Behavioral disorders which start in child’s and juvenile age. Child’s and juvenile schizophrenia. Childs autism. ADHD.

 

Attention Deficit Disorder

An Introduction to ADD/ADHD

Have you ever had trouble concentrating, found it hard to sit still, interrupted others during a conversation or acted impulsively without thinking things through? Can you recall times when you daydreamed or had difficulty focusing on the task at hand?

Most of us can picture acting this way from time to time. But for some people, these and other exasperating behaviors are uncontrollable, persistently plaguing their day-to-day existence and interfering with their ability to form lasting friendships or succeed in school, at home and with a career.

Unlike a broken bone or cancer, attention deficit hyperactivity disorder (ADHD, also sometimes referred to as just plain attention deficit disorder or ADD) does not show physical signs that can be detected by a blood or other lab test^*. The typical ADHD symptoms often overlap with those of other physical and psychological disorders.

The causes remain unknown, but ADHD can be diagnosed and effectively treated. Many resources are available to support families in managing ADHD behaviors when they occur.

ADHD, also known as attention deficit disorder (ADD) or hyperkinetic disorder, has been around a lot longer than most people realize. In fact, a condition that appears to be similar to ADHD was described by Hippocrates, who lived from 460 to 370 BC. The name Attention Deficit Disorder was first introduced in 1980 in DSM-III, the third edition of the ‘Diagnostic and Statistical Manual of Mental Disorders’, used in psychiatry. In 1994 the definition was altered to include three groups within ADHD: the predominantly hyperactive-impulsive type; the predominantly inattentive type; and the combined type. ADHD usually appears in childhood but can be diagnosed in adults.

Recent steps forward in our understanding of ADHD include:

• An estimated 3 to 5 per cent of children are affected – approximately 2 million children in the US. In a classroom of 25 to 30 children, it is likely that at least one will have ADHD.
• ADHD is among the most common mental disorders among children. It is one of the top reasons for referral to a pediatrician, family physician, pediatric neurologist, child psychiatrist or psychologist. ADHD is best diagnosed by a child psychologist or other child specialist in ADHD.
• ADHD is about three times more common among boys than girls.
• The symptoms of ADHD do not always go away – up to 60 per cent of child patients retain their symptoms into adulthood. Many adults with ADHD have never been diagnosed, so may not be aware they have the disorder. They may have been wrongly diagnosed with depression, anxiety, bipolar disorder or a learning disability.
• ADHD has been identified in every nation and culture that has been studied.

ADHD is difficult for everyone involved to deal with. As well as the difficulty of living with the symptoms, wider society may face challenges. Some experts have linked ADHD with an increased risk of accidents, drug abuse, failure at school, antisocial behavior and criminal activity. But others view ADHD in a positive light, arguing that it is simply a different method of learning involving greater risk-taking and creativity.

ADHD is often accompanied by:

• anxiety
• learning disabilities
• speech or hearing problems
• obsessive-compulsive disorder
• tics
• behavioral problems such as oppositional defiant disorder (ODD) or conduct disorder (CD)

Exactly what causes ADHD has not been pinpointed, though many practitioners believe neurobiological or genetic elements play a role. In addition, numerous social factors such as family conflict or poor child-rearing practices, while not causing the condition, may complicate the course of ADHD and its treatment.

Symptoms of Attention Deficit Disorder (ADHD)

The main features of attention deficit disorder (or ADHD) areinattention, hyperactivity, and impulsivity. But because most young children display these behaviors from time to time, it is important not to assume that every child you see with these symptoms has ADHD. However, if the symptoms continue, advice should be sought from a qualified mental health professional.

Symptoms of attention deficit disorder usually develop over several months. In general, impulsiveness and hyperactivity are observed before one notices the lack of attention, which often appears later. It also may go unnoticed because the “inattentive daydreamer” may be overlooked when the child who “can’t sit still” at school or is otherwise disruptive will be noticed. The observable symptoms of ADHD will therefore vary a great deal depending on the situation and the specific demands it makes on the child’s self-control.

Different forms of ADHD may result in the child being labeled differently. For example, an impulsive child may be labeled a “discipline problem.” A passive child may be described as “unmotivated.” But ADHD could be the cause of both behavior patterns. It may only be suspected once the child’s hyperactivity, distractibility, lack of concentration, or impulsivity start affecting school performance, friendships, or behavior at home.

The official diagnosis of ADHD includes the three major symptoms (inattentiveness, hyperactivity and impulsiveness). The most recent version of the handbook for mental health professionals states that people with ADHD may have any or all of the major symptoms.

Three subtypes of ADHD are recognized by professionals:

• Predominantly Hyperactive-Impulsive Type — If symptoms of hyperactivity-impulsivity but not symptoms of inattention have been shown for at least six months to an extent that is disruptive and inappropriate for the individual’s developmental level.
• Predominantly Inattentive Type — If symptoms of inattention but not symptoms of hyperactivity-impulsivity have been shown for at least six months to an extent that is disruptive and inappropriate for the individual’s developmental level.
• Combined Type — If symptoms of both inattention and hyperactivity-impulsivity have been shown for at least six months to an extent that is disruptive and inappropriate for the individual’s developmental level.

Hyperactive/Impulsive Type of ADHD

Hyperactive children always seem to be “on the go” or constantly in motion. They dash around touching or playing with whatever is in sight, or talk incessantly. Sitting still at dinner or during a school lesson or story can be difficult. They squirm and fidget in their seats or roam around the room. Or they may wiggle their feet, touch everything, or noisily tap their pencil. Hyperactive teenagers or adults may feel internally restless. They often feel the need to stay busy and may try to do several things at once.

Impulsive children seem unable to control their immediate reactions or think before they act. They will often blurt out inappropriate comments, show their emotions without restraint, and act without considering the consequences. They may find it hard to wait for things they want, or to take their turn in games. They may grab a toy from another child or hit out when upset. As teenagers or adults, impulsive people may choose to do things that have an instant reward instead of seeing through activities which take more effort but would lead to greater but delayed rewards.

Indicators of hyperactivity-impulsivity:

• Feeling restless, fidgeting with hands or feet, and squirming while seated
• Running, climbing, or leaving a seat in situations where sitting or quiet behavior is expected
• Blurting out answers before hearing the whole question
• Interrupting or intruding on others
• Having difficulty waiting in line or taking turns or enjoying leisure activities quietly
• Adolescents or adults may feel very restless, as if “driven by a motor”, and talk excessively.

Inattentive Type of ADHD

Children diagnosed with the Predominantly Inattentive type of ADHDhave trouble focusing on any one thing and may get bored with a task after only a few minutes. However, if they are doing something they really enjoy, they usually have no trouble paying attention. But focusing deliberate, conscious attention to organizing and completing a task or learning something new is difficult.

Homework is particularly hard for these children. They will forget to write down an assignment, or leave it at school. They will forget to bring a book home, or bring the wrong one. The homework, if finally finished, will be full of mistakes. It is often accompanied by frustration for the child and their parents.

Inattentive children are rarely impulsive or hyperactive, but have a significant problem paying attention. They often appear to be daydreaming, “spacey,” easily confused, slow moving, and lethargic. They may process information more slowly and less accurately than other children. This child has a hard time understanding what he or she is supposed to do when a teacher gives oral or even written instructions. Mistakes are frequent. The child may sit quietly and appear to be working, but in reality is not fully attending to or understanding the task and the instructions.

Children with this form of ADHD often get along better with other children than the more impulsive and hyperactive forms, as they may not have the same sorts of social problems common with the other forms of ADHD. Because of this, their problems with inattention are often overlooked.

Indicators of inattention:

• Not giving close attention to details or making careless mistakes in schoolwork, work, or other play activities.
• Becoming easily distracted by irrelevant sights and sounds
• Failing to pay attention to instructions and making careless mistakes, not finishing work, chores or duties
• Losing or forgetting things like toys, pencils, books, assignments and tools needed for a task
• Having trouble organizing activities, often skipping from one uncompleted activity to another
• Not appearing to listen when spoken to directly
• Avoiding or disliking things that take a lot of mental effort for a long period of time

Combined Type of ADHD

Children exhibiting hyperactivity, impulsivity and inattention are considered to have the combined type of ADHD, which combines all of the above symptoms.

Problems Related to ADHD

ADHD is often present alongside other mental health problems, such as a learning disability or oppositional defiant disorder. When the individual is affected by such disorders, these should be treated in conjunction with ADHD, by a well-qualified mental health professional or team of specifically-trained professionals.

Some of the disorders often linked with ADHD:

Learning Disabilities

About 20 to 30 percent of children with ADHD also have a learning disability (LD). This is a problem that is unexpected given the child’s general intelligence In preschool children, this often appears as a difficulty understanding certain sounds or words and/or difficulty in expressing oneself in words. In school age children, reading or spelling disabilities, problems writing, and arithmetic disorders may appear. One specific type of reading disorder, dyslexia, is quite common. Reading disabilities affect up to eight percent of elementary school children.

A child with ADHD may struggle with learning, but he or she can often learn adequately once successfully treated for the ADHD, whereas a learning disability will need specific treatment.

Tourette Syndrome

Occasionally people with ADHD have an inherited neurological disorder called Tourette syndrome. This usually appears in childhood, and is characterized by multiple physical (motor) tics and at least one vocal (phonic) tic. These nervous tics and repetitive mannerisms may include eye blinks, facial twitches, grimacing, clearing the throats frequently, snorting, sniffing, or barking out words. These symptoms can be controlled with medication. Although this syndrome is rare, it is common for people with Tourette syndrome to have ADHD. Both disorders will require treatment that may include medications.

Oppositional Defiant Disorder

Oppositional Defiant Disorder is defined as an ongoing pattern of disobedient, hostile, and defiant behavior toward authority figures that goes beyond the bounds of normal childhood behavior. It affects up to half of all children with ADHD, particularly boys. To meet this diagnosis, the child’s defiance must interfere with their ability to function in school, home, or the community and have been happening for at least six months.
These children tend to act in ways that are stubborn and non-compliant, and may lose their temper, arguing with adults and refusing to obey rules. They may deliberately annoy people, blame others for their mistakes, be resentful, spiteful, or even vengeful.

Conduct Disorder

Conduct disorder is a more serious pattern of antisocial behavior which may eventually develop in 20 to 40 percent of children with ADHD. It is defined as a pattern of behavior in which the rights of others or the social norms are violated. Symptoms include over-aggressive behavior, bullying, physical aggression, cruel behavior toward people and pets, destruction of property, lying, truancy, vandalism, and stealing.

These children are at a high risk of getting into trouble at school or with the police. They are also at high risk for experimenting with drugs, and later dependence and abuse. They need immediate help, otherwise the conduct disorder may develop into antisocial personality disorder.

Anxiety and Depression

Children with ADHD can also struggle with anxiety and/or depression. Treatment for these problems can help the child to handle their ADHD more effectively. This works the other way too – effective treatment of ADHD can reduce the child’s anxiety or depression through improved confidence and ability to concentrate.

Bipolar Disorder

Because there are some symptoms which can be present both in ADHD and bipolar disorder, it is often difficult to differentiate between the two conditions. For this reason, there are no accurate statistics on how many children with ADHD also have bipolar disorder.

Bipolar disorder is a condition defined by extreme moods, occurring on a spectrum from debilitating depression to unbridled mania. Between these states, the individual can experience a normal range of moods.

However, bipolar disorder in children often involves a faster cycling of the extreme mood states, even within one hour. Children may also experience the symptoms of mania and depression simultaneously. Experts describe this pattern as a chronic mood dysregulation, including irritability.

The symptoms which can overlap between ADHD and bipolar disorder include high levels of energy and a reduced need for sleep. But elated mood and grandiosity – an inflated sense of superiority — are distinctive signs of bipolar disorder.

Causes of Attention Deficit Disorder 

As with all mental disorders, the exact cause of attention deficit disorder (ADHD) is unknown, so parents should not blame themselves for this problem. It is likely that many factors play a role in each case of ADHD, very little of which has to do with specific parenting or child rearing skills.

Inevitably, parents will ask themselves “What did I do to cause this?” or “How could I have prevented it?”, but most of the evidence points to genetic factors, environmental facts or brain damage.

Instead, parents should focus on how best to help their child with ADHD. Experts hope that someday, understanding the causes of the condition will lead to effective therapies, and evidence is building on the side of genetic causes for ADHD rather than elements of the home environment. Certain aspects of a child’s environment may, however, affect the symptom severity of ADHD once it is established.

Possible causes of ADHD include:

Genes

ADHD has a strong genetic basis in the majority of cases, as a child with ADHD is four times as likely to have had a relative who was also diagnosed with attention deficit disorder. At the moment, researchers are investigating many different genes, particularly ones involved with the brain chemical dopamine. People with ADHD seem to have lower levels of dopamine in the brain.

Children with ADHD who carry a particular version of a certain gene have thinner brain tissue in the areas of the brain associated with attention. Research into this gene has showed that the difference are not permanent, however. As children with this gene grow up, their brains developed to a normal level of thickness and most ADHD symptoms subsided.

Nutrition and Food

Certain components of the diet, including food additives and sugar, can have clear effects on behavior. Some experts believe that food additives may exacerbate ADHD. And a popular belief is that refined sugar may be to blame for a range of abnormal behaviors.

However, the belief that sugar is one of the primary causes of attention deficit disorder does not have strong support in the research data. While some older studies did suggest a link, more recent research does not show a link between ADHD and sugar. While the jury is still out on whether sugar can contribute to ADHD symptoms, most experts now believe that the link is not a strong one. Simply removing sugar from a child’s diet is unlikely to significantly impact their ADHD behavior.

Some studies also suggest that a lack of omega-3 fatty acids is linked to ADHD symptoms. These fats are important for brain development and function, and there is plenty of evidence suggesting that a deficiency may contribute to developmental disorders including ADHD. Fish oil supplements appear to alleviate ADHD symptoms, at least in some children, and may even boost their performance at school.

The Environment

There may be a link between ADHD and maternal smoking. However,women who suffer from ADHD themselves are more likely to smoke, so a genetic explanation cannot be ruled out. Nevertheless, nicotine can cause hypoxia (lack of oxygen) in utero.

Lead exposure has also been suggested as a contributor to ADHD. Although paint no longer contains lead, it is possible that preschool children who live in older buildings may be exposed to toxic levels of lead from old paint or plumbing that has not been replaced.

Brain Injury

Brain injury may also be a cause of attention deficit disorder in some very small minority of children. This can come about following exposure to toxins or physical injury, either before or after birth. Experts say that head injuries can cause ADHD-like symptoms in previously unaffected people, perhaps due to frontal lobe damage.

Other Possible Causes

ADHD researchers are currently investigating the frontal lobes of the brain — the areas controlling problem-solving, planning, understanding other people’s behavior, and restraining our impulses.

The brain is divided into two halves, and the two frontal lobes communicate through a bundle of nerve fibers called the corpus callosum. These areas, and nearby brain cells, are being examined by ADHD researchers. Using brain imaging methods, the experts can get an idea of the location of the psychological deficits of ADHD.

A 2002 study found that children with ADHD had 3-4 percent smaller brain volumes in all the brain regions measured. But children on ADHD medication had similar brain volumes to unaffected children, in some of the areas measured.

