Sam Goldstein

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Symptom Relief And Long-Term Outcome For ADHD

Created by Dr. Sam Goldstein, Ph.D. under General Articles

Symptom Relief And Long-Term Outcome For ADHD

Sam Goldstein, Ph.D.
This is a SamGoldstein.com Monthly Article – June, 2002
Copyright ? 2004 Dr. Sam Goldstein – All Rights Reserved

Despite optimism by professionals and researchers years ago that treating ADHD in childhood led to improved outcome in adulthood, current research has not supported this perception. In fact, the research suggests that relieving the symptoms of ADHD may not necessarily contribute to increasing the likelihood of positive outcome in the adult years. In this month’s article I’ll address this issue and suggest a dual focus for the treatment of ADHD in childhood.

We all accomplish our goals and successes in life through out strengths and abilities. Happy, successful adults frequently comment that in part their success lay in finding something in life they were good at, having the opportunity to develop that skill or ability, and being appreciated for that activity. This speaks to an important issue relative to the treatment of ADHD. Is symptom relief for ADHD equivalent to positively changing long-term outcome? Unfortunately, as far as we are currently aware, the answer is no. First, let’s focus on symptom relief. A number of longitudinal studies over multiple years, including the recently completed multi-site study involving over 300 children with ADHD funded by the National Institute of Mental Health has unequivocally demonstrated that the symptoms and immediate impairment caused by the symptoms of ADHD are dramatically reduced through a combination of education about the condition, medication, parent behavior management training and in classroom teacher support. Although initial data analysis of this research demonstrated that medication alone appeared to be the most powerful intervention, recent re-analysis of these data leaves no doubt that the combination of interventions is superior to medication alone. Medication in combination with behavior modification intervention improved students’ performance on a range of academic measures including note taking, daily assignments, and quiz scores. Consistently and conscientiously applied parenting strategies involving behavior management as well as in classroom educational support are very effective in reducing the impairing problems caused by the symptoms of ADHD. The use of some classes of medications, particularly those that affect certain neurotransmitters in the brain, are also very effective in increasing self-control and thereby reducing symptoms and impairment. In particular, stimulant and antidepressant medications that affect the neurotransmitters, dopamine and norepinephrine appear quite beneficial for ADHD. In contrast, the currently popular antidepressant medications that impact serotonin, such as Prozac and Zoloft, have not been found to be beneficial for ADHD.

As we follow children with ADHD growing up, unfortunately, those who responded best to our symptom focused interventions were not necessarily those who turned out to be most functional as adults. Thus, although we once believed that relieving the immediate symptoms of ADHD led to better life outcome, treatment alone doesn’t predict outcome. From a common sense perspective, if every day of a child’s life is better, certainly the sum total of his or her life should be better. Yet, we have had difficulty demonstrating this fact. What we have demonstrated, however, is that the factors that contribute to good life outcome for all children are particularly important for children with handicapping conditions such as ADHD.

Our current treatment for ADHD is now dual focused. First, we focus on research proven interventions involving medication, education, parent training and classroom intervention to reduce the symptoms of and impairment caused by ADHD. By making tasks interesting and payoffs valuable, we have discovered that children with ADHD function dramatically better. Our treatment for ADHD, however, has now taken on a second, equally important component. Providing children with ADHD with opportunities to develop a resilient mindset. Children with such a mindset are empathic. They communicate effectively. They learn to problem solve, develop a social conscience and most importantly are self-disciplined. Parents engaged in the process of raising resilient youngsters possess an understanding that is sometimes explicit, at other times implicit or intuitive of what they can to do nurture this mindset in their children. To do this requires parents to appreciate the components of resilience so that their interactions with their children are guided by an important set of principles, ideas, and actions. Although each child’s road to adulthood is shaped by a variety of factors, these guideposts provide principles applicable for all roads and thus can direct all parents in raising resilient children. Dr. Robert Brooks and I elaborate the guideposts, principles and strategies of this model in our book, Raising Resilient Children (Contemporary, 2001).

Just as some children require more support, effort and instruction to learn to ride a bicycle or swim, we now believe that it is critically important for us to provide support for children with ADHD to assist them in developing self-control. Day in and day out modeling of the behaviors necessary to become self-disciplined may assist children with ADHD in developing the internal skills necessary to function more effectively in future life.

What Is Necessary And Sufficient To Evaluate ADHD?

Created by Dr. Sam Goldstein, Ph.D. under General Articles

What Is Necessary And Sufficient To Evaluate ADHD?

Sam Goldstein, Ph.D.
This is a SamGoldstein.com Monthly Article – May, 2002
Copyright ? 2004 Dr. Sam Goldstein – All Rights Reserved

A health insurance representative informed me last week that it was her opinion and her company’s policy that an evaluation for ADHD can be completed in as short a time as an hour. Yet some professionals take hours administering a variety of tests before a diagnosis is made. In this month’s article I will review important issues in the diagnostic process of ADHD.

It is important for parents to understand that when children struggle emotionally, behaviorally or developmentally it is more likely than not that they may experience difficulty in a number of important life activities. The process of assessment is not just to count symptoms and proclaim diagnoses but to understand a child’s strengths as well as weaknesses in ways that assist in providing support and help. To be wise consumers of an ADHD assessment, parents must first understand the important role normally maturing self-control plays in child development. Self-control is critically important to learn, behave, manage emotions, develop friendships and function effectively in community activities. Thus, it is not surprising that the co-occurrence of learning, behavioral and emotional problems is the rule rather than the exception for children receiving diagnoses of ADHD. The diagnostic process, therefore, must carefully explore many of these co-occurring problems not only to provide appropriate diagnoses and assistance but also to identify early signs or risk factors that may speak to an emerging problem in the future. This process allows parents, educators and professionals to provide help and assistance before children fail. For example, preschoolers with delayed development of self-control are often disinterested in sedentary, pre-academic activities. Their lack of practice leads to limited proficiency. This often makes them appear as if they may have a learning disability. Yet some children with ADHD also demonstrate weaknesses in key skills necessary for early academic achievement. A thorough assessment allows a professional to not only examine the issue of ADHD but also the possibility that beyond the symptoms of ADHD lie weaknesses in skills necessary for early academic learning. Further, it is well recognized that among children with early language and learning problems, parent and teacher reports of hyperactive, impulsive and inattentive behavior are often elevated, not necessarily the result of a biological risk but as a result of the child’s day in and day out frustration. Only a thorough assessment can tease out and provide an understanding of these risks and their relationships.

