Perspectives of a Clinical Psychologist
Although Attention-Deficit/Hyperactive Disorder (ADHD) is a household word, there are a lot of misunderstandings and misconceptions about the disorder.
Below are 10 myths about ADHD that I frequently encounter in the media and when working with families.
1. ADHD is a straightforward diagnosis.
This may seem true based upon the prevalence of ADHD in the U.S.. Indeed, one might be tempted to assume the diagnosis is uncomplicated, simple, or quick. In fact, the opposite is true. ADHD is a complex disorder and diagnosis should only be made following a careful evaluation by a licensed clinical psychologist or other qualified professional. The abundance of ADHD diagnoses has led some to ask whether the disorder is being been handed out too lightly, while others suggest that ADHD may also be “under-diagnosed” in many cases. Both arguments undoubtedly have their merits. In the absence of a comprehensive assessment by a qualified professional, the risk of ADHD misdiagnosis is a legitimate concern.
2. ADHD is a behavioral disorder.
In fact, ADHD is a neurodevelopmental disorder. While ADHD is well known for its behavioral symptoms, the underlying cause and mechanisms of the disorder are neurological. As such, the diagnostic process should take into account not only an individual’s behaviors, but his or her overall neurodevelopmental profile. While behavioral checklists are a good first step, results to not ensure accurate diagnosis. Checklists should be supported by clinical interview and neuropsychological assessment by a psychologist or other professional with expertise in diagnosing ADHD.
3. ADHD is an attention deficit problem.
Actually, ADHD is an attention regulation problem. In fact, many individuals with ADHD can “hyperfocus” on a topic of interest for long periods of time. Their problem is not that they cannot sustain attention to a task; it is that they cannot regulate (i.e., moderate or switch) their attention. Sometimes their attention is fleeting, while other times it’s laser-focused. The possibility of ADHD should not be discounted in individuals who demonstrate the ability to work on a project of interest or play video games for hours at a time.
4. ADHD only affects attention.
Unfortunately, this is not true. If undiagnosed or ignored, ADHD can lead to other problems like anxiety and depression. The consequences can be enormously damaging across an individual’s social, academic, and professional lives. Having ADHD is like walking across a minefield every day of your life. It’s not a matter of whether you will step on a mine; it’s simply a matter of when. Years of living with fear of making mistakes, forgetting, and “screwing up” is not only frustrating and confusing, it’s possibly traumatic. It’s little surprise that the disorder has been correlated with low self-esteem, anxiety, and depression in both kids and adults.
5. Behavioral symptoms are sufficient for diagnosing ADHD.
This is a common misconception. Just because an individual exhibits the symptoms of ADHD does not mean he or she actually has the disorder. After all, ADHD shares many behavioral symptoms with other problems like anxiety, depression, stress, impaired executive function, auditory processing disorder, visual processing weaknesses, and other neurological pathologies/abnormalities. An evaluation that takes into account an individual’s overall neurodevelopmental profile – and not just his or her behavioral symptoms – will improve the probability of accurate diagnosis.
6. ADHD looks the same in everyone.
Again, not true. We are each unique in our circumstances, temperaments, interests, abilities, skills, strengths and weaknesses. Not surprisingly, ADHD affects everyone differently. Inattention, hyperactivity, and impulsivity can manifest in different ways and at different times for different people. For example, extroverts with impulsivity may display more obvious symptoms than an introvert who works to hide these symptoms. Some kids can appear hyperactive, while others seem quiet and reserved. Certain students struggle more with ADHD when they are overstimulated, while others are more challenged when under-stimulated. Alternatively, visual-spatial learners can look inattentive for reasons that have nothing to do with ADHD. And whenever environmental and learning environments are a “poor fit,” ADHD-like symptoms typically worsen.
7. There is a single test for diagnosing ADHD.
Unfortunately, this is not true. Because ADHD is so complex – and it affects everyone differently – the ADHD diagnostic process should incorporate not only behavioral checklists and patient history, but also neuropsychological assessments. ADHD “profiles” can be gleaned from a battery of tests that measures IQ, attention, memory, and executive function. Developing a comprehensive profile of the “whole person” helps confirm (or rule out) the presence of ADHD, even if behavioral symptoms are not obvious. Comprehensive assessment also supports differential diagnosis – in other words, “teasing out” other factors that may be causing ADHD-like behavioral problems.