One big difference was the amount of “white matter” — long-distance connections between brain regions that normally become stronger as a child grows up. Children with ADHD who had never taken medication had an abnormally small volume of white matter.

How is ADHD Diagnosed?

While the symptoms of attention deficit disorder (ADHD) may appear commonplace in many people’s behavior (as many symptoms for mental disorders are), there are a set of specific diagnostic criteria used by trained mental health professionals to make the diagnosis.

The official diagnostic criteria for ADHD state that the symptoms must occur beyond the extent that is normal for the person’s age, and must occur in a variety of different situations (e.g., not just school). For a diagnosis of ADHD, the symptoms must also have appeared before the age of 7 (for childhood ADHD), and have continued for at least 6 months.

Impairments due to the symptoms of ADHD must also have been observed in at least two different settings, such as at school, at work, in the community, at social events, or at home. For example, a child who is overly active in the playground but has no problems concentrating on their schoolwork may not be appropriate for a diagnosis of ADHD.

So the critical questions to consider before an ADHD diagnosis is made are whether the symptoms are: (a) excessive compared with what would be expected; (b) longer-term rather than in response to a recent change; and (c) pervasive rather than limited to one environment.

ADHD Diagnosed in Children

The signs of possible attention deficit disorder may first be noticed long before the child begins school. Their lack of attention, hyperactivity, and impulsivity may be seen when these lose interest in playing a game or watching a TV show, or if the child runs around and seems completely out of control. Parents may feel it is necessary to contact a pediatrician or a child psychologist to undergo an assessment of whether or not their child’s behavior is appropriate for their age. Often they will be reassured that the child is behaving withiormal limits and is just unusually exuberant or a little immature for their developmental stage.

Sometimes it’s another adult who first suspects that a child may have attention deficit disorder, such as a babysitter or teacher. Teachers with experience of the disorder are particularly well-placed to identify the symptoms of ADHD, especially as the symptoms are particularly evident in the school environment when teachers have come to know how children “typically” behave. The inattentive form of ADHD may be missed for some time in pupils who are seemingly cooperative.

Once a specialist is consulted, the professional will begin to gather information on the child’s unusual behavior and rule out possible causes other than ADHD, for example:

• A sudden change in the child’s life, such as death of a close relative, divorce, or a parent’s job loss
• Previously undetected seizures
• Middle ear infection, which can cause hearing problems
• Other types of medical disorder that may be affecting the child’s brain
• Learning disability
• Anxiety and/or depression

These factors can usually be ruled out with help from the parents and school, but tests may be necessary. Alongside this information, the specialist will find out how the child’s behavior is currently being handled, and look into the nature of the child’s home and school to find out if they are unusually stressful or chaotic.

The child will then be assessed directly, and their behavioral symptoms will be observed in a range of environments and compared against those set out in the diagnostic manual. The specialist will give special attention to the child’s behavior during situations which call for the most self-control, and noisy or unstructured situations such as parties. Their response to during needing sustained attention (reading, working math problems, or playing a board game) will be observed.

This data will allow the specialist to pieces together a profile of the child, finding out which specific ADHD symptoms the child shows, how often, and in which situations. Children with ADHD will vary on their age when symptoms began, the pattern of symptoms – whether they are chronic or come and go in phases, and the extent to which they interfere with aspects of the child’s life such as friendships, school activities, home life, and community activities.

Other related problems, if they exist, may also be identified during diagnosis.

The assessment will include speaking with teachers who have taught the child since they began school. Standard evaluation forms — known as behavior rating scales — are filled in by the teachers, rating their observations of the child’s behavior. Results are then compared with what would be considered “normal”.

Interviews also take place with the child’s teachers, parents, and possibly other adults who know the child well. They will be questioned on how the child behaves in many settings, and may be given a rating scale to mark the severity and frequency of the behavior.

Further tests that are often given include: social adjustment, mental health, intelligence, and learning achievement.

Originally, attention deficit disorder was a strictly childhood disorder diagnosed only in children. Nowadays, experts no longer believe that the symptoms of ADHD disappear in adulthood. Figures suggest that up to two-thirds of children with the disorder will continue to display ADHD behaviors well into adulthood. As the individual grows up, he or she will become more aware of the challenges this brings.

But many adults with ADHD were never diagnosed with a problem in their early years, or were given the wrong diagnosis — such as a learning disability, attitude problem, or personality or character disorder.

Nevertheless, the disorder may be the underlying cause of many personal and work problems including difficult relationships, anger,depression, and alcohol or substance abuse. Once a proper diagnosis is made, the individual can begin to find their own way of coping, even using their excess energy in positive ways.

For adults, ADHD diagnosis involves examining the individual’s past as well as their current difficulties. Family members may be asked to help. The specialist will review and assess their childhood and recollections of behaviors that may fit the ADHD symptoms. Academic and job performance will be evaluated, as will family relationships and the nature and quality of the person’s friendships.

The specialist must be careful to rule out from a ADHD diagnosis adults who believe they have the disorder, but who seemingly had no problems in childhood. These individuals may need advice with their current issues, but the label of ADHD, and its recommended treatment, will probably not be helpful.

The basic symptoms of ADHD are the same for both adults and children. However, adults may also suffer from low self-esteem, an increased sense of frustration, and many problems caused by lack of focus and organisational skills. They may need further assessments to rule out mistaken diagnosis of other conditions, with which they may have been labeled for decades.

Following diagnosis, counseling may be of great help in understanding the impact of ADHD on their life. Certain drug therapies may be very beneficial, such as antidepressants for depression or anxiety.

After Diagnosis

Once a correct diagnosis is made, the child or adult with ADHD caow be given help to manage their condition. For parents of children with ADHD, adults with ADHD, and even the children themselves, diagnosis can be a relief because it helps explain behavior problems which may have occurred for a long time previously.

Now a new journey can begin in which the condition is explored and specific action taken. Educational, medical, and emotional support can be given, such as informing teachers, other staff at school, and other adults who often interact with the child. Lessons may need to be planned differently, and the most effective medication for the individual can be explored.

Treatment

Treatment for attention deficit hyperactivity disorder (ADHD) has two important components — psychotherapy interventions (for both the child and the parents; or the adult with ADHD) and medications. There is a significant amount of research demonstrating that medication alone won’t really help address so many of the core issues a child or adult with ADHD has. So while medication may help with some immediate relief from some of the symptoms, the person with attention deficit disorder still ofteeeds to learn the skills needed to be successful while living with the disorder.

This treatment article is divided into two major sections — medication treatments for ADHD are covered in the rest of this article, whilepsychotherapy and other treatments for ADHD are covered in the next section.

In the past, ADHD treatment has typically focused on medications. The specific class of medication most commonly prescribed for ADHD is stimulants. These stimulant medications — like Ritalin (methylphenidate) or Adderall (an amphetamine) — are commonly prescribed, well-tolerated, act quickly (usually soon after a person takes them), and in most people, have few side effects. These medications also have a robust research base supporting their effectiveness in treatment of attention deficit disorder.

Children vary a great deal in their response to medication treatments. Finding the combination with the highest efficacy and fewest side-effects is a challenge in every case. A child’s prescribing physician (preferably, a child psychiatrist rather than a general practitioner or pediatrician) will aim to discover the medication and dose that’s best for your child. If one medication doesn’t appear to be working after a few weeks of treatment, a doctor will often try another medication. This is normal and most people will switch medications to find the one that works best for them at least once.

The side effects of stimulants may include reduced appetite, headache, a “jittery” feeling, irritability, sleep difficulties, gastrointestinal upset, increased blood pressure, depression or anxiety, and/or psychosis or paranoia. If you experience any of these symptoms, you should talk to your doctor.

Many parents may be concerned about having stimulant medications prescribed to their child. This is a typical concern amongst parents, but such medications are not addicting, nor do they produce a “high” in a person with ADHD who takes them. Researchers are still unclear as to why stimulant medications do not “over-stimulate” people who take them, but it is hypothesized that people with ADHD have a problem with certaieurotransmitters in their brain that the medication helps correct. We do not yet know exactly why some drugs help some people, but not others, nor the exact mechanism that makes stimulants effective. We do know that they work in most people who take them, effectively treating the symptoms of attention deficit disorder.

Medications Used to Treat ADHD

Stimulant medications commonly prescribed for attention deficit disorder include methylphenidate (Ritalin, Concerta, Metadate, Methylin) and certain amphetamines (Dexedrine, Dextrostat, Adderall). Methylphenidate is a short acting drug, and in older forms, had to be taken multiple times a day. Longer-acting versions of the drug are now available for once-daily use. Although taking stimulants for treatment may seem risky, there is significant research that demonstrates that when taken as directed by your psychiatrist or physician, they are safe and effective in the treatment of adult ADHD.

Drug treatment for ADHD began decades ago. Some of the best results have been found with the stimulant drugs listed below. “Approved age” means that the drug has been tested and found safe and effective in children of that age.

Trade Name	Generic Name	Approved Age
Adderall Adderall XR	amphetamine (extended release)	3 and older
Concerta	methylphenidate (long acting)	6 and older
Cylert*	pemoline	6 and older
Daytrana (patch)	methylphenidate	6 and older
Dexedrine Dextrostat	dextroamphetamine	3 and older
Focalin	dexmethylphenidate	6 and older
Metadate ER Metadate CD	methylphenidate (extended release)	6 and older
Ritalin Ritalin SR Ritalin LA	methylphenidate (extended release) (long acting)	6 and older
Strattera	atomextine	6 and older
Tenex, Intuniv #	guanfacine hydrochloride	12 and older
Vyvanse	lisdexamfetamine	6 and older
* – Because of its potential for serious side effects affecting the liver, Cylert should not ordinarily be considered as first-line drug therapy for ADHD. # – Tenex is short-term preparation and Intuniv is the long-term preparation brand name

Stimulant drugs are often beneficial in curbing hyperactivity and impulsivity, and helping the individual to focus, work, and learn. Sometimes the drugs will also help with coordination problems which may hinder sports and handwriting.

Under medical supervision, these stimulant drugs are quite safe and do not make the child feel “high”, although they may feel slightly different. To date, there is not convincing evidence that children risk becoming addicted to these drugs, when used for ADHD. In fact, a study at Massachusetts General Hospital and Harvard Medical School found that substance abuse rates were lower among teenagers with ADHD who stayed on their medication than those who stopped.

Many of the stimulant drugs come in short-term and long-term forms, and some are made as “sustained-release” — they are taken in the morning before school and are effective all day. The most suitable preparation for each child will be discussed by the parents and physician.

Even after adjusting the type and dosage of medications, about ten per cent of children will gaio benefit from stimulant drugs. In this case, other types of drug can be tried, such as antidepressants.

Occasionally a child may be prescribed a drug “off label”, meaning that its use in children, or for ADHD has not yet been approved by the FDA. This is common with newer drugs, many of which are given for ADHD. Later studies will produce better evidence on their safety and effectiveness.

Other, newer kinds of drugs, have also been approved for the treatment of attention deficit disorder. These non-stimulant medications include Strattera (atomoxetine, a selective norepinephrine reuptake inhibitor) and Vyvanse (lisdexamfetamine dimesylate). These drugs typically offer similar benefits to stimulants, but act in a different way on the brain. Some people may find they better tolerate these drugs.

Another useful category of drugs for adults with ADHD are the antidepressants, either alongside or instead of stimulants. Antidepressants which target the brain chemicals dopamine and norepinephrine are the most effective. These include the older form ofantidepressant known as the tricyclics, as well as new antidepressants, such as Venlafaxine (Effexor). The antidepressant Bupropion (Wellbutrin) has been found useful in trials of adult ADHD, and may also help reduce nicotine cravings.

ADHD Drug Side-effects

The majority of side-effects are minor and do not result in stopping the medication. They may be alleviated by lowering the dosage, but you should always consult the prescribing physician before making any changes to you or your child’s medication.

For most medications prescribed for attention deficit disorder, the most commonly observed side effects are:

• Decreased appetite – often low in the middle of the day and more normal by suppertime. Good nutrition is a priority
• Insomnia – may be relieved by taking the drug earlier in the day, or adding an antidepressant
• Increased anxiety and/or irritability
• Mild stomach aches or headaches
• Tics (more rare)

These medications only control ADHD symptoms on the day they are taken, so it’s important to remember that the disorder is not actually cured. While drugs can enable the child to use their skills more easily, an effort is still needed to improve schoolwork or knowledge in other areas.

As well as medication, behavioral therapy, emotional counseling, and practical support will also help a person with ADHD cope with the disadvantages of the disorder.

Helpful Hints About Medication:

• ADHD drugs can help a child focus and improve behavior in many settings
• They may help reduce or avoid emotional problems or addictions
• Four out of five children with ADHD will still need medication as teenagers, and over half as adults
• Children who also have bipolar disorder, and are taking drugs such as lithium or Depakote, may or may not be suitable for ADHD medication as well. If so, it may be given at a lower dose.

Research References

One of the large-scale studies that examined medication treatment for ADHD is called the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (or MTA). The MTA included 579 elementary school boys and girls with ADHD. Four treatment four treatment programs were compared: (1) medication management alone; (2) behavioral treatment alone; (3) a combination of both; or (4) routine community care.

Treatment was given for 14 months, during which the children were regularly assessed for ADHD symptoms by specialists and teachers.

The children on medication were seen by the prescribing physician once a month. Those given behavioral treatment met with a behavior therapist up to 35 times and attended a special 8-week summer camp. The routine community care group saw a community-treatment doctor, selected by the parents, once or twice a year.

The best improvements were seen in the group given combined treatments, and the group on medication alone. Of these, combined treatment led to the biggest improvements in anxiety, academic performance, oppositionality, parent-child relations, and social skills. In addition, some children in the combined group could be successfully treated on lower does of medication than those on medication alone.

Another NIMH-funded study investigated drug treatments for pre-schoolers with ADHD. The Treatment of Attention Deficit Hyperactivity Disorder in Preschool-Age Children (PATS) study included 165 children, aged 3 to 5.5 years. It examined the safety and efficacy of a stimulant drug called methylphenidate, which has been widely given to children under the age of 6, despite a lack of evidence on safety and efficacy.

The children appeared to benefit from low doses of methylphenidate, but 11 per cent stopped using the drug because of side-effects. The drug was effective at doses from 7.5 to 30 mg/day, with a mean optimal dose of 14.22 mg/day. (Average adult daily dosage is between 20 mg and 30 mg).

The researchers said that more children taking the drug showed a decrease of ADHD symptoms than did those on placebo. They suggest that preschoolers be started at low doses, and that further studies are needed to test higher doses.

Overall, 30 per cent of parents reported adverse events in their children, including emotional outbursts, difficulty falling asleep, repetitive behaviors/thoughts, irritability, and decreased appetite. But these may have been due as much to lack of medication efficacy as to the action of the drug, said the researchers.

Nevertheless, due to fears over side-effects, preschoolers with ADHD on methylphenidate treatment need to be carefully monitored, they concluded.

Additional Treatments 

If you use only medication to try and treat attention deficit hyperactivity disorder (ADHD), you’re likely to only get a partial response that does little to help the child or adult with all of the effects of living with ADHD. Psychotherapy and other specific therapeutic interventions are not only important options to consider — they are mandatory in order to treat the long-term issues that go hand-in-hand with attention deficit disorder.

