Does my child really have ADHD?


EEG studies are also beginning to differential between different types of ADHD.  In fact, A. Clark found two distinct EEG clusters of children with inattentive ADD. One characterized by an increase in high amplitude theta with deficits in delta and beta waves, while the other was characterized by an increased in slow wave activities (delta and theta) along with deficiencies of fast wave activity (beta).  So, in these two groups we see ADD symptoms with both cortical hypoarousal and with a pattern consistent with a maturational lag.  This suggests that ADHD should be re-conceptualized not in terms of observed behaviors per se’, but rather in terms of the type of central nervous system abnormality underlying the behavioral manifestations. Doing this, might add significantly to predictive validity of the diagnostic system which is currently weak.  (Clarke, 2002)


In fact, if you look at the DSM-IV Criteria for ADHD you wouldn’t see any symptoms for problems in regulating emotions.  But, as a practitioner with over twenty years experience working with individuals with ADHD, I fully concur with Thomas Brown, Ph.D. of Yale Medical School when he asserts that both researchers and clinicians report chronic problems in emotional regulation as characteristic of many individuals with ADHD.  In fact, he views the crux of ADHD to involve inconsistency in initiating and sustaining the arousal necessary to regulate organization, energy, alertness, planning, memory and mood  (Brown T. , 1995); a finding which is consistent with numerous EEG studies documenting a disproportionate ratio of slow wave activity in the brain of individuals with ADHD. Utah’s Criteria for ADHD in adults does include affective liability, emotional reactivity and a hot temper (Wender, 1995) Likewise, the CAARS Adult ADHD Rating Scale includes four emotional control factors for identifying ADHD .


Models of ADHD


Barkley’s model of ADHD is the one most parents are familiar with due to his association with C.H.A.D.D..  He posits five major components of executive function impairment in ADHD. These include self-regulation of affect, motivation and arousal, reconstitution or behavior analysis for planning and synthesis. According to Brown (Brown, 2001) emotional overshadows thinking and the individual is unable to push emotion to the back of the mind in order to carry out the task at hand.   He asserts, in fact, that emotional dysregulation is a core component of ADHD; a position that the undersigned endorses because it makes sense. It is also consistent with research indicating that ADHD patients that ADHD-related psychopathology is associated with prefrontal brain dysfunction, probably related to processes of response inhibition and/or cognitive response control.  (Fakkatter, 2003)


The fact is that all information processing has an emotional basis in that emotion is the fuel source that drives cognitive activity. As Kenneth Dodge indicated emotion is the  is the energy source that drives, directs,  amplifies or attenuates cognition.  (Dodge, 1991) Though we don’t consciously attach emotion to all our thoughts and actions,   emotional value or valence is automatically attached to any stimuli or activity whether internal or external in origin.  As a result, if our emotional modulation is impaired, so is our cognition.


Brain imaging has even revealed a “gating” of emotion that reduces affective interference when we are engaged in more valued or complex cognitive tasks.  (Pochon, 2001)  Thus, it is not surprising that many people with ADHD self-report Chronic  impairment in their ability to modulate how emotional affects their daily life.  Thus, even though the DSM-IV have not caught up with current research findings it is clear that impairment in the regulation of emotions is actually a core characteristic of ADHD.  This impairment, naturally like all other traits,  occurs along a continuum being greater in some individuals than in others.  Moreover, some people with ADHD who also have more severe impairment of specific emotions may have comorbid conditions such as Depression, OCD or Bipolar Disorder.


Damaging effect of ADHD


From the practical perspective, perhaps the most damaging impact of ADHD is the social ineptness associated with it.  People with ADHD often experience chronic problems in social relationships. They are viewed by others as too much in a rush, clueless, too intense, and too aloof or isolated.  These characteristics may be experienced as hurtful by others in the person’s life and their reactions to these characteristics are, in turn, experienced as painful by the individual with ADHD. Often others interacting with an individual with ADHD fail to comprehend that despite a normal level of cognitive intelligence (as measured by IQ testing), these people have significant impairments in the area of emotional intelligence.  The practical result, however, is that the individual with ADHD has  strained relationships with teachers and mentors, strained employer-employee relationships, strained relationships with friends and strained family relationships. 


