Attention Deficit Hyperactivity Disorder (ADHD): Accurate Diagnosis is the Key to Effective Interventions

At Mindworks, we frequently receive inquires from parents concerned about ADHD. In this article, I will try to present some general information to help parents become a bit more familiar with this relatively common disability. One of the first things we all associate with ADHD is hyperactivity—the kid you see running around like he’s wearing a jetpack with a frantic mother chasing him. While hyperactivity does occur in many children with ADHD, the fact that your child is very active does not necessarily warrant a diagnosis. The Diagnostic and Statistical Manual of the American Psychiatric Association contains three subtypes of ADHD, including Hyperactive, Inattentive, and Combined. ADHD is a constellation of symptoms and behaviors that cannot be explained by any other cause (such as anxiety, learning disability, or a thyroid disorder). Contrary to what many people assume, ADHD is not just having a short attention span. Many parents are confused by the fact that their child can happily spend two hours playing a video game, yet can not complete a short homework worksheet. ADHD is a neurological disorder that has a significant, pervasive impact on learning and behavior.

As Dr. Larry B. Silver has noted, ADHD is a ‘life disability.’ It is not just problems at school. Children with ADHD experience difficulties across settings, meaning that these children have problems with tasks that require sustained attention to detail wherever they go, from the Cub Scout meeting to the homework table. There are two major characteristics of children with ADHD that make life harder for them and the people who love them. One is a weakness with ‘Executive Functioning.’ Executive functioning is our ability to work efficiently, strategically, and to execute our plans mindfully. For example, writing and reading comprehension tend to be the downfall of many children with ADHD, because successful reading and writing depend on executive functioning. Another problematic symptom is difficulty with impulse control (also known as behavioral disinhibition). The child with ADHD has little ability to control his or her impulses, and may routinely violate rules, irritate other people, make careless mistakes, or complete tasks in a haphazard manner.

When talking to parents about testing for ADHD, I recommend investing in at least one very through, comprehensive psychological evaluation. One of the reasons for this is that I want to be able to recommend the most effective academic and behavioral interventions that will match the child’s particular pattern of strengths and weaknesses, but just as importantly, I do not want to be wrong in my diagnosis. ADHD is known as a ‘diagnosis of exclusion,’ meaning that you must make sure that nothing else could be causing the symptoms. Doing a quick parent interview or a couple of symptom checklists is not adequate. Additionally, it is currently estimated that as many as 50% of children with ADHD also have specific learning disabilities. Not only are these children at risk for school problems, they are far more likely than peers to have significant levels of anxiety, depression or behavioral problems. Researcher Dr. Russell Barkley has described children with ADHD as being several years less emotionally mature than typical peers. This means that both parents and child are likely to need additional support.

-Dr. Rebecca Resnik

Licensed Clinical Psychologist

Some Thoughts about Behavior Plans

Behavior plans are one of the most popular approaches for trying to systematically change a child’s behaviors. Decades of research has shown that even an earthworm can respond to a simple behavior plan. So why do so many frustrated parents come to us at Mindworks with the classic lament “We tried that, it didn’t work.”? As with most things in life, it’s because there is almost never a simple answer to a complex problem.

Helping our children develop self-control is one of the most challenging tasks we parents face. One reason behavior plans can fail to make lasting changes is that people understand them as ways of making a child to comply. Getting people to comply is pretty easy. I can get you to do anything I want if I threaten you with a nasty enough consequence. However, once I’m not around or I can’t make good on my threat, you’re going to go right back to doing what you want. While we all need our children to comply with our rules, the true goal of a behavior plan is to teach the child to do something new.

When we take a teaching approach to modifying behavior, we come at the problem differently. Now our goal is to help the child choose a better set of behaviors than whatever behaviors are causing problems. As the psychologist Reginald Lourie noted, we must not eliminate a behavior without giving the child an attractive option for how to handle a stressful situation. If we just focus on stamping out a particular behavior, the child will find another way of dealing with his anger, frustration, boredom or shame (e.g. the child goes from hitting to biting). Remember, the goal is not just short-term compliance, its long-term development of self-control. Behavior plans have many common pitfalls. A major problem is lack of consistency, or using the plan sporadically or for too short a time period. This inconsistency creates a situation like a person gambling at a slot machine. Your child is the gambler, hoping for a pay-off (i.e. you giving in!). Guess who is the slot machine? When the ‘gambler’ never knows when the machine will ‘pay-off’ he is very, very, motivated to keep pushing buttons until it does. Kids are always looking for how to ‘beat the system’ and many parents give up as soon as the child finds a weakness in the plan that he can exploit. Every plan has weaknesses your child will find. That’s a delicate phase in implementation.