8. A diagnosis of ADHD guarantees a prescription for medication.
This is not just a myth, but a harmful one. In some cases, parents who suspect an attention issue (and know in their heart that their child is struggling) avoid seeking diagnostic help out of fear that their child will be medicated. The truth is that medication is a highly individualized choice, and it’s not for everyone who has ADHD. Depending on personal preference and circumstances, medication may not be desirable or even effective. Furthermore, there are other ways to support, treat, and embrace ADHD – for example, behavioral interventions, lifestyle changes, family supports, and skills-building approaches. Don’t be afraid of an ADHD diagnosis simply because you think it means you’ll have to take medication.
9. ADHD is all bad.
Actually, there may be many upsides to ADHD. One of the greatest is creativity. The ability to jump from idea to idea, to synthesize seemingly unrelated topics, and to wander inside a world of imaginative creativity has probably contributed to the success of some of history’s great entrepreneurs, artists, inventors, scientists, writers, and teachers.
10. ADHD is an excuse for unruly behavior.
No one chooses to “have ADHD.” But while having the disorder is not anyone’s fault, managing ADHD is ultimately the individual’s responsibility. Successful living is rooted in self-awareness and self-understanding, both of which can be supported by an accurate and clear diagnosis of ADHD. Next, coaching and skill-building can scaffold ownership of ADHD symptoms by helping an individual understand the disorder and how it affects him or her. By developing strategies for circumventing limitations and designing a lifestyle that capitalizes upon advantages, ADHD becomes just another part of life. And like life, ADHD is simply what you make of it.
— Dr. Katen
“Live the life you were meant to live!”
©2016 Individual Matters. All rights reserved. Permission is granted to share this article with others, as well as to print or post it on other websites, so long as credit is given to the author.
Behavioral Checklists Are Just the First Step Towards Accurate Diagnosis
Attention-Deficit/Hyperactive Disorder (ADHD) is an incredibly complex neurodevelopmental disorder. While behavioral checklists serve as useful starting points for identifying the possible presence of ADHD, they may be inadequate when used in isolation.
What is ADHD?
ADHD is classified as a neurodevelopmental disorder whose essential feature is “a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development” (DSM-V). The disorder begins in childhood and lasts into adulthood, often causing a lifetime of personal, academic, and professional struggles.
What causes ADHD?
Unraveling the neurodevelopmental causes of ADHD is still at the frontier of neuropsychological research. Numerous theoretical models have been proposed for understanding what causes the disorder, how it impacts daily functioning, and how it correlates with other issues. In recent decades, ADHD has had an assortment of other labels, including “minimal brain dysfunction”, “hyperkinetic reaction of childhood”, “executive function disorder”, and “attention deficit disorder (ADD).” Some experts simply refer to ADHD as a “symptom complex” – that is, a cluster of behavioral symptoms whose neurological cause is not well understood. Other experts regard ADHD a “context disorder” – a group of behaviors that stem from a mismatch between an individual and his/her environment.
How is ADHD diagnosed?
In most cases, ADHD is assessed in a medical setting and the diagnosis based upon an individual’s behavioral symptoms. Since no genetic or blood test exist for ADHD, the diagnostic process often relies upon behavioral checklists completed by (and dependent upon the observations of) parents and teachers. Checklists ask parents and teachers to rate the severity of a child’s conduct at home and in the classroom.
Why might checklists be insufficient?
ADHD is not a behavioral disorder—it is a neurodevelopmental disorder. Behavioral checklists, as the name suggests, measure the presence of specific behaviors. These behaviors may be symptomatic of a neurodevelopmental disorder like ADHD, or they might be due to something else. The most informative way to assess the neurodevelopmental workings of a child’s brain is to use objective neuropsychological testing.
Since checklists only emphasize behaviors, relying solely upon them to make an ADHD diagnosis invites the risk of misdiagnosis. The behaviors listed on ADHD checklists can be caused by a variety of other factors, including anxiety, auditory and visual processing issues, temperament, fine motor delays, learning styles, learning disabilities, sensory processing difficulties, poor environmental fit, physical health problems, and/or other neurological pathologies/abnormalities. In other words, just because a child displays a large number of behaviors that are typically associated with ADHD, this is not confirmation of the presence of ADHD.
Why does accurate diagnosis of ADHD matter?
Accurate diagnosis is essential for effective intervention. For example, a child with sensory issues may display behaviors that are nearly identical to symptoms of ADHD. Based upon a checklist, this child might be diagnosed with ADHD. Interventions for ADHD can include behavioral strategies, skills-building, environmental modifications and, in some cases, medication. While a child with a sensory processing may benefit from behavioral strategies and environmental modifications, medication would not be appropriate. Furthermore, a child with sensory issues needs occupational therapy. If diagnosed with ADHD, he may be less likely to be assessed and treated by a sensory processing expert.
