHD have a least one psychiatric disorder in addition
to ADHD
Naturally, part of
the problem lies in the way medicine has set up the diagnostic
criteria. Disorders don’t fit neatly into one category or another.
Basically, disorders overlap one another because when brain
functioning is impaired through illness or injury, there is seldom
discrete impairment. Rather, impairment in one area or function of
the brain impacts other areas and functions, so that the behavioral,
cognitive, social and emotional manifestations of various brain
problems overlap one another. In the end, it is, I think, unlikely
that we will be able to make discrete differentiation among all
these disorders, but rather that they will have to be formulated as
points along continuous continuums with fuzzy and overlapping
boundaries. What may prove useful is weighing different risk
factors that contribute to different manifestations, and attempting
to control or or modulate those. In short, we simply aren’t very
good at diagnosis. But, because ADHD is fundamentally a
developmental disorder of impaired executive functions an as
executive functions cross the boundaries of many disorders due to
impairment in various brain structures involved in executive
functioning, ADHD inherently cuts across other disorder that involve
the same impaired executive functions. This means that ADHD is a
foundational disorder and that it by its very nature increases the
risk for the diagnosis of other disorders that also result from
impaired executive functions.
Why is there so
much comorbidity?
Whether or not
other disorders are manifests and when depends on a range of factors
including which impairment in which brain structures common to both
disorders underlies the ADHD. For example, the genetic abnormalies
that predispose someone to have ADHD a reading disorder related to
cerebral hypoactivation, may also predispose one to have or
depression which is also a function of cerebral hypoactivation More
significantly, however, the adaptive malfunctions that arise from
the impaired executive functions in ADHD themselves increase the
likelihood of inducing other diagnoses. For instance, if one does
not consider the consequences of their actions and use them to guide
decision making then one is more likely to drive a vehicle at
excessive speed while intoxicated, and therefore, to sustain a
traumatic brain injury and, thus, have brought about comorbid
diagnosis. Likewise, if one does not prioritize and weight
alternative, but acts in the presence without forethought, one is
more likely to accept illegal substances when they are presented,
and therefore, more likely to become a substance abuser and add this
comorbid diagnosis to the already existing diagnosis of ADHD.
What is common
between ADHD and other comorbidities is some level of executive
functioning impairment that is manifest in impaired information
processing, social-emotional regulation and arousal or motivation.
Thus, it is important to ponder whether effective treatment of ADHD
in childhood or adolescence might reduce the risk for comorbid
disorder, or at the minimum decrease their severity.
Does ADHD underlie
other diagnoses?
The second
essential question to consider is whether or not undiagnosed by
comorbid ADHD may account for some of the impairment attributed to
other disorders.
These are difficult
diagnostic and prognostic issues to tease out. The fact is that when
you look at learning and language disorders (such as disorders of
expressive language, receptive language, reading, math and written
expression), arousal and motivation disorders (such as dysthmia/depression
For the disorders
of learning and language, the executive impairment is coupled with
impairment in particular types of information processing. For the
disorders of arousal and motivation, the executive impairment is
coupled with either hypo or hyper arousal. For the disorders of
social and emotional regulation, the executive function impairment
is coupled with an impaired ability to regulate action based upon
feedback from the environment or an anticipation of other’s
emotional reaction. Thus, it is reasonable to hypothesize that if
we were to treat the executive impairment of ADHD effectively, this
component might be subtracted from the other disorders, thereby,
mitigating their severity and complexity.