ADHD Symptoms and Assessment of Causes
ADHD can manifest with or without hyperactivity or Behaviour Disorders. Most children with ADHD can be well behaved and polite and are beautiful children of normal intelligence and many have above average intelligence. However, they can often be overly inattentive and be easily distracted, they can be fidgety and may tend to make impulsive mistakes. The media often concentrates on presenting mostly the hyperactive children with associated behaviour disorders as representative of ADHD. Consequently, parents with the more inattentive subtype are understandably unwilling to accept that their child may have ADHD.
Diagnosis of ADHD
ADHD is diagnosed with a clinical history and "Behavioural questionnaires" in accordance with the criteria set in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-V). The DSM-V, like its many predecessors, was designed by the American Psychiatric Association to help prescribe psychiatric medication. It is not used to identify the underlying causes of "Mental Health "issues. Unfortunately, the diagnosis often leads only to the prescription of medication to help control the "symptoms", leaving the underlying causes untreated, and with frequent side-effects.
ADHD is not a disease like diabetes, or shingles, nor is it a disorder with a single cause. After 20 years of assessing and conducting neuroimaging studies of over 3000 children with ADHD within the Clinic and at the Brain Sciences Institute at Swinburne University, we have come to the conclusion, as many other scientists have, that ADHD is just a label for a range of behaviours for which there might be a number of underlying causes. Some of these causes are easily identified, such nutrient deficiencies in our western-style diet and toxins; others require genetic testing for mutations that can cause brain malfunction but which can be addressed by up-regulating the expression of the mutated genes with specific nutrients.
Adults with ADHD
Although we have concentrated on childhood ADHD on this web site, adults with ADHD undergo a similar diagnostic and treatment protocol at the clinic, and respond equally well to treatment.
ADHD Symptoms: Assessment and Treatment of causes.
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) of the American Psychiatric Association, ADHD is a diagnosis applied to children and adults who consistently display certain characteristic behaviours over a period of time.
Traditionally ADHD is diagnosed if the child has some of the characteristic behaviours on a list which is so broad that it covers most undesirable childhood behaviours. The list covers all children with attention problems: from the polite, dreamy inattentive child to the extremely hyperactive out of control one.
After decades of research, science has yet to identify "the cause" behind the different ADHD behaviours, and it is unlikely that a single cause will ever be found. There has been a diversity of causal factors proposed, and the wide range of core symptoms with associated adverse behaviours suggest that ADHD may be a catch-all umbrella for a range of underlying disorders, that result in a wide range of behavioural manifestations.
The United States summit on ADHD concluded that the disorder is best treated with a multidisciplinary approach, and the Surgeon General urged practitioners from different disciplines to cooperate in the diagnosis and treatment of the disorder (including QEEG studies) so that children may receive the best treatment options.
Assessing ADHD at the Clinic
In the clinic, assessment of ADHD begins with a diagnosis based on behaviours followed by an assessment of the possible causes of these behaviours
- Assessment of Attention Deficit/Hyperactivity Disorder: Behaviours are assessed to determine whether they are outside of normal limits. This is the traditional assessment method and the behavioural observations do not look for causes. It is based solely on the DSM-V behavioural criteria for ADHD.
Assessment of metabolic and brain dysfunctions: Metabolic and brain dysfunctions that are likely to cause the symptoms of attention deficits and abnormal behaviours. This second stage of assessment is less common in general clinical practice and requires assessment by Health Professionals with training in (a) Medicine, (b) Psychology, (c) Psychophysiology and Clinical Neuroscience and (d) Nutritional and Environmental medicine.
- Assessment may include evaluation of brain function through neuroimaging and investigation of diet, nutrition and food sensitivities. Tests may be carried out to determine the possible causes of chronic ear, nose and throat infections, recurrent abdominal upsets and metabolic dysfunctions that can cause brain dysfunction and consequently attention deficits and abnormal behaviours.
Assessment of ADHD Behaviours
Not everyone who is overly hyperactive, inattentive, or impulsive has an attention deficit disorder. Since most people sometimes blurt out things they didn't mean to say, bounce from one task to another, or become disorganized and forgetful, how can specialists tell if the problem is ADHD? To assess whether a person has ADHD, we consider several critical questions: Are these behaviours excessive, long-term, and pervasive? That is, do they occur more often than in other people the same age? Are they a continuous problem and not just a response to a temporary situation? Do the behaviours occur in several settings or only in one specific place like the playground or school? The person's pattern of behaviour is compared against a set of criteria and characteristics of the disorder.