In the clinical diagnostic process there are eighteen symptoms of ADHD. These symptoms can be assessed through direct observation and history taking but can also very efficiently be assessed by asking parents and teachers to complete well-researched normative questionnaires. In fact this quickly allows a professional to obtain parent and teacher input specifically concerning the presentation and severity of ADHD symptoms. However, parents should be cautioned that when this type of questionnaire process is the only means of assessment the rate of false positive diagnoses may equal the rate of accurate diagnoses of the general population. Time saving questionnaires and even a brief history provide a very efficient means of identifying the 20% of children in the general population who may struggle. To truly understand the reasons for these struggles, a good evaluator must take a much more detailed and careful history as well as explore the possibility that symptoms could be the result of other conditions. Keep in mind that complaints of inattention, off task behavior and non-compliance are the most common complaints parents make about children. In particular inattentiveness is a characteristic description of children with depression, anxiety, oppositional behavior and even learning disability. For many of these children their inattentiveness is not the result of a biologically based problem with developing self-control.

At the other extreme, it is also not necessary to administer a ten hour neuropsychological battery to a child referred for symptoms of ADHD in which a brief history and general questionnaires reveal no indications of delayed academic achievement or performance, severe emotional problems or family adversity. When parents suspect their children may experience problems as a result of ADHD, a good place to begin is by obtaining a book or video about the subject and becoming educated about common signs, symptoms and behaviors as well as co-occurring problems. If parents are then concerned their child may experience symptoms of ADHD to an impairing degree, I suggest they speak with their pediatrician or family practitioner. Most physicians working with children today also work closely with child psychologists and can refer the child for an initial consultation. I also suggest parents request a consultation with their child’s school psychologist. Although school personnel usually are not in the position to make a diagnosis of ADHD, the input they can provide to the physician and community psychologist is invaluable in the diagnostic process.

Finally, keep in mind that when children leave school they are not asked their weakest subject and most annoying behavior and then assigned a job involving both for life. In fact, it is just the opposite. We accomplish our goals in life through our strengths and assets. For me, an evaluation considering ADHD in a child must also place equal focus on defining and understanding that child’s strengths and abilities.

Is ADHD Really A Problem Paying Attention?

Created by Dr. Sam Goldstein, Ph.D. under General Articles

Is ADHD Really A Problem Paying Attention?

Sam Goldstein, Ph.D.
This is a SamGoldstein.com Monthly Article – April, 2002
Copyright ? 2004 Dr. Sam Goldstein – All Rights Reserved

Many parents and teachers report that although children with ADHD are not supposed to be able to pay attention, there are many activities or situations during which their attention span appears focused, if not even more focused than unaffected children. In this month’s article I will address this often misunderstood issue.

Problems sustaining attention are not the cause but one consequence of having ADHD. If you provide a child with ADHD with a roll of coins and bring him or her to an interesting arcade, that child “pays attention” quite well. In fact in some cases children with ADHD may sustain activities of interest such as computer games longer than unaffected children. What is it about the condition of ADHD that leads to this phenomena? The fact of the matter is that children with ADHD have trouble paying attention in only some situations. These are situations in which children must bring on line increased self-control and effort in order to remain attentive. Such situations are defined as repetitive, effortful, uninteresting, and usually not of the child’s choosing. When these situations do not provide immediate, frequent, predictable and meaningful payoffs or rewards for completion, children with ADHD struggle even further. Keep in mind that all of us struggle to sustain attention and effort in these types of situations.

What is it unaffected children do to function in these situations that children with ADHD appear unable or incapable of doing? The answer: self-regulate. Self-regulation or self-control must be brought online in these types of circumstances. Thus, when tasks are interesting and pay-offs valuable, research studies find that children with ADHD pay attention reasonably well. As tasks become more repetitive, less interesting and offer only delayed reinforcement, children with ADHD lose focus and sustained attention faster than others. Thus, it is not that children with ADHD have something unaffected children don’t have. It’s that unaffected children are maturing quicker in a skill that children with ADHD struggle to develop – self-control. In fact, in research studies, children receiving a diagnosis of ADHD possess the self-regulation or self-control of children approximately two thirds of their chronological age. It is not that their self-control isn’t developing, it’s that it is developing at a much slower pace.

Self-control allows human beings to think, plan and organize; to open a window as it were between experience and response; to not necessarily be locked into a first response when faced with problems; to separate thought from feeling; to carefully consider alternatives and to sustain effort and focus even in the face of frustration or boredom. Although the clinical term for the condition still contains the words attention and hyperactivity, it is increasingly recognized by researchers and professionals that these are consequences of delayed or faulty self-control. Even parents of children with ADHD are quick to comment that there are many situations or activities during which their children appear to pay attention quite well, even if while engaged in those activities their children respond thoughtlessly or impulsively.

As scientific research emerges defining problems with the development of self-control as the core deficit in children with ADHD, a better understanding of treatment is also developing. Medications used to treat ADHD do not necessarily improve attention. They increase self-control leading to sustained effort, focus, attention, impulse control and enhanced capacity to manage physical activity. Central nervous stimulants, in fact, do not reduce hyperactivity but stimulate a center in the brain that human beings use to govern and regulate themselves. It is for this reason that stimulants such as caffeine are popular in our culture because even unaffected individuals many derive some small benefits in regards to enhanced self-control from them. We now recognize, however, that while stimulant medication may reduce immediate symptoms of ADHD, the medication alone does not appear to contribute to positive long-term adult outcome for these children. Programs are being developed to help children during their formative years experience increased opportunities to learn and develop the self-control that is so essential and necessary to become a productive member of society. Time will tell the effectiveness of this approach. Presently, the programs that I am using have been developed by Dr. Myrna Shure. These are set in a usable framework in her three books, (Raising a Thinking Child, Raising a Thinking Pre-Teen and I Can Problem Solve).

ADHD As An Advantage/Adaptation Revisited

Created by Dr. Sam Goldstein, Ph.D. under General Articles

ADHD As An Advantage/Adaptation Revisited

Sam Goldstein, Ph.D.
This is a SamGoldstein.com Monthly Article – March, 2002
Copyright ? 2002 Dr. Sam Goldstein – All Rights Reserved

It is romantic and intriguing to believe that great hunters, explorers, inventors and politicians may have experienced ADHD and in fact the qualities of ADHD were in part responsible for fueling their success. Though many intelligent, well-meaning individuals are seduced by this belief, new data has not been generated in the past three years to support this theory. In fact, just the opposite; volumes of new data have been collected and analyzed refuting this idea. In this month’s article I re-visit this theme and begin with a metaphor – the “Just So Story” which I’ve offered in past years as a common sense basis to consider the supposed adaptive advantages of ADHD.