In addition to the possibility of over-diagnosing ADHD, behavioral checklists can also lead to under-diagnosing. Some children do not display obvious symptoms of ADHD and, therefore, will not score highly enough on a behavioral checklist completed by their parents or teachers. This is particularly true for children who have only an inattentive type of ADHD, as well as introverts, highly compliant children (aka “pleasers”), and the intellectually gifted. Under-diagnosis is also common among girls who suffer from the inattentive form of ADHD. As a result, girls often develop social anxiety and depression, for which they may seek help. In these cases, intervention usually focuses on their anxiety and mood symptoms, while the underlying ADHD goes undetected.
In short, if you have met one child with ADHD, you have met one child with ADHD. It is not a behavioral disorder, but a neurodevelopmental one – and it is exceptionally complex. ADHD affects everyone differently, and not everyone who displays ADHD-like symptoms truly has the disorder. While behavioral checklists are a good first step, individuals suspected of having ADHD should be referred to a psychologist or other professional who specializes in this disorder and provides objective neuropsychological assessments.
– Dr. Katen
©2016 Individual Matters. All rights reserved. Permission is granted to share this article with others, as well as to print or post it on other websites, so long as credit is given to the author.
How to Pay for Learning Assessments?
To use insurance or to private-pay? That is the question, right? Perhaps you’ve already decided to go forward with a psychoeducational (or learning) assessment for your child or yourself. Or maybe you’re still busy comparing services, costs, and trying to determine whether and how to pay for the assessment. No doubt you’ve spent a lot of time researching options. You understandably want to find the best possible assessment service – but also at the most reasonable cost!
Somewhere during your research, you’ve probably wondered whether to pay for the psychoeducational assessment with insurance or private-pay (i.e., paying with cash, check, or credit card). What are the advantages of each payment option? And which is right for you and your family?
Both options – insurance and private-pay – have their advantages:
- Can reduce the cost burden. Depending on your insurance plan, as well as the type of assessments and diagnosis, insurance companies may pay for some or all of the costs of testing for “medical” conditions (usually these refer to mental health or neuropsychological issues that are deemed “medically necessary”).
- Discounts are typically available for going through “in-network” providers.
- Other discounts may be available when you use “out-of-network” providers.
- Insurance does not pay for “learning” or “educational” assessments. Insurance policies do not typically cover “learning” or “educational” assessments such as testing for learning disabilities. In general, insurance does not pay for psychoeducational assessments of academic achievement, cognitive (IQ) testing, or personality and temperament inventories. However, as discussed above, your health insurance might cover assessments of certain “medical” conditions. For example, depending on your insurance policy, you might be reimbursed for assessment of mental health issues or, in some cases, ADHD. Your policy might also pay for certain types of neuropsychological testing that your physician believes to be a “medical necessity.”
- In order for insurance to pay, you must be diagnosed. This is important to consider before you decide to utilize insurance. Since health insurance is part of the medical model, you (or your child) must be diagnosed with a mental health condition if you utilize insurance. This stipulation is important to understand up front, since any subsequent diagnosis will become part of your permanent medical record – possibly affecting your future insurance coverage, school options, employment, etc.
- Your privacy is protected. When you pay privately, you share an agreement with your psychologist – and no one else. With the exception of special cases (e.g., issuance of a court order, or in situations where someone’s life or safety is threatened), your records will never be released without your written authorization. Cash sessions are entirely confidential. Conversely, insurance companies can and do audit psychologists – meaning your (or your child’s) records must be made available to the insurance company and, quite possibly, various other “third party entities” (such as government agencies). Even if your psychologist is not audited, he/she is still required to submit certain information about you to your insurance company (see below).
- Only you and your psychologist determine scope of care. When you pay privately, your psychologist will work with you to formulate goals and intervention based upon your unique circumstances. These plans can be modified, continued, or concluded based on the decisions you make together – in confidence. On the other hand, insurance companies require psychologists to submit client treatment plans – which their claims departments will then decide to approve or deny. When you choose to utilize insurance, the type of assessment, results and diagnoses, and recommended treatment must be submitted to your insurance company. Their claims department will then determine whether the outcomes and recommendations of your sessions fit the insurance company’s decision-making matrix.
- You have more options. When you pay privately for an assessment, your psychologist can utilize any assessment tools that he/she believes will be most helpful and appropriate for yielding a clear and comprehensive profile. He/she is not constrained by what your insurance company will or will not pay for.
- No hidden costs. Private-pay typically involves “flat fee” rates. For example, if an assessment is advertised as $800, then that’s the final cost. All agreed upon services will be provided for that price. There are no “extra” or “hidden” costs. You will not receive any “surprise” follow-up bills.