According to the DSM-V, there are three subtypes of ADHD.
1. ADHD, Predominantly Inattentive Subtype.
This subtype is diagnosed if symptoms of inattention have persisted for at least 6 months and are age inappropriate. The inattentive ADHD child may fail to give close attention to details or may make careless mistakes.
The child may have difficulty sustaining attention in tasks or play activities, and may not seem to listen when spoken to directly. Often the child may not follow through on instructions and may fail to finish schoolwork and chores, and may have difficulties organising tasks and activities. The child may be forgetful and often lose things necessary for school assignments, pencils, books and school jumpers. There may be a reluctance to engage in tasks that require sustained mental effort. Hence there may be considerable arguments and excuses to avoid schoolwork or homework.
2. ADHD, Predominantly Hyperactive-Impulsive Subtype.
This subtype is diagnosed if there are some symptoms of hyperactivity-impulsivity along with fewer symptoms of inattention.
These include frequent fidgetiness with hands or feet or squirming particularly when required to sit still. There is likely to be difficulties playing or engaging in leisure activities quietly, and the child may seem to be constantly on the go, or may talk excessively. Often the child will leave his/her seat in the classroom or in other situations in which remaining seated is expected. There may be excessive inappropriate running and climbing. As the child grows into adolescence or adulthood, this may subside and feelings of restlessness may remain.
The impulsive child often blurts out answers before questions have been completed, and has difficulties awaiting his/her turn. Consequently there may be frequent inappropriate interruptions, intrusions into games or butting into conversations.
3. ADHD, Combined Subtype.
When both symptom of inattention and hyperactivity-impulsivity are present, the child may be diagnosed as having the Combined Type of ADHD
Caution. Because everyone shows some of these behaviours at times, the DSM-V contains very specific guidelines for determining when they indicate ADHD. The behaviours must appear early in life, before age 7, and continue for at least 6 months. In children, they must be more frequent or severe than in others of the same age. Above all, the behaviours must create a real handicap in at least two areas of a person's life, such as school, home, work, or social settings. So someone whose work or friendships are not impaired by these behaviours would not be diagnosed with ADHD. Nor would a child or adult who seems overly active at school or work but functions well elsewhere.
The DSM-IV diagnosis is a label informing us that the observed behaviours are considered outside the normal range. However, the label tells us nothing about the possible underlying causes. Parents often tell us that they are disappointed that they are none the wiser about the causes of their child's difficulties.
Behaviours that are not necessarily ADHD
There are many Medical, Metabolic and Psychological factors that are associated with attention deficits, hyperactivity and inappropriate behaviours without warranting a diagnosis of ADHD. ADHD should only be diagnosed when all other causal factors have been excluded.
The following conditions would NOT QUALIFY for a diagnosis of ADHD. Some of these conditions result in temporary symptoms and others result in chronic (long-term) symptoms.
- Attention lapses during absence (petit mal) seizures.
- Underachievement at school due to a learning disability.
- A middle ear infection or grommets that may reduce hearing sensitivity.
- Central Auditory Processing Disorder
- Visual Processing Disorder
- Disruptive or unresponsive behaviours due to childhood depression or anxiety.
- Anxiety, chronic fears and childhood depression can make a child seem overactive, quarrelsome, impulsive, or inattentive.
- Over-active or under-active thyroid.
- Undiagnosed and untreated diabetes.
- A child who becomes overactive and easily distracted after the death of a family member or friend or after some traumatic loss or fearful experience may be dealing with unresolved grief and/or emotional problems.
- A chronic middle ear infection or mild asthma, often the result of dairy intolerance, can also make a child seem distracted and uncooperative and lead to Learning Difficulties.
- So can living with a family member who is physically or emotionally abusive or neglectful.
Can you imagine a child trying to focus on a math lesson when he or she is unsure about his/her safety at home or worried about being unloved. Such a child is showing the effects of stress and emotional issues, not ADHD.
Perhaps the child has a learning disability and is not developmentally able to learn to read and write at the class level. Such a child may seem inattentive and may play up in class. Or maybe the work is too hard or too easy, leaving the child frustrated or bored.
