ADHD: Research expands understanding of a complicated and common diagnosis

In the last 15 years, research into attention deficit hyperactivity disorder (ADHD) has shed more light on this complicated diagnosis, reaffirming some concepts and dispelling others. While new interventions have been, and continue to be, studied and new assessment tools created, some of the previous therapies still prevail.

In recent years, ADHD has gone from being a specialty diagnosis to one of the most diagnosed and treated disorders, according to Barry Josephson, Ph.D., of Psychological Associates in Warwick, R.I., a multi-disciplinary practice. Six to ten percent of the population carries a diagnosis of ADHD, which translates to two children in every classroom, he says. While many clinicians use this label for behavioral issues, they often misunderstand the underlying physiological diagnosis. “It’s important for practitioners who deal with children to develop some sophistication in treating patients with ADHD,” Josephson says.

For Josephson, the key to successful outcomes is collaboration between clinician, parents and school, as well as a levelheaded approach. “The patient needs basic behavior modification, reward training and accommodation/support from the school and at home,” he says. Cognitive behavioral therapy (CBT), which ranked as the treatment of choice two decades ago, still remains a priority option. “CBT helps the student learn coping skills,” Josephson says, emphasizing the efficiency and effectiveness of a multi-disciplinary approach.

In his practice, psychologists, a clinical social worker, psychology graduate students and a psychiatrist collaborate to help educate and empower the patient and parents, optimizing treatment outcomes. Josephson says, “We provide support for pediatricians and other doctors who are trying to help the patient.”

ADHD symptoms usually present at an early age, but Jacobson recommends waiting until a child is six years old when the brain has developed to evaluate the situation. He also indicates that genetics plays a significant role in the development of ADHD.

Jacobson dispels the notion that ADHD is more prevalent in males. “Girls are catching up,” he says. Today’s more sophisticated parents now regard indicators, such as falling grades, restlessness and inability to concentrate, as potential signs of ADHD.

Edward Jacobs, Ph.D., BCN, owner of Jacob Associates in Londonderry, N.H., explains that diagnostic methods have not changed much through the years, although the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has been altered slightly. “We look for specific systems and we classify them a little differently, although the diagnosis is still based on behavioral observation,” he says. Psychological, intelligence quotient and executive functioning tests are not the best way to make a diagnosis, but an accepted way to gather information, he points out. Observation from the client, parents, peers, teachers and friends in combination are more accurate in determining a diagnosis, Jacobs says.

Jacobs says that the 18 items on the criteria list mean something different to each person, but basically, a practitioner evaluates symptoms, such as difficulty concentrating, making careless mistakes on boring or difficult projects, getting distracted easily, feeling restless, talking too much in social situations or interrupting others, among others, and how often they occur. “We then look at how much they interfere with life and when did the symptoms develop,” says Jacobs. “We also look at cultural and family differences.” He points out that in some families, several individuals talking at once is a common practice. However, he emphasizes that it’s important to ascertain the symptoms are not because of another diagnosis. “Inattention and impulsivity can exist in other conditions, such as learning disabilities and processing disorders,” he adds.

Degree of severity can be determined by evaluating the frequency, intensity and duration of symptoms, Jacobs notes.

Jacobs utilizes neurofeedback to treat his clients with ADHD and employs brain mapping to identify the parts of the brain that are misfiring, which varies with each person. Medically non-invasive with few, if any, adverse effects, neurofeedback trains the brain to increase or decrease a state of arousal, according to Jacobs. He recommends approximately 40 sessions of 30-40 minute durations twice a week to achieve lasting results and advises against using medication at the same time to avoid confusion as to which modality is working.

Some 15 years ago, children with ADHD might have been placed in residential care, but this action should be the last resort for those who cannot be maintained in the community, Jacobs says. “It would have to be an exceptionally severe case and would have to be integrated between the primary care physician, parent and the school,” he says.

One of the most under-used and often misunderstood treatment options, hypnosis may help clients achieve focus, according to Bob Deutsch, Ph.D., a private practitioner in West Hartford, Conn. He notes that many health care professionals are misinformed when it comes to hypnosis, which, according to the American Society of Clinical Hypnosis, “is a state of inner absorption, concentration and focused attention.” He says, “Many are under the impression that we teach relaxation, but it’s far more than just relaxation.”

When clients come to Deutsch, he attempts to empower them with the skills they already have. “I use [self-hypnosis] to create more control. Like those without ADHD, these clients can learn how and when to use it,” he says. “The goal is to have the patient leave the office aware of his own skills.”

Many of Deutsch’s clients present with co morbid diagnoses, which makes learning the art of self-hypnosis challenging. “Those with numerous attentional diagnoses may have difficulty staying on task and remembering to practice the skill,” he says.

Reports of a dietary connection, particularly sugar, to ADHD may be over-interpreted, says Jacobs, noting that some research on Omega-3 fish oil as well as sleep deprivation is on-going.

McLean Hospital is currently recruiting for a study involving uridine, which occurs naturally in some foods, such as broccoli, brewer’s yeast and organ meats, as a treatment option for ADHD.

A National Institute of Mental Health study indicates that a combination of medication and counseling is the benchmark treatment for ADHD. Jacobs says, “Biological intervention and CBT has to be tailored to the individual,” he says. “It’s now believed that ADHD is a lifelong condition. But the nervous system matures over time and the brain gets better so the symptoms decrease every year.”