How to Treat and Diagnose Attention Deficit Disorder
How do you diagnose ADD? When do you treat it? Are we creating a generation of drug addicts?
A few weeks ago, I did an article that talked about attention deficit disorder from my own unique perspective: I have it. This week I am going to cover more of the details about this condition, specifically how it is diagnosed and how it is treated. If you didn’t read the last article on ADD, it would be a good idea to do so before reading this. I will be very disappointed with you if you don’t.
How is Attention Deficit Disorder Diagnosed?
OK, so how do you know a person has attention deficit disorder with or without hyperactivity? The diagnosis is not made using a stethoscope or that thingy you use to look in the ears, but by asking questions. Hearing the story from the person is important, but perhaps more important is the view of their parents, spouse, teachers and/or employers.
There are a number of criteria used to make the ADD diagnosis, and the most widely accepted are those of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders–commonly referred to as the DSM IV. That manual defines the characteristics of the two varieties of ADD: inattentive and hyperactive-impulsive. What’s the difference between the two? I’ll put all of the criteria in the show notes at the bottom of the page, but it basically comes down to how a person reacts to losing focus. Some people drift off into the outer reaches of space, while others fidget and go from thing to thing to thing. Inattentive type tends to happen in girls, while the hyperactive flavor tends to be in boys. The root problem is still the same: lack of focus, and both are referred to as ADD.
Having parents and teachers fill out a Connors or Vanderbilt questionnaire is how many physicians and psychologists make the ADD diagnosis. There are a number of tests for adults as well. All of these tests are flawed, however, in that the person doesn’t have to be truthful when they fill them out. That is why I usually get several people’s perspective when making the diagnosis. The more the merrier.
What Other Conditions Are Mistaken for ADD?
There are a number of conditions that could contribute to or even cause attention problems, including:
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Hearing or vision problems
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Psychiatric problems, such as anxiety, depression, obsessive-compulsive disorder, and bipolar disorder
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Use of medications that can cause fatigue, such as antihistamines or antidepressants
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Fatigue (I once had a child who was being treated for ADD when in reality the problem was sleep apnea. Treating the sleep apnea cured the ADD.)
The bottom line is that a careful evaluation needs to be made before attaching the label of ADD.
When Should You Treat ADD with Medication?
So let’s say we have a clear diagnosis of ADD. The next thing to do is to prescribe medications, right? No! Whenever any disease or condition is diagnosed, the first question you and your doctor should ask is: So what? What difference does it make to have the diagnosis and what difference would treatment make?
Remember my story? I was never treated until I started self-medicating with coffee in college. Did this make things harder for me? Yes, it did. But that hardship is big part of who I am today. We don’t want to remove all obstacles from in front of people–especially children.
But there are certainly times when treatment must be considered. These include:
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When the person is failing or doing poorly at an important task such as work or school.
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When the condition is causing harm to relationships In the case of children affected relationships may be with parents or siblings at home or with teachers or fellow classmates at school. In the case of adults affected relationships may include marriages or other important relationships.
Please be aware that hyperactive ADD is diagnosed far earlier than the inattentive variety. This is because teachers are much less likely to complain about a child who is staring at the dots on the ceiling tiles than they are about the child hanging from the ceiling tiles. People with inattentive ADD are often assumed to be not as smart as other children, which is a real shame because often they are actually smarter.
How to Treat ADD
The treatment of ADD falls into two main approaches: improving the environment, and giving medications. Of the two, the pills get the attention, but the environment is a lot more important.
The following things can improve the environment for a person with ADD:
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Use Structure: In general, people with ADD have a hard time staying on task and so they do better in a structured setting with clear expectations.
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Switch it up: Boredom is the enemy. That is why boys with ADD have no problem focusing on video games; these games change a lot and are exciting.
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Minimize distractions: When I was in school I discovered that I did much better in classes when I sat in the front of the classroom.
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Be clear: Vague or complicated instructions need to be avoided. Breaking tasks down to smaller parts and checking off each part when done helps a lot. A small number of long-term deadlines are not as good as many shorter-term ones. Get-it-Done Guy has a great tip on providing context that can be adapted for this situation.
