Tailoring Treatments for Individuals and Families with ADHD

Some clinicians claim that every patient with ADHD should receive multimodal treatment. This fancy phrase simply means that medication alone is often not enough to fully treat ADHD. Typically, behavioral treatments and education are added to the list of treatment modalities that should be provided for every patient. But although it is true that educating the patient and family about the nature of ADHD and its treatment is an essential component of any adequate treatment plan, it is not true...

The Limits of Neuropsychological Tests of Executive Functions

Some neuropsychological tests traditionally have been labeled as tests of executive function (EF tests). These include the Wisconsin Card Sorting Test, the Stroop Color-Word Test, the Tower of London, the Rey-Osterrieth Complex Figure Test, the California Verbal Learning Test, and various computerized continuous-performance tests. Most of these tests were originally developed to assess patients with schizophrenia or those who had suffered damage to the frontal lobes of the brain. At first...

Communicating Effectively with Others

One important aspect of cooperating with others is learning to communicate effectively. This reciprocal process involves far more than simply understanding the meanings of specific words that are heard and stringing words together in an appropriate way to speak to others. Careful examination of the processes involved in interpersonal communication shows it to be a complex interaction that often places heavy demands on the executive functions impaired in individuals with ADHD. Our son, Phil, is...

Disorders of Arousal and Motivation

Pennington (2002) proposed a category called disorders of motivation, which includes (1) depression and dysthymia, (2) anxiety disorders, (3) posttraumatic stress disorder, and (4) bipolar illness. Each of these involves disruptions in the arousal motivation system of the brain. To this category I have added obsessive-compulsive disorder as well as substance abuse and dependence. These two additional disorders are also essentially disruptions in the brain's normal regulation of arousal and...

Executive Functions and the Brains Signaling System

Recognition of the amazing fact that executive functions generally operate without conscious awareness offers an important caveat to my use of the orchestra conductor as a metaphor for executive functions. Some might take my metaphor literally and assume that there is a special consciousness in the brain that coordinates other cognitive functions. One might picture a little man, a homunculus, a central executive somewhere behind one's forehead, exercising conscious control over cognition like a...

Nonstimulant Medications for ADHD

Although stimulant medications are effective in alleviating ADHD symptoms in most children, adolescents, and adults who suffer from the disorder, about 20 to 30 percent do not respond well to stimulants. For these individuals, nonstimulant medications may be effective. Even among those who do experience significant relief from their symptoms when taking stimulants, there are many who experience significant difficulties with mood, anxiety, tics, or other problems that may be exacerbated, or at...

The Development of Executive Functions in the Brain

These complex structures and neurochemical processes that facilitate executive functions are not fully developed at birth. They are formed and gradually refined in a carefully timed sequence of events that begins early in fetal development, continues into infancy, and matures quite slowly throughout childhood and into adolescence and adulthood. Although virtually all neurotransmitter systems are present in the cortex at birth, Francine Benes (2001) has shown that the systems for dopa-mine and...

Cluster 6 Monitoring and Self Regulating Action

Most descriptions of the disorder now known as ADHD emphasize problems with hyperactive and impulsive behavior. Many persons identified with this disorder tend to act without sufficient forethought, or are chronically restless and hyperactive, finding it very difficult to slow down and adequately control their actions. Children with ADHD have often been seen as wild, restless, and impulsive, unable sufficiently to control their words and bodies and so needing much more supervision from teachers...

Fact Add is a complex disorder that involves impairments in focus organization motivation emotional modulation memory

Imagine a large carton filled with photographs taken throughout your life. The carton is filled with snapshots of you and various family members roller skating or riding bikes, fishing off a pier or swimming in a lake, dressing up for Halloween or setting off for the first day of school. Some are posed with you in your Scout or Little League uniform or in costume for a dance recital. Others are candid shots taken around a birthday cake, in the midst of holiday celebrations, or at other...

Realistic and Unrealistic Hope

Any discussions of hope usually emphasize that one should use willpower and determination to overcome adversity. This view often is used to challenge persons with ADD syndrome. Children, adolescents, and adults with ADD syndrome often are told that if only they will push themselves hard enough and long enough, if only they will put forth enough determined effort, then they will be able to overcome their problems with inconsistency, disorganization, working memory, emotional regulation, and so...

Chemicals That Alleviate Impairments of ADD Syndrome

Charles Bradley's accidental discovery in 1937 of the benefits of stimulants for hyperactivity, discussed earlier, there have been over two hundred scientifically controlled research studies consistently indicating that 70 to 80 percent of persons with ADHD show significantly less impairment from their ADHD symptoms when they are treated with appropriate doses of specific medications. The improvements produced by these medications cure nothing impairments return to baseline levels...