Impairment in social intelligence


By impairment in social intelligence I refer to difficulty discriminating between different emotions and a consequent deficit in the ability to monitor either their own emotions or the emotions of others.  Thus, they cannot effectively use this emotional information to think about and guide their action choices.  In order to understand and appropriately coach the ADHD individual in your life, you need to understand that a good fund of information and a good ability to reason about impersonal things, does not correlate with a good ability to understand and reason about emotional things.  The fact is different neural circuits in the brain are involved in mediation of this emotional cognition.



Impairment in communication


Children with ADHD  and  those who have conduct disorders do not interpret emotions in others as accurately as non disabled individuals. (Cadesky, 2000)  They are also less adept than others at identifying emotions (Norvilitis, 2000).  Not surprisingly they are also more impaired than non disabled peers in attending to social data and predicting social outcomes. (Zentall SS, 2001)


Like other children on the autistic spectrum, children wtih ADHD evidence pragmatic language problems.  For example, they talk too much in unstructured settings and conversely may speak too little when expected to. They have problems introducing, maintaining and changing topics of conversation, as well as difficulty being specific, accurate and concise when conveying information.   In fact, Tannock et al found pragmatic speech deficits in sixty percent of ADHD boys. (Tannock, 1996).


Continuum of impairment


Among individuals with ADHD there is a wide variation in emotional intelligence.  Many ADHD individuals evidenced  impaired emotional intelligence.  Others, such as those with Asperger’s Disorder or Autism may evidence impaired emotional intelligence even though they do not have ADHD.  But, there seems to be a certain continuum or continuity among these disorders.


Asperger’s Disorder evidences normal verbal ability during early development, but an inability to empathize and interact with peers.  There is a lack of social and emotional reciprocity This is combined with unusual interests and narrow focus on those interests to the exclusion of other interests.  In addition to odd speech patterns and literal language we also observe poor non-verbal communication. (Klin, 2000)  (Attwood, 1998)


With Non-Verbal LD as defined by Byron Rourke we see deficits in visualization, perceptual organization, conceptual organization, the ability to grasp the overall picture and problems with summarizing and integrating information.


When comparing these  ADHD and Non-Verbal LD with Aspergers  we note that individuals with Asperger Syndrome have virtually all the characteristics of Non Verbal LD. Both have problems with behavior and adaptive functioning, both have IQ test profiles where the verbal quotient is greater than the performance quotient and similar neuropsychological profiles with impaired right hemisphere functioning.  (Rourke, 2000). When we look at Asperger’s Syndrome and High Functioning Autism, we find  appear to be the same disorder when we look at the research data. So, we may need to view these disorders as being more different in degree or emphasis than as distinct entities.    For instance, we know that Asperger’s children demonstrate less severe early symptoms, a milder developmental course and better out-come than high functioning autistics, but they still appear to involve the same fundamental symptomatology and only differ in degree or severity.  (Ozonoff, 2000)


Right hemisphere impairment


The right hemisphere of our brain is the less understood hemisphere in terms of function. But, we do know that the right hemisphere permits us to assemble a whole “gestalt” or complete view of the situation.  It permits us to correlate the tone of voice, pitch, rate of speech with the facial expression, gestures and body stance to enable us to differentiate a lie from the truth or a joke from a serous statement.  We know that multiple research studies have pointed to right hemisphere impairments in individuals with ADHD. We know also that right hemisphere impairments underlie many of the impairments in executive functioning that we see in both Non Verbal Learning Disabilities and ADHD.  Still, emotional intelligence is complex and difficult to assess and to treat.  (Wasserstein, 2001)


Comorbid conditions


Not only is ADHD a complex disorder within itself, but, is it one that is frequently complicated by comorbid conditions.  It is estimated that approximately sixty percent of ADHD i8ndividuals also have one or more psychiatric or learning disorders.    In fact, it is six times more likely for an individual with ADHD to have another disorder than it is for someone without ADHD! A full seventy percent of children with ADHD have a least one psychiatric disorder in addition to ADHD (MTA, 1999) These psychiatric comorbidities include mood disorders, anxiety disorders, impulse disorders, substance abuse disorders and other psychiatric disorders.   This high comorbidity rate raises the question of why there are such high rates of comorbidity between ADHD and other disorders.