Once some of the behavior problems are under control, the child may be better able to understand the challenges they may have caused to the people around them. Everyone involved can benefit from techniques to manage the past and present consequences of ADHD behavior, and counseling the child and the family group may offer a solution.

Parenting training has been shown to be an effective and an important component of any treatment of ADHD in children. Parents who have a child with an attention deficit disorder should look into getting such training from an ADHD coach or therapist with experience in helping parents with ADHD. These parent training exercises help the parent learn to help their child who has attention deficit disorder, keep their behavior on-task, and correct it in a positive and reinforcing manner wheeeded. Think of the TV show, “Super Nanny” — except that the therapist helps the parents learn how to best help their child with ADHD.

Psychotherapy for ADHD

We have decades’ worth of research demonstrating the effectiveness of a wide range of psychotherapies for the treatment of ADHD in both children and adults. Some people turn to psychotherapy instead of medication, as it is an approach that does not rely on taking stimulantmedications. Others use psychotherapy as an adjunct to medication treatment. Both approaches are clinically accepted.

In psychotherapy (commonly, cognitive-behavioral therapy for ADHD), the child can be helped to talk about upsetting thoughts and feelings, explore self-defeating patterns of behavior, learn alternative ways to handle emotions, feel better about him or herself despite the disorder, identify and build on their strengths, answer unhealthy or irrational thoughts, cope with daily problems, and control their attention and aggression. Such therapy can also help the family to better handle the disruptive behaviors, promote change, develop techniques for coping with and improving their child’s behavior.

Behavioral therapy is a specific type of psychotherapy that focuses more on ways to deal with immediate issues. It tackles thinking and coping patterns directly, without trying to understand their origins. The aim is behavior change, such as organizing tasks or schoolwork in a better way, or dealing with emotionally charged events when they occur. In behavior therapy, the child may be asked to monitor their actions and give themselves rewards for positive behavior such as stopping to think through the situation before reacting.

Psychotherapy will also help a person with attention deficit disorder to boost their self-esteem through improved self-awareness and compassion. Psychotherapy also offers support during the changes brought about through medication and conscious efforts to alter behavior, and can help limit any destructive consequences of ADHD.

Social Skills Training for ADHD

Social skills training teaches the behaviors necessary to develop and maintain good social relationships, such as waiting for a turn, sharing toys, asking for help, or certain ways of responding to teasing. These skills are usually not taught in the classroom or by parents — they are typically learned naturally by most children by watching and repeating other behaviors they see. But some children — especially those with attention deficit disorder — have a harder time learning these skills or using them appropriately.

Social skills training helps the child to learn and use these skills in a safe practice environment with the therapist (or parent).
Skills include learning how to have conversations with others, learning to see others’ perspective, listening, asking questions, the importance of eye contact, what body language and gestures are telling you.

Social skills training is done in a therapy office, or parents can learn them and teach them in the home. The therapist teaches the behaviors that are appropriate in different situations and then those new behaviors are practiced with the therapist. Clues that can be taken from people’s facial expressions and tone of voice may be discussed.

Support Groups for ADHD

Mutual self-help support groups can be very beneficial for parents and individuals with ADHD themselves. A sense of regular connection to others in the same boat leads to openness, problem-sharing, and sharing of advice. Concerns, fears and irritations can be released in a compassionate environment where members can safely let off steam and know that they are not alone.
As well as this type of support, the groups can invite experts to give lectures and answer specific questions. They can also help members to get referrals to reliable specialists.

Psych Central hosts two support groups online for people with attention deficit disorder: Psych Central ADHD support group andNeuroTalk’s ADHD support group.

Parenting Skills Training for ADHD

Parenting Skills Training provides parents with tools and techniques in order to manage their child’s behavior. For example, immediately rewarding good behavior with praise, tokens or points that can be exchanged for special privileges. Desirable and undesirable behavior is identified in advance by parents and/or teachers. Parents can try using “time-out” when the child becomes too unruly, but also sharing enjoyable quality time each day.

Through this system, the child’s behavior can often be effectively modified. They can be taught how to ask politely for objects rather than grabbing them, or to complete a simple task from start to finish. The expected behavior is made clear to the child so the decision of whether to earn the reward or not is in their hands. The rewards should be something that the child truly wants, and with ADHD children they may need to be given more often than with other children. Over time, the child will learn to associate good behavior with positive results, so will control their behavior naturally.

Some lessons from parenting skills training which are particularly relevant to ADHD are: to structure situations in ways that will allow the child to succeed (e.g. avoid allowing the child to get overstimulated), help the child divide large tasks into small steps, provide frequent and immediate rewards and punishment, set up a structure ahead of potentially problematic situations, and provide more supervision and encouragement during unrewarding or tedious situations.

The parents themselves can benefit from methods of stress management, including meditation, relaxation techniques and exercise.

Suggestions to help children with ADHD with organizing:

• Have the same schedule every day, from the moment the child wakes up until they go to sleep. The routine includes homework time and playtime. Keep it written down somewhere prominent, like the refrigerator door or a noticeboard. Changes should be planned well in advance.
• Use organizers for homework and other activities which need to be given thought. This will highlight the importance of writing assignments down, and gathering the necessary books.
• Keep everyday items in the same place, so they are easily found, “a place for everything and everything in its place”. Include clothing, bags and school items.

When consistent rules are in place, the child with ADHD is more likely to understand and follow them, at which point small rewards can be given. This may work particularly well if the child has previously become used to criticism.

Issues around schooling

The better informed you are as a parent, the more effective advocate you can be for your child. Take advice on how ADHD affects your child’s life at school, and meet with teachers to discuss management techniques.

Either way, teachers need to be kept up to date when a child is being assessed, diagnosed, and treated for ADHD, including behavior modification therapies, medications or a combination of both.

If you are unsure whether ADHD is the problem, you can either ask the local school district to conduct an evaluation, or you may prefer to seek the services of an outside professional.
When requesting that that the school system evaluates your child, send a letter including the date, your and your child’s names, and the reason for requesting an evaluation, and keep a copy of the letter in your own files.

It is now the law that schools must conduct an evaluation for ADHD if one is requested. This is their legal obligation, but if the school refuses to evaluate your child, you can either get a private evaluation or enlist some help in negotiating with the school.

Help is often as close as a local parent group. Each state has a Parent Training and Information (PTI) center as well as a Protection and Advocacy (P&A) agency.

Following diagnosis, the child will qualify for special education services. This includes a joint assessment between the school and parents, of the child’s strengths and weaknesses. After the assessment, an Individualized Educational Program (IEP) will be drawn up, which will be regularly reviewed and approved.

The transition to a new school year can be difficult, bringing with it a new teacher and new schoolwork. Your child will need lots of support and encouragement at this time, so never forget – you are your child’s best advocate.

ADHD in Adults

When people think about attention deficit disorder (ADHD), they usually consider it a childhood problem. However, a large proportion — between 30 and 70 percent — of children with the condition remain affected throughout adulthood.

In the late 1970s, the first studies were done into adult attention deficit disorder. Individuals were retrospectively diagnosed in their childhood through assessment by interview. As a result, standardized criteria were set down to help specialists diagnose ADHD in adults, called the Utah Criteria. These, and other newer tools such as the Conners Rating Scale and the Brown Attention Deficit Disorder Scale, combine data on personal history and current symptoms.

In general, adults with the condition will not have considered ADHD as an explanation for their problems, which may include poor organizational skills, bad time-keeping and lack of sustained attention. Their everyday lives can be full of challenges that are not experienced by adults without the disorder, so diagnosis can be a great relief.

ADHD Diagnosis in Adults

Because adults with ADHD do not usually believe they have the condition, it may take a specific event to trigger their suspicions. For example if their child is being assessed for or has been diagnosed with ADHD, or once the adult seeks medical advice for another issue such as anxiety, depression or an addiction.

For the diagnosis to be given to an adult, the individual must have symptoms which began in childhood and are ongoing up to the present. These may include distractibility, impulsivity and restlessness. Diagnosis must be accurate and is best undertaken by an expert in adult ADHD. It will include taking a personal history and often involve gathering information from one or more of the individual’s close relatives, friends or colleagues. The specialist will want to check for other undiagnosed conditions (such as learning disabilities, anxiety, or affective disorders), and may give a physical examination as well as the usual psychological tests.

Having been diagnosed with ADHD, an adult can start to make sense of the problems they may have suffered for a long time. It can help him let go of bad feelings about himself, and improve low self-esteem. It can also aid close relationships by giving others an explanation for unusual behaviors. To help face up to and overcome these issues, the individual may wish to begin psychotherapy or other counseling.

ADHD Treatment in Adults

Medical treatment for adult ADHD can be similar to that for children — many of the same stimulant drugs can be of benefit, including the newer drug Strattera (atomoxetine).

Another useful category of drugs for adults with ADHD are the antidepressants, either alongside or instead of stimulants. Antidepressants which target the brain chemicals dopamine and norepinephrine are the most effective. These include the older form ofantidepressant known as the tricyclics. In addition, the newer antidepressant drug Venlafaxine (Effexor) may be helpful. The antidepressant Bupropion (Wellbutrin) has been found useful in trials of adult ADHD, and may also help reduce nicotine cravings.

The effects of drugs can be different in adults and children. This must be taken into account when treating adult attention deficit disorder, as must any other medications which will be taken at the same time for psychological or physical conditions, so that adverse interactions are avoided.

As well as drug treatment, adults with ADHD can benefit from education and psychotherapy. Learning about the condition is likely to give a sense of empowerment. With assistance, the patient can devise techniques to counter the effects of the disorder. It may be a good idea to set up systems involving well-planned calendars, diaries, lists, notes, and official locations for important items such as keys and wallets. Paperwork systems can help reduce the potential confusion of bills and other vital documents and correspondence. Such routines will give a sense of order and achievement.

Psychotherapy can provide an opportunity to explore emotions related to ADHD, such as anger that the problem was not diagnosed much earlier. It may boost self-esteem through improved self-awareness and compassion, and offer support during the changes brought about through medication and conscious efforts to alter behavior and limit any destructive consequences of ADHD.

The therapist can also help their patient see the beneficial effects of high energy levels, spontaneity and enthusiasm that ADHD can bring.

Medications Used in the Treatment of Attention-Deficit / Hyperactivity Disorder

By JOHN M. GROHOL, PSY.D.

 

Many studies have documented the efficacy of stimulants in reducing the core symptoms of ADHD. In many cases, stimulant medication also improves the child’s ability to follow rules and decreases emotional overreactivity, thereby leading to improved relationships with peers and parents. The most powerful effects are found on measures of observable social and classroom behaviors and on core symptoms of attention, hyperactivity, and impulsivity. The effects on intelligence and achievement tests are more modest. Most studies of stimulants have been short-term, demonstrating efficacy over several days or weeks.

Despite the efficacy of stimulant medications in improving behaviors, many children who receive them do not demonstrate fully normal behavior (eg, only 38% of medically managed children in one study received scores in the normal range at 1-year follow-up). Although there is demonstrated efficacy of stimulants lasting at least to 14 months, the longer term effects of stimulants remain unclear, attributable in part to methodologic difficulties in other studies.

Stimulant medications currently available include short-, intermediate-, and long-acting methylphenidate, and short-, intermediate-, and long-acting dextroamphetamine. The McMaster report reviewed 22 studies and showed no differences comparing methylphenidate with dextroamphetamine or among different forms of these stimulants. Each stimulant improved core symptoms equally. Individual children, however, may respond to one of the stimulants but not to another. Recommended stimulants require no serologic, hematologic, or electrocardiogram monitoring.

Current evidence supports the use of only 2 other medications for ADHD, tricyclic antidepressants2 and bupropion. The use of nonstimulant medications falls outside this practice guideline, although clinicians should select tricyclic antidepressants after the failure of 2 or 3 stimulants and only if they are familiar with their use. Clonidine, one of the antihypertensive drugs occasionally used in the treatment of ADHD, also falls outside the scope of this guideline. Limited studies of clonidine indicate that it is better than placebo in the treatment of core symptoms (although with effect sizes lower than those for stimulants). Its use has been documented mainly in children with ADHDand coexisting conditions, especially sleep disturbances.

Detailed instructions for determining the dose and schedule of stimulant medications are beyond the scope of this guideline. However, a few basic principles guide the available clinical options.

Unlike most other medications, stimulant dosages usually are not weight dependent. Clinicians should begin with a low dose of medication and titrate upward because of the marked individual variability in the dose-response relationship. The first dose that a child’s symptoms respond to may not be the best dose to improve function. Clinicians should continue to use higher doses to achieve better responses. This strategy may require reducing the dose when a higher dose produces side effects or no further improvement. The best dose of medication for a given child is the one that leads to optimal effects with minimal side effects. The dosing schedules vary depending on target outcomes, although no consistent controlled studies compare different dosing schedules. For example, if there is a need for relief of symptoms only during school, a 5-day schedule may be sufficient. By contrast, a need for relief of symptoms at home and school suggests a 7-day schedule.

Stimulants are generally considered safe medications, with few contraindications to their use. Side effects occur early in treatment and tend to be mild and short-lived. The most common side effects are decreased appetite, stomachache or headache, delayed sleep onset, jitteriness, or social withdrawal. Most of these symptoms can be successfully managed through adjustments in the dosage or schedule of medication. Approximately 15% to 30% of children experience motor tics, most of which are transient, while on stimulant medications. In addition, approximately half of children with Tourette syndrome have ADHD. The effects of medication on tics are unpredictable.

Generic Class (Brand Name)	Daily Dosage Schedule	Duration	Prescribing Schedule
Stimulants (First-Line Treatment)
Methylphenidate
Short-acting (Ritalin, Methylin)	Twice a day (BID) to 3 times a day (TID)	3-5 hr	5-20 mg BID to TID
Intermediate-acting (Ritalin SR,     Metadate ER, Methylin ER)	Once a day (QD) to BID	3-8 hr	20-40 mg QD or 40 mg in the morning and 20 early afternoon
Long-acting (Concerta, Metadate     CD, Ritalin LA*)	QD	8-12 hr	18-72 mg QD
Amphetamine
Short-acting (Dexedrine, Dextrostat)	BID to TID	4-6 hr	5-15 mg BID or 5-10 mg TID
Intermediate-acting (Adderall,     Dexedrine spansule)	QD to BID	6-8 hr	5-30 mg QD or 5-15 mg BID
Long-acting (Adderall-XR*)	QD		10-30 mg QD
Antidepressants (Second-Line Treatment)
Tricyclics (TCAs)	BID to TID		2-5 mg/kg/day†
Imipramine, Desipramine
Bupropion
(Wellbutrin)	QD to TID		50-100 mg TID
(Wellbutrin SR)	BID		100-150 mg BID

 

If you’re a parent of a child who’s recently been diagnosed with attention deficit hyperactivity disorder (ADHD), you may be devastated and overwhelmed. If you’re an adult who’s recently been diagnosed, you may be going through “various stages of grief” after learning that your “lifelong difficulties caow be explained by a medical condition,” said Terry Matlen, MSW, ACSW, licensed psychotherapist and founder of ADD Consults. Fortunately, ADHD is highly treatable and whether one is diagnosed at 30 or 80, “your quality of life will change for the better,” Matlen said.