A psychologist can help you get through it without having the whole plan go down in flames. It is vital to get help from an expert to make sure your plan is developmentally appropriate! Lots of great plans fail because they are better suited to older children or for those without disabilities. The child must have the maximum chance for success, because there’s nothing harder than trying to implement a second, third, or fourth plan after failed attempts. A psychologist can also help you avoid pitfalls like inappropriate consequences. Too many well meaning people enact consequences that make the situation worse for everybody. For example, some people take recess from a child who desperately needs to let off steam, cancel birthday parties, or put a withdrawn, avoidant child into time-out.

Keep in mind that changing troublesome behavior does not happen overnight, and can be incredibly discouraging. The good news is that when behavior plans are proactive, fair and a good match for the child, they can and do help children change!

-Dr. Rebecca Resnik

Of note, Dr. Resnik was just interviewed with the Voice of America to present a televised series of parenting tips in Urdu speaking Pakistan. It's a reminder that behavioral problems and parenting challenges are universal!

New Assessment Measures

At MindWorks, we are dedicated to keeping our assessment tools up to date to keep up with research regarding how to measure a child's strengths and weaknesses, whether it be in academics, sensory issues, or social skills. We have recently acquired the NEPSY-2 (Neuropsychological Test of Development for Children), K-CPT (Kiddie Continuous Performance Test), and the PALS-Version 2 (Process Assessment of the Learner) in Reading, Writing, and Math. These tests are vital pieces of our assessment battery because it allows us to work with children as young as three. We can now detect precursor reading, writing, and math problems in very young children, allowing for earlier prevention. The NEPSY-2 has integrated more subtests that measure for social perspective and inhibition problems. The K-CPT is one computerized test that we use to evaluate for attention and vigilance in children as young as age 4.

These three new tests add to our 50+ meausres that we choose from when we create an individualized battery for your child.

When you are deciding who should work with your child, be sure to ask if the clinic, agency, school, or individual psychologist is using the most updated, emperically validated measures and is not just limited to a cookbook assessment battery.

At MindWorks, we only have doctoral level licensed clinical psychologists (PhD or PsyD) and thus our entire practice is dedicated to excellence in testing and therapy practice, rather than spreading ourselves thin in too many directions.

If you would like more information about the new NEPSY-2, CPT-2, or PALS-2, please give me a call.

-Rachna Varia, PhD, Director of Testing

A feedback letter from a client

I received an e-mail from a family I worked with earlier this year. With her permission, she is allowing me to post it on this blog (alias used for her son's name)

Dear Dr. Varia,

I thought I'd write and update you on Michael's status since we met with you in August. I am SO grateful for your testing and advice. It gave us the information we needed to understand Michael's struggle with school, and to get him the help he clearly needs.

Michael was determined "Eligible" for help with his "Specific Learning Disability". An IEP was created on October 23. He had been placed in an 8th grade team of students that had special ed teachers already in the primary course classrooms on the second day of school, "just in case" he qualified for help. I am quite sure that just having those extra teachers available to help, for they help all of the kids, not just the ones assigned to them, helped him accomplish all A's and B's on his first quarter interims!

Michael has expressed relief in knowing that there is an explanation for his school difficulties, and that he is not alone moving forward. He's been very receptive to the help of his new teaching team, and continues to work hard at home.

I am so glad we were referred to you, and for the work you did with Michael. I just wish we'd caught it sooner. I know that if Michael had been identified sooner, it would have saved him, and me, much anguish. The silver lining is that it has been caught, and his future will be enhanced. I am so grateful for your work with Michael. Sure, we paid for the evaluation, but knowing it was done by a highly educated professional that specializes in this sort of assessment, and who prepared reports that were detailed and specific to him made it clearly worth the investment. His future was at stake, and has been brightened by your help.

A Call for Routine Psychological Check Ups for Children

The tragedy at Virginia Tech last spring precipitated a long needed debate about the interaction of mental health services, courts, law enforcement and other social systems. Hopefully, risk assessment procedures and community responses will continue to improve for at-risk youth. As a child psychologist, I must articulate the value that could be gained by instituting standard psychological check ups.