Naturally, part of the problem lies in the way medicine has set up the diagnostic criteria. Disorders don’t fit neatly into one category or another.   Basically, disorders overlap one another because when brain functioning  is impaired through illness or injury, there is seldom discrete impairment. Rather, impairment in one area or function of the brain impacts other areas and functions, so that the behavioral, cognitive, social and emotional manifestations of various brain problems overlap one another.  In the end, it is, I think, unlikely that we will be able to make discrete differentiation among all these disorders, but rather that they will have to be formulated as points along continuous continuums with fuzzy and overlapping boundaries.    What may prove useful is weighing different risk factors that contribute to different manifestations, and attempting to control or or modulate those.   In short, we simply aren’t very good at diagnosis. But, because ADHD is fundamentally a developmental disorder of impaired executive functions an as executive functions cross the boundaries of many disorders due to impairment in various brain structures involved in executive functioning, ADHD inherently cuts across other disorder that involve the same impaired executive functions.  This means that ADHD is a foundational disorder and that it by its very nature increases the risk for the diagnosis of other disorders that also result from impaired executive functions.


Why is there so much comorbidity?


Whether or not other disorders are manifests and when depends on a range of factors including which impairment in which brain structures common to both disorders underlies the ADHD.  For example, the genetic abnormalies that predispose someone to have ADHD a reading disorder related to cerebral hypoactivation, may also predispose one to have or depression which is also a function of cerebral hypoactivation More significantly, however, the adaptive malfunctions that arise from the impaired executive functions in ADHD themselves increase the likelihood of inducing other diagnoses. For instance, if one does not consider the consequences of their actions and use them to guide decision making then one is more likely to drive a vehicle at excessive speed while intoxicated, and therefore, to sustain a traumatic brain injury and, thus, have brought about comorbid diagnosis.  Likewise, if one does not prioritize and weight alternative, but acts in the presence without forethought, one is more likely to accept illegal substances when they are presented, and therefore, more likely to become a substance abuser and add this comorbid diagnosis to the already existing diagnosis of ADHD.


What is common between ADHD and other comorbidities is some level of executive functioning impairment that is manifest in impaired information processing, social-emotional regulation and arousal or motivation.  Thus, it is important to ponder whether effective treatment of ADHD in childhood or adolescence might reduce the risk for comorbid disorder, or at the minimum decrease their severity.  (Kessler, 2006, April )  In other words, if we treat ADHD, do we reduce the risk of the individual becoming a substance abuse or suffering a traumatic brain injury?


Does ADHD underlie other diagnoses?


The second essential question to consider is whether or not undiagnosed  by comorbid ADHD may account for some of the impairment attributed to other disorders.  (Kessler, 2006, April )  Finally, it is important to ascertain whether effective treatment of ADHD in adult can reduce the severity of their comorbid disorders as in the case of a recovering alcohol supplementing AA with EEG neurofeedback.


These are difficult diagnostic and prognostic issues to tease out. The fact is that when you look at learning and language disorders (such as disorders of expressive language, receptive language, reading, math and written expression), arousal and motivation disorders (such as dysthmia/depression, anxiety, PTSD, Bipolar, OCD or substance abuse) and Disorders of Social/Emotional Regulation (such as Asperger’s ODD, Conduct Disorder, Tourette’s and Pick’s Disease) all of these disorders involve impairments in executive functions in common.


For the disorders of learning and language, the executive impairment is coupled with impairment in particular types of information processing.  For the disorders of arousal and motivation, the executive impairment is coupled with either hypo or hyper arousal.  For the disorders of social and emotional regulation, the executive function impairment is coupled with an impaired ability to regulate action based upon feedback from the environment or an anticipation of other’s emotional reaction.  Thus, it is reasonable to hypothesize that if we were to treat the executive impairment of ADHD effectively, this component might be subtracted from the other disorders, thereby, mitigating their severity and complexity.