But knowing what treatments are effective and how to find them can seem just as overwhelming as the diagnosis. Here’s a clear-cut look at managing ADHD, from evaluation to treatment.

Common Misconceptions

• ADHD is over-diagnosed. “It really depends on the community; ADHD can be over-diagnosed in some communities and under-diagnosed in others,” said Arthur L. Robin, Ph.D, licensed psychologist and chief of psychology at the Children’s Hospital of Michigan. For instance, ADHD may be under-diagnosed in an inner city where no one talks about it, but over-diagnosed in an affluent suburban area, where parents are more aware of ADHD and may think their child has the condition if he or she isn’t doing well in school.
• Inattention, distractibility and impulsivity are character flaws. ADHD is a neurobiological disorder, and these “character flaws” are symptoms.
• You can will yourself out of ADHD. “The fact is, and research backs this, that the harder one tries, the worse the symptoms seem to get,” Matlen said.
• Children outgrow ADHD. “What people typically outgrow is the hyperactive part of ADHD. What remains is the inattentive and impulsive parts of the disorder which can cause impairments in academic, personal and occupational arenas,” said Adelaide Robb, M.D., associate professor of psychiatry and pediatrics at the Children’s National Medical Center in Washington, DC.

Diagnosis

“The best antidote to under-diagnosis and over-diagnosis is an appropriate evaluation,” Robin said. Pediatricians, who are at the frontline, don’t have the time necessary to conduct a comprehensive evaluation, so they may jump to conclusions and prescribe medication, he said. To avoid this, ask your pediatrician to help you find a mental health professional. Also, note that ADHD symptoms must occur across settings, including at school and home. Adults can ask their primary care physicians for a referral.

According to Robin, an appropriate evaluation entails: systematically reviewing ADHD symptoms from the DSM-IV with parents; getting input from teachers, who complete standardized rating scales; conducting a thorough interview with parents and children; and ruling out alternative explanations. To rule out learning disabilities or low cognitive ability, the practitioner administers an IQ and achievement test.

For diagnosis in adults see here.

Steps to Successful Treatment

1.     “Be thankful. ADHD is a condition that can be managed effectively when it is recognized and understood,” said Peter Jaksa, clinical psychologist and director of ADHD Centers in Chicago.

2.     Educate yourself about ADHD. Whether it’s you or your child, become an authority on ADHD. Read online resources (e.g.,Psych Central, Attention Deficit Disorder Association, Children and Adults with Attention Deficit/Hyperactivity Disorder); attendconferences ; and seek support groups.

For parents, learn about how ADHD affects your child “in school, socially and at home”; what parenting techniques work for kids with ADHD; and your child’s educational rights, Matlen said. For adults, understand your ADHD brain by cataloguing how ADHD impacts your daily functioning, Robin said. For some, the biggest impact is on organization, ability to follow through, short-termmemory and attention to details, he said. Does ADHD interfere with work, intimate relationships, parenting your kids?

3.     Talk to professionals about treatment options. Choose professionals who regularly see people with ADHD. Look at your treatment options as “tools in a tool chest to be used as needed across your life,” Robin said. These tools typically include medication, cognitive-behavioral therapy (CBT) and organizational strategies—an effective combination for treating ADHD.

4.     Become an advocate. “Parents are the most important and strongest advocates” for their kids, Jaksa said. Help kids “understand that they aren’t ‘dumb’—that their brains are simply wired differently,” Matlen said. “Meet with your child’s teachers before school starts to inform them about your child’s history and “discuss strategies that would be helpful for your child,” Jaksa said. If your child doesn’t have an Individualized Education Plan (IEP), talk to the principal and school psychologist about doing the evaluation, he said. Don’t be afraid to ask how therapy is going, Robin said. If it doesn’t seem successful, seek another therapist.

Disclosing Your Diagnosis

“People with ADHD should treat their personal ADHD information like any other kind — think about who should know and what that information could do, both in a positive or potentially negative way,” Matlen said. Telling loved ones may help them better understand what’s been going on and allow them to be helpful and supportive, she said. If loved ones don’t seem to understand, “give them articles, books and websites where they can learn more,” Matlen said.
At work, Sandy Maynard, M.S., an ADHD coach who operates Catalyst Coaching, advises against disclosing your diagnosis. Instead, identify “what you need to perform better” and ask for it, she said. A boss will rarely refuse a reasonable accommodation.

Treatment

ADHD “is a lifelong condition that doesn’t go away, so managing it is a lifelong responsibility”; however, this doesn’t mean that individuals will need medication or therapy forever, Jaksa said. “There are millions of people with ADHD living productive, happy lives who have learned how to manage it well and no longer need professional treatment, or only need treatment for a brief time to deal with challenging life changes,” he said.

Psychotherapy

Traditional talk therapies that focus on insight and support are ineffective for ADHD. The best approach is for therapists to use evidence-based manuals, which research has shown are effective—like CBT—and adapt them to individual cases, Robin said. “The therapy needs to be more behavioral, practical and goal directed,” Jaksa said.

CBT targets maladaptive thoughts and behaviors. A therapist helps individuals move from “I caever be successful” to “I may have failed at some things, but I can make changes.” When procrastination is a problem, a therapist will help “develop prompts, reminders, schedules, time management tools to accomplish major tasks,” Robin said.

You’ll work on prioritizing, problem solving and picking the best solution, said Steven A Safren, Ph.D., director of behavioral medicine at Harvard Medical School and co-author of Mastering Your Adult ADHD. “We try to make people know what they need to do. If they decide not to do it that’s a rational decision, vs. a surprise of backed-up bills, taxes and homework,” he said. Therapy also may address low self-esteem,anxiety and depression, as these commonly co-occur with ADHD.

The length of therapy depends on the type of patient and the presence of co-occurring conditions, which can prolong treatment. Adults seeking therapy to improve organization, time management and defeating thoughts can see improvement in 10 to 12 sessions with CBT, Robin said. Sessions are once a week or every other week. With younger patients, therapists mainly work with parents on management strategies. Modifying behavior and improving school functioning typically takes about 10 to 15 sessions over four to six months, he said. For teens, 18 sessions is recommended, which Robin and his colleagues outline in the manual, Defiant Teens.

Learn more about childhood treatment here.

Common Challenges in Psychotherapy

• Teens. Adolescents usually don’t want to attend therapy, said Robin, co-author of Your Defiant Teen: 10 Steps to Resolve Conflict and Rebuild Your Relationship. They may be in denial about their diagnosis and refuse to deal with it. Instead of being confrontational, Robin finds what the teen is passionate about (e.g., sports) and discusses how ADHD may improve that interest.
• Appointments. Patients commonly forget their therapy appointments. This is why it’s important to start treatment by creating a calendar system—it facilitates therapy—which Safren’s CBT model does.
• Tasks. Individuals have difficulty completing tasks between sessions, because they simply forget. Some of Robin’s patients “take brief notes during the therapy session and clearly summarize the action steps to take before the session,” he said.
• Relationships. Patients’ significant others may misconstrue their behavior and believe the patient isn’t motivated to change, not realizing that ADHD is to blame, Robin said. Bringing your significant other to therapy can help tremendously.

Medication

Pharmacological therapy usually follows these steps:

• Selecting a medication. “Many adults will benefit from the samemedications as benefit kids with ADHD,” Robin said. “Selecting medication includes gathering information about other blood relatives with the same disorder who responded well or poorly to a specific condition,” said Dr. Robb, the psychiatrist at Children’s National Medical Center.

When patients take their medication depends on how ADHD impairs them, Robin said. Work with your physician to identify the purpose of your medication. Children typically take medication to improve school performance, social interactions and impulsive behavior, he said. Some of the adults Robin works with are mostly concerned about positive interactions and “not losing their cool with their spouses and kids.” They take medication in the evenings and weekends. Other adults have difficulty focusing on work, so they take medication during the day.

• Starting medication. The doctor prescribes medication at its lowest dose to minimize side effects “titrated up to a target and or maximum dose until ADHD symptoms improve or side effects become troublesome,” Dr. Robb said.
• Seeing improvement. Two-thirds of individuals starting on a stimulant will experience a “good result” with the first medication, she said. You’ll typically notice an improvement in attention and concentration and reductions in hyperactivity, physical restlessness, impulsivity and “activation difficulties”—easier-to-start tasks patients usually avoid, Jaksa said. Of individuals starting Strattera, three-fifths will have a good result, Dr. Robb said.
  For information on medication in children, check out this parent-friendly guide.

Concerns about Medication

People have various concerns about medication, including worries that it leads to dependence and substance abuse, can stunt growth and increase the risk for suicide and cardiovascular problems.

“If the person is taking the right medication, at the right dosage level for him or her, the side effects of stimulants tend to be pretty mild – some appetite loss, maybe trouble falling asleep, some increase in blood pressure for some individuals,” Jaksa said.

According to research and clinical experience, when stimulant medication is taken properly, it isn’t physically addictive, he said. In fact, “People with ADHD who are properly medicated have less substance abuse, and less risk for future abuse, than those who are not medicated,” Jaksa said. He added that ADHD medications will not stunt a child’s growth as long as the child is receiving proper nutrition.
If patients are taking medications that increase the risk for suicide, they “should be monitored for those thoughts,” Dr. Robb said. Before medication is started, the physician should obtain a familial history of “cardiovascular risks, including fainting episodes and change in exercise tolerance,” she said. If taking stimulants, adults with heart disease or high blood pressure “should be followed closely by their cardiologist/internist.”

Maximizing Medication

Tips for taking medication safely and effectively include:

• Take it consistently.
• Never adjust the dose without medical supervision.
• Communicate with your doctor.
• Disclose if you’re taking any “vitamin/herbal supplements, over-the-counter medications and prescription medications, and if you’ve developed a new medical condition (e.g., asthma),” Dr. Robb said.
• Make medication part of your daily routine (e.g., take it after breakfast), Jaksa said. Use reminders: Carry a pill box, set the alarm on your watch or have backup medication at school or work, Safren said.
• Avoid alcohol and illicit drugs.

ADHD Coaches

An ADHD coach also can become an integral part of your treatment team. A coach provides individuals with strategies and tools to accomplish their goals and overcome challenges. “A coach can be there in the moment,” Robin said. One of the coaches Robin collaborates with holds weekly homework sessions to help teens complete schoolwork effectively.

When choosing a qualified coach, get professional testimonials (from psychologists or psychiatrists) and ask about educational background. Look for a relevant degree such as psychology or education, which serves as a foundation for coaching. Ask about conferences the coach attends and how many ADHD clients he or she sees, said Maynard, who was instrumental in developing The National Attention Deficit Disorder Association’s coaching guidelines.

For more information on coaching and how it differs from therapy, seehere.

Pitfalls and Pointers

Everyone is bound to make mistakes when managing ADHD or parentinga child with ADHD. Here’s a list of common pitfalls followed by practical solutions:

• Slacking off on organizational and time management tools, leading to “a slow downward spiral,” Maynard said.

Fix this by using the system until it becomes automatic, Safren said. As a reminder, create a list of current goals and email them to yourself at random times, as one of Maynard’s clients does.

• Snapping at a loved one or colleague; being passive-aggressive.

For starters, make sure you’re getting enough sleep, nutrition and exercise, all of which help our moods, Maynard said. For instance, exhaustion can exacerbate anger.

Identify your triggers and intervene, she said. Try relaxing your shoulders, counting to 10 or taking deep breaths. Instead of talking “in the heat of the moment,” say “I need a time out,” Robin said. Instead of shooting off an email, put it in your draft folder and read it when you’ve calmed down, Maynard said.

• Forgetting things, especially when leaving the house.

Before flying out the door, “pat down” (Do I have my keys, cell phone, wallet and planner?), “look around” (“what have I left behind? Is the oven off?”) and “think about” (“what was I just doing?” and “what am I doing next?”), Maynard said. Apply this to work: After a meeting, immediately review your calendar and consider what you need to do next.

• Trying to reason with children age 10 or younger.

Apply positive and negative consequences, Robin said. For more information on behavioral strategies, see here.

• Grounding a child for bad grades.

This doesn’t improve a child’s school performance. Instead, create consequences that will do so, such as “do 20 minutes of extra math problems every day,” Robin said.

• Doing just one more thing before you leave.

Set a schedule at the beginning of the day, and train yourself to stick to it no matter what, Robin said.

• Hopping from one paper topic to the fifth.

Though you may know more about these subjects than the professor, you still receive an F, because you never submitted the assignment. Define the objective of your project; break it down into definable pieces and ask the professor for suggestions on approaching the project, Maynard said. At work, consult your colleagues or boss about how to approach the project.

General Tips

• Get enough sleep. “ADHD symptoms worsen with lack of sleep,” Matlen said. Stay away from stimulating activities (such as computer games or TV) at least one hour before bed, find boring things to help slow down the brain and write down thoughts and plans to reduce ruminating in bed, she said. Keep a regular sleep schedule.
• Get regular exercise. This is dismissed as just another common piece of advice, but “studies show that exercise does help with cognition, memory, hyperactivity and more,” Matlen said.
• Get help. Whether it’s hiring a professional organizer, ADD coach or babysitter—even when you’re at home—“allow yourself to get help,” said Matlen, author of Survival Tips for Women with ADHD.
• Re-evaluate expectations. Societal expectations for women are endless, from the perfect mom to the flawless homemaker. “As Dr. Ned Hallowell says, ‘just be organized enough,’ meaning don’t beat yourself up if you can’t keep your house immaculate. Just keep things organized enough so you can get by,” said Matlen, who also co-hosts a website for women with ADHD.
• Boost self-confidence. ADHD can shatter self-esteem. To cultivate confidence, Maynard suggested: Stay focused on accomplishments, not shortfalls; don’t compare yourself to others; pat yourself on the back when others don’t; view mistakes as learning experiences; and choose friends wisely, avoiding overly critical or judgmental people.
• Make tasks meaningful. To complete tasks, individuals usually need to be excited and engaged. “Find a way to make that task meaningful for you to stay motivated and follow through,” Maynard said.
• Show up. If you’re unable to focus, your first instinct is to skip class. Instead, “suit up and show up, because you will walk away with something and learn,” Maynard said.
• Study smarter. When studying, “know yourself,” she said. Ask yourself: “How do I study best — in my dorm or the library; with a partner or alone; early in the morning or in the afternoon?”
• Avoid multitasking and discard distractions. Before starting a project, identify things that disrupt your concentration, Maynard said. It also may help to quantify your attention span. Time how long you pay attention to a task, and then try working on the task for that long, Safren said.
• Prepare for the worst. Though you can’t plan for everything, think about your worst-case scenario and how you can prevent it, Maynard said. For instance, you may keep your calendar on your computer and cell phone and own a hard copy.

Is There an ADD Epidemic in Adults?

Do you procrastinate? Do you have trouble with self-discipline, focus and motivation? Are you sometimes forgetful? If the answer is yes, then join the club!

Most of us recognize these as some of the symptoms of ADD or Attention Deficit Disorder. (OMG – maybe we all have ADD.)