The fanciful tales of Rudyard Kipling, including how the zebra got his stripes or the elephant her trunk are entertaining. Yet few would interpret these “Just So Stories” as truth or for that matter even testable theory. There is, however, a popular view that all human qualities, including anatomical features, behaviors, quirks and idiosyncracies, arose and developed through a process of natural selection. Supposedly these factors provided the organisms that possessed or exhibited them with an evolutionary advantage.

Thus, it is not surprising that there is an increasingly popular and seductive trend among the public and some professionals to view the symptoms of ADHD as adaptive behaviors. It has been suggested that these behaviors evolved to serve a functional purpose in the distant past but may not fit well within current culture and expectation. Through some unexplained process, these qualities were selected for their adaptive advantages, providing carriers of the genes for these qualities with either greater reproductive or inclusive fitness over others. However, readers pursuing a brief introduction to evolutionary theory or evolutionary psychology will quickly realize that it is implausible to perceive symptoms or behaviors related to ADHD as being advantageous regardless of the time or cultural context in which one examined the data. The model of ADHD as adaptive does not appear to fit what is known about ourselves, our ancestors or about ADHD. In fact, a better fit is to suggest that those who do not suffer from ADHD clearly have an adaptive and likely selective advantage across multiple generations given that they represent the current norm. A much more plausible argument is that ADHD rather than representing an adapted or evolved set of valuable qualities reflects weaknesses in the development of efficient self-regulation and self-control. These functions likely fall on a normal curve similar to height or weight. Readers taking the time to understand evolutionary concepts will quickly conclude that falling to the bottom of a normal curve in the development of self-control rather than representing an advantage represents a disadvantage.

It is important for readers to keep in mind that by definition the diagnosis of ADHD is provided not just because an individual meets symptom count but because those symptoms cause chronic and significant impairment across multiple life domains. The diagnosis is pervasive. When children are provided with the diagnosis in research studies most still meet the diagnostic criteria many years later. Even in adult outcome studies, though at least half of adults may not meet the full diagnostic criteria for ADHD they still report daily impairments. In the nearly 4,000 peer reviewed, scientific studies dealing with ADHD over the past thirty years, there hasn’t been a single study in which the group with ADHD performed better on a valuable trait, asset or behavior than those without ADHD. This is not to moralize, demonize, nor pathologize children with ADHD. It is to suggest that being delayed in the development of self-control in our complex society is no picnic. It is no blessing for the children who struggle with this problem nor for their dedicated teachers or parents who live with and love them.

Although it has been suggested that some individuals historically and currently who have achieved success have done so because they are inattentive or novelty seeking, it is yet to be scientifically demonstrated that the symptom qualities of ADHD by themselves lead to positive life outcome. It is my belief that if in fact many great men and women struggled with ADHD, their greatness was obtained because they possessed other skills and abilities and were afforded opportunities to overcome this condition. Fortunately, the symptoms of ADHD can be treated and managed effectively leading to more successful and happier lives for those who may struggle against it’s diminished capacity for self-control. We must turn our attention to the multiple forces and critical problems that appear to be increasingly creating a vulnerable youth as we enter this new millennium. I continue to not believe we do not need to create myths or “Just So Stories” to help children with ADHD and their families feel better about this impairing condition. Rather, I believe it is time that we begin focusing on the strengths and assets of all children while managing those liabilities that impair their ability to succeed in the world we have created for them.

The ADHD Critics: More Passion Than Science

Created by Dr. Sam Goldstein, Ph.D. under General Articles

The ADHD Critics: More Passion Than Science

Sam Goldstein, Ph.D.

This month’s article may read more like an editorial than a review of research, set of clinical guidelines or treatment practice. Though I have made a point to avoid using my monthly article as an editorial forum, my daily mailbag led me to change my mind, at least for this month.

In last week’s mail I received a correspondence containing four documents. The return address was someone in Honolulu whom I do not know nor did that person make any effort to identify him/herself within the correspondence. The first was a copy of a number of recent editorial cartoons sarcastically addressing the issue of psychiatric medications for children. These were from major media such as Newsweek and the New York Times. The second was two pages of short quotes by many well-respected professionals concerning ADHD. The title of this sheet was ADHD: Fact, Fiction or Fraud? Most of the quotes were taken out of context. Most reflected opinion not necessarily scientific fact.

The third was a copy from an occupational therapy weekly newsletter. It was a one-page viewpoint titled ADHD is Biopsychiatric Social Control. The author, an occupational therapist, cited a number of authors of recent texts critical not only of ADHD but of psychiatry in general. Absent any substantive fact, this author suggested that “ADHD is biopsychiatric social control under the guise of therapeutic intervention. It gives permission to parents and professionals to micro manage a child’s life. This may ultimately create a helpless and dependent individual rather than in independent and resilient person” (Parry, 10/8/98, OT Week). Ms. Parry is certainly entitled to her opinion. It would be nice if she provided some facts to support her inflammatory statements. Her statements in general reflect pseudo science and a lack of understanding on her part of the current state of science in psychiatry and psychology.

Finally, the last document was an article titled ADHD: An Educational, Cultural Model from the December, 2001 issue of the Journal of School Nursing. The authors, Jane Lundholm-Brown and Mary E. Dildy, offer an interesting overview of ADHD, from the perspective of the “traditional medical model” versus what they define as an Educational Cultural Model (ECM). They cite themselves as the authors of this alternate model, suggesting that “in the ECM the child is not considered physiologically disordered. Instead, children are recognized as individuals with varying levels of energy who differ in temperament, attention span, intensity, mood, distractibility, intelligence, talent and personal interests. Additional consideration will be given to the potential effects of family dynamics and societal influences on the behavior and attentiveness of children” (pg. 307). Ironically, this purported new model is not so new nor is it theirs except by title. What they describe is in fact the current standard of care in the evaluation of emotional, behavioral and developmental problems in childhood. Well over twenty-five years ago, pioneering researcher, Dr. Keith Conners, referred to the assessment and treatment of ADHD as a biopsychosocial phenomena that can only be understood by taking into account not only genetics and biology but environment and experience as well.

Lundholm-Brown and Dildy then go on to describe a very narrow, rather antiquated view of the “medical model of ADHD.” Their description has long since been abandoned by researchers and most mainstream clinicians. They suggest that the medical model of ADHD places “little emphasis on the educational and cultural factors that may contribute to the cause of behavioral and attention problems in children” (pg. 310). I am not sure what resource or authoritative volume they relied on for their definition of a medical model but this certainly is not the current state of affairs in the science of ADHD. A review even of my previous monthly articles stands testament to the recognized complexity of this condition and the multiple forces that ultimately shape and determine a child’s behavior in any given setting.

