ADHD Primer for Parents - Part 4
S. L. Crum, B.S., M.S., Ph.D.

Difficulties evaluating executive functions

There are multiple difficulties in evaluation executive functions not the least of which is the fact that executive functions modulate and control other functions. Therefore, when executive functions are impaired, scores on other functions are depressed. Additionally, when we assess a single function, multiple sub functions contribute to the score we obtain; which means that executive function deficits may be masked. For instance, my daughter has a definite deficit in the ability to hold several ideas in her head at the same time; which one would expect to impede her performance on math tests. In reality because she has learned effective compensatory mechanism for math calculation, It does not depress the total score. Only by looking at her work sheet, could one determine the great effort she exerts to compensate for her deficit in mental control. Thus, while more difficult to quantify, complex daily functions may be more sensitive diagnostic indicators of how executive function deficits will impact the individual’s life over the long hall. This is one reason that a careful history and clinical questionnaires play an important role in diagnosis.

Periods of challenge

Parents may wonder whether there are certain tasks or developmental periods that pose the most challenge for children with ADHD. The fact is that the transition times moving to middle school, moving to high school, moving on to college and moving into the work force are high risk periods. Middle school poses new challenges for students because they now have to cope with multiple teachers all giving different assignments due on different dates and all of whom have different standards. High school poses new problems because there are so many required courses that one cannot effectively maximize strengths and minimizes weaknesses by selecting those courses you would be most likely to succeed with. This is the same time period where social expectation escalate with pressure to date, to rebel against parental norms, and to establish an independent sense of identity all come into play. Going off to college, can also be particularly demanding because of the loss of parental monitoring and support, and the need to manage his own household routines and monitor his own behaviors. Establish a independent household or one with a partner also presents complex challenges where the ADHD individual’s capacity to plan, prioritize, organize, and self-monitor may be taxed beyond a reasonable limit.

ADHD is not outgrown

Unfortunately, the DSM-IV Criteria for diagnosing ADHD in adults is based on data from individuals between the ages of four and seventeen. More significantly, most of the examples provided don’t aptly apply to adults, and the cutoff applied to adult functions to identify only the most seriously impaired. At the same time, it fails to recognize the emotional dysregulation that has such a significant impact on the lives of adults with ADHD along with the dysregulation of arousal which can cause ADHD individuals to either over commit or to be hypo active in relationships and work settings.

A key concept for parents to recognize is that ADHD is not outgrown. It is unremitting from childhood throughout adulthood whether or not co-morbid disorders are in their active phase. If an adult finds themselves easily distracted by extraneous stimuli and often making impulsive decisions, has difficulty initiating or ceasing activities, starts projects or tasks without listening to or reading instructions, evidences poor follow through on promises or commitments to others, has trouble getting things done in the proper sequences, drives faster than others, has difficulty sustaining attention to leisure activities or other tasks or has difficulty organizing their own tasks and activities, according to the diagnostic criteria suggested by Barkley (Barkley, 2006), the individual may be struggling with Adult manifestations of hitherto undiagnosed ADHD.

A thorough neuropsychological evaluation

To confirm whether or not an adult is suffering from ADHD, I recommend a full neuropsychological evaluation that included: semi-structured interviews, detailed ADD rating scales (Brown ADD Scale, Conner’s Rating Scale, Barkley, BASC), interviews with family members and tests of executive functions and working memory. A good evaluation should explore the individual’s chief complaints along with the history of impairment, which domains and setting impairment has been experienced and over what durations, along with the history of similar symptoms in blood relatives. The evaluation also needs to look at current ability to adapt to demands at school, work and at home. When evaluating the current living situation the evaluator needs to look at both current stressors and the nature and extent of supports in place. Relationships with family members and peers need to be explored to determine how much they are monitoring, coaching, directing, and reminding the individual. Additionally, medical issues and medications must be considered, as well as both past and current use of substances. Sleep, appetite, and arousal needs to be evaluated. Previous evaluations also need to be reviewed for evidence of the disorder or data that is contrary to this diagnosis.

A good evaluator will take particular note of the WMI and PSI Index Scores on the WISC-IV and WAIS-III as these are more sensitive to problems in attention, memory and processing speed than the VCI and PRI Index Scores. These individuals also perform significantly poorer on the Story Memory Test than would be expected given their IQ. Performance on continuous performance measures such as the IVA and TOVA need to be considered. Of particular note, many individuals who have been diagnosed as having a “central auditory processing disorder” actually meet the DSM-IV criteria for ADHD, inattentive type. So, this factor should be weighed. Additionally, it is important to screen for likely co-morbid disorders using measures such as CBCL, Conners, BASC, CDI, BASC.

Learning Disorders and ADHD

In children with ADHD, seventy percent have one or more specific learning disabilities (Mayes, 2000). Those with reading disorders will show a core phonological processing deficit. They recognize words when they hear them, but, they are unable to recognize them in written form. Fluency, processing speed and working memory may also be impaired. Reading disorder have been linked to abnormalities in chromosome 6 & 15, so we know the cause is physiological, but how devastating the impact is depends to a large extent on the effectiveness of the reading methodology and the supports put in place both at home and in school.