But these struggles are not the exclusive domain of ADD. Difficulty getting things done and falling prey to distraction, a wandering mind and temptation is a reality for most of us at times. And, of course, it’s all compounded by the constant lure of digital distractions.

With ADD, however, overcoming these obstacles is not simply a matter of choice, Here, lack of capacity can trump the best intentions to use willpower and self-discipline to stay on track, Further, ADD deficits often cause longstanding effects on career and relationships, leading to underachievement, and a chronic sense of frustration, shame, and failure.

ADD is a neurobiological syndrome beginning in childhood that is chronic, pervasive, and hard-wired, with a strong genetic component (Barkley, 2010, Hallowell, 2005). Research indicates that about four percent of adults in the U.S. have ADD (Hallowell, 2005). ADD symptoms also include forgetfulness, impulsivity and difficulties with organization, time management, staying on task, and shifting attention — being able to unglue oneself from a task or knowing when to stop (Barkley, 2010).

ADD symptoms are essentially executive function deficits, interfering with the ability to follow through on conscious intentions and sustain future- or goal-directed activity. Researchers have called ADD a condition of “nearsightedness” (Barkley, 2006, p. 56) with regard to time. ADD creates a blind spot for the future, often leading to short-sighted decisions and procrastination (Barkley, 2006).

Seventy-five percent of people with ADD have at least one other co-existing condition, usually anxiety, depression, or substance abuse. Although medicine helps 80 percent of people with ADD, lack of response or worsening of symptoms may occur when untreated co-existing conditions are mistakenly attributed to ADD (Hallowell, 2005).

For example: Jenny held a high-status academic position. In her struggle with ADD, she was most affected by distractability and procrastination, often surfing the web for interesting political news instead of doing her work.

Jenny was raised by a very critical father who shamed her when she didn’t meet his expectations, or when she asked a question he thought was stupid. Although ADD was an aspect of Jenny’s problem, even with structure and medication, it did not remit until she addressed the psychological issues driving her avoidance.

Jenny internalized the perfectionism imposed on her by her dad, along with a sense of inadequacy, shame, and fear of disapproval. She was easily triggered into a flood of anxiety around her work, fearing she’d be exposed as an imposter. This led to cycles of inertia, shame and further avoidance. When Jenny could recognize and change the inner critical voice in her head modeled after her dad, she lowered the stakes she set for her performance, and could make use of strategies to treat her ADD.

Structural and biochemical differences in ADD brains limit the capacity to regulate oneself, or have self-control. It makes it difficult to initiate, persevere, or stop behavior so that actions are in line with one’s future goals, rather than immediate impulses. Further, depletion of dopamine, a neurotransmitter involved in the experience of pleasure and reward, creates difficulty sustaining a feeling of vitality, contributing to a pull toward behaviors that provide stimulation or an adrenaline rush.

Some researchers have found that the secret to harnessing the energy of the ADD mind is finding a naturally compelling creative outlet where focus comes easily. Successful adaptation involves compensation for deficits, for example, by finding environments compatible with the strengths of the ADD brain. Such environments are often fast-paced, intellectually or physically stimulating, or structured, perhaps with regular deadlines paced at short intervals.

Work that requires intense energy, here-and-now attention, independent thinking, imagination and tenacity may also capitalize on ADD assets. Most important, educating ourselves and our loved ones about ADD is essential to prevent needless judgment, shaming, and self-blame that are common with this condition. Then, instead, we will be in a position to harness the unique, inspired energy of the ADD mind.

 

 

 

 

Autism

Autism. Not until the middle of the twentieth century was there a name for a disorder that now appears to affect an estimated 3.4 every 1,000 children ages 3-10, a disorder that causes disruption in families and unfulfilled lives for many children. Research from 2009 suggests autism now affects every 1 in 110 children.

In 1943 Dr. Leo Kanner of the Johns Hopkins Hospital studied a group of 11 children and introduced the label early infantile autism into the English language. At the same time a German scientist, Dr. Hans Asperger, described a milder form of the disorder that became known as Asperger syndrome.

Thus these two disorders were described and are today listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as two of the five pervasive developmental disorders (PDD), more often referred to today as autism spectrum disorders (ASD). All these disorders are characterized by varying degrees of impairment in communication skills, social interactions, and restricted, repetitive and stereotyped patterns of behavior.

Autism spectrum disorders can often be reliably detected by the age of 3 years, and in some cases as early as 18 months. Studies suggest that many children eventually may be accurately identified by the age of 1 year or even younger. The appearance of any of the warning signs of ASD is reason to have a child evaluated by a professional specializing in these disorders.

Parents are usually the first to notice unusual behaviors in their child. In some cases, the baby seemed “different” from birth, unresponsive to people or focusing intently on one item for long periods of time. The first signs of an ASD can also appear in children who seem to have been developing normally. When an engaging, babbling toddler suddenly becomes silent, withdrawn, self-abusive, or indifferent to social overtures, something is wrong. Research has shown that parents are usually correct about noticing developmental problems, although they may not realize the specific nature or degree of the problem.

The pervasive developmental disorders, or autism spectrum disorders, range from a severe form, called autistic disorder, to a milder form, Asperger syndrome. If a child has symptoms of either of these disorders, but does not meet the specific criteria for either, the diagnosis is called pervasive developmental disorder not otherwise specified (PDD-NOS). Other rare, very severe disorders that are included in the autism spectrum disorders are Rett syndrome andchildhood disintegrative disorder. This brochure will focus on classic autism, PDD-NOS, and Asperger syndrome, with brief descriptions of Rett syndrome and childhood disintegrative disorder below.

Prevalence of Autism

In 2007 — the most recent government survey on the rate of autism — the Centers for Disease Control (CDC) found that the rate is higher than the rates found from studies conducted in the United States during the 1980s and early 1990s (survey based on data from 2000 and 2002). The CDC survey assigned a diagnosis of autism spectrum disorder based on health and school records of 8 year olds in 14 communities throughout the U.S. Debate continues about whether this represents a true increase in the prevalence of autism. Changes in the criteria used to diagnose autism, along with increased recognition of the disorder by professionals and the public may all be contributing factors. Nonetheless, the CDC report confirms other recent epidemiologic studies documenting that more children are being diagnosed with an ASD than ever before.

Data from an earlier report of the CDC’s Atlanta-based program found the rate of autism spectrum disorder was 3.4 per 1,000 for children 3 to 10 years of age. Summarizing this and several other major studies on autism prevalence, CDC estimates that 2-6 per 1,000 (from 1 in 500 to 1 in 150) children have an ASD. The risk is 3-4 times higher in males than females. Compared to the prevalence of other childhood conditions, this rate is lower than the rate of mental retardation (9.7 per 1,000 children), but higher than the rates for cerebral palsy (2.8 per 1,000 children), hearing loss (1.1 per 1,000 children), and vision impairment (0.9 per 1,000 children).3 The CDC notes that these studies do not provide a national estimate.

Autism Spectrum Disorders In-Depth

The autism spectrum disorders are more common in children and teens than are some better known disorders such as diabetes, spinal bifida, or Down syndrome. A recent study of a U.S. metropolitan area estimated that 3.4 of every 1,000 children 3-10 years old had autism. Research from 2009 suggests autism now affects every 1 in 110 children. And that number appears to be only increasing. Autism is on the rise.

The earlier the disorder is diagnosed, the sooner a child can be helped through treatment interventions. Pediatricians, family physicians, daycare providers, teachers, and parents may initially dismiss signs of autism spectrum disorders (ASD), optimistically thinking the child is just a little slow and will “catch up.” However, early detections and intervention can make a big difference in the life of a child with autism.

Children with autism demonstrate deficits in three primary areas:

1.     Social interaction

2.     Verbal and nonverbal communication, and

3.     Repetitive behaviors or interests

In addition, they will often have unusual responses to sensory experiences, such as certain sounds or the way objects look. Each of these symptoms runs the gamut from mild to severe. They will present in each individual child differently. For instance, a child may have little trouble learning to read but exhibit extremely poor social interaction. Each child will display communication, social, and behavioral patterns that are individual but fit into the overall diagnosis of ASD.

Children with ASD do not follow the typical patterns of child development. In some children, hints of future problems may be apparent from birth. In most cases, the problems in communication and social skills become more noticeable as the child lags further behind other children the same age. Some other children start off well enough. Oftentimes between 12 and 36 months old, the differences in the way they react to people and other unusual behaviors become apparent. Some parents report the change as being sudden, and that their children start to reject people, act strangely, and lose language and social skills they had previously acquired. In other cases, there is a plateau, or leveling, of progress so that the difference between the child with autism and other children the same age becomes more noticeable.

ASD is defined by a certain set of behaviors that can range from the very mild to the severe. The following possible indicators of ASD were identified on the Public Health Training Network Webcast, Autism Among Us.

Indicators of Autism Spectrum Disorders

• Does not babble, point, or make meaningful gestures by 1 year of age
• Does not speak one word by 16 months
• Does not combine two words by 2 years
• Does not respond to name
• Loses language or social skills

Some Other Indicators:

• Poor eye contact
• Doesn’t seem to know how to play with toys
• Excessively lines up toys or other objects
• Is attached to one particular toy or object
• Doesn’t smile
• At times seems to be hearing impaired

Social Symptoms of Autism

 

From the start, typically developing infants are social beings. Early in life, they gaze at people, turn toward voices, grasp a finger, and even smile.

In contrast, most children with ASD seem to have tremendous difficulty learning to engage in the give-and-take of everyday human interaction. Even in the first few months of life, many do not interact and they avoid eye contact. They seem indifferent to other people, and often seem to prefer being alone. They may resist attention or passively accept hugs and cuddling. Later, they seldom seek comfort or respond to parents’ displays of anger or affection in a typical way. Research has suggested that although children with ASD are attached to their parents, their expression of this attachment is unusual and difficult to “read.” To parents, it may seem as if their child is not attached at all. Parents who looked forward to the joys of cuddling, teaching, and playing with their child may feel crushed by this lack of the expected and typical attachment behavior.

Children with ASD also are slower in learning to interpret what others are thinking and feeling. Subtle social cues—whether a smile, a wink, or a grimace—may have little meaning. To a child who misses these cues, “Come here” always means the same thing, whether the speaker is smiling and extending her arms for a hug or frowning and planting her fists on her hips. Without the ability to interpret gestures and facial expressions, the social world may seem bewildering. To compound the problem, people with ASD have difficulty seeing things from another person’s perspective. Most 5-year-olds understand that other people have different information, feelings, and goals than they have. A person with ASD may lack such understanding. This inability leaves them unable to predict or understand other people’s actions.

Although not universal, it is common for people with autism spectrum disorders also to have difficulty regulating their emotions. This can take the form of “immature” behavior such as crying in class or verbal outbursts that seem inappropriate to those around them. The individual with ASD might also be disruptive and physically aggressive at times, making social relationships still more difficult. They have a tendency to “lose control,” particularly when they’re in a strange or overwhelming environment, or when angry and frustrated. They may at times break things, attack others, or hurt themselves. In their frustration, some bang their heads, pull their hair, or bite their arms.

Communication Difficulties in Autism

By age 3, most children have passed predictable milestones on the path to learning language; one of the earliest is babbling. By the first birthday, a typical toddler says words, turns when he hears his name, points when he wants a toy, and when offered something distasteful, makes it clear that the answer is “no.”

Some children diagnosed with autism spectrum disorders remain mute throughout their lives. Some infants who later show signs of ASD coo and babble during the first few months of life, but they soon stop. Others may be delayed, developing language as late as age 5 to 9. Some children may learn to use communication systems such as pictures or sign language.

Those who do speak often use language in unusual ways. They seem unable to combine words into meaningful sentences. Some speak only single words, while others repeat the same phrase over and over. Some ASD children parrot what they hear, a condition called echolalia. Although many children with no ASD go through a stage where they repeat what they hear, it normally passes by the time they are 3.

Some children only mildly affected may exhibit slight delays in language, or even seem to have precocious language and unusually large vocabularies, but have great difficulty in sustaining a conversation. The “give and take” of normal conversation is hard for them, although they often carry on a monologue on a favorite subject, giving no one else an opportunity to comment. Another difficulty is often the inability to understand body language, tone of voice, or “phrases of speech.” They might interpret a sarcastic expression such as “Oh, that’s just great” as meaning it really IS great.

While it can be hard to understand what ASD children are saying, their body language is also difficult to understand. Facial expressions, movements, and gestures rarely match what they are saying. Also, their tone of voice fails to reflect their feelings. A high-pitched, sing-song, or flat, robot-like voice is common. Some children with relatively good language skills speak like little adults, failing to pick up on the “kid-speak” that is common in their peers.

Without meaningful gestures or the language to ask for things, people with ASD are at a loss to let others know what they need. As a result, they may simply scream or grab what they want. Until they are taught better ways to express their needs, ASD children do whatever they can to get through to others. As people with ASD grow up, they can become increasingly aware of their difficulties in understanding others and in being understood. As a result they may become anxious or depressed.
Repetitive Behaviors

Although children with ASD usually appear physically normal and have good muscle control, odd repetitive motions may set them off from other children. These behaviors might be extreme and highly apparent or more subtle. Some children and older individuals spend a lot of time repeatedly flapping their arms or walking on their toes. Some suddenly freeze in position.

As children, they might spend hours lining up their cars and trains in a certain way, rather than using them for pretend play. If someone accidentally moves one of the toys, the child may be tremendously upset. ASD childreeed, and demand, absolute consistency in their environment. A slight change in any routine—in mealtimes, dressing, taking a bath, going to school at a certain time and by the same route—can be extremely disturbing. Perhaps order and sameness lend some stability in a world of confusion.

Repetitive behavior sometimes takes the form of a persistent, intense preoccupation. For example, the child might be obsessed with learning all about vacuum cleaners, train schedules, or lighthouses. Often there is great interest iumbers, symbols, or science topics.

SYMPTOMS

A total of six (or more) items from (a), (b), and (c), with at least two from (a), and one each from (b) and (c):

·         qualitative impairment in social interaction, as manifested by at least two of the following:

o    marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction

o    failure to develop peer relationships appropriate to developmental level

o    a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)

o    lack of social or emotional reciprocity

·         qualitative impairments in communication as manifested by at least one of the following:

o    delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)

o    in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others

o    stereotyped and repetitive use of language or idiosyncratic language

o    lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level

·         restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:

o    encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus

o    apparently inflexible adherence to specific, nonfunctional routines or rituals

o    stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)

o    persistent preoccupation with parts of objects

Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.

The disturbance is not better accounted for by Rett’s Disorder or Childhood Disintegrative Disorder.  

Conditions Associated with Autism

There are a number of concerns that often accompany someone with autism spectrum disorders (ASD), otherwise known as autism.

Sensory Problems

When children’s perceptions are accurate, they can learn from what they see, feel, or hear. On the other hand, if sensory information is faulty, the child’s experiences of the world can be confusing. Many ASD children are highly attuned or even painfully sensitive to certain sounds, textures, tastes, and smells. Some children find the feel of clothes touching their skin almost unbearable. Some sounds—a vacuum cleaner, a ringing telephone, a sudden storm, even the sound of waves lapping the shoreline—will cause these children to cover their ears and scream.