It is unfortunate my mysterious correspondent was willing to take the time to provide information and attempt to shift what he/she perceived to be my opinion yet was unwilling to reveal his/her identity. I can only assume that this person identified me as one of those professionals who rigidly adheres to the “medical model of ADHD” and is on a quest to diagnose as many children in the population as possible, handing them off to the pha.rmaceutical industry for a life-time of medications. Unfortunately, this could not be further from the truth.

Perhaps the practices of some professionals in the field contributes to the misguided views of the public or other professionals? In the very same day’s mail, I also received a set of records to review of an unfortunate eight-year-old child with a history of significant behavioral and emotional problems beginning at a very young age. Despite the efforts of caring, conscientious parents, parents raising three other children who in fact were doing quite well, this child was struggling. He had been evaluated a number of times. His parents had attempted a number of behavioral, educational and medical interventions. In fact, I was not surprised to note that this child had been treated with multiple psychiatric medications in the past with mixed results. These included medications in multiple classes from the anti-convulsants to the anti-depressants. Included were Seroquel, Depakote, Tenex, Clonidine, Zyprexa, Ritalin, Adderall and Wellbutrin. They had been attempted in various combinations following a diagnosis of early onset bipolar disorder and ADHD. Did this child have ADHD or bipolar disorder? It was difficult to tell from the records. Certainly this child was struggling. Had these medications been beneficial? Once again it was difficult to tell from the records as specific targets for medication treatment or careful monitoring of medication response had not been completed.

Unfortunately, I am seeing more and more children coming in to our tertiary care, university affiliated neuropsychology clinic with similar behavioral and medical histories. As Dr. Robert Brooks and I have noted in our work, especially in the area of resilience, a review of all sources of childhood data suggests that children are finding it increasingly more difficult to meet the expectations and demands of our culture. In response, more and more are experiencing problems. More and more of them come into our clinics and offices taking multiple medications, sometimes for problems that medicines have yet to be demonstrated as effective for in children.

How are these two items in my mail related? They both reflect actions based more on passion than science. Try as I might, I can’t find an extensive literature of editorials, articles or opinions raising questions about this increasing trend. I also cannot find scientific research supporting this increasing pattern of prescribing and the prescription of multiple psychiatric medications to children simultaneously. I am not questioning the good work of many of the medical clinicians with whom I interact, I am just suggesting for example there is scant scientific literature to support the 300,000 plus children receiving anti-hypertensives such as Tenex and Clonidine or the over one million children receiving SSRI’s such as Prozac and Zoloft let alone polypha.rmacy. Ironically, there is a very solid research base concerning the immediate symptom relief offered by the stimulant medications for children with impaired self-control leading to inattentive, hyperactive and impulsive behavior. I also cannot find an extensive literature questioning the existence conditions other than ADHD that present in childhood such as anxiety, depression or learning disability.

What is it about ADHD that has created such a backlash among some professionals as well as the community at large? Why is it that ADHD so routinely stirs controversy based more on philosophy than fact? Why is it that many professionals can’t seem or are unwilling to take the time to read, review and understand the scientific literature, that very clearly demonstrates the physical and genetic bases for children at risk to receive diagnoses of ADHD? Why is it that these people have so much difficulty understanding that ADHD is not an “it” but a reflection of the pace at which a child develops self-regulation and self-control. Thus, increased cultural demands upon children increases the number struggling to meet the expectations of the culture. This acts as but one more force leading children to the doorsteps of physicians and psychologists. Why is it that many of these individuals choose to close their eyes to fact, arguing that ADHD is a condition invented by phar.maceutical companies to sell pills, a means to micro manage children’s behavior, an excuse for bad parenting or poor education or a problem caused by a variety of mysterious phenomena? Perhaps in the end it comes down to the fact that opinion is cheap and easy. It is easy to blame parents as inadequate when their children struggle to develop effective self-control. It is easy to point a finger of guilt at a parent who struggles to help a child learn to sustain attention or sit still only to find the child experiencing increasing problems. It is easy to blame professional organizations, support groups or drug companies.

Why is it that people have so much trouble understanding that ADHD is not a diagnosis based purely on symptoms but on impairment as well? The diagnosis of ADHD is made not to categorize, pathologize, moralize or demonize human beings but to assign risk and to gaze into the future through the eyes of the diagnosed child. By comparing that child to other children with a similar pattern of symptoms and impairment, other children for whom future risks and outcome are known, we can plan and more effectively work with the diagnosed child. By doing so, we well understand the risks children who fail to develop self-discipline and self-control face academically, emotionally, behaviorally, vocationally and even in the lifestyle choices they make. What is it about these critics that blinds them to recognizing the common sense that in every classroom worldwide some children struggle with developing self-control? Even if it is one out of twenty, that is five percent of the population. That is five percent of all children who simply struggle to sustain effort, and require more time, patience and support to develop the self-discipline necessary to deal with life’s daily requirements.

In my work with parents, I often provide the analogy of teaching children to swim or ride a bicycle. We all accept that based on the underlying skills necessary to master these abilities, children will vary in their progress. We accept that balance and coordination make a difference in the pace at which children learn to swim or ride a bicycle. Some will achieve quickly. Most will require some assistance but some, despite our assistance, will continue to struggle. When they struggle, as long as they get on the bicycle or into the water, we are very encouraging. We don’t ask them to try harder. We don’t question their effort or motivation. We don’t ask how many times do we have to tell or show you? We are supportive and empathic. We recognize that the acquisition of these abilities for some children is difficult and that our role as parents and professionals is to provide sufficient opportunity, patience, encouragement and support to allow mastery of these abilities. I strongly believe that children with ADHD need the same empathy and support. Their only “crime” is that they are delayed in the development of self-control. These children require more time to master the self-regulatory skills necessary for success in every day life. I am not suggesting that practice will make perfect, just that there is enough scientific evidence to recognize that repeated practice over time enhances performance. Our mindset with children struggling to develop self-control is not to just provide a diagnostic label, a prosthetic environment and a prescription, but to find a way to facilitate the development of self-regulation and self-control. Keep in mind that while the medicines we provide children for ADHD offer strong symptom relief, we have not demonstrated that they change long-term outcome. As I have noted, the day a child with ADHD stops taking medicine usually looks like the day before they ever started, regardless of how long they have been taking the medication. The same outcome holds true for behavior management as well. Symptom relief is not synonymous with changing long-term outcome. To help children with ADHD, we must find ways to strengthen and enhance their self-discipline. In the January, 2002 issue of the Journal of the American Academy of Child and Adolescent Psychiatry, Dr. Joseph Strayhorn provides two excellent articles reviewing the strong relationship of faulty self-control, not just to ADHD but to a host of other emotional, behavioral and adjustment problems. Dr. Strayhorn offers a model to begin a concerted effort to enhance the development of self-control in children at risk.