- Often less expensive than insurance. In the long run, the cost of a psychoeducational assessment may end up being less when you private-pay. One reason is “deductibles.” Insurance companies typically require you to pay a certain amount before they will cover additional costs. If this amount (i.e., your deductible) is greater than the cost of the evaluation, your insurance policy will not pay. Keep in mind that, just because you have received an initial quote for reimbursement, this does guarantee you will actually be reimbursed (as mentioned above, claims may still be denied). Furthermore, since insurance companies direct scope of care, they may agree to cover only a limited-scope assessment. And in all cases, the insurance company will require a diagnosis. But what if no diagnosis is warranted? And what if further testing is appropriate? When all is said and done, you may be left with more questions than answers, and the total cost of the assessment process will increase substantially.
- You pick your provider. Perhaps most importantly, when you pay privately you are able to choose your provider based on “best fit” for you (and your child).
What should you do?
There is no single, best, “right” way to pay for a psychoeducational assessment. Both insurance and private-pay have their advantages. Here are a few final suggestions to consider:
- If you have insurance coverage, check your particular plan by calling the customer service number on your card. Ask the representative about the benefits of using in-network and out-of-network providers, as well as to explain exactly what is (and is not) covered by your plan.
- If you have a Health Savings Plan, you may be able to use these funds to pay for psychoeducational assessment. Check with your HSA provider.
- If you can afford to do so, use cash or check to pay for psychoeducational assessment. This ensures the highest levels of privacy and comprehensive service options.
- If you need to use insurance, get a quote from your company, pay privately first, and then seek reimbursement. Your psychologist can issue you a detailed invoice with insurance billing codes. However, keep in mind that, if you do utilize insurance, your psychologist will still be required to issue a diagnosis (and then submit it to the insurance company). But with this option, you can at least have greater freedom in your choice of psychologists.
- If you still have questions or are uncertain about the options, call and ask your psychologist. They love helping individuals and families – and they will be more than happy to provide information or answer any questions you have!
– Dr. Katen
Is your child struggling in school? “Refusing” to complete chores at home? Is homework an epic battle every night? Does your child complete the homework but forget to turn it in? Does your child’s desk, bag, and room look like they were hit by a tornado? Are their emotions intense and unpredictable? Do you find yourself referring to them as “lazy”? Perhaps the reason is a weakness in executive functioning.
If a child were an airplane, executive functions (EFs) would be the pilot. While many parts and processes of a plane may be in good working order, only the pilot can set a destination, take off, steer the plane where it needs to go, address any issues along the way, and land safely. Without a skilled pilot, the plane is nothing more than a complex assembly of hi-tech parts and equipment sitting idly in a hangar.
Similarly, our brains are powerful and complex mechanisms. But without efficient EFs, individuals may find it difficult to achieve even the simplest goals. From fixing a lunch, to cleaning a room, to learning math, to organizing a school project… EFs are needed to set and reach objectives of all dimensions. Without strong EF skills, a child is essentially a plane without a pilot.
Though the term EF is often described as a singular brain function, it is in fact comprised of multiple, interconnected, complex skills and abilities—so much so that even the experts cannot not agree on a single EF model.
Dr. Thomas Brown’s model offers parents and teachers a clear and straightforward way to categorize skills, understand strengths and weaknesses, develop interventions, and scaffold success. Brown divides EF into 6 “clusters”:
- Activation (getting started, organizing, prioritizing)
- Focus (sustaining and shifting attention)
- Effort (regulating attention, sustaining effort, processing speed)
- Emotion (moderating frustration, excitement, anger)
- Memory (juggling and recalling information)
- Action (controlling pace of action and impulsivity)
The key to any successful intervention is to correctly identify the specific area of struggle. Dr. Brown’s model provides a framework for identifying and understanding which area(s) of EF your child might be struggling with so that intervention may be tailored accordingly.
Children do not wake up in the morning and choose to “fail” at life or in school. So why, then, is life so challenging at times? If you answered “yes” to any of the questions at the beginning of this post, it is possible that the culprit is a weakness in executive functioning. – Dr. Katen
©2016 Katrina Katen. All rights reserved. Permission is granted to share this article with others, as well as to print or post it on other websites, so long as credit is given to the author.
– Frank Coppola, MA, ODC, ACG
Creativity: The Upside of ADHD (Attention-Deficit/Hyperactivity Disorder)
When many people think of Attention-Deficit/Hyperactivity Disorder, or ADHD (formerly called ADD), they tend to picture a hyper and oppositional kid who is bouncing off walls. Or maybe they envision a day dreamer who never listens. Or they think of a disorganized and habitually late adult, whose desk is a mess, and who can never remember where he put his phone. While attention regulation – and sometimes hyperactivity and impulsivity – are certainly part of this “disorder,” there are also many advantages to having ADHD.