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Provide supervision: Kids with ADD do much better in a smaller classroom where they can be brought back on task. The same is true for adults
What Medications are Used to Treat ADD?
If people still struggle even after making environmental changes, medications are considered. The main drugs used to treat ADD are amphetamines. These drugs stimulate the part of the brain that causes a person to focus and improve their attention. They work extremely well.
Stimulant drugs such as Ritalin and Adderal are so effective that they are used with alarming frequency. This has raised some questions: Are we medicating our children because they are acting like children? Are adults taking them just to avoid struggle? Are we creating a bunch of drug addicts by giving these drugs?
Are ADD Medications Necessary?
Well, these medications should never be given unless a qualified professional makes the diagnosis. I do think people are being over-treated. Many kids are treated because they are getting B’s. Many adults just want to get more things done. The desire to escape struggle makes these medications tempting to many people. But you don’t treat ADD because it is there; you treat it because it is causing a problem.
That being said, for people who really need them, stimulant medications are very beneficial. One study showed that children with ADD who were not treated with medications were seven times more likely to use illegal drugs later in life than those who were treated. That flies in the face of concerns that we are creating a bunch of addicts by medicating kids for ADD. Why is this? People do drugs when they are hopeless. A child labeled as an underachiever or a troublemaker will often lose hope.
Quick and Dirty Tips for Treating ADD
Let me recap this by giving my Quick and Dirty Tips about treating ADD:
Tip 1: Use objective testing
Being tested by a psychologist or PCP is the first step in making the diagnosis.
Tip 2: Rule out other problems
I can’t emphasize enough the importance of looking for other reasons for inattention or hyperactivity before jumping to the diagnosis and treatment of ADD
Tip 3: Change the environment first
Knowing how to compensate for your weaknesses is at least as important as succeeding. If the environment can be changed, change it.
Tip 4: Medicate problems, not just a diagnosis
Just having ADD is not enough to merit medication. The ADD has to be causing enough problems that not treating is worse than treating. Escaping struggles can have a negative impact in the long run. A child’s character is more important than their math grades.
Tip 5: When appropriate, medicate carefully
The drugs for ADD are very strong and tightly controlled by the government and they can really help. Never share ADD medications with anyone else. Because they are controlled drugs, sharing them with others is the legal equivalent of trafficking cocaine.
Tip 6: Don’t play Bejeweled when you have ADD and have an article you need to write.
If you have questions you want answered, send them to housecalldoctor@quickanddirtytips.comcreate new email. You can find me on Twitter as @housecalldoc and on Facebook under “House Call Doctor.”
Let me remind you that this podcast is for informational purposes only. My goal is to add to your medical knowledge and translate some of the weird medical stuff you hear, so when you do go to your doctor, your visits will be more fruitful. I don’t intend to replace your doctor; he or she is the one you should always consult about your own medical condition.
Catch you next time! Stay Healthy!
DSM IV Criteria for Attention Deficit Disorder
INATTENTION (need 6 of 9)
- often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities
- often has difficulty sustaining attention in tasks or play activities
- often does not seem to listen when spoken to directly
- often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (no if oppositional behavior or doesn’t understand instructions)
- often has difficulty organizing tasks and activities
- often avoids, dislikes, or is reluctant to engage in tasks or activities that require sustained mental effort (such as schoolwork or homework)
- often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
- often easily distracted by extraneous stimuli
- often forgetful in daily activities
HYPERACTIVITY-IMPULSIVITY (need 6 of 9)
- often fidgets with hands or feet or squirms in seat
- often leaves seat in classroom or in other situations in which remaining seated is expected
- often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
- often has difficulty playing or engaging in leisure activities quietly
- is often “on the go” or often acts as if “driven by a motor”
- often talks excessively
- often blurts out answers before questions have been completed
- often has difficulty awaiting turn
- often interrupts or intrudes on others (e.g., butts into conversations or games)
REQUIREMENTS
- Present at least 6 months, maladaptive and inconsistent with development level
- Some symptoms that caused impairment were present before age 7
- Some impairment from the symptoms is present in two or more settings (e.g., at school {or work} and at home)
- There must be clear evidence of clinically significant impairment in social, academic or occupational functioning