Chapter 1: Do I or My Child Have An Attention Deficit Disorder What are attention deficits exactly and how do you know if you are suffering from them? These are the first questions we must address before discussing treatment of ADD. To do so, let's take a quick look at the history of this condition and the evolution of its definition and diagnosis.
Attention deficits have evolved over the years in the terminology used and the classification of the symptoms. The latest revisions to the disorders are defined in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, or DSM IV. Currently all attention deficits are grouped under the designation AD/HD or attention deficit/hyperactive disorder. Two main categories of AD/HD are defined, AD/HD predominantly inattentive and AD/HD predominantly hyperactive-impulsive. A third category is considered, AD/HD-combined, that is, a combination of inattentive and hyperactive or impulsive types. For all three types, the condition must have persisted for at least six months, and have occurred before the age of seven, in order to be identified as a true attention deficit disorder. The adult condition is diagnosed by examining childhood history, interviewing parents and others who knew the individual as a child, plus evaluating the adult symptoms.
THE AD/HD-INATTENTIVE TYPE
AD/HD-inattentive describes the child or adult who has trouble paying attention, completing assignments, frequently daydreams, and is easily distracted. This classification has replaced the older term "ADD," although most professionals still call the condition ADD.
Many AD/HD-inattentive children are quick learners and are easily bored. They need fast-paced activities to keep them engaged. Others with attention problems respond well to a structured environment both at home and at school. We can assist these children with learning by providing more structure so they are comfortable and know what to expect.
Adults with the inattentive type of AD/HD function best when they resist the tendency to procrastinate, which is one of their worst problems. Being extremely forgetful, absentminded, and unorganized are other characteristics of the adult disorder. Many adults have learned to overcome these problems by instituting structured procedures into everything they do. They often find they accomplish most when they work from detailed to-do lists, and counteract forgetfulness with procedures such as designating a specific place to store keys when not in use. They often choose professions that require quick decision making and physical activity over those that require intense concentration for long periods of time. Others develop a technique known as "hyperfocus" that allows them to shut out all distractions around them in order to accomplish tasks.
THE AD/HD-HYPERACTIVE/IMPULSIVE TYPE
AD/HD-hyperactive/impulsive individuals are always on the go and tend to be unpredictable, impatient, hot tempered, and impulsive. They can, however, maintain attention for long periods of times, especially if engaged in something that interests them. Children with this type of attention deficit often find computer-based activities engaging, interesting, and self-instructing; others do well in sports, dance, gymnastics, or music. Giving them opportunities to explore these kinds of activities can be quite helpful.
Adults with this kind of AD/HD can have trouble with relationships, both in their personal lives and in careers. This is because they often resent authority of any kind. They often choose business entrepreneurship, which allows them more flexibility and use of their talents than other work models. Change for this group of individuals is often welcomed, although they can also be fanatics about order.
THE AD/HD-COMBINED TYPE
AD/HD-combined refers to the children, or occasionally the adults, who are inattentive, impulsive, and hyperactive. They can have any of the symptoms included in the other two groups. They are often described as those who talk too much, constantly distract others, butt into conversations, do not wait their turn, are forgetful, lack responsibility, and are unable to follow instructions or get along with peers. They have the greatest difficulty fitting into the mainstream of life and are extremely resistant to change. As a result, these individuals are most likely to have learning difficulties, defiant behavior, and developmental disorders along with AD/HD.
DSM IV categorization of the disorders may seem quite clear, and you may have already been trying to decide whether any of these descriptions fit you or your child. However, getting AD/HD diagnosed can be confusing and frustrating, especially for parents. Not only is it devastating to discover your child has a disability, but finding out the exact nature of the child's condition can be elusive.
