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

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

When should my child be tested?

Parents often ask us when is the right time for a child to receive testing or therapy services. They may have heard people tell them to wait until third grade, or until a child is 7, or even “Don’t worry, he’ll grow out of it.” There is no magic age for testing and therapy, and if your instinct as a parent is telling you that something is not right, its time to act. Time is one of our most valuable assets in helping children. Most problems that took a while to develop take a while to improve, and when better to make changes than at a time in life when the brain is most adaptable? Early intervention is vital if you have concerns about a very young child (under 5) or if things have been getting steadily worse and worse for your child over time.

For children with ADHD and learning disabilities (as many as half of all children with ADHD also have learning disabilities), testing is critical as soon as problems are noted at school and home. Children with average intelligence can usually cope with the demands of the first grade curriculum, at least for the first part of the year. First grade is a time when the basic skills are introduced. Each task is short, involving only a few steps to complete. First grade work is highly structured, and most things the child reads will have helpful pictures. Homework can usually be completed in a half-hour. If your child is having learning problems in kindergarten or first grade, this can mean that the problems are particularly important to address. If the first year of school is unsuccessful, children may become convinced that they will never be able to do well. Feelings of frustration can lead to school avoidance or disruptive behaviors. As a former teacher, I have observed that some children quickly get a reputation among teachers for being 'trouble.' Once it sticks, the label is one that follows the child from year to year. It is much harder to develop a working partnership with school staff when everyone in the school has decided that your child is a 'problem.'

Many of the children I see come during the third grade. The reason for this is simple if you are aware of the scope and sequence of the elementary school curriculum. Third grade is when academic tasks require sustained attention to detail. Almost everything takes more time to complete and involves more steps. Instead of taking five seconds to complete a math problem, it can now take a few minutes to complete each problem (e.g. borrowing and carrying operations). Instead of writing a single word or sentence, the child must do a book report. Children with reading comprehension problems have an exceedingly difficult time understanding chapter books and text books. The helpful pictures they depended on are gone. Projects can take a week or more of planning, which is the downfall of a child with executive functioning impairment. These changes in the curriculum can cause child's academic progress to stall. Children who can not sustain attention or understand most of what they read fall behind their classmates very quickly. This can be a disheartening event for the child. Some develop anxious fears that they are not smart enough to learn. Many cope by convincing themselves that they don't care anyway, that school is stupid or that all teachers are against them. This state of affairs should be a thing of the past now that we have so many treatments and educational interventions, yet I still see children who have gone for years without receiving the help they need.

When deciding whether or not to test, it is important to understand that troubling symptoms can happen for a lot of different reasons. Symptoms like irritability can indicate conditions such as ADHD, depression, anxiety, obsessive compulsive disorder, sensory integration disorder, or even a medical problem like a sleep or elimination disorder. Children are complex beings who, unfortunately, do not often know how to tell us what is wrong. When we ask a child questions like "Why aren't you doing your work?" or "Why can't you sit still?" we get answers like "I don't know." Testing can give us the answers the children can not. I have yet to meet a child who is unsuccessful because he chooses to be. I believe that all children want very badly to make their parents and teachers proud. Research has shown that when children can not meet adult expectations at school and home, they are at-risk for secondary mental health problems like depression or anxiety. Children with undiagnosed disabilities often feel terrible. When kids feel terrible they may become disruptive, avoidant, or even aggressive. It makes sense if you think about it from the child's perspective, who can be happy spending six hours a day feeling like a failure or getting punished? As adults, we would quit a job like that, but kids don't have that option. Children are stuck with school, whether it goes well or not. Children who feel chronically frustrated, irritated, stupid or disliked need help before they become so discouraged that they give up school, or worse, on themselves.

Rebecca Resnik, PsyD, Licensed Clinical Psychologist and Former Special Education Teacher

Why should I have a private psychological assessment?

I recently spoke with a very happy father. He told me that he was cancelling our appointment for psychological testing because his insurance company was going to arrange for him to have his child tested for only $15. And as I wished him well and hung up the phone, I understood why he sounded so excited. Fifteen dollars compared to the cost of a private assessment, well who wouldn’t be thrilled? And if you get an assessment though the school system its free. Free sounds awfully good compared to expensive private testing, but the problem is that like with many things in life, if it sounds too good to be true to be, it probably is.

