The Family Therapist’s Role in Treating Children with AD/HD(© 2001 AAMFT article reproduced with permission.) Attention Deficit Hyperactivity Disorder or AD/HD (DSM IV 314.00 and its associated subtypes) has received a great deal of publicity. Many clients want to know if they have AD/HD as it can explain many of their problems, such as drug and alcohol addiction, spousal abuse, and failures in their personal and professional relationships. Family therapists are often the first one consulted. We can function as the provider of psychotherapy services as well as the case manager. The services these families need can include group and family therapy, medication management, and academic tutoring as well as behavioral interventions such as social skills training and time and/or organizational management. The family therapists needs to be knowledgeable as to which services are appropriate and for whom. ATTENTION DEFICIT HYPERACTIVITY DISORDERThe occurrence of Attention Deficit Disorder in the population is approximately 5-7%. There are two major forms of AD/HD: the impulsive and hyperactive type and the inattentive, impulsive type. The impulsive-hyperactive type is prone to act out aggressive behaviors and has trouble sitting or waiting without fidgeting. This type frequently acts out or speaks out impulsively without considering the consequences of their actions. The inattentive type can appear to be anxious, withdrawn or depressed. We now think that Learning Disabilities occur in about 30-50% of those who have this form of AD/HD. Unlike other problems that can be mistaken for AD/HD, there is no sudden onset. These behaviors are present throughout the life-span. While only 5-7% of the population, people with AD/HD account for:
HOW AD/HD AFFECTS THE BRAINRecent research clearly shows that the brains of individuals with AD/HD function differently. Many researchers have noted that the frontal cortex functions more slowly. PET scans showed that less glucose is metabolized in the prefrontal cortex (Zametkin, et. Al., 1990). In 1997, a national medical symposium on Neuroimaging in Learning Disabilities and Developmental Disorders was held. Papers presented indicated that MRI and PET scans showed differences in the frontal cortex region of the brain (Bonnet, 1998). While all these neuroimaging techniques are still experimental, they indicate that there are physical, neurological correlates to AD/HD. One way to describe this slowing of brain activity is to say that the brain functions too slowly while processing sensory information. What this means is that the child or adult fails to sort and store sensory stimuli. So, when the stimulation level is low, the patient can focus well, even hyper-focus. But the same person in a room filled with noise or activity becomes increasingly stimulated from the amount of sensory information that they receive. They are unable to filter it out or process it fast enough. New research indicates that this failure to gate or limit sensory information may be due to increased levels of dopamine in the caudate, an area of the basal ganglia which is responsible for the brain’s braking mechanism (Murphy, 1997). The increased dopamine is thought to slow down the gating mechanism. Other structures implicated are the prefrontal cortex, the basal ganglia, the caudate nucleus and the globus pallidus, all structures relating to executive functions (Barclay, 1998). FORMING A DIAGNOSISOne of the best ways to begin an assessment of AD/HD is to take a family history, since 80-90% of the AD/HD cases appear to involve heredity. The therapist should look for signs of impulsivity, distractibility or hyperactivity in two environments before the age of 7 (DSM IV). A common statement which AD/HD adults have heard repeatedly from their parents and/or teachers was “…if you would only pay attention." When interviewing a family or an adult, some useful questions are:
With children, school and home behavioral checklists are used to assess the prevalence of AD/HD behaviors. Hyperactive children are often more easy to diagnose as they tend to act out their behaviors. Another method of assessment for children is to use academic and psychological tests to tease out the difference between Learning Disabilities and AD/HD. For most family therapists, this type of assessment falls outside the scope of our training and licensure and needs to be referred. With adults, most practitioners rely on a comprehensive family history, psychological tests, achievement tests and continuous performance tests. Some practitioners use computer generated continuous performance tests such as the IVA, TOVA or Connor's CPT test as part of their assessment. The client is presented with an auditory or visual stimulus such as a number(s) or letter(s). The client responds by clicking a button on their computer mouse. These responses are evaluated as to the response time, consistency, stamina, omission and commission. The final scores are supposed to represent auditory or visual inattention (omission) or impulsive behaviors (commission). Unfortunately, the tests do not distinguish between a slow response due to an auditory or visual processing problem (a distinct type of learning disability) as opposed to a slow response caused by distractibility. While these tests can yield useful information, they should not be used in isolation. CO-MORBIDITY IN ADULTSExact figures for the percentage of the adult population who suffers from AD/HD are not available. Most of the studies have used male children as subjects and there are only a handful of studies based on other ethnic populations, girls or women. AD/HD is harder to recognize in adults because one rarely sees AD/HD without a co-morbid condition. These conditions can include alcohol and drug addiction, depression (unipolar and bipolar), obsessive compulsive disorder, anxiety or phobias, conduct disorder or oppositional defiant disorder, or learning disabilities. A disproportionate number of adults with alcohol and drug problems report AD/HD behavior problems as children. Current studies indicate that if the AD/HD child is not treated before age 12, they are seven times more likely to be abuse alcohol or drugs as adults. However, if they are treated before the age of 7, their probability drops to what is normal for the population (Miller, 1997). UNDERDIAGNOSED POPULATIONSThe most underdiagnosed subgroup is probably the AD/HD group with LD. This is particularly true in economically disadvantaged populations (Cantwell, 1996). Since the definition of Learning Disabilities is that there is a 1.5 to 2 year discrepancy between the child (or adult's) ability versus their level of performance, someone in the child's environment has to notice that they have abilities