Some children's attention and class participation improve when the class structure and lessons are adjusted to meet the emotional needs or learning style of the child. Although such children need help to get on track at school, they probably don't have ADHD.
During certain stages of development, many children of that age tend to be inattentive, hyperactive, or impulsive and do not have ADHD. Preschoolers have lots of energy and run everywhere they go, but this doesn't mean they are hyperactive. They may need to be given appropriate outlets for their inquisitiveness and energy. Many teenagers go through a phase when they are messy, disorganized, and question or even reject authority.
Other disorders that can be co-morbid with (accompany) ADHD?
One of the difficulties in diagnosing ADHD with a questionnaire only is that it is often accompanied by other disorders. QEEG, which examines brain function is better able to differentiate between the disorders which have so much behavioural overlaps. The following are a few examples.
Many children with ADHD also have a specific learning disability (LD), which means they have trouble mastering language or certain academic skills, typically reading, writing or maths. ADHD is not in itself a specific learning disability. But because it can interfere with concentration and attention, ADHD can make it doubly hard for a child with LD to do well in school.
Learning Disorders are diagnosed when the individual's achievement on individually administered, standardized tests in reading, mathematics, or written expression is substantially below that expected for age, schooling, and level of intelligence. The learning problems significantly interfere with academic achievement or activities of daily living that require reading, mathematical, or writing skills. A variety of statistical approaches can be used to establish that a discrepancy is significant.
PANDAS AND PANS:
PANDAS is an acronym for a condition called Paediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS). Current research suggests that Tourettes and OCD may, at least in some cases, result from the effect of the body's own immune system's antibodies attacking parts of the brain. The onset usually occurs following an Ear, Nose or Throat (ENT) infection from Group A Beta Haemolytic Streptococcus (GABHS). GABHS antibodies in some cases can damage parts of the brain resulting in a range of behavioural disorders. OCD, Oppositional Defiant Disorder, Tourettes, ADHD and even psychosis. People with Tourettes have tics and other involuntary movements, such as eye blinks, facial twitches or complex body movements that they cannot control. Others may grimace, shrug, sniff, or bark out words. Foul swearing can also be a manifestation of the disorder. Often Tourettes symptoms are accompanied by symptoms of obsessive compulsive disorder (OCD).
PANS is a more recent name for an auto immune response to a wider range of organisms that can include other bacteria, mycoplasma or viruses. The symptoms are episodic, meaning that they appear or get worse when there is an infection, such as a sore throat, or chest infection and eventually settle down until the next episode. In time the brain tissues may not recover completely leaving more permanent symptoms. Both PANAS and PANS have been well researched by scientists at the National institute of Health. (NIH) in the USA.
Yet, few doctors, Paediatricians and Psychiatrists understand PANS and PANDAS. As with any new concept, the establishment first refuses to acknowledge it. It may take decades before the concept is accepted widely. See our PANDAS/PANS WEB PAGE.
Oppositional Defiant Disorder and Conduct Disorder:
Nearly half of all children with ADHD tend to have another condition, called oppositional defiant disorder. These children may overreact or lash out when they feel threatened or challenged. They may be stubborn, have outbursts of temper, or act belligerently or defiantly. Sometimes this progresses to more serious conduct disorders. Children with this combination of problems are at risk of getting in trouble at school, and even with the police. They may take unsafe risks and break laws, they may steal, set fires, destroy property, and drive recklessly. It's important that children with these conditions receive help before the behaviours lead to more serious problems.
Many children with ADHD, mostly younger children and girls, experience other emotional disorders. About one-fourth feel anxious. They feel tremendous worry, tension, or uneasiness, even when there's nothing to fear. Because the feelings are scarier, stronger, and more frequent than normal fears, they can affect the child's thinking and behavior. Others experience depression. Depression goes beyond ordinary sadness. Depressed children may feel so "down" that they feel hopeless and unable to deal with everyday tasks. Depression can disrupt sleep, appetite, and the ability to think.
Because emotional disorders and attention disorders so often go hand in hand, every child who has ADHD should be checked for accompanying anxiety and depression. Of course, not all children with ADHD have a co-morbid disorder. Nor do all people with learning disabilities and Tourettes syndrome for example, have ADHD. But when they do occur together, the combination of problems can seriously complicate a person's life. For this reason, it's important to ensure a proper diagnosis of other disorders in children who have ADHD.