In ASD, the brain seems unable to balance the senses appropriately. Some ASD children are oblivious to extreme cold or pain. An ASD child may fall and break an arm, yet never cry. Another may bash his head against a wall and not wince, but a light touch may make the child scream with alarm.

Mental Retardation

Many children with autism spectrum disorders have some degree of mental impairment. When tested, some areas of ability may be normal, while others may be especially weak. For example, a child with ASD may do well on the parts of the test that measure visual skills but earn low scores on the language subtests.

Seizures

One in four children with ASD develops seizures, often starting either in early childhood or adolescence. 5 Seizures, caused by abnormal electrical activity in the brain, can produce a temporary loss of consciousness (a “blackout”), a body convulsion, unusual movements, or staring spells. Sometimes a contributing factor is a lack of sleep or a high fever. An EEG (electroencephalogram—recording of the electric currents developed in the brain by means of electrodes applied to the scalp) can help confirm the seizure’s presence.

In most cases, seizures can be controlled by a number of medicines called “anticonvulsants.” The dosage of the medication is adjusted carefully so that the least possible amount of medication will be used to be effective.

Fragile X Syndrome

This disorder is the most common inherited form of mental retardation. It was so named because one part of the X chromosome has a defective piece that appears pinched and fragile when under a microscope. Fragile X syndrome affects about two to five percent of people with ASD. It is important to have a child with ASD checked for Fragile X, especially if the parents are considering having another child. For an unknown reason, if a child with ASD also has Fragile X, there is a one-in-two chance that boys born to the same parents will have the syndrome. 6 Other members of the family who may be contemplating having a child may also wish to be checked for the syndrome.

A distinction can be made between a father’s and mother’s ability to pass along to a daughter or son the altered gene on the X chromosome that is linked to fragile X syndrome. Because both males (XY) and females (XX) have at least one X chromosome, both can pass on the mutated gene to their children.

A father with the altered gene for Fragile X on his X chromosome will only pass that gene on to his daughters. He passes a Y chromosome on to his sons, which doesn’t transmit the condition. Therefore, if the father has the altered gene on his X chromosome, but the mother’s X chromosomes are normal, all of the couple’s daughters would have the altered gene for Fragile X, while none of their sons would have the mutated gene. Because mothers pass on only X chromosomes to their children, if the mother has the altered gene for Fragile X, she can pass that gene to either her sons or her daughters. If the mother has the mutated gene on one X chromosome and has one normal X chromosome, and the father has no genetic mutations, all the children have a 50-50 chance of inheriting the mutated gene.

The odds noted here apply to each child the parents have 7 in terms of prevalence, the latest statistics are consistent in showing that 5% of people with autism are affected by fragile X and 10% to 15% of those with fragile X show autistic traits.

Tuberous Sclerosis

Tuberous sclerosis is a rare genetic disorder that causes benign tumors to grow in the brain as well as in other vital organs. It has a consistently strong association with ASD. One to 4 percent of people with ASD also have tuberous sclerosis.

How Autism is Diagnosed

Although there are many concerns about labeling a young child with anautism spectrum disorder, the earlier the diagnosis of autism is made, the earlier needed interventions can begin. Evidence over the last 15 years indicates that intensive early intervention in optimal educational settings for at least 2 years during the preschool years results in improved outcomes in most young children with autism spectrum disorders.

In evaluating a child, clinicians rely on behavioral characteristics to make a diagnosis. Some of the characteristic behaviors of autism spectrum disorders (ASD) may be apparent in the first few months of a child’s life, or they may appear at any time during the early years. For the diagnosis, problems in at least one of the areas of communication, socialization, or restricted behavior must be present before the age of 3. The diagnosis requires a two-stage process. The first stage involves developmental screening during “well child” check-ups; the second stage entails a comprehensive evaluation by a multidisciplinary team.

Autism Screening

A “well child” check-up should include a developmental screening test. If your child’s pediatrician does not routinely check your child with such a test, ask that it be done. Your own observations and concerns about your child’s development will be essential in helping to screen your child. Reviewing family videotapes, photos, and baby albums can help parents remember when each behavior was first noticed and when the child reached certain developmental milestones.

Several screening instruments have been developed to quickly gather information about a child’s social and communicative development within medical settings. Among them are the Checklist of Autism in Toddlers (CHAT), the modified Checklist for Autism in Toddlers (M-CHAT),11 the Screening Tool for Autism in Two-Year-Olds (STAT), and the Social Communication Questionnaire (SCQ) (for children 4 years of age and older).

Some screening instruments rely solely on parent responses to a questionnaire, and some rely on a combination of parent report and observation. Key items on these instruments that appear to differentiate children with autism from other groups before the age of 2 include pointing and pretend play. Screening instruments do not provide individual diagnosis but serve to assess the need for referral for possible diagnosis of ASD. These screening methods may not identify children with mild autism, such as those with high-functioning autism or Asperger syndrome.

During the last few years, screening instruments have been devised to screen for Asperger syndrome and higher functioning autism. The Autism Spectrum Screening Questionnaire (ASSQ),14 the Australian Scale for Asperger’s Syndrome, and the most recent, the ChildhoodAsperger Syndrome Test (CAST), are some of the instruments that are reliable for identification of school-age children with Asperger syndrome or higher functioning autism. These tools concentrate on social and behavioral impairments in children without significant language delay.

If, following the screening process or during a routine “well child” check-up, your child’s doctor sees any of the possible indicators of ASD, further evaluation is indicated.

The Diagnostic Evaluation of Autism

The second stage of diagnosis must be comprehensive in order to accurately rule in or rule out an ASD or other developmental problem. This evaluation may be done by a multidisciplinary team that includes a psychologist, a neurologist, a psychiatrist, a speech therapist, or other professionals who diagnose children with autism.

Because ASDs are complex disorders and may involve other neurological or genetic problems, a comprehensive evaluation should entail neurologic and genetic assessment, along with in-depth cognitive and language testing. In addition, measures developed specifically for diagnosing autism are often used. These include the Autism Diagnosis Interview-Revised (ADI-R)17 and the Autism Diagnostic Observation Schedule (ADOS-G).

The ADI-R is a structured interview that contains over 100 items and is conducted with a caregiver. It consists of four main factors—the child’s communication, social interaction, repetitive behaviors, and age-of-onset symptoms. The ADOS-G is an observational measure used to “press” for socio-communicative behaviors that are often delayed, abnormal, or absent in children with ASD.

Still another instrument often used by professionals is the Childhood Autism Rating Scale (CARS). It aids in evaluating the child’s body movements, adaptation to change, listening response, verbal communication, and relationship to people. It is suitable for use with children over 2 years of age. The examiner observes the child and also obtains relevant information from the parents. The child’s behavior is rated on a scale based on deviation from the typical behavior of children of the same age.

Two other tests that should be used to assess any child with a developmental delay are a formal audiologic hearing evaluation and a lead screening. Although some hearing loss can co-occur with ASD, some children with an autism spectrum disorder may be incorrectly thought to have such a loss. In addition, if the child has suffered from an ear infection, transient hearing loss can occur. Lead screening is essential for children who remain for a long period of time in the oral-motor stage in which they put any and everything into their mouths. Children with an autistic disorder usually have elevated blood lead levels.

Customarily, an expert diagnostic team has the responsibility of thoroughly evaluating the child, assessing the child’s unique strengths and weaknesses, and determining a formal diagnosis. The team will then meet with the parents to explain the results of the evaluation.

Although parents may have been aware that something was not“quite righ” with their child, when the diagnosis is given, it is a devastating blow. At such a time, it is hard to stay focused on asking questions. But while members of the evaluation team are together is the best opportunity the parents will have to ask questions and get recommendations on what further steps they should take for their child. Learning as much as possible at this meeting is very important, but it is helpful to leave this meeting with the name or names of professionals who can be contacted if the parents have further questions.

Additional Aids for Autism

When your child has been evaluated and diagnosed with an autism spectrum disorder, you may feel inadequate to help your child develop to the fullest extent of his or her ability. As you begin to look at treatment options and at the types of aid available for a child with a disability, you will find out that there is help for you. It is going to be difficult to learn and remember everything you need to know about the resources that will be most helpful. Write down everything. If you keep a notebook, you will have a foolproof method of recalling information. Keep a record of the doctors’ reports and the evaluation your child has been given so that his or her eligibility for special programs will be documented. Learn everything you can about special programs for your child; the more you know, the more effectively you can advocate.

For every child eligible for special programs, each state guarantees special education and related services. The Individuals with Disabilities Education Act (IDEA) is a Federally mandated program that assures a free and appropriate public education for children with diagnosed learning deficits. Usually children are placed in public schools and the school district pays for all necessary services. These will include, as needed, services by a speech therapist, occupational therapist, school psychologist, social worker, school nurse, or aide.

By law, the public schools must prepare and carry out a set of instruction goals, or specific skills, for every child in a special education program. The list of skills is known as the child’s Individualized Education Program (IEP). The IEP is an agreement between the school and the family on the child’s goals. When your child’s IEP is developed, you will be asked to attend the meeting. There will be several people at this meeting, including a special education teacher, a representative of the public schools who is knowledgeable about the program, other individuals invited by the school or by you (you may want to bring a relative, a child care provider, or a supportive close friend who knows your child well). Parents play an important part in creating the program, as they know their child and his or her needs best. Once your child’s IEP is developed, a meeting is scheduled once a year to review your child’s progress and to make any alterations to reflect his or her changing needs.

If your child is under 3 years of age and has special needs, he or she should be eligible for an early intervention program; this program is available in every state. Each state decides which agency will be the lead agency in the early intervention program. The early intervention services are provided by workers qualified to care for toddlers with disabilities and are usually in the child’s home or a place familiar to the child. The services provided are written into an Individualized Family Service Plan (IFSP) that is reviewed at least once every 6 months. The plan will describe services that will be provided to the child, but will also describe services for parents to help them in daily activities with their child and for siblings to help them adjust to having a brother or sister with ASD.

Treatment of Autism

There is no single best treatment package for all children with ASD. One point that most professionals agree on is that early intervention is important; another is that most individuals with ASD respond well to highly structured, specialized programs.

Before you make decisions on your child’s treatment, you will want to gather information about the various options available. Learn as much as you can, look at all the options, and make your decision on your child’s treatment based on your child’s needs. You may want to visit public schools in your area to see the type of program they offer to special needs children.

Guidelines used by the Autism Society of America include the following questions parents can ask about potential treatments:

• Will the treatment result in harm to my child?
• How will failure of the treatment affect my child and family?
• Has the treatment been validated scientifically?
• Are there assessment procedures specified?
• How will the treatment be integrated into my child’s current program? Do not become so infatuated with a given treatment that functional curriculum, vocational life, and social skills are ignored.

The National Institute of Mental Health suggests a list of questions parents can ask when planning for their child:

• How successful has the program been for other children?
• How many children have gone on to placement in a regular school and how have they performed?
• Do staff members have training and experience in working with children and adolescents with autism?
• How are activities planned and organized?
• Are there predictable daily schedules and routines?
• How much individual attention will my child receive?
• How is progress measured? Will my child’s behavior be closely observed and recorded?
• Will my child be given tasks and rewards that are personally motivating?
• Is the environment designed to minimize distractions?
• Will the program prepare me to continue the therapy at home?
• What is the cost, time commitment, and location of the program?

Among the many methods available for treatment and education of people with autism, applied behavior analysis (ABA) has become widely accepted as an effective treatment. Mental Health: A Report of the Surgeon General states,“Thirty years of research demonstrated the efficacy of applied behavioral methods in reducing inappropriate behavior and in increasing communication, learning, and appropriate social behavior.”

The basic research done by Ivar Lovaas and his colleagues at the University of California, Los Angeles, calling for an intensive, one-on-one child-teacher interaction for 40 hours a week, laid a foundation for other educators and researchers in the search for further effective early interventions to help those with ASD attain their potential. The goal of behavioral management is to reinforce desirable behaviors and reduce undesirable ones.

An effective treatment program will build on the child’s interests, offer a predictable schedule, teach tasks as a series of simple steps, actively engage the child’s attention in highly structured activities, and provide regular reinforcement of behavior. Parental involvement has emerged as a major factor in treatment success. Parents work with teachers and therapists to identify the behaviors to be changed and the skills to be taught. Recognizing that parents are the child’s earliest teachers, more programs are beginning to train parents to continue the therapy at home.

As soon as a child’s disability has been identified, instruction should begin. Effective programs will teach early communication and social interaction skills. In children younger than 3 years, appropriate interventions usually take place in the home or a child care center. These interventions target specific deficits in learning, language, imitation, attention, motivation, compliance, and initiative of interaction. Included are behavioral methods, communication, occupational and physical therapy along with social play interventions. Often the day will begin with a physical activity to help develop coordination and body awareness; children string beads, piece puzzles together, paint, and participate in other motor skills activities. At snack time the teacher encourages social interaction and models how to use language to ask for more juice. The children learn by doing. Working with the children are students, behavioral therapists, and parents who have received extensive training. In teaching the children, positive reinforcement is used.

Children older than 3 years usually have school-based, individualized, special education. The child may be in a segregated class with otherautistic children or in an integrated class with children without disabilities for at least part of the day. Different localities may use differing methods but all should provide a structure that will help the children learn social skills and functional communication. In these programs, teachers often involve the parents, giving useful advice in how to help their child use the skills or behaviors learned at school when they are at home.

In elementary school, the child should receive help in any skill area that is delayed and, at the same time, be encouraged to grow in his or her areas of strength. Ideally, the curriculum should be adapted to the individual child’s needs. Many schools today have an inclusion program in which the child is in a regular classroom for most of the day, with special instruction for a part of the day. This instruction should include such skills as learning how to act in social situations and in making friends. Although higher-functioning children may be able to handle academic work, they too need help to organize tasks and avoid distractions.

During middle and high school years, instruction will begin to address such practical matters as work, community living, and recreational activities. This should include work experience, using public transportation, and learning skills that will be important in community living.

All through your child’s school years, you will want to be an active participant in his or her education program. Collaboration between parents and educators is essential in evaluating your child’s progress.

The Adolescent Years of Autism

Adolescence is a time of stress and confusion; and it is no less so for teenagers with autism. Like all children, they need help in dealing with their budding sexuality. While some behaviors improve during the teenage years, some get worse. Increased autistic or aggressive behavior may be one way some teens express their newfound tension and confusion.

The teenage years are also a time when children become more socially sensitive. At the age that most teenagers are concerned with acne, popularity, grades, and dates, teens with autism may become painfully aware that they are different from their peers. They may notice that they lack friends. And unlike their schoolmates, they aren’t dating or planning for a career. For some, the sadness that comes with such realization motivates them to learew behaviors and acquire better social skills.

Autism Dietary and Other Interventions

In an effort to do everything possible to help their children, many parents continually seek new treatments. Some treatments are developed by reputable therapists or by parents of a child with ASD. Although an unproven treatment may help one child, it may not prove beneficial to another. To be accepted as a proven treatment, the treatment should undergo clinical trials, preferably randomized, double-blind trials, that would allow for a comparison between treatment and no treatment. Following are some of the interventions that have been reported to have been helpful to some children but whose efficacy or safety has not been proven.