that are not actualized. The discrepancy cannot be due to emotional problems or lack of exposure in their environment. Without other evidence to support it, the assumption is that the child’s failure to perform is due to their lack of exposure in their environment rather than to a Learning Disability. Girls are also underdiagnosed. Since girls often do not act out the way boys with learning or attention problems do, they often go unnoticed. If we don’t expect girls to excel, then we won’t notice if they don’t succeed. This is particularly true in minority women. In the only study done on the effects of AD/HD on women, over 77% had anxiety or depression (Cantwell, 1996). THE VALUE OF DIAGNOSING THE PROBLEMMany family therapists don't like to use diagnostic labels. Many schools of family therapy feel that the diagnosis makes the patient become the focus of the family’s problems (the Identified Patient). These therapists would prefer to see the problem systemically. In families with AD/HD and Learning Disabilities the family members often are relieved to understand the nature and scope of the problem. It allows them to reframe why the problem exists. After years of problems or failures, they understand that the affected person is not lazy, crazy or stupid. Many AD/HD clients have made dramatic changes in their lives after they have received the diagnosis of AD/HD. WHAT AD/HD IS NOTDSM IV criteria states that to make the diagnosis of Attention Deficit Disorder the major symptoms of impulsivity, inattention and/or hyperactivity should be present BEFORE THE AGE OF 7 and be observed in at least two environments. If a child is only impulsive at home, but not at school, (or vice versa), there is probably a different reason for the impulse problem. Some adult problems that can mimic AD/HD are Bipolar Disorder and Anxiety. A distinguishing feature of AD/HD is that the fidgeting does not have a cognitive component. In other words, the person fidgets for no reason that they can identify. Another distinguishing feature of AD/HD is that there is not a sudden onset of symptoms. People with AD/HD can describe life-long problems. A person who describes a sudden onset of disorganization, anxiety, or depression, the person is not describing AD/HD. If a person describes early traumatic experiences, as well as some of the AD/HD criteria, one should refer this individual to a psychologist for further testing. THE SCOPE OF THE PROBLEMLearning Disabilities and Attention Deficit Disorder affect many aspects of the child and adult's social world. They affect the person’s abilities to stay on task, to follow directions, to comprehend instructions, to finish activities on time, to delay gratification, and to learn appropriate social rules. While the psychological and social consequences are profound, most adults and children are extremely deficient in certain basic skills. The family therapist needs to bare in mind the scope of the person's limitations when choosing the form of therapy to recommend. THERAPEUTIC INTERVENTIONSome of the therapeutic interventions include: A. Psycho-Education—describe scope of problem B. Family Therapy—behavior management C. Behavioral therapy for family and child
D. Remedial therapies
b. sensory-motor integration for coordination E. Use of assistive technologies
ROLE OF THE FAMILY THERAPISTFamilies are often overwhelmed and need help forming a treatment plan. One of the questions I always ask is “what is the most pressing problem?” Is it the child’s behavior? Or is it the child’s failure to learn information? The answer leads to the formulation of a treatment plan. Some generalities do apply to these families as most of them need to learn strategies to organize the family and to manage their children’s behaviors. Research shows that behavioral interventions, such as contingency contracting or cost-reward plans, work best (NIH position statement, 1998). Many of these families are chaotic and lack routine, structure or ritual. Family therapy interventions that function to help the parent create structure or boundaries are very useful. Since many children and adults with AD/HD do not have sufficient impulse control to enact new behaviors, medications are often recommended by medical doctors to help them gain some impulse control. Many children need remedial education or the use of assistive technology that is frequently provided by public schools or private educational therapists. Since many children and adults failed to learn social cues or rules while growing up, social skills training can be an effective intervention if done as a small, behavioral group. Giler (1998) recommends social skills group be done at schools as a pull-out program, or as an after school therapy group. Therapists that work with this population, need to be familiar with all these therapeutic options and need to help the family choose which intervention to use and when to use it. Therapist need to understand that these families need many kinds of therapy and the combined interventions may take place over a three to five year period. The family therapist is in the ideal position to educate the family, help them learn structure and behavior management techniques, and train children and young adults in appropriate social skills. Lastly, the family therapist can be invaluable as the case manager who helps the family design and manage a treatment plan. References:Barkley, R.A. (1998). Attention-Deficit Hyperactivity Disorder. Scientific American. 279 (3): 66-74 Bloomquist, M.S. (1996) Skills Training for Children with Behavior Disorders: A parent and Therapist Guidebook. N.Y.: Guildford Press. Bonnet, K.A. (1998). Brain Imaging in Learning Disabilities and Developmental Disorders. LDA Newsbrief. March/April. Cantwell, (1996). Talk at LDA on Learning Disabilities. Murphy, K. (1997). ADD Research: Adults with AD/HD and the Driving Performance of Adolescents with AD/HD. Attention Magazine. Summer, C.H.A.D.D. Giler, J.Z. (1998). The ADDept Social Skills Curriculum and training video, Hallowell, E.M. & Ratey, J.J. (1994). Driven to Distraction. N.Y: Simon and Schuster Miller, G. E. (1997). Pharmacological Treatments for AD/HD. CES talk. September 27, 1997, Santa Barbara, CA. NIH Consensus Statement Nov. 16-18, 1998. Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder. In Press. Available on NIH website as Statement 110. Rief, S.F. (1993). How to Reach and Teach ADD/AD/HD Children. West Nyack, N.Y.: Center for Applied Research in Education. Zametkin, A.J., Nordahl, T.E., Gross, M., King, A.D., Semple, W.E., Rumsey, J. Hamburger, S. and Cohen, R.N. Cerebral glucose metabolism in adults with hyperactivity of childhood onset. New England Journal of Medicine, 323 (1990) 1361-1366. << back to top |