Inattention Interferes with Learning to Read and Do Math

Such high rates of academic underachievement and failure among children with ADHD may result from a number of causes, one of which is likely to be chronic inattention. David Rabiner and colleagues (2000) reported on a large study of children monitored from kindergarten through fifth grade. They found that children identified by their teachers in kindergarten as being more inattentive than most others in their class had significantly lower reading achievement when they reached fifth grade. The...

Antihypertensives

Clonidine and guanfacine, marketed as Catapres and Tenex, respectively, were originally developed as medications to reduce high blood pressure. They have been found helpful for reducing excessive hyperactivity and impulsivity in children with ADHD, but there is currently no evidence that these agents improve the cognitive impairments of ADHD. The effects for clonidine usually persist for about six hours, while guanfacine usually lasts a bit longer. Usual daily doses reported by the group led by...

ADHD Rating Scales

Regardless of the age of the patient being evaluated, detailed ADHD symptom rating scales should be used. These scales are typically listings of cognitive, emotional, and behavioral problems often experienced by individuals with ADHD. Standardized scales have been administered to selected samples of individuals within a particular age group who have been carefully diagnosed with ADHD and to a sample of individuals matched for age and socioeconomic variables who are in the general population,...

Sometimes One Stimulant Works Better Than Another

This difference between the two primary stimulant medications may explain why some individuals with ADHD respond to one medication better than another. Eugene Arnold 2000 reviewed studies that compared patients with ADHD on consecutive trials of both MPH and AMP. Of these patients, more than 66 percent responded well to AMP and over 56 percent responded well to MPH most responded equally well to both. The overall response rate to one or another of these stimulants was 85 percent. There are...

Very Intelligent People with ADHD Are Often Overlooked

Sometimes persons with a higher overall IQ who suffer from ADHD are at greater risk of having their impairments overlooked. At Yale, Donald Quinlan and I studied adults who sought evaluation for chronic atten-tional problems, all of whom had a tested IQ in the superior range in terms of intelligence, they were in the top 1 to 9 percent of the general population. Despite their very high IQ scores, 42 percent of these men and women had dropped out of their postsecondary schooling at least once,...

Cluster 5 Utilizing Working Memory and Accessing Recall

When asked about memory, many persons with ADD syndrome describe a peculiar contradiction. Many report that they are quite good at accessing long-term memories, for example, they can recall details from experiences years earlier. Yet most complain of chronic difficulties in their ability to hold one thought or bit of information in mind while simultaneously doing something else. They often forget what they were just about to say or the purpose for which they have just walked into a room. They...

Parenting and Sustaining Partnerships

It is not only women who find that ADD syndrome can unexpectedly disrupt life in the middle adult years. One man with unrecognized ADD sought consultation at age forty-three when his wife shocked him by announcing that she wanted to end their sixteen-year marriage. When the couple came for consultation together, the wife quietly presented her long pent-up frustration and her reasons for wanting to leave I've just reached a point where I am fed up with too much giving and not enough getting...

How Can Medications Help

In assessing effectiveness of treatments for ADD syndrome, it is important to ask What is the desired outcome Some studies answer this question by analyzing how stimulant medications affect a patient's performance not on combined DSM-IV symptoms of ADHD, but on specific tasks orchestrated by executive functions. Seven of these studies are briefly described here. Often persons with ADD work too quickly and don't recognize when they need to slow down to do a good job. Deborah Krusch and others...

Brain Centers That Regulate Alertness and Fine Tune Cognition

Norepinephrine System Locus Coeruleus

At the back of the brain are circuits that play important roles in regulating alertness and fine-tuning cognitive processes. Systems of the brain that control motivation, memory, and so forth are linked to the brain's alertness and to cycles of wakefulness and sleep. Aspects of the warning system for potential danger continue to operate during sleep so that, for example, a person might awaken from slumber to the smell of smoke or a sudden, unfamiliar sound. Yet for the most part, executive...

Disorders of Social Emotional Regulation

In my reformulation of Pennington's categories, I have grouped together the following disorders, all of which are characterized by various types and degrees of disruption in social-emotional regulation of action Asperger's disorder, oppositional defiant disorder, conduct disorder, and Tourette's syndrome. Chapter 2 describes how individuals with ADD syndrome often are impaired in their ability to manage frustration and modulate emotions, as well as in their ability to monitor and self-regulate...