Multidisciplinary Assessment tools At the Behavioural Neurotherapy Clinic
In a multidisciplinary model, pathology laboratory tests, measures from Psychology, Neuroscience and Psychophysiology can be used to investigate medical and neurophysiological conditions that can give rise to sleep difficulties, anxiety, depression chronic fatigue minor head injuries and psychiatric disorders. The information provided by these tests guide treatment protocols that are tailored to the causal factors that underpin the difficulties experienced.
The following are "some" of the assessment tools that "may" be used at the clinic, depending on child's history and presentation:
At your first consultation at the clinic, questionnaires will be placed in your clinic portal for completion prior to attending your next consultation. Following the initial interview with one of the clinic's psychologists, a number of assessment tools will be recommended based on your history and current presentation.
A detailed history, including family details is taken to establish relevant familial factors, that may contribute to a better understanding of the presenting problems. Clients are asked to fill out a detailed multiple-choice questionnaire that collects relevant information on family health history, pregnancy and birth, infancy and early childhood and an up to date health and behavioural history.
The history sheds light on the extent and time scale of the behaviours and their effect on the family and school dynamics. There is also a built-in screening for other disorders.
Quantitative electroencephalography (QEEG).
Quantitative EEG (QEEG) is the statistical analysis of the electrical activity of the brain. It is a brainmapping tool used to evaluate differences in brain function compared to a database of people without difficulties. In the brainmap sample above, the colour black, and one colour gradation above and below on the scale represents the normal range.
The hotter colours represent excesses of brain electrical activity and colder deficits. Some of these excesses and deficits are abnormal and are related to specific behavioural and/or learning difficulties or mood disorders. QEEG enables the formulation of treatment options guided by the brain patterns associated with abnormal behaviours rather than relying only on questionnaires.
Until recently QEEG studies were carried out mostly by neuroscientists in Brain Research and Neurophysiology Laboratories. Although the technique is taught and used at many Medical Schools in the United States: e.g. UCLA Medical School, Harvard Medical School and New York University Medical school (to name a few). QEEG has not been taught in Australian Medical schools, although QEEG is used at the Brain Sciences Institute at Swinburne University and other Universities in Australia for research. Only a few health professionals with specialised training use QEEG clinically. Since 1990 there are over 30,000 QEEG studies listed on the US National Library of Medicine database, and over 95% of these published EEG studies use QEEG methods.
QEEG is very useful in revealing the underlying abnormal brainwave patterns associated with ADHD and many other disorders. The system can discriminate with more than 90% accuracy ADHD from Learning difficulties and from normal. The Behavioural Neurotherapy Clinic uses the Neuroguide System from Applied Neuroscience Inc. in St Petersburg, Florida. USA.
Test of Variables of Attention (T.O.V.A)
The Test of Variables Of Attention (TOVA) is a computer administered continuous performance test which has become widely used as an adjunct for the diagnosis of ADHD.
It is also an excellent objective method of assessing the effectiveness of medication for ADHD, without relying solely on parent's/teachers reports and an interview in the paediatricians' office. The clinic offers this test as a service to paediatricians as an empirical means of titrating ADHD medication. Parents may ask their paediatrician that this test be carried out before medication is given, and to adjust medication dose. Alternatively the clinic may provide this service to parents directly. The TOVA reduces the likelihood of under or over-medication. It ensures that the medication dose is optimum for the child. A comprehensive computer generated report is provided to the referring medical practitioner or to parents.
The TOVA scores below compare a child with ADHD who has a minor head injury (MTBI), caused by a fall off a bicycle, to an average or high performer on the TOVA.
The TOVA task requires students to press a specially designed micro switch whenever a "target" appears on the screen, and to refrain from pressing when a "non-target" appears. The scores are compared to an age appropriate database to produce standardised scores, which gives useful objective information on four variables of attention:
- Ability to sustain attention and mental effort
- Impulse control
- Brain processing speed (reaction time).
- Distractibility (variability in the response times)
For more information on the TOVA TEST click here.