DIAGNOSING AD/HD
Amazingly, a variety of doctors applying DSM IV criteria to evaluate the same child will often arrive at different conclusions. Each observer brings his or her own judgment to the diagnosis and there are no standard or "normal" levels of activity upon which to base comparisons. A physician must determine whether your child's behavior is extreme or inappropriate for his age, and professional opinions can vary for many reasons, including which area of the country the child comes from! Areas of the United States with the greatest incidence of AD/HD are the Great Lakes region, the upper East Coast, and the southeast and southern regions. Regional influences do seem to affect the diagnosis, for reasons that are as yet unclear. Interestingly enough, however, we find the areas of greatest incidence of AD/HD overlap those of highest concentration of nitrates and phosphates from long-term agricultural and industrial applications. Add to this the fact that attention deficits are actually a cluster of symptoms, and every diagnosis will differ in at least one aspect. In the end, many parents are frustrated and angry because they cannot get a simple answer: Does my child have an attention deficit disorder ... and if so, what kind? What, then, should you look for in an accurate diagnosis of AD/HD?
MEDICAL REVIEW
A diagnosis for this disorder should be given only after a thorough evaluation by a team of professionals who specialize in AD/HD. First, you should see a pediatrician to rule out possible medical reasons for the disorder. AD/HD will not reveal itself through the usual battery of laboratory tests, although some abnormalities in brain function have been observed with the use of brain-imaging techniques such as magnetic resonance imaging (MRI) and positron emission tomography (PET) scans. "There is no laboratory test or set of tests that currently can be used to make a definitive diagnosis," according to Dennis Cantwell, M.D., Journal of the American Academy of Child and Adolescent Psychiatry, August 1996. These techniques to determine faulty brain function are rarely used with children, however, because little is known about the relationship between observed abnormalities and symptoms.
HISTORY AND OBSERVATION
Parents or care-givers are really the only ones who can provide specific evidence that a child had AD/HD tendencies before he or she entered school. Parents often notice different behavior patterns in their child from birth. However, AD/HD behavior usually becomes most noticeable to parents and teachers in children between the ages of three and four, and is often seen when a child is placed in preschool.
Teacher observations are important in helping to define the specific kind of AD/HD a child has because of his or her ability to make comparisons with a child's peers to determine age-appropriate behavior. The teacher also has evidence of the child's performance or lack of it, through handwriting samples and workbooks. Teachers are constantly evaluating a child's work habits, off-task behaviors, responsibility, and social skills. Oftentimes a teacher is the first to suspect a child has AD/HD and may seek assistance from the school psychologist to help evaluate the child.
Next, a professional team that usually includes a psychiatrist or psychologist and a therapist performs a battery of tests. They obtain information from standard questionnaires about the child's behavior that are filled out by the child's parents and teacher. The psychiatric team also observes the child either in the classroom or in an observation area at a medical center.
Following observation, they test the child to measure his ability to sustain attention, his I.Q., and his learning rate. The tests and parental observations are then evaluated by the team of professionals who collectively agree on a definitive diagnosis. Currently there are no standard tests for the adult disorder, which is diagnosed by current symptoms, interviews, and childhood history.
DIAGNOSTIC TESTS
Diagnostic tests for children typically include Connor's parent and teacher rating scales, which rank a child's behavior based on DSM IV criteria. Parents should be aware that behaviors of an ADD child mentioned in Connor's include: doesn't appear to listen, loses things a lot, fails to do things, throws temper tantrums, and instigates physical abuse toward siblings or parents. For teachers, the behaviors an ADD child might show in school include off-task behavior, leaving his/her seat, interrupting others, and shifting from one task to another. The more infractions a child commits, the higher the score, with a score of 48 the highest possible. Fifteen is considered the point at which AD/HD is suggested.
The Test of Variables of Attention or TOVA measures learning aptitude in children and adults. This non-language-based test measures a person's ability to complete tasks, concentrate for periods of time, and make connections between concepts. It is often used to determine if learning disabilities exist. Both the Connor and TOVA tests are easy to administer and are often used to assess results in clinical trials.
Additional tests include the Child Behavior Checklist for parents and teachers, and the newest test based on DSM IV criteria, the Attention-Deficit/Hyperactivity Disorder Test, or AD/HDT. This test helps categorize AD/HD individuals aged three to twenty-three years and can be completed by parents, teachers, and other professionals. There are separate tests for males and females, since the behaviors between the sexes are quite different.