There is inadequate attention given to the mental health needs of children. While there are uniformly accepted schedules for immunizations and annual physicals, we lack a similar strategy to track and treat our children’s emotional and behavioral health. Mental health check ups should be as widely accepted as dental check ups. This is a simple idea that has been discussed in the mental health community for some time; however, it hasnot received adequate attention among the public at large.

Five, twelve and seventeen.

When children start kindergarten, enter puberty and launch into adulthood they are prone to significant social and emotional upheaval. These transitions are widely believed to be critical time-windows in child development. Thus, at these three intervals, every child
would benefit from a standard psychological check up. This service would be affordable and simple to conduct. In one hour, a clinician could conduct a parent interview, a child interview and score a brief psychological test completed by the parent within 15 minutes.

We currently have remarkably useful, scientifically validated tools at our disposal which differentiate normal developmental struggles from clinical symptoms. Commonly used behavior rating scales compare a parent’s ratings about their child to thousands of other parent ratings. This provides the psychologist with data about how extreme a particular problem may be. For instance, a psychologist can quickly let a family know if their ratings about, say, aggression or thought problems were at the 50th, 75th or 90th percentile compared to other children the same age.

Symptoms that can be assessed in this manner include social problems, attention problems, mood problems, anxiety, adaptability and the like. Check ups could yield three simple outcomes. Parents could be told if a child appears to be growing up normally, is at-risk, or requires formal assessment and treatment. This would not, as some people fear, lead to an overwhelming trend of labeling or pathologizing healthy children.
Psychologists are well trained to appreciate the signs of adaptability and health in children and families. Well-trained clinicians recognize that children and families thrive when their competencies are validated and praised.

Preventative psychological care makes good sense. If recognized early, many moderate “warps” in a child’s personality can be improved with simple interventions. I have seen children overcome school phobias, cease aggressive behavior, pull up failing grades and begin using respectful language at home after only a few therapy visits. Problems such as
these can often be treated quickly, protecting children from unnecessary suffering. We must also recognize that there are children facing severe and chronic mental health conditions requiring intensive and long-term treatments. Even children in this category need systems in place to reassess their progress at critical ages. Child psychologists, who are trained in a scientist-practitioner model, can use validated measures to assess if clients are maintaining a healthy developmental trajectory.

The coordination of psychological care and medical care must become routinized. A significant number of pediatric office visits pertain to psychological issues. Children are frequently brought in to see their pediatrician or family doctor because of symptoms such as mood changes, phobias, temper problems, tics, sleep difficulties, learning problems, or attention problems. Unfortunately, it is rare for families to be granted a full-hour to discuss these matters and it is even less common for families to receive a multi-modal assessment that combines interview, play observation and psychological testing. When
the expertise of physicians and psychologists are combined, children and families are far better served.

Five, twelve and seventeen.

This simple schedule should remind us of the new standard in mental health care for children.

Lisa Bennett, Ph.D.; Licensed Clinical Psychologist, Certified School Psychologist

Our Mission Statement and Philosophy

MindWorks Philosophy and Mission Statement
What Makes MindWorks Work.

MindWorks, Clinical Psychology is committed to providing the highest-quality therapy, consultation, and assessment services by having specific standards for its:

1. Clinical Services
2. Staff
3. Environment

1) Clinical Services. MindWorks believes in a family systems model of therapy where children are not treated in isolation, but parents are made active participants in creating change. Assessments are based on creating a roadmap for clinical concerns and are individualized and thorough. MindWorks believes in communication with other parties and a collaborative model of care.

2) Staff. MindWorks believes that high quality services can be provided to clients by having excellent clinical staff. Staff is carefully selected to have a combination of professional acumen, personal warmth, sincerity, and approachability. MindWorks offers contractors a flexible schedule, steady stream of clients, and the ability to focus on clinical work instead of administrative and insurance tasks. MindWorks’ contractors are encouraged to create niche clinical services for professional and business satisfaction and growth. In addition, MindWorks is dedicated to a family friendly work environment where personal needs are prioritized (time off, child-care, pregnancy, professional development).

3) Environment. MindWorks provides a client-friendly office atmosphere where both adults and children feel comfortable. MindWorks strives to create an environment where clients are not anxious about receiving services and rather experience the clinic as a secure place. This Environment is created through clinician warmth, speedy communication and coordination, and a décor that is inviting and colorful.