In the final analysis , I am not so much annoyed by the critics but perplexed as to what we as a professional and scientific field can do to help the public understand the nature of ADHD and the truth about what we know. I believe that most professionals want to do the right thing. Certainly there are some with their own agendas for whom belief and rhetoric are the only “facts” they will ever rely upon. But by far the majority, my mysterious correspondent and the authors of those pieces I received in the mail, mean well and truly want to help children. I remain optimistic and confident that eventually the goal of helping children, one that we all share regardless of our opinions and ideas, will bring us together. The events of 2001 argue strongly that we must find a way to do so, not just for the increasing number of children experiencing problems fitting into the world we have designed, but for all children. I invite each of you to consider your opinions and beliefs. Examine the science of those opinions and recognize that the goal of helping all children develop self-discipline and other resilient qualities and ensuring stress hardiness must be first on all of our “to do” lists.

Intelligence And ADHD

Created by Dr. Sam Goldstein, Ph.D. under General Articles

Intelligence And ADHD

Sam Goldstein, Ph.D.
This is a SamGoldstein.com Monthly Article – November, 2001
Copyright © 2001 Dr. Sam Goldstein – All Rights Reserved

Three questions are frequently asked regarding the relationship between intelligence and ADHD. One, does the population of individuals with ADHD represent a normal distribution in terms of intellectual skills? Two, are there characteristics unique to children with ADHD demonstrating superior or better intellectual abilities? Three, are there similar or different characteristics of ADHD in those demonstrating deficient intellectual abilities. In this month’s article, I will briefly review the literature on intelligence and ADHD and address these three important questions.

It is likely that ADHD has a uni-directional effect on intelligence in a number of ways. The impact of limited self-control and impaired sustained attention may well, to a small degree, diminish the acquisition of intellectual skills. However, to a larger degree ADHD is likely to interfere with the application of skills and the efficient test taking strategies necessary to perform well on intelligence tests. Researchers have found a link between IQ and ADHD as well as a link between IQ and other types of behavioral problems. Rates of hyperactive-impulsive behavior and measures of intelligence appear to have a negative association. In contrast, association between ratings of conduct problems and intelligence are often much smaller, in some cases, non-significant. When hyperactive-impulsive behavior is controlled, the relationship among verbal I.Q., achievement and disruptive behavior appears to be relatively specific to the hyperactive-impulsive element observed in disruptive behavior disorders. When efforts are not made to control for I.Q., samples of children with ADHD do differ significantly from controls, particularly demonstrating lower verbal intelligence. It has been suggested that this difference is consistent with a theoretical model of ADHD as noted by Dr. Russell Barkley, reflecting a disorder of poor impulse control.

Measures of sustained attention and inhibition are associated to a small but significant degree with measures of intelligence. Matching subjects with ADHD with controls and statistically controlling for I.Q. differences appears to reduce or eliminate the effects of ADHD upon intelligence. Group differences in Verbal I.Q. should not be viewed as an artifact of group selection nor as a source of error to be removed. These differences may in fact reflect real differences in the two populations. The preponderance of the data suggests, however, that less than 10% of the variance in Verbal I.Q. is accounted for by ADHD. Thus, the population of individuals with ADHD generally falls along a normal distribution in terms of intellectual skills. One might expect that 3% to 5% of those with gifted intellect will meet the symptom criteria for ADHD.

In contrast, the impact ADHD has on the efficient use of intellectual skills is likely greater. This phenomenon, however, is nearly impossible to evaluate given the idiosyncratic differences in children and their responses to differing environmental circumstances. Once again it is reasonable to conclude that children with ADHD demonstrate a generally normal distribution of intellectual skills. However, due to their poor self-control, assessment at any give moment may yield underestimates of their intellectual abilities, particularly on tasks requiring inhibition. Attention problems have been reported as quite common in the intellectually handicapped population, a problem that should not be thought to skew this bell curve but rather likely reflects the fact that a variety of neurological problems can lead to symptoms of hyperactivity, inattention and impulsivity.

I believe the research in this area is well-grounded, and has been generated and replicated over a twelve to fifteen-year span. Why then does it continue to be suggested anecdotally that children with ADHD fall inordinately at the higher end of the intellectual distribution? Why then has it been suggested that ADHD, specifically problems with impulsivity, may reflect some form of dysfunctional creativity? Viewing impulsivity as a potentially positive symptom attribute of ADHD may be a means of influencing the general public’s view of the disorder as somehow beneficial. Scientifically, this quality is and continues to be a significant liability. There is no scientific data to suggest that children with ADHD are more intelligent nor creative. Their impulsivity may result in their being quicker to offer suggestions and ideas and in some circumstances, this may result in adults perceiving them as more creative. The idea that children with ADHD attend to different aspects in their environment, resulting in their gathering and using more diverse information is simply unsubstantiated.

A number of writers have argued that the overlap between creativity and ADHD results from the fact that creative individuals may be sensation seeking. Some have suggested that a significant proportion of children diagnosed with ADHD are in fact simply intelligent, creative and bored! Yet, no data has been provided to support this hypothesis.

The preponderance of the data argues that intellectual processes are generally independent from ADHD. Although children with ADHD may perform inconsistently or deficiently on measures of intellectual skill, this should not lead one to assume that deficiencies in intellect, or for that matter, inconsistencies in intellectual performance are diagnostic of ADHD. Though it may be the case that intelligence is a protective factor and for some individuals with ADHD may serve to insulate them from the adversity of the condition, intelligence clearly falls far short of protecting someone with ADHD from the adverse experiences observed and reported at home, school and on the playground. It is time we put aside the notion that individuals with ADHD are smarter than the rest of us or for that matter, simply misdiagnosed geniuses bored with the repetitive, “bland educational environment we have created.”

Answer To Commonly Asked Questions: Part One

Created by Dr. Sam Goldstein, Ph.D. under General Articles

Answer To Commonly Asked Questions: Part One

Sam Goldstein, Ph.D.
This is a SamGoldstein.com Monthly Article – July, 2001
Copyright ? 2001 Dr. Sam Goldstein – All Rights Reserved

Not surprisingly, I have learned that having a website results in dozens of questions per month from parents and professionals. I have correlated these questions and in particular chosen those who answers are often elusive or simply unavailable from most clinicians. I have modified and enhanced some of the questions as well. Over the next six months my monthly articles address one question per month.

Question #1

Many parents and teachers report that although children with ADHD are not supposed to be able to pay attention, there are many activities or situations during which their attention span appears focused, if not even more focused than unaffected children. If ADHD is a problem of paying attention, how is this possible?