Dietary interventions are based on the idea that 1) food allergies cause symptoms of autism, and 2) an insufficiency of a specific vitamin or mineral may cause some autistic symptoms. If parents decide to try for a given period of time a special diet, they should be sure that the child’s nutritional status is measured carefully.

A diet that some parents have found was helpful to their autistic child is a gluten-free, casein-free diet. Gluten is a casein-like substance that is found in the seeds of various cereal plants—wheat, oat, rye, and barley. Casein is the principal protein in milk. Since gluten and milk are found in many of the foods we eat, following a gluten-free, casein-free diet is difficult.

A supplement that some parents feel is beneficial for an autistic child is Vitamin B6, taken with magnesium (which makes the vitamin effective). The result of research studies is mixed; some children respond positively, some negatively, some not at all or very little.

In the search for treatment for autism, there has been discussion in the last few years about the use of secretin, a substance approved by the Food and Drug Administration (FDA) for a single dose normally given to aid in diagnosis of a gastrointestinal problem. Anecdotal reports have shown improvement in autism symptoms, including sleep patterns, eye contact, language skills, and alertness. Several clinical trials conducted in the last few years have found no significant improvements in symptoms between patients who received secretin and those who received a placebo.

Medications for Autism

are often used to treat behavioral problems, such as aggression, self-injurious behavior, and severe tantrums, that keep the person with an autism spectrum disorder (“autism”) from functioning more effectively at home or school.

The medications used are those that have been developed to treat similar symptoms in other disorders. Many of these medications are prescribed “off-label.” This means they have not been officially approved by the U.S. Food and Drug Administration (FDA) for use in children, but the doctor prescribes the medications if he or she feels they are appropriate for your child. Further research needs to be done to ensure not only the efficacy but the safety of psychotropic agents used in the treatment of children and adolescents.

On October 6, 2006 the U.S. Food and Drug Administration (FDA) approved risperidone (generic name) or Risperdal (brand name) for the symptomatic treatment of irritability in autistic children and adolescents ages 5 to 16. The approval is the first for the use of a drug to treat behaviors associated with autism in children. These behaviors are included under the general heading of irritability, and include aggression, deliberate self-injury and temper tantrums.

Olanzapine (Zyprexa) and other antipsychotic medications are used “off-label” for the treatment of aggression and other serious behavioral disturbances in children, including children with autism. Off-label means a doctor will prescribe a medication to treat a disorder or in an age group that is not included among those approved by the FDA. Other medications are used to address symptoms or other disorders in children with autism. Fluoxetine (Prozac) and sertraline (Zoloft) are approved by the FDA for children age 7 and older with obsessive-compulsive disorder. Fluoxetine is also approved for children age 8 and older for the treatment of depression.

Fluoxetine and sertraline are antidepressants known as selective serotonin reuptake inhibitors (SSRIs). Despite the relative safety and popularity of SSRIs and other antidepressants, some studies have suggested that they may have unintentional effects on some people, especially adolescents and young adults.

In 2004, after a thorough review of data, the Food and Drug Administration (FDA) adopted a “black box” warning label on allantidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the agency extended the warning to include young adults up to age 25. A “black box” warning is the most serious type of warning on prescription drug labeling. The warning emphasizes that patients of all ages should be closely monitored, especially during the initial weeks of treatment, for any worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations.

A child with autism may not respond in the same way to medications as typically developing children. It is important that parents work with a doctor who has experience with children with autism. A child should be monitored closely while taking a medication. The doctor will prescribe the lowest dose possible to be effective. Ask the doctor about any side effects the medication may have and keep a record of how your child responds to the medication. It will be helpful to read the “patient insert” that comes with your child’s medication. Some people keep the patient inserts in a small notebook to be used as a reference. This is most useful when several medications are prescribed.

Anxiety and depression. The selective serotonin reuptake inhibitors (SSRI’s) are the medications most often prescribed for symptoms of anxiety, depression, and/or obsessive-compulsive disorder (OCD). Only one of the SSRI’s, fluoxetine, (Prozac®) has been approved by the FDA for both OCD and depression in children age 7 and older. Three that have been approved for OCD are fluvoxamine (Luvox®), age 8 and older; sertraline (Zoloft®), age 6 and older; and clomipramine (Anafranil®), age 10 and older. Treatment with these medications can be associated with decreased frequency of repetitive, ritualistic behavior and improvements in eye contact and social contacts. The FDA is studying and analyzing data to better understand how to use the SSRI’s safely, effectively, and at the lowest dose possible.

Behavioral problems. Antipsychotic medications have been used to treat severe behavioral problems. These medications work by reducing the activity in the brain of the neurotransmitter dopamine. Among the older, typical antipsychotics, such as haloperidol (Haldol®), thioridazine, fluphenazine, and chlorpromazine, haloperidol was found in more than one study to be more effective than a placebo in treating serious behavioral problems. However, haloperidol, while helpful for reducing symptoms of aggression, can also have adverse side effects, such as sedation, muscle stiffness, and abnormal movements.

Placebo-controlled studies of the newer“atypica” antipsychotics are being conducted on children with autism. The first such study, conducted by the NIMH-supported Research Units on Pediatric Psychopharmacology (RUPP) Autism Network, was on risperidone (Risperdal®). Results of the 8-week study were reported in 2002 and showed that risperidone was effective and well tolerated for the treatment of severe behavioral problems in children with autism. The most common side effects were increased appetite, weight gain and sedation. Further long-term studies are needed to determine any long-term side effects. Other atypical antipsychotics that have been studied recently with encouraging results are olanzapine (Zyprexa®) and ziprasidone (Geodon®). Ziprasidone has not been associated with significant weight gain.

Seizures. Seizures are found in one in four persons with autism spectrum disorders (ASD), most often in those who have low IQ or are mute. They are treated with one or more of the anticonvulsants. These include such medications as carbamazepine (Tegretol®), lamotrigine (Lamictal®), topiramate (Topamax®), and valproic acid (Depakote®). The level of the medication in the blood should be monitored carefully and adjusted so that the least amount possible is used to be effective. Although medication usually reduces the number of seizures, it cannot always eliminate them.

Inattention and hyperactivity. Stimulant medications such as methylphenidate (Ritalin®), used safely and effectively in persons withattention deficit hyperactivity disorder, have also been prescribed for children with autism. These medications may decrease impulsivity and hyperactivity in some children, especially those higher functioning children.

Several other medications have been used to treat ASD symptoms; among them are other antidepressants, naltrexone, lithium, and some of the benzodiazepines such as diazepam (Valium®) and lorazepam (Ativan®). The safety and efficacy of these medications in children with autism has not been proven. Since people may respond differently to different medications, your child’s unique history and behavior will help your doctor decide which medication might be most beneficial.

Adults with Autism

 

Some adults with an autism spectrum disorder (ASD), especially those with high-functioning autism or with Asperger syndrome, are able to work successfully in mainstream jobs. Nevertheless, communication and social problems often cause difficulties in many areas of life. They will continue to need encouragement and moral support in their struggle for an independent life.

Many others with ASD are capable of employment in sheltered workshops under the supervision of managers trained in working with persons with disabilities. A nurturing environment at home, at school, and later in job training and at work, helps persons with ASD continue to learn and to develop throughout their lives.

The public schools’ responsibility for providing services ends when the person with ASD reaches the age of 22. The family is then faced with the challenge of finding living arrangements and employment to match the particular needs of their adult child, as well as the programs and facilities that can provide support services to achieve these goals. Long before your child finishes school, you will want to search for the best programs and facilities for your young adult. If you know other parents of adults with autism, ask them about the services available in your community. If your community has little to offer, serve as an advocate for your child and work toward the goal of improved employment services. Research the resources listed in the back of this brochure to learn as much as possible about the help your child is eligible to receive as an adult.

Living Arrangements for the Adult with Autism

Independent living. Some adults with ASD are able to live entirely on their own. Others can live semi-independently in their own home or apartment if they have assistance with solving major problems, such as personal finances or dealing with the government agencies that provide services to persons with disabilities. This assistance can be provided by family, a professional agency, or another type of provider.

Living at home. Government funds are available for families that choose to have their adult child with ASD live at home. These programs include Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), Medicaid waivers, and others. Information about these programs is available from the Social Security Administration (SSA). An appointment with a local SSA office is a good first step to take in understanding the programs for which the young adult is eligible.

Foster homes and skill-development homes. Some families open their homes to provide long-term care to unrelated adults with disabilities. If the home teaches self-care and housekeeping skills and arranges leisure activities, it is called a“skill-developmen” home.

Supervised group living. Persons with disabilities frequently live in group homes or apartments staffed by professionals who help the individuals with basic needs. These often include meal preparation, housekeeping, and personal care needs. Higher functioning persons may be able to live in a home or apartment where staff only visit a few times a week. These persons generally prepare their own meals, go to work, and conduct other daily activities on their own.

Long-term care facilities. This alternative is available for those with ASD who need intensive, constant supervision.

Asperger’s Disorder

The essential features of Asperger’s Disorder are severe and sustained impairment in social interactions with others, and the development of restricted, repetitive patterns of behavior, interests, and activities. A person with Asperger’s often appear to lack empathy toward others, have difficulty with nonverbal behavior (such as making eye contact or having facial expressions), and may show an intense obsession with very defined, narrow topics of interest.

Some people with Asperger’s may engage in long-winded, one-sided conversations with others, without regard to the other person’s interest in what they’re saying. Sometimes a person may speak in a monotone voice or unusually fast, and may have odd body postures or gestures. Click here for the specific symptoms used to diagnose Asperger’s Disorder.

In contrast to autism, there are no clinically significant delays in language (e.g., single words are used by age 2 and communicative phrases are used by age 3). In addition, there are no clinically significant delays in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood.

Prevalence

Information on the prevalence of Asperger’s Disorder is limited, but it appears to be more common in males.

Course

Asperger’s Disorder appears to have a somewhat later onset than Autistic Disorder, or at least to be recognized somewhat later. Motor delays or motor clumsiness may be noted in the preschool period.

Difficulties in social interaction may become more apparent in the context of school. It is during this time that particular idiosyncratic or circumscribed interests (e.g., a fascination with train schedules) may appear or be recognized as such.

As adults, individuals with the condition may have problems with empathy and modulation of social interaction. This disorder apparently follows a continuous course and, in the vast majority of cases, the duration is lifelong.

Familial Pattern

Although the available data are limited, there appears to be an increased frequency of Asperger’s Disorder among family members of individuals who have the disorder.

Asperger’s Syndrome

By MARGARITA TARTAKOVSKY, M.S.

Asperger’s Disorder — also known as Asperger’s Syndrome or just AS — is a mild form of autism, recognized as a mental health concern that sometimes requires treatment. Asperger’s is usually diagnosed inchildhood or as a young teenager, and is characterized by social impairment, isolation, and what others might see as eccentric behavior.

The disorder’s name comes from Hans Asperger, an Austrian physician who first described the syndrome in 1944.

Asperger’s: Impairments in Social Interactions with Others

Although the social criteria for Asperger’s Disorder (also known as Asperger’s Syndrome or AS) and autism are identical, AS usually involves fewer symptoms and presents differently than autism.

Individuals with Asperger’s Disorder often isolate themselves, but they’re still aware of the presence of others, even though the way they approach people can be inappropriate and even peculiar. For example, they might have a one-sided and long-winded conversation with a person — usually an adult — about an unusual and narrow topic.

Also, although individuals with Asperger’s are often self-described loners, they usually express great interest in making friends and meeting people. Unfortunately, their awkward approach, insensitivity to other’s feelings and odd facial expressions and body language (e.g., signs of boredom, quick to leave, avoiding eye contact or staring inappropriately) make developing relationships difficult. This can lead to chronic frustration. Even worse, some individuals get so upset that they develop symptoms of depression, which may require treatment, including medication.

Individuals with AS often also display inappropriate emotional aspects of social interactions. They can come off as being insensitive. They might appear to lack empathy or to disregard another person’s expressions and gestures altogether. However, people with AS usually are able to describe other people’s emotions and intentions — they’re just unable to act on this knowledge in an intuitive and spontaneous way, so they end up losing the rhythm of the interaction. Because they have such a poor sense of intuition and spontaneity, people with AS rely on formal, rigid rules of behavior, making them appear inappropriately and overly formal in social situations.

Some of these symptoms also appear in individuals with higher-functioning autism, though perhaps to a lesser extent. Most autistic people seem withdrawn and unaware of or uninterested in other people.

Asperger’s: Impairments in Communication with Others

Unlike autistic individuals, those with AS don’t usually have significant speech problems, but their language and speech skills still differ from people without the disorder. As a whole, people with AS have an odd way of using language. Specifically, their communication differs in three major ways.

1.     People with AS don’t have quite the degree of rigid inflection and intonation as autistic individuals, but they still tend to speak in a monotone. Pitch typically lacks variation and is simply peculiar. They might talk too loudly or too formally. They tend to misunderstand the nuances of language, such as taking a sarcastic remark seriously or not grasping a joke or a metaphor.

2.     They may go off on tangents during a conversation and their speech can seem incoherent. Even though in some cases this symptom might mean a possible thought disorder, it’s more likely that the incoherent speech is a result of their one-sided, egocentric conversational style, inability to provide background information, clearly distinguish changes in topic and tendency to express their inner thoughts.

3.     Some experts view the long-winded and one-sided conversations as one of the most prominent differential features of the disorder. The child or adult may talk incessantly, usually about their favorite subject, often completely disregarding whether the listener is interested, engaged or trying to interject a comment, or change the subject. Despite such long-winded monologues, the individual may never come to a point or conclusion. Usually the other person can’t get a word in and is unable to change the conversation.

Even though it’s possible that these symptoms stem from significant deficits in pragmatics skills or a lack of insight into, and awareness of, other people’s expectations, the challenge is to understand them developmentally as strategies of social adaptation.

Asperger’s: Restricted and Repetitive Patterns of Behavior, Interests and Activities

The DSM-IV criteria for Asperger’s Disorder and autism are identical, requiring the presence of at least one symptom from this category. The most commonly seen symptom in AS is an all-absorbing preoccupation with an unusual and very narrow topic (e.g., snakes, names of stars, maps, TV guides, railway schedules). A person with AS will usually know the topic inside and out and want to talk about it all the time during social interactions. Although this symptom may not be easily recognized in children, since strong interests in one topic are so common, it may become more salient with age, as interests shift to odd and narrow topics. The topics may change every year or two, but the intensity with which they are studied remains the same.

Individuals with AS tend to have rigid routines and dislike change. For instance, children may be very particular about how they eat.

Asperger’s: Physical Clumsiness

Delayed motor development — that is, the ability to move one’s physical body with ease and grace — is an associated feature, although it’s not a required criterion for diagnosis of Asperger’s Disorder. Individuals with AS may have a history of delayed motor skills such as riding a bike, catching a ball or opening jars. They are often awkward, with a rigid walk, odd posture and problems with visual-motor coordination.

Although this differs from motor development in autistic children, whose motor skills often are a relative strength, it is somewhat similar to patterns seen in older autistic individuals. The similarity might stem from different underlying factors, however, such as psychomotor deficits in AS and poor body image and sense of self in autism. This highlights the importance of describing this symptom in developmental terms.