Wechsler Intelligence Scale for Children (WISC V)
The WISC is used to test the general thinking and reasoning skills of students aged six through sixteen. The scores show how well a student did compared to a group of thousands of students the same age from across the United States and Australia. The highest possible score is 160, and the lowest possible score is 40. Half of all students will score less than 100, and half of all students will score more than 100. Scores from 90 to 109 are considered average. This test has three main scores: a Verbal IQ score, a Performance IQ score, and a Full Scale IQ score. The Verbal IQ score indicates how well a student does on tasks that require listening to questions and giving spoken answers to them.
These tasks evaluate the skills required for understanding verbal information, thinking with words, and expressing thoughts in words. The Performance IQ score indicates how well a student does on tasks that require examining and thinking about things such as designs, pictures, and puzzles and solving problems without using words. These tasks evaluate his skills in solving nonverbal problems, sometimes using eye-hand coordination, and working quickly and efficiently with visual information. The skills evaluated are often referred to as visuo-spatial skills. The Verbal and Performance scores are combined into the Full Scale IQ score. The WISC-III Full Scale score is one way to view a student's overall thinking and reasoning skills.
The WISC-III has 13 subscales which are used to assess various aspects of verbal and non-verbal (visuo-spatial) intellectual skills. The results can give a very good indication of which cognitive functions are not optimal and help formulate treatment strategies.
Red Cell Essential Fatty Acid Profile
Every cell in the body has a lipid membrane protecting its boundaries. The brain consists of 70% lipids and 40% of the brain is made up of the long chain Omega 3 EFAs (of the kind we get from fish). Studies consistently indicate that deficiencies of Omega 3 EFAs (derived from fish) are associated with serious brain and systemic dysfunctions. Many of these studies prove that Omega 3 EFAs are essential for brain function. It is known that deficits are associated with all kinds of Psychiatric disorders, ADHD, Autism, cardiovascular disease, diabetes and cancer. The red cell Essential Fatty Acid Profile test is a specialised blood test that gives detailed composition of fatty acids in the red cells and is an excellent marker for identifying specific EFA deficiencies.
Omega 3 EFAs and Gut function
The gut cell wall, the epithelium, is constantly exposed to billions of organisms and toxins daily. The importance of the protective effect of the lipid membrane of each cell in the epithelium cannot be understated. If the lipid membrane is lacking in Omega 3 fatty acids, the protection fails and unfriendly organisms, irritants and toxins irritate the gut wall, possibly giving rise to Irritable Bowel Syndrome and Inflammatory Bowel Diseases. Of course it is not as simple as that, there is a multitude of other nutrients and systems and their interactions at play, and these also need to be considered.
Extended Faecal Microbiology Analysis (FMA)
Intestinal dysbiosis is a condition whereby the various bacteria usually found in the large bowel are abnormally distributed. Often there is an overgrowth of streptococcus and enterococcus for example and a reduction in the beneficial flora such as E-Coli, lactobacillus and Bifidobacteria. This imbalance can interfere in the breakdown of food into nutrients and may also lead to Irritable Bowel Syndrome and malabsorption, conditions which are strongly associated with depression, anxiety disorder and fatigue. EFMI is conducted by Bioscreen, a specialist pathology laboratory at Melbourne University. Bioscreen grows the faecal bacteria over three weeks and counts the colonies to estimate the bacterial profile. The test provide the most accurate estimate of bacteria profile in the bowel enabling experienced clinicians to treat the disorder effectively. This test should not be confused with the parasitology and pathogen testing usually conducted through the pathology lab faecal tests looking for pathogenic bacteria and parasites.
Summary of Assessments in ADHD: These are used only as required
- Quantitative EEG to evaluate the brain patterns, differentiates ADHD from other disorders
- TOVA (Test of variables of Attention) continuous performance tasks.
- WISC-III IQ test to evaluate aspects of intellectual functioning.
- Red cell Essential fatty Acids (blood test) to test whether EFAs are normal or abnormal.
- Extended Faecal microbiology (faeces sample) to evaluate bowel bacteria profile.
- IgG food allergy panel (Blood test) to test for autoimmune antibodies to foods.
- Intestinal Permeability test (urine test) to test for Leaky Gut.
- Mineral hair analysis (hair sample) to test for deposits of nutritional and heavy metals.
- Blood tests for nutritional and/or toxic elements.