Answer

Problems sustaining attention are not the cause but one consequence of having ADHD. If you provide a child with ADHD with a roll of coins and bring him or her to an interesting arcade, that child “pays attention” quite well. In fact in some cases children with ADHD may sustain activities of interest such as computer games longer than unaffected children. What is it about the condition of ADHD that leads to this phenomena? The fact of the matter is that children with ADHD have trouble paying attention in only some situations. These are situations in which children must bring on line increased self-control and effort in order to remain attentive. Such situations are defined as repetitive, effortful, uninteresting, and usually not of the child’s choosing. When these situations do not provide immediate, frequent, predictable and meaningful payoffs or rewards for completion, children with ADHD struggle even further. Keep in mind that all of us struggle to sustain attention and effort in these types of situations.

What is it unaffected children do to function in these situations that children with ADHD appear unable or incapable of doing? The answer: self-regulate. Self-regulation or self-control must be brought online in these types of circumstances. Thus, when tasks are interesting and pay-offs valuable, research studies find that children with ADHD pay attention reasonably well. As tasks become more repetitive, less interesting and offer only delayed reinforcement, children with ADHD lose focus and sustained attention faster than others. Thus, it is not that children with ADHD have something unaffected children don’t have. It’s that unaffected children are maturing quicker in a skill that children with ADHD struggle to develop – self-control. In fact, in research studies, children receiving a diagnosis of ADHD possess the self-regulation or self-control of children approximately two thirds of their chronological age. It is not that their self-control isn’t developing, it’s that it is developing at a much slower pace.

Self-control allows human beings to think, plan and organize; to open a window as it were between experience and response; to not necessarily be locked into a first response when faced with problems; to separate thought from feeling; to carefully consider alternatives and to sustain effort and focus even in the face of frustration or boredom. Although the clinical term for the condition still contains the words attention and hyperactivity, it is increasingly recognized by researchers and professionals that these are consequences of delayed or faulty self-control. Even parents of children with ADHD are quick to comment that there are many situations or activities during which their children appear to pay attention quite well, even if while engaged in those activities their children respond thoughtlessly or impulsively.

As scientific research emerges defining problems with the development of self-control as the core deficit in children with ADHD, a better understanding of treatment is also developing. Medications used to treat ADHD do not necessarily improve attention. They increase self-control leading to sustained effort, focus, attention, impulse control and enhanced capacity to manage physical activity. Stimulants, in fact, do not reduce hyperactivity but stimulate a center in the brain that human beings use to govern and regulate themselves. It is for this reason that stimulants such as caffeine are popular in our culture because even unaffected individuals many derive some small benefits in regards to enhanced self-control from them. We now recognize, however, that while stimulant medication may reduce immediate symptoms of ADHD, the medication alone does not appear to contribute to positive long-term adult outcome for these children. Programs are being developed to help children during their formative years experience increased opportunities to learn and develop the self-control that is so essential and necessary to become a productive member of society. Presently, the programs that I like best have been developed by Dr. Myrna Shure. They appear at the end of this week’s installment.

Impulsivity, Inattention and Language

Created by Dr. Sam Goldstein, Ph.D. under General Articles

Impulsivity, Inattention and Language

Sam Goldstein, Ph.D.
This is a SamGoldstein.com Monthly Article – June, 2001
Copyright ? 2001 Dr. Sam Goldstein – All Rights Reserved

Toddlers and preschoolers at risk to receive a diagnosis of ADHD are often impulsive and inattentive. These children also demonstrate a higher incidence of problems with language development. In some studies as many as 50% to 70% of young children with hyperactive and impulsive behavior were experiencing problems in understanding and expressing ideas through language. These children also demonstrated a high rate of learning disability when they entered school. It is unclear whether their temperament contributes to delayed language or delayed language contributes to their difficulty temperamentally.

Before they learn to speak and begin to attach verbal labels to things, infants must touch, feel and taste as a means of gaining information about the world. Once they learn to use language effectively, words replace touch. Impulsive toddlers, however, often have difficulty making this transition. Typically they continue to need to touch and feel things, possibly as a means of gaining sensory input from the world. This problem may lead to difficulty understanding personal space in older children with ADHD.

In long-term studies, Dr. Walter Mischel and colleagues found a most interesting relationship between a young child’s ability to use language skills while waiting for rewards and later success as a teenager or young adult. In Dr. Mischel’s study, a group of preschool children were given a snack and asked to wait a period of time before eating it. Some were able to wait, others ate the snack immediately. The children were then given a second snack and told if they could delay eating for a specific period of time they would be rewarded with additional snacks. Again some children immediately ate the snack and some did not. Dr. Mischel discovered that those who were able to wait talked to themselves and convinced themselves that waiting was worthwhile. In other words, they used language to delay gratification. In the smaller group of children who could not wait, verbal strategies were often absent. These children often attempted to use physical strategies such as covering their eyes as a means of delaying gratification, often with little success. Dr. Mischel attempted to teach these children verbal strategies similar to those used by the children capable of waiting but this group could not implement these strategies independently.

Both groups of children were followed as they grew up. As teenagers the group able to delay eating the snack functioned significantly better in many areas, including academic achievement, college entrance exams and general behavior than the group who could not wait. While the snack test is certainly not a clinical measure and would not be expected to be an accurate predictor of future behavior for every child, findings from this research are important. Research in this area helps us understand the relationship between language, the ability to wait for rewards and future success. Impulsive children, unfortunately, appear to have greater problems using language to guide their behavior. As we have come to understand that the core problem for children with ADHD is an immaturity in the development of self-control and self-regulation the connection between language and ADHD has become better understood. Language appears to be the primary means by which each of us develops, strengthens and maintains the capacity for self-control. Self-control enables us to delay gratification or reward. Self-control enables us to stick with boring, repetitive, effortful or uninteresting activities, to manage our emotions, to plan, organize, inhibit and open a window between experience and response. Self-control enables us to consider our actions, change the course of action if it is ineffective and monitor our behavior as we progress. The use of language in this semantic way, as a means of relating and conveying meaning, appears to be critically tied to the development of self-control and the capacity to sustain attention and inhibit impulsive behavior.

Past efforts focused on helping children develop self-control skills through the use of language based self-talk strategies, however, have not been found to be particularly effective in modifying the symptoms and consequences of ADHD. If current theory is correct, why haven’t these strategies been effective? In part, I believe it is because knowing what to do is not the same as doing what you know. Thus, simply teaching a child with ADHD a language based strategy to facilitate self-control does not guarantee the child will be sufficiently self-cued as to when to use the strategy nor capable of consistently implementing and bringing the strategy on line at the right moment. Keep in mind that most children with ADHD appear to know what to do but don’t do what they know. Increasingly we believe as a profession that this problem results from an inability to track cues and to use language to facilitate self-control.