 
Symptoms of Asperger’s Disorder

is a syndrome that typically appears first inchildhood, and is primarily characterized by a person’s difficulty in everyday social interactions with others. For instance, a person with Asperger’s may engage in long-winded, one-sided conversations without noticing or caring about the listener’s interest. They also often lack usual nonverbal communication skills, such as engaging in eye contact with others they’re talking to, or failing to react and empathize with other people’s stories and conversation. This may make them seem insensitive, although that is rarely the case. They may have a hard time “reading” other people or understanding humor.

Adults, too, may have Asperger’s, as often the disorder is not properly diagnosed in childhood. Asperger’s is considered the mildest, least severe form of autism. The following five criteria primarily characterize Asperger’s Disorder.

1. A significant, ongoing impairment in social interactions with others, as demonstrated by at least two of the following symptoms:

• Significant difficulty in the use of multiple nonverbal behaviors such as the lack of eye contact, few facial expressions, awkward or clumsy body postures and gestures
• Failure to develop friendships with other children of the same age
• Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)
• Failure to express appropriate and corresponding social or emotional reactions, such as when conversing or playing with others. For example, a child who shows little or no reaction, feelings or empathy to another child talking with them.

2. Restricted and repetitive patterns of behavior, interests, and activities, as shown by at least one of the following symptoms:

• A significant and encompassing preoccupation or obsession with one or two restricted topics, that is abnormal either in intensity, subject or focus (such as baseball statistics or the weather)
• Seemingly inflexible adherence to specific routines or rituals that serve little purpose
• Repetitive motor mannerisms. For example, hand or finger flapping or twisting, or complex whole-body movements.
• A persistent preoccupation with parts of objects

3. The set of symptoms causes significant impairment in social, occupational, or other important areas of functioning.

4. There is no significant general delay in language (e.g., single words used by age 2, communicative phrases used by age 3).

5. There is no significant delay in cognitive development (such as reading or math skills) or in the development of age-appropriate self-help skills, behavior, and curiosity about the environment in childhood.

Early Signs of Asperger’s Disorder

It’s important to note that a person with Asperger’s disorder has no general delay in language acquisition, cognitive development and adaptive behavior (other than in social interaction). This contrasts with typical developmental accounts of autistic children who show marked deficits and deviance in these areas prior to age 3.

Other common descriptions of the early development of individuals with Asperger’s include certain characteristics that may be helpful in identifying it earlier on. These characteristics include:

• A certain precociousness in learning to talk (e.g., “He talked before he could walk!”)
• A fascination with letters and numbers. In fact, the young child may even be able to decode words, with little or no understanding of them (“hyperlexia”)
• The establishment of close relationships to family members, but inappropriate relationships or interactions with friends and others (rather than withdrawal or aloofness as in autism). For example, in Asperger’s the child may attempt to initiate contact with other children by hugging them or screaming at them and then puzzle at their responses.

These behaviors are sometimes described for higher-functioning autistic children as well, albeit much more infrequently than they are for children with Asperger’s.

Treatment 

There are a wide variety of helpful treatments for Asperger’s Disorder that help an individual learn better social skills and communication cues, to help them be able to interact socially more naturally. At present, like most mental disorders, there is no “cure” for Asperger’s Disorder. But by focusing on learning ways to cope with the symptoms and pick up on social cues, most individuals with Asperger’s Disorder lead fairly typical lives, with close friends and loved ones.

Psychosocial Interventions for Asperger’s

According to the National Institute of Neurological Disorders and Stroke, the ideal treatment for Asperger’s coordinates therapies that address the three core symptoms of the disorder: poor communication skills, obsessive or repetitive routines, and physical clumsiness. There is no single best treatment package for all children with AS, but most professionals agree that the earlier the intervention, the better.

An effective treatment program builds on the child’s interests, offers a predictable schedule, teaches tasks as a series of simple steps, actively engages the child’s attention in highly structured activities, and provides regular reinforcement of behavior. It may include social skills training, cognitive behavioral therapy, medication for co-existing conditions, and other measures.

• Individual psychotherapy to help the individual learn social skills training, to better detect social cues, and how to deal with the emotions surrounding the disorder
• Parent education and training
• Behavioral modification
• Social skills training
• Educational interventions

Psychiatric Medications

• For hyperactivity, inattention and impulsivity: Psychostimulants (methyphenidate, dextroamphetamine, metamphetamine), clonidine, Tricyclic Antidepressants (desipramine, nortriptyline), Strattera (atomoxetine)
• For irritability and aggression: Mood Stabilizers (valproate, carbamazepine, lithium), Beta Blockers (nadolol, propranolol), clonidine, naltrexone, Neuroleptics (risperidone, olanzapine, quetiapine, ziprasidone, haloperidol)
• For preoccupations, rituals and compulsions: SSRIs (fluvoxamine, fluoxetine, paroxetine), Tricyclic Antidepressants (clomipramine)
• For anxiety: SSRIs (sertraline, fluoxetine), Tricyclic Antidepressants (imipramine, clomipramine, nortriptyline)

With effective treatment, children with Asperger’s disorder can learn to cope with their disabilities, but they may still find social situations and personal relationships challenging. Many adults with AS are able to work successfully in mainstream jobs, although they may continue to need encouragement and moral support to maintain an independent life.

History of Asperger’s Disorder

 

Asperger Syndrome (AS, also known as Asperger’s Disorder) is a severe developmental disorder characterized by major difficulties in social interaction, and restricted and unusual patterns of interest and behavior.

Autism is the most widely recognized pervasive developmental disorder (PDD). Other diagnostic concepts with features somewhat similar to autism have been less intensively studied, and their validity, apart from autism, is more controversial.

One of these conditions, termed Asperger syndrome (AS) was originally described by Hans Asperger, who provided an account of a number of cases whose clinical features resembled Kanner’s (1943) description of autism (e.g., problems with social interaction and communication, and circumscribed and idiosyncratic patterns of interest). However, Asperger’s description differed from Kanner’s in that speech was less commonly delayed, motor deficits were more common, the onset appeared to be somewhat later, and all the initial cases occurred only in boys. Asperger also suggested that similar problems could be observed in family members, particularly fathers.

This syndrome was essentially unknown in the English literature for many years. An influential review and series of case reports by Lorna Wing (1981) increased interest in the condition, and since then both the usage of the term in clinical practice and number of case reports and research studies have been steadily increasing. The commonly described clinical features of the syndrome include:

1.     paucity of empathy;

2.     naive, inappropriate, one-sided social interaction, little ability to form friendships and consequent social isolation;

3.     pedantic and monotonic speech;

4.     poor nonverbal communication;

5.     intense absorption in circumscribed topics such as the weather, facts about TV stations, railway tables or maps, which are learned in rote fashion and reflect poor understanding, conveying the impression of eccentricity; and

6.     clumsy and ill-coordinated movements and odd posture.

Although Asperger originally reported the condition only in boys, reports of girls with the syndrome have now appeared. Nevertheless, boys are significantly more likely to be affected. Although most children with the condition function in the normal range of intelligence, some have been reported to be mildly retarded. The apparent onset of the condition, or at least its recognition, is probably somewhat later than autism; this may reflect the more preserved language and cognitive abilities. It tends to be highly stable, and the higher intellectual skills observed suggest a better long-term outcome than is typically observed in autism.

Higher Functioning Autism or Asperger’s?

There are many similarities with autism without mental retardation (or “Higher Functioning Autism”), and the issue of whether Asperger syndrome and Higher Functioning Autism are different conditions is not resolved.

To some extent, the answer to this question depends on the way clinicians and researcher make use of this diagnostic concept, since until recently there was no “official” definition of Asperger syndrome. The lack of a consensual definition led to a great deal of confusion as researchers could not interpret other researchers’ findings, clinicians felt free to use the label based on their own interpretations or misinterpretations of what Asperger syndrome “really” meant, and parents were often faced with a diagnosis that nobody appeared to understand very well, and worse still, nobody appeared to know what to do about it.

School districts are ofteot aware of the condition, insurance carriers could not reimburse services provided on the basis of this “unofficial” diagnosis, and there was no published information providing parents and clinicians alike with guidelines on the meaning and implications of Asperger syndrome, including what should the diagnostic evaluation consist of and what forms of treatment and interventions were warranted.

Asperger’s Ascent to an Official Diagnosis

This situation has changed somewhat since Asperger syndrome was made “official” in DSM-IV (APA, 1994), following a large international field trial involving over a thousand children and adolescents with autism and related disorders (Volkmar et al., 1994). The field trials revealed some evidence justifying the inclusion of Asperger syndrome as a diagnostic category different from autism, under the overarching class of Pervasive Developmental Disorders. More importantly, it established a consensual definition for the disorder which should serve as the frame of reference for all those using the diagnosis. However, the problems are far from over. Despite some new research leads, knowledge on Asperger syndrome is still very limited. For example, we don’t really know how common it is, or the male/female ratio, or to what extent there may be genetic links increasing the likelihood of finding similar conditions in family members.

Clearly, the work on Asperger syndrome, in regard to scientific research as well as in regard to service provision, is only beginning. Parents are urged to use a great deal of caution and to adopt a critical approach toward information given to them. Ultimately, the diagnostic label – any label, does not summarize a person, and there is a need to consider the individual’s strengths and weaknesses, and to provide individualized intervention that will meet those (adequately assessed and monitored) needs. That notwithstanding, we are left with the question of what is the nature of this puzzling social learning disability, how many people does it affect, and what can we do to help those affected by it. The following guidelines summarize some of the information currently available on those questions.

How Asperger’s Disorder is Diagnosed

Asperger’s Disorder (also known as Asperger’s Syndrome, or AS), like other pervasive developmental disorders (PDDs), involves delays and deviant patterns of behavior in multiple areas of functioning, that often require the input of professionals with different areas of expertise, particularly overall developmental functioning, neuropsychological features, and behavioral status. Hence the clinical assessment of individuals with this disorder is most effectively conducted by an experienced interdisciplinary team.

A few principles should be made explicit prior to a discussion of the various areas of assessment. First, given the complexity of the condition, importance of developmental history, and common difficulties in securing adequate services for children and individuals with AS, it is very important that parents are encouraged to observe and participate in the evaluation. This guideline helps to demystify assessment procedures, avails the parents of shared observations that can then be clarified by the clinician, and fosters parental understanding of the child’s condition. All of these can then help the parents evaluate the programs of intervention offered in their community.

Second, evaluation findings should be translated into a single coherent view of the child: easily understood, detailed, concrete, and realistic recommendations should be provided. When writing their reports, professionals should strive to express the implications of their findings to the patient’s day-to-day adaptation, learning, and vocational training.

Third, the lack of awareness of many professionals and officials of the disorder, its features, and associated disabilities ofteecessitates direct and continuous contact on the part of the evaluators with the various professionals securing and implementing the recommended interventions. This is particularly important in the case of AS, as most of these individuals have average levels of Full Scale IQ, and are ofteot thought of as ieed for special programming. Conversely, as AS becomes a more well-known diagnostic label, there is reason to believe that it is becoming a fashionable concept used in an often unwarranted fashion by practitioners who intend to convey only that their client is currently experiencing difficulties in social interaction and in peer relationships. The disorder is meant as a serious and debilitating developmental syndrome impairing the person’s capacity for socialization and not a transient or mild condition. Therefore, parents should be briefed about the present unsatisfactory state of knowledge about AS and the common confusions of use and abuse of the disorder currently prevailing in the mental health community. Ample opportunity should be given to clarify misconceptions and establish a consensus about the patient’s abilities and disabilities, which should not be simply assumed under the use of the diagnostic label.

In the majority of cases, a comprehensive assessment will involve the following components: history, psychological assessment, communication and psychiatric assessments, further consultation if needed, parental conferences, and recommendations.

Taking a History of the Asperger’s Patient

A careful history should be obtained, including information related to pregnancy and neonatal period, early development and characteristics of development, and medical and family history. A review of previous records including previous evaluations should be performed and the information incorporated and results compared in order to obtain a sense of course of development. Additionally, several other specific areas should be directly examined because of their importance in the diagnosis of Asperger’s Disorder. These include a careful history of onset/recognition of the problems, development of motor skills, language patterns, and areas of special interest (e.g., favorite occupations, unusual skills, collections). Particular emphasis should be placed on social development, including past and present problems in social interaction, patterns of attachment of family members, development of friendships, self-concept, emotional development, and mood presentation.

Psychological Assessment for Asperger’s

This component aims at establishing the overall level of intellectual functioning, profiles of strengths and weaknesses, and style of learning. The specific areas to be examined and measured include neuropsychological functioning (e.g., motor and psychomotor skills,memory, executive functions, problem-solving, concept formation, visual-perceptual skills), adaptive functioning (degree of self-sufficiency in real-life situations), academic achievement (performance in school-like subjects), and personality assessment (e.g., common preoccupations, compensatory strategies of adaptation, mood presentation).

The neuropsychological assessment of individuals with AS involves certain procedures of specific interest to this population. Whether or not a Verbal-Performance IQ discrepancy is obtained in intelligence testing, it is advisable to conduct a fairly comprehensive neuropsychological assessment including measures of motor skills (coordination of the large muscles as well as manipulative skills and visual-motor coordination, visual-perceptual skills) gestalt perception, spatial orientation, parts-whole relationships, visual memory, facial recognition, concept formation (both verbal and nonverbal), and executive functions. A recommended protocol would include the measures used in the assessment of children with Nonverbal Learning Disabilities (Rourke, 1989). Particular attention should be given to demonstrated or potential compensatory strategies: for example, individuals with significant visual-spatial deficits may translate the task or mediate their responses by means of verbal strategies or verbal guidance. Such strategies may be important for educational programming.

Communication Assessment for Asperger’s

The communication assessment aims to obtain both quantitative and qualitative information regarding the various aspects of the child’s communication skills. It should go beyond the testing of speech and formal language (e.g., articulation, vocabulary, sentence construction and comprehension), which are often areas of strength. The assessment should examine nonverbal forms of communication (e.g., gaze, gestures), nonliteral language (e.g., metaphor, irony, absurdities, and humor), prosody of speech (melody, volume, stress and pitch), pragmatics (e.g., turn-taking, sensitivity to cues provided by the interlocutor, adherence to typical rules of conversation), and content, coherence, and contingency of conversation; these areas are typically one of the major difficulties for individuals with AS. Particular attention should be given to perseveration on circumscribed topics and social reciprocity.

Psychiatric Examination for Asperger’s

The psychiatric examination should include observations of the child during more and less structured periods: for example, while interacting with parents and while engaged in assessment by other members of the evaluation team. Specific areas for observation and inquiry include the patient’s patterns of special interest and leisure time, social and affective presentation, quality of attachment to family members, development of peer relationships and friendships, capacities for self-awareness, perspective-taking and level of insight into social and behavioral problems, typical reactions iovel situations, and ability to intuit other person’s feelings and infer other person’s intentions and beliefs. Problem behaviors that are likely to interfere with remedial programming should be noted (e.g., marked aggression). The patient’s ability to understand ambiguous nonliteral communications (particularly teasing and sarcasm) should be examined (as, often, misunderstandings of such communications may elicit aggressive behaviors). Other areas of observation involve the presence of obsessions or compulsions, depression, anxiety and panic attacks, and coherence of thought.