There are three primary types of math disorder that may be associated with ADHD. These include a visuospatial disorder where the individual misaligns number columns and misinterprets place values. The second is semantic memory math disorder where the individual has an inability to learn math facts/tables or is very slow to retrieve facts. The third is a procedural math disorder where the individual relies upon counting on their fingers or finger writing, as well as evidences procedural errors involving signs and sequencing. In fact, an individual may have any combination of these math disorders.

Disorders of written expression may also be present with significant deficits in the ability to write grammatically correct sentences and/or to organize paragraphs, as well as with poor spelling. These individuals general have a history of chronic difficulty deciding what to write, presenting their ideas in a systematic fashion and elaborating upon them or flushing them out with details.

A curious question is whether ADHD and these co-morbid disorders are actual separate disorders. There are those who believe that learning disabilities are hard-wired problems in the brain while ADHD is a chemical problem. In reality, a shared genetic etiology has been documented for ADHD and Reading Disorder. , and we have already established that both involve impairment in executive functions; particularly in working memory. So, it may be that both disorders are a function of abnormal chemical processes and brainwave patterns secondary to hitherto unidentified structural abnormalities. The fact is we don’t know, but the commonalities appear to be mounting.

So, what do you want to look for if you are having your child assessed for a learning disorder? Naturally, the history of chronic difficulties in specific courses, on specific types of tasks and in specific modalities needs to be queried, and level of performance needs to be explored with measures such as the WJ-III or WIAT-II Achievement Tests. Reading should be explored using measures such as the Nelson Denny Reading Test and the GORT-R and writing through measures such s the TOWL. Neuropsychological measures should also be employed to examine check for right hemisphere and executive dysfunction, and visual and auditory perceptual and spatial processing which might complicate the learning disorder.

Gifted and ADHD

Gifted individuals with ADHD pose additional challenges for evaluators, parents and teachers. They have all the problems of those with superior IQ who do not have ADHD (such as being under challenged, easily bored, lacking patience with slower learners), and because of their intelligence their ADHD is often recognized later than it is with non gifted ADHD individuals. In fact, because they can utilize their good level of intelligence make contribute to verbal precocity; symptoms of ADHD may not appear until later when their verbal mediation techniques are no longer sufficient to address environmental challenges. Often these children face a unique stressor of being chastised for their ADHD because parents and teachers set higher expectations for them than their peers based upon their I.Q, completely oblivious to the fact that their deficits in executive functioning precludes a consistently high level of performance in areas where executive functioning demands are high. Thus, when they fail to follow through on a report which they clearly have the cognitive intelligence to handle with ease, parents and teachers fail to recognize the arousal issues and in persistence which make their expectations unrealistic; accordingly they blame the child for being lazy or unmotivated, and by doing so undermine the child’s self-esteem and belief that he can understand and meet the expectations placed upon him.

The fact is that despite superior cognitive intelligence quotients, over forty percent of gifted children with ADHD dropped out of secondary education at least once and an equivalent number were underemployed. Evaluation has shown that these individuals have Working Memory Indexes (WMI) and Processing Speed Indexes (PSI) which are significantly below their overall level of cognitive functioning. Moreover, parents report dramatically more problems with activation, focus, effort, emotion and memory for gifted children with ADHD than those will simply ADHD (Brown, 2003) They also evidenced significant impairment on measures of executive functioning. Basically, it appears that if the patient currently suffers from symptoms caused by developmental impairments of executive functions the diagnosis of ADHD is likely appropriate.

Ongoing Assessment

A key factor in managing ADHD is ongoing assessment. The initial assessment helps to establish the diagnosis, educate the patient and family about the nature of the disorder and co-morbidities, and serve as the basis for development of a plan of intervention. But, ongoing assessment is necessary to monitor the effectiveness of treatment and environmental supports, as well as to identify any identifying emerging co-morbidities, and the need for changes in environmental supports as environmental demands alter.

As far as IDEA is concerned, the question of whether or not a diagnosis of ADHD constitutes a disability depends upon whether or not the individual is substantially limited in a major life activity and whether it contributes to significant impairment in the student’s ability to profit from the general education curriculum. A through neuropsychological evaluation can be of considerable value in making this determination.

Parents and students, keep in mind the research in the field of ADHD is ongoing, and new information is constantly being shared. So it is important to make a point of keeping up with the current literature to the best of your ability.

Presented as a community service by,

Susan L. Crum, B.S., M.S., Ph.D.
Special Needs Coach
Able2Learn
Email: Able2learn@live.com
Voice and Fax: 863-471-0281
Website: specialeducationsupport.org

Bibliography

Barkley, R. (2006). Attention-Deficit Hyperactivity Disorder: Handbook for Dkiagnosis and Treatment-Third Edition. New York: Guilford Press.

Brown, P. Q. (2003).

Keiser, G. &. (1998).

Mayes, S. (2000). Learning Disabilties and ADHD: Overlappoing Spectrum Disorders. Journal of Learning Disabilities , Vol 33,. No 5, 417-424.

Willcutt, P. &. (2000).