I suggest that the reason children with ADHD have not benefitted from the development of self-control strategies is not failure of the strategies but failure of the mindset of facilitators. Just as some children take an inordinately long period of time to develop the skills to swim or ride a bicycle, children with ADHD are going to take a long time to learn to use language for efficient self-directed behavior. If parents and professionals develop a “learning to swim mindset” accepting that some children take longer and recognizing that with repeated trials all kinds of skills can develop then they are more likely to help children with ADHD develop self-control. Remember that ADHD has a strong biological basis. Therefore, if these problems are not the result of a faulty reinforcement history, simply modifying consequences is not likely to lead to long-term significant change. With the children in our Center, I am increasingly directing their parents and teachers to utilize a model developed by Myrna Shure (author of the texts Raising a Thinking Child and I can Problem Solve) as a means of creating daily dialogue to facilitate self-control development in children with ADHD. Time will tell as to the effectiveness of this intervention. However, the development of self-control appears to be an essential component for the future life success of children with ADHD.

Is All Disruptive Behavior ADHD?

Created by Dr. Sam Goldstein, Ph.D. under General Articles

Is All Disruptive Behavior ADHD

Sam Goldstein, Ph.D.
This is a SamGoldstein.com Monthly Article – April, 2001
Copyright ? 2001 Dr. Sam Goldstein – All Rights Reserved

Take the bus test. Imagine sitting on a public bus along side a nine-year-old child. There might be a variety of behaviors the child might engage in that would disturb or disrupt you. There might be other aspects of the child’s behavior, while not disruptive that might cause you concern or worry about the child’s development, adjustment or welfare. Thus, from this common sense perspective children can exhibit two basic kinds of problems. Those that disturb, disrupt or annoy adults and those that cause adults to worry about the child’s welfare, adjustment or behavior. The latter set of behaviors are usually not disturbing or disruptive. We can easily sit along side a child experiencing depression and learning disability without being disturbed or disrupted on our ride. Yet we would worry about that child’s welfare and adjustment. In contrast, we become disturbed and often angered when children act in hyperactive, impulsive, defiant or aggressive ways. At one time, all of these descriptions were considered part and parcel of Attention Deficit Hyperactivity Disorder. It is not difficult to understand why this belief existed. Certainly a child experiencing problems sustaining attention, prone to act in hyperactive and impulsive ways most certainly will exhibit aggressive and oppositional behavior.

Over the past ten years, however, an emerging solid body of research literature has demonstrated that not all disruptive behavior is symptomatic nor consequential of ADHD. From a common sense perspective I choose to view ADHD as resulting from incompetence as opposed to non-compliance. Because of their impulsive, often unthinking ways of interacting with their environment children with ADHD are prone to behave in resistant or oppositional ways. However, oppositional behavior, we have come to understand, is also fueled by environmental adversity, including parents’ behavior and psychiatric status, parenting strategies and even more important, the consistency with which discipline is provided. Thus, while many children with ADHD are described as oppositional and in fact in clinic settings perhaps as many as half also receive a diagnosis of Oppositional Defiant Disorder, an equal if not greater number of children exhibiting oppositional behavior do so in the absence of experiencing Attention Deficit Hyperactivity Disorder. In this month’s article, I will briefly review the condition we have come to describe as Oppositional Defiant Disorder.

All children misbehave occasionally. In many circumstances when this misbehavior defies adults’ rules, limits or directions, we refer to the behavior as oppositional. All children are oppositional at times. Certainly oppositionality could in part be viewed as a process by which children begin to develop independence. Most of us, however, recognize when a child’s defiant behavior is not the normal, predictable assertion of independence but arises instead from resentment, anger, unhappiness or impulsivity. Excessively oppositional children are extremely negative and provocative in their behavior. At times they can even be spiteful or vindictive based upon how they are treated. Such children lose their tempers frequently and without good reason. They argue with adults, appear angry, resentful and are easily irritated. They often blame others for their misbehavior, defy rules, deliberately annoy people and may use inappropriate language. At times adults view this pattern of behavior as not only resistant but an effort on the child’s part to draw negative attention, suspecting these behaviors resulted from the child’s inability to draw positive attention. Some children exhibit what has been described as passive aggressive behavior, agreeing to comply but never following through. Children with the inattentive type of ADHD are often accused of this problem despite the fact that their difficulties result from lack of focus rather than planned resistance.

Oppositional and delinquent behavior are not one in the same. Although their attitudes may be negative and even hostile, children with oppositionality tend to direct their negative behaviors towards and adults and children with whom they interact on a regular basis at home or at school. They tend to be very pleasant with strangers or other individuals they don’t know well. Delinquent children by contrast behave badly towards unfamiliar adults and children as well as their families. They often do so in public settings and with an aggressive component.

More often than not when children experience school problems, they also experience emotional or behavioral problems at home. However, they are much more likely to let it all hang out at home where they feel comfortable rather than at school where a teacher might think badly of them. When called by the school to discuss their child’s academic problems, parents may come away with the distinct impression that the conference was about two entirely different children. The well behaved, cooperative student the teacher sees at school and the defiant, angry and temperamental child parents view at home. This is especially true when children experience anxiety as well. Such children would never consider misbehaving in school yet at home their anxiety and anger translates into negative behavior. When children in fact act out at school, they have usually crossed a line emotionally and display a willingness to let the world view their problems and unhappiness. A significant number of these children appear at great risk for developing outright delinquent behaviors.

It is not completely understood why children become excessively oppositional. As noted, oppositionality may be contributed to by four primary factors, including the child’s temperament, parents’ temperament, parenting strategy and consistency of discipline. There may in fact be a biological basis to this problem as well. Many youngsters exhibiting oppositional behavior as Dr. Barbara Ingersoll has described, appear to be looking for a fight almost from the moment of birth.

esearchers report that some adopted children, even though they live with calm and accommodating adoptive parents in a supportive environment behave in an oppositional manner that closely resembles the behavior of their birth parents. The fact is, some children appear to come to the world wired to be oppositional. As infants they can be fussy and difficult to comfort. Their terrible two stages are truly terrible with every frustration leading to a tantrum. As they grow older they continue to be quick to anger and do not seem to care about the feelings of others. Some of these children are defiant in all situations. Others can be defiant in one or another situation. Some appear to be easy going until they begin to experience school problems, at which point they become angry, negative and deliberately oppositional at home as well as at school. After years of being calm and easy to please they suddenly appear to be spoiling for a fight.

It is also not surprising that children struggling at school academically frequently develop defiant patterns of behavior. Their academic performance may not meet the expectation of the environment. This leads them to regularly receive huge doses of negative feedback and criticism. Eventually this constant flow leads to frustration and these children begin pushing back in retaliation. Parents may come to believe that these children are merely being disobedient and that disobedience is the cause rather than the consequence of school problems. Closer scrutiny frequently reveals, however, that the behavior has followed rather than preceded poor school performance.

