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Diagnosis and treatment of ADHD

1)  What does ADHD look like?

I am often asked about whether an individual has ADHD.  Here is some background describing ADHD!  In evaluating whether someone has ADHD, we use the criteria from the diagnostic and statistical manual of mental disorders (now DSM-5), although the ICD-10 criteria is also used.  I am presenting the more “classic” features here.

To meet criteria, symptoms must be present for at least 6 months to a degree that is maladaptive and not consistent with a child’s developmental level.  Symptoms may come from the inattentive or hyperactive/impulsive type clusters of symptoms.  Classic inattentive symptoms include making careless mistakes, losing things frequently, avoiding mentally taxing tasks, and disorganization, just to name a few.  Classic hyperactive/impulsive type symptoms include fidgeting, talking too much, and blurting out answers to questions before the questions have been completed.  Additional diagnostic considerations include the doctor’s judgment of how impaired the person is (socially, academically, occupationally), how persistent the symptoms have been, how pervasive they are (do they occur in at least 2 settings?), age of onset (is there a history of onset prior to age 12?), and whether symptoms might be better accounted for by another condition.  Worldwide prevalence is estimated to be at 5.29%, meaning that ADHD is common!

2)  If I have ADHD as a child, does that mean that I will always have it?

 

Of people who have ADHD in childhood, 30-40% will exhibit symptoms in adolescence, and up to 65% will exhibit symptoms into adulthood.

3)  What are the risks associated with ADHD?

People with ADHD tend to exhibit more of the following problems:  unintentional injuries, hospitalization, arrest, antisocial behavior, depression/anxiety, family/marital conflict, divorce, low self-esteem, substance use/abuse, motor vehicle crashes/road rage/tickets, school failure, academic underachievement, peer problems, risky sexual behavior, and work underachievement.  Some of these problems stem from impulsivity (making decisions without thinking through consequences).  There is also a higher rate of oppositional defiant disorder, conduct disorder, learning disability, anxiety, and depression in people with ADHD.  There are popular books that may put people with ADHD on a pedestal, stating they have special qualities, and while individuals may, group data suggest increased risk for the above problems as a group.

4)  How is the brain with ADHD different?

Scientists say that ADHD is caused by brain structure and chemicals, genetics, brain injury or infection during development or birth, and environmental factors.  Twin studies have shown a higher rate of ADHD in identical twins reared together and apart, providing support for a genetic basis of ADHD.  There are chemical changes that have been shown to be present in the brains of individuals with ADHD, including decreased dopamine and norepinephrine in the brain.   fMRI studies show decreased blood flow in certain parts of the brain (anterior cingulate) and increased blood flow in other parts of the brain (frontal striatum) in ADHD vs people who do not have ADHD.

5)  What are the most effective treatments for ADHD?

For school-aged children, first line ADHD therapy includes both medication treatment AND behavior interventions.  Stimulants are the first line treatment (Ritalin, methylphenidate).  Best behavior interventions include parent training and classroom changes.  Play therapy or 1:1 therapy with kids has not been shown to be particularly useful.  There is also no proven benefit for interactive metronome training, occupational therapy, or vision therapy for ADHD.  These findings are based on the famous “MTA study” conducted at Duke.  This study showed that for children ages 7-10 with ADHD (combined type), well-delivered medication is superior to behavioral management and may be sufficient for ADHD symptoms.  However, combined medication and behavior management approaches may achieve best results for problems such as parent-child conflict, academic difficulties, social skills, anxiety, and oppositional/aggressive symptoms.  Behavioral interventions have been shown to work best when the goal is to change behavior by modifying the physical and social environment, not the therapist working with the child to “fix” him or her.  It is parent training that has been shown to work most effectively.

6)  What parenting approaches have been shown to work best for ADHD?

Providing rewards for desired behavior, planned ignoring, use of appropriate consequences, structure, and consistency.

7)  What classroom behavior interventions have been shown to be useful for treatment of ADHD?

Preferred seating, modified work assignments (reduced load, fewer problems on page), test modifications (alternate location, test in a quiet environment, extra test time)

In reading over this information, it is important to avoid self-diagnosing but rather to consult a licensed professional for guidance.  I recommend speaking with pediatricians, psychiatrists, psychologists, or neuropsychologists for further details.

Learn more about scheduling ADHD/Learning Disabiltiy testing for your child

About the Author:

Dr. Messler is a board certified clinical neuropsychologist and licensed psychologist who has provided thousands of evaluations where the question of traumatic brain injury was raised. She has also served as expert consultant and witness. She believes it is critical to provide an objective, scientifically defensible opinion, and to help the jury and court understand the implications of the neuropsychological aspects of cases before them. As a prior active duty neuropsychologist, she has extensive experience in the area of military forensic neuropsychology.