Dr. Paul Wender, from the University of Utah, has developed a test that is used to identify adults who have lingering symptoms from an AD/HD condition in childhood. This test is called the Utah Criteria for the Diagnosis of AD/HD-Residual Type. Dr. Russell Barkley, an expert in adult AD/HD, has also developed a detailed, structured interview that is often used to identify the adult disorder. Both tests are important in identifying AD/HD in adults, since no standardized tests are available.
If your child has been through an ADD testing process more than once, you may have been given different versions of the AD/HD diagnosis. This is common. Don't be discouraged if this has been your experience. For our purposes it doesn't matter which form of AD/HD your child has or even if he has a mild undiagnosed case of the disorder; whatever situation you face, my 30-Day Plan will help curtail AD/HD symptoms because with it we are addressing the underlying nutritional needs of the brain. If you are a parent just trying to improve your child's behavior or quiet it a bit, the suggestions here will be equally effective.
WHAT SHOULD YOU LOOK FOR?
One of the more common tip-offs to parents that their child might be AD/HD is that they've always noticed that their child behaves differently from others his/her age. Edward Hallowell, M.D., and John Ratey, M.D., Boston psychiatrists and authors of Driven to Distraction, emphasize that AD/HD behavior is characterized by comparison with a group of peers. Among others his own age the AD/HD child is markedly more impulsive, restless, and inattentive. AD/HD is different from "high energy." It is a more intense pattern of behavior that must have persisted for at least six months, occurred before the age of seven, and set the child's actions apart from others' his age. When I discussed the diagnosis with Dr. Ratey in June 1998, he emphasized that to be truly characterized as AD/HD, the behaviors must be severe enough to be disabling.
Observation of these behaviors is often what compels parents to check out AD/HD as a possible cause. They first suspect AD/HD when it is evident that their three-year-old's behavior is unlike that of other children his or her age. Often, they note that the child was "different" from birth. The family case study I will present in chapter 2 clearly illustrates this point. Observations such as these are extremely valuable in arriving at a diagnosis of AD/HD, because they involve behaviors only the parents may have observed. Most experts agree that the earlier a child is identified as AD/HD, the better. However, they caution that use of medication in response to such a diagnosis in a child under age six is unwarranted and not proven to be beneficial.
A child's first three years are the most critical in his or her development of healthy self-esteem. Early detection of problem behaviors gives parents the chance to work on any emotional and learning issues effectively that arise along with ADD in their child. Therapies, such as nutrition and behavior modification, are better utilized at this early age as well. Nutrition is the best therapy you can use for your preschool child, whether he or she is AD/HD or not. Healthy eating habits can easily be taught to young children. Their young brains are easily molded by good nutrients, but they can just as easily be disrupted by harmful ones like hydrogenated fats and additives. I will show you why this is the case and guide you through the process of dietary change.
AD/HD does occur in very small children, and they are often our brightest and most promising youth. Many AD/HD-diagnosed children have been considered below average in intelligence, and we have to be extremely careful that AD/HD children do not get the idea that they are stupid or slow. Parents, seeking to avoid this stigma, come to their AD/HD child's defense by describing him or her as having a "different learning style." This approach is fine, but if we truly believe it, we must provide some accommodation for these differences. Parents often find themselves battling for their child's right to an educational style that fits his or her needs. If the public education system cannot meet these special needs, parents may need to consider private, charter, or home schooling.
"PURE" AD/HD RARELY EXISTS!
Diagnosis of AD/HD is often complicated by the presence of other conditions that coexist or are comorbid with AD/HD. The most common are learning disabilities, including poor visual perception, auditory-language dysfunction, and poor memory and/or communication skills. As a result, the AD/HD child with learning disabilities may be assigned to special education classes.
Neuropathological disorders that typically coexist with AD/HD are autism, oppositional defiant disorder, and pervasive developmental disorder. These conditions dramatically affect the outcome and treatment of the AD/HD individual. We are just beginning to link these coexisting conditions with dysfunctions in specific areas of the brain. As more is learned about coexisting conditions, better treatment strategies can be planned. Nutrition is the common thread that runs through all of them, however, and a specific dietary plan should be part of any treatment.