One of the greatest gifts of the ADHD mind is creativity. The abilities to jump from idea to idea, to connect seemingly unrelated topics, and to wander (apparently without aim) inside a world of imaginative thought is a double-edged sword. In some situations, these traits can be disabling. But when understood and effectively channeled, these same handicaps become the seeds for ingenuity and discovery. “Impulsivity” can spark spontaneous and brilliant solutions. “Hyperactivity” can fuel the creative process. A “lack of focus” is an advantage when it frees a person from preconceived notions or strategies that aren’t working – and if it results in heightened concentration on more important activities and goals. Indeed, the creative juices of ADHD often produce novel and ingenious solutions, theories, and inventions.
Albert Szent-Gyorgyi, a Hungarian physiologist who won the Nobel Prize in Physiology or Medicine in 1937 and discovered vitamin C, said,
– Albert Szent-Gyorgyi, Physiologist
– Dr. Katen
Attention issues, learning challenges, and social and emotional issues
Parents often feel lost, frustrated, and powerless when their child is struggling at school. Although motivated by love and a fundamental desire to help their child, parents may be unsure why their child is having trouble and what steps to take in figuring it out. There are many reasons a child may be struggling, and, although these may be obvious in some cases, for most children the root cause is complex and not immediately evident.
One underlying cause may be attention issues, which can result in academic problems, negative behaviors, and social difficulties. Academic performance is greatly affected by poor attention because it creates gaps in knowledge. In the classroom, new knowledge builds upon previously mastered material and, as the child progresses in school, gaps in foundational knowledge become increasingly problematic. Behavioral symptoms of attention issues can look very different for each individual child. For example, some children are disruptive, some stare out the window, and others present as engaged while, in fact, their thoughts are elsewhere. Since children in this latter group are not characteristically hyperactive and disruptive, they are at highest risk because their attention problems are least likely to be identified. In addition to academic and behavioral disruptions, attention issues can also result in social and emotional struggles. Children with ADHD are often socially immature and experience low self-esteem.
A learning challenge may also be the culprit of low academic performance. A learning disorder is suspected when academic achievement is substantially below what is normal for age, schooling, and level of intelligence. Not surprisingly, learning disorders significantly interfere with school performance and achievement. Beyond failing grades, these problems can also cause demoralization, low-self esteem, and deficits in social skills. Children may become disruptive in class or simply “check out.” Furthermore, undiagnosed learning disorders can impact students into adulthood when they feel ashamed and “stupid.” As a result, personal relationships and careers may suffer. Contrary to popular belief, learning disorders are not indicative of low intelligence and do not assure failure; some of the greatest thinkers of our time are believed to have had learning and/or attention deficits.
Social and emotional issues can also lead to academic problems. A child weighed down with sadness, anxiety, low self-esteem, and turbulent relationships is less likely to find the focus and motivation necessary to be successful on tests and assignments. Every individual expresses and deals with social and emotional issues in his own way – a reality which presents additional challenges to parents who seek to understand what is going on with their child.
Many times a child’s difficulty at school is not due to a disorder or attention problem, but instead relates to a particular learning environment or style. For instance, children who are advanced in a certain area, but who are not challenged to the upper level of their abilities, are at risk for disrupting class, losing motivation, hiding their talents to fit in with peers, and developing an unhealthy view of why they are different. Sometimes a child simply has a different style of learning. For example, a visual-spatial thinker (someone who conceptualizes in images, and who sees “the whole” rather than organizing information into “silos”) learns most effectively when they understand the big picture first and can utilize their non-verbal abstract learning skills. Visual-spatial students also typically have “light bulb” moments when they grasp a concept all at once rather than in a step-by-step manner. Recognizing and capitalizing upon individual strengths and learning styles are essential for maximizing academic achievement and personal growth throughout one’s life.
When attempting to understand the cause of a student’s struggles at school, a good first step is psycho-educational testing. Essentially, psycho-educational testing removes a great deal of guess work by distinguishing between “can’ts” (inabilities) from “won’ts” (behavioral choices), and by giving parents solid answers and direction. Results of testing reveal how an individual thinks and learns, information which can be used to offer recommendations based on cognitive, emotional, social, and behavioral functioning, as well as individual strengths and interests. Once parents clearly and comprehensively understand their child’s struggles, they can focus on promoting strengths, developing skills, seeking supportive learning accommodations, and collaborating with educators. Ultimately, the goal of psycho-educational testing is to maximize the child’s potential and lay the foundation for personal and professional success.
– Dr. Katen