For many children with ADHD also experiencing oppositional behavior, a positive, robust response to medication often leads to increased self-control and subsequently reduced oppositionality. Nonetheless, oppositional behavior with or without ADHD places children at increased risk for later life problems and thus this pattern of behavior must be addressed. There are a number of good texts and parent training resources. Here are a few of my favorites.

Update On Adult ADHD

Created by Dr. Sam Goldstein, Ph.D. under General Articles

Update On Adult ADHD

 

Sam Goldstein, Ph.D.
This is a SamGoldstein.com Monthly Article – February, 2001
Copyright © 2001 Dr. Sam Goldstein – All Rights Reserved

The existence of ADHD as a clinically impairing condition is irrefutable. Though the etiology of the condition and precise symptom profile remain debatable concepts, presenting symptoms and impairing consequences are easily observed and measured. In light of current theories portraying ADHD as a condition of impaired development, it should not be a great philosophical nor academic leap to accept the condition as presenting throughout the life span. Yet scientific method requires more than just hypotheses and theory before belief can confidently be described as fact. Though thousands of peer reviewed studies dealing with ADHD in childhood have been published, the literature still contains fewer than 100 peer reviewed articles dealing with adult ADHD. The numbers of studies have been increasing significantly year-by-year, including the ongoing reported results from a number of longitudinal studies following children with ADHD into their adult years. Yet, as with any emerging condition, each published study holds the promise of new data, insight and perhaps a new path to follow in regards to ADHD in the adult years. Time will determine which paths bear fruit and which may result in dead ends.

It is an unfortunate phenomena that for the time being the field of adult ADHD is driven as much if not more by lay publications and experts whose "facts" are primarily based upon their clinical experiences. Clinical practice for many professionals working with adults with ADHD is guided more by these phenomena and less by available scientific literature. In clinical practice and even research the misunderstanding of the developmental nature of the diagnosis, particularly the fact that a set of childhood derived symptoms are currently applied to adults causes misunderstanding and misinformation. For example, some researchers have suggested, based upon research review, that as adults grow older fewer meet the childhood criteria for ADHD and therefore most recover. Yet, when normative data is collected across age and gender in adulthood, it is clear that ADHD symptoms persist and cause impairment for a significant group of adults throughout their adult years. These adults with ADHD also display greater self-reported psychological problems, more driving problems and more frequent changes in employment. They often have a history of inconsistent educational experience and multiple marriages. I am not suggesting that it would be impossible for someone with ADHD to obtain a graduate degree or develop a stable marriage, just that those with ADHD are less likely to do so than individuals in the general population.

In the last fifteen years the biopsychosocial nature of this condition across the life span has become increasingly apparent. Adults with ADHD demonstrate longer delay when their attention is misdirected. They have difficulty switching tasks. On neuropsychological testing they often have trouble with sustained effort, planning, organization, visual tracking and auditory attention. Some researchers have suggested that these weaknesses reflect problems with executive control or frontal lobe skills. Interestingly, most of these skills are not strongly related to intelligence.

Though some authors have suggested that ADHD may reflect an adapted pattern of skills developed based upon an evolutionary model, the emerging research literature is sobering. Not a single childhood nor adult study exists to suggest those with ADHD hold any type of advantage over individuals without this condition. Further, the increased recognition that ADHD reflects not so much a problem sitting still or paying attention but rather a problem of self-regulation or self-control provides a workable hypothesis to explain the myriad of problems currently identified for adults with histories of ADHD. This plausible explanation for ADHD explains that rather than representing an adapted or evolved set of valuable qualities, individuals with ADHD suffer from weaknesses in the development of efficient self-regulatory and executive functions. Qualities of ADHD appear to place individuals at the lower tail of an adaptive bell curve for these skills. This should not pathologize or those with ADHD but help readers understand and empathize with their plight.

It has been estimated from available literature that approximately one third of adults with ADHD progress satisfactorily into their adult years. Another one third continue to experience some problems while the final one third continues to experience and often develops significant problems. By combining a number of well conducted outcome studies it is reasonable to conclude that 10% to 20% of adults with histories of ADHD experience few problems. Sixty percent continue to demonstrate symptoms of ADHD and experience social, academic and emotional problems to at least a mild to moderate degree. Finally, 10% to 30% develop anti-social problems in addition to their continued difficulty with ADHD and other comorbid problems such as depression and anxiety. Many of these negative outcomes are linked to the continuity, severity and persistence of ADHD symptoms. There is also very limited data to suggest that females at outcome when controlling for initial presentation are at reduced risk for some problems in comparison to males. Their rates of comorbid depression and anxiety are likely equal, if not higher, however. A number of ongoing studies are demonstrating that adults with ADHD report very similar symptoms as described in children with ADHD. The impact of these symptoms upon their lives, however, is clearly different. Further, at least to a mild degree, most adults in the general population will report experiencing some symptoms related to inattention and impulse control.

Ultimately the life course for any human being is impacted by varied and multiple factors. An increasing body of literature operating from a developmental pathways model, however, has demonstrated that a number of childhood variables can be used to predict in a general way risk of adult problems as well as identifying insulating or protective factors that reduce risk and increase the chances of a satisfactory transition into adult life. As a field, researchers dealing with childhood disruptive disorders, including ADHD are slowly beginning to examine these protective factors. For the time being there is limited data available specific to the population of individuals with ADHD in this regard. It is quite likely, however, that those factors that insulate and protect children from other psychiatric conditions, including disruptive disorders likely affect those with ADHD. Thus, living in an intact household above the poverty level with parents free of psychiatric problems, consistent in their parenting style, emotionally and physically available to their children, appear to be among the most powerful variables predicting good outcome. Specifically in regards to ADHD the development of aggressive behavior, depression or substance abuse may increase risk of adverse adult outcome. Additional negative outcome variables, include parental psychopathology, learning disability and lower intellect.

The good news is that there is an emerging trend to suggest that the combination of medication, cognitive therapy and life coaching appears to significantly benefit adults with ADHD. I am optimistic that as research and clinical attention turns to the adult ADHD population, our ability to define and prescribe both psychological and ph-armacological interventions for this population will result in treatment success consistent with that reported during the childhood years.

In the winter of 2001, Dr. Goldstein and Dr. Phyllis Ann Teete’s edited work, Clinical Interventions for Adult ADHD (Academic Press) will be published. Drs. Keith Conners, Russell Barkley, Michael Gordon, Tim Wilens, Robert Brooks, Art Robin, Tom Phelan and Kathleen Nadeau are among twenty contributors to this volume.

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