Allergies are extremely common in AD/HD individuals, both children and adults. Allergies cause disruption in brain function, and minimizing their effects is so important in overcoming AD/HD that I have devoted a detailed explanation on how they affect the condition in chapter 8. Although allergies are a common problem in those with AD/HD, each victim of this mysterious disabling condition will have his or her own set of symptoms. That's why parents will say "my child has an attention deficit disorder," indicating the individual uniqueness and kaleidoscope of symptoms seen in AD/HD. Physicians must take time to determine what characterizes each child's case by carefully differentiating between symptoms presented. But is this really happening?
INAPPROPRIATE DIAGNOSIS
Results of a survey of pediatricians published recently in the Archives of Pediatric and Adolescent Medicine, revealed that doctors often spend less than an hour arriving at a diagnosis of AD/HD. Experts agree that this does not allow enough time for your child to be accurately diagnosed. The diagnosis of an attention deficit disorder is arrived at by compiling the child's history from several people, as we have seen, including the child. This, if done properly, obviously requires more than an hour. Therefore, if your child has been diagnosed quickly or by someone not qualified to do so, you should question the diagnosis and get another opinion.
"PUSHY" PARENTS
Doctors are not alone in rushing to give an AD/HD diagnosis. Amazingly, some parents push to have their child diagnosed and will "shop" among doctors to obtain the diagnosis they seek. They do this for two reasons, the primary one being to get the child on stimulant medication, which they view as beneficial for their child and others in the family. Some parents may even see medication as a convenient way to control unruly, not necessarily AD/HD, behavior, or the medication may seem like a foregone conclusion, having been suggested to parents by school authorities. Families on welfare in some states may qualify for additional benefits for each child diagnosed AD/HD, which also can be an incentive for parents to look for this diagnosis. Older children also have an incentive to be officially diagnosed as AD/HD because the disease has been officially designated an American disability. As such, this label earns a student extended time for completing standardized tests like the SAT, giving him a better chance to score well. It can also qualify a student for professional schools to which he might otherwise not be admitted.
MEDICATION ALONE IS NOT EFFECTIVE
The accurate diagnosis and treatment of AD/HD with medication have brought relief to thousands. Still, those who specialize in treating this condition agree that use of stimulant medication alone is not the answer ... and a growing number of specialists reserve medication for those who do not respond well to other remedies. This group of physicians recognizes the importance of nutrition but, until now, have not had an easy program that their AD/HD patients can implement. My 30-Day Plan was inspired in large part by encouragement from these professionals.
Even if you or your child is getting along well on medication, my 30-Day Plan should be an essential part of the program. Learning how dietary change can turn around the life of any child or adult suffering from AD/HD is the message I hope to share with everyone reading this book.
HELPING YOUR AD/HD CHILD
The child with AD/HD, like the rest of us, is trying to figure out his place in the world and how to succeed within the family environment, at school, and with peers. He has to develop career goals, figure out how to meet them, and succeed in adult relationships. These children literally have a different mind-set, as we are discovering as we learn more about brain function. Therefore, during the developmental process, their self-esteem takes a battering as they struggle to be comfortable with who they are and how to take advantage of the considerable gifts they possess. The most important task you as a parent have is to help and encourage your child during this discovery process. If you are the partner of an adult with AD/HD, you have the same task, to help your partner achieve success by optimizing his or her natural abilities.
It is interesting to contemplate why we consider AD/HD the plague of the nineties--just as we are beginning to understand that attention deficits involve the brain's ability to focus on survival skills that have sustained humans for centuries. This mind-set has been with us all along--it's just that today the warrior/survivor types are trapped in an endless sea of "executive skills" to which they are ill suited. And those with brilliant creative minds are ridiculed for being "different" and not allowed to daydream. As we become increasingly sedentary and our dietary practices worsen, we will continue to have ever more individuals diagnosed AD/HD. The pathway we must follow to lessen the assault on the brain by this relatively new lifestyle pattern and improve self-esteem has to be nutrition.
I'm going to use a case history in the next chapter to show you how one family discovered their attention deficits and how they overcame the problem.
Copyright (c) 1999 Marcia Zimmerman