So what are you paying for when you invest in a private assessment? You are paying for time, expertise, and information you can trust. One of the first considerations is time. There’s no getting around the amount of time that a psychologist spends producing a quality report, and ideally it is the psychologist’s time. Some psychologists do not do their own testing, instead they pass you off to a technician or a student after the initial interview. The test administration, consulting, scoring and writing is very labor intensive, and it should be. No one wants to be treated by someone who is in a rush or taking short-cuts. Its worth paying for someone to make your case a priority. A private psychological evaluation should be custom designed around what you want to determine, as well as your child’s strengths and weaknesses. Tests and procedures should be thoughtfully selected, not simply used because they are the only ones you have. It is crucial to find a psychologist who has many tools at his or her disposal and the expertise to know how to use them.

It is unlikely that a psychologist will make useful recommendations unless he or she takes the time to study how an individual solves a variety of problems in the form of tests, tasks and even play. When you walk out of a psychologist’s office, you should have a large document in your hand that gives you insight into how your mind (or your child’s mind) works and lays out a plan for what steps to take next. A comprehensive assessment should lead to specific, concrete recommendations that address educational interventions, therapy, strategies for home, parenting advice, and information to inform medical treatments as appropriate.

When I do a psychological evaluation, I begin by budgeting six hours of ‘face to face’ time with the individual and his/her family. This is as much as three times the amount of time many people spend doing a psychological evaluation. My psychological evaluations resemble the neuropsychological assessments that I learned to do as in intern at a pediatric hospital in Baltimore. I study the person’s functioning exhaustively until I’m satisfied that I understand the problem, both what it is and what I can safely determine that it is not. After those six hours, I start calling everyone I have permission to consult with (physicians, teachers, tutors, even relatives) to get a complete picture of how the person is doing across home, school, and work. I review old testing reports and work samples. Then I set up to work writing your evaluation that takes me hours upon hours. I do not fill your name into a template. I do not dictate my reports to a transcription service. I do not cut and paste ‘cookie cutter’ recommendations into the report. Finally, the family and I sit down and have a feedback session, where we talk about the findings in detail and spend time problem solving. People who come to see me generally complete the entire process in a month or less.

Rebecca Resnik, PsyD - Licensed Clinical Psychologist

If your car is making a screeching noise, do you only want the battery checked?

We often get requests for "ADHD testing."

I understand that there is a lot of media attention (excuse the pun) on ADD, ADHD, impulsivity, inattention. However, symptoms of inattention or restlessness are common in many learning and emotional problems such as learning disabilities, anxiety, moodiness, and motivational issues.

So if I go to the car mechanic and ask him or her to check only my battery because of the screeching noise, I would be remiss in not also having the whole car looked at. The engine, brakes, and all that other car stuff that I know very little about but may in fact be part of the problem. Thus, I have to trust that the mechanic should look at the whole car so he can ultimately not only fix the screeching sound but also make the car run more smoothly.

After years of doing different types of testing, we have now made it a MindWorks policy not to do "just ADHD testing." If you really want to find out why your child is having certain symptoms that may be affecting him or her at school and at home, we need to understand how the child learns, processes information, rule/out learning disabilities, and make sure that anxiety or depression is not creating these symptoms.

In the past, when we have only done "ADHD testing" (an IQ test, a checklist for attention symptoms, and a computerized test for viglilance and reaction time), we are often left with unanswered questions about why the child is struggling to read or is not doing well in geometry.

Like everyone, I am always a little suspicious when the car mechanic needs to check the entire car and am afriad that he is going to tell me that I am going to have spend money on x, y, and z, when I was only expected x. However, our testing comes from a health based perspective, so that we are identifying the strengths in your child to help overcome and compensate for the possible relative weaknesses.

So, next time you call ask for ADHD testing, expect me (or one of the other clinicians) to talk about why we feel it is important to take a whole child approach and not just focus on the battery. : )

-Rachna Varia, PhD; Director of Testing

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.