Cause and Effect – ADD Center Specializes in Diagnosing This Disorder

Dr. Mitchell Clionsky often suggests two books to patients diagnosed with attention deficit/hyperactivity disorder, which is commonly referred to as ADHD. The first is “Driven to Distraction,” and the second is “You Mean I’m Not Lazy, Stupid or Crazy?! The Classic Self-Help Book for Adults with Attention Deficit Disorder.”

The second tome recognizes the fact that many people with ADHD have been labeled any or all of those things — lazy, stupid, or crazy — and that they also berate themselves for their inability to stay focused, complete tasks, or even make money, which Clionsky says is a common problem for small-business owners because they frequently start too many projects at once, fail to bill clients in a timely fashion, or become overwhelmed by bookkeeping and detailed paperwork.

“There is so much shame and stigma associated with ADHD,” said Clionsky, the board-certified neuropsychologist and co-founder of the ADD Center of Western Massachusetts in Springfield. “Children feel stupid if they fail an exam because they got distracted, skipped a page, or forgot they were supposed to multiply rather than divide. They often do their homework but forget to turn it in, and feel embarrassed and defensive when their parents reprimand them.

“But they are not lazy, and they are not stupid,” he went on. “They have a deficit that involves their brain’s ability to produce or release the chemical known as dopamine, which allows people to stay focused.”

The Mayo Clinic defines ADHD as a chronic condition that affects millions of children and often persists into adulthood. It includes a combination of problems, such as difficulty sustaining attention, hyperactivity, and impulsive behavior. Children with the disorder frequently struggle with low self-esteem, troubled relationships, and poor performance in school. It occurs more often in males than in females, and behaviors can be different in boys and girls.

Two years ago, the Centers for Disease Control and Prevention reported that up to 11{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of children in the U.S. have been diagnosed with ADHD. Thankfully, about half of them will outgrow it in their teens and 20s, but millions of adults remain undiagnosed, and even if children improve, they may still exhibit some signs of the disorder throughout their lives.

However, many other medical conditions cause similar symptoms, and Clionsky said depression, anxiety, and trauma can lead to an inability to concentrate and stay focused. In addition, frequent bouts of tonsillitis that cause children to sleep poorly can make it difficult for them to concentrate and perform well in school because they are always tired. But a number of studies, including a recent one conducted by the University of Michigan, show that when children diagnosed with ADHD have their tonsils removed, half of them no longer exhibit the problematic behaviors.

The same situation can result if a person has obstructive sleep apnea.

“We recommend that many people have a sleep study done before they start taking medication for ADHD; in some cases, the symptoms resolve once they are treated for the apnea,” Clionsky noted, adding that the inability to get enough oxygen while sleeping can make people inattentive during the day.

“No one has ADHD until it’s been proven — it’s a medical problem that requires a careful and detailed evaluation,” he continued. “When it is correctly diagnosed and properly treated, children and adults can perform so well that it seems miraculous. But the diagnostic process is complex, and there is a lot of variability.”

He explained that ADHD appears to have a genetic component and tends to run in families; if a parent has ADHD, his or her children have more than a 50{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} chance of being diagnosed with the disorder, and if an older child has ADHD, their siblings have more than a 30{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} chance.

However, some people have two conditions that exist at the same time. For example, Clionsky says a person with ADHD and obsessive compulsive disorder may have everything perfectly lined up in their cabinets, but be completely disorganized in almost every other aspect of their life. Meanwhile, a child may be depressed and also have attention deficit disorder.

“It’s a neurologically based condition. But there is no blood test, litmus test, or MRI scan that can prove a person has ADHD, which is what makes a clinical diagnosis so complex,” Clionsky told HCN, noting that people who have a hard time concentrating due to ADHD can pay attention under novel or interesting circumstances. “A 7-year-old may act completely normal when his mother takes him to the doctor; it’s a novel experience, so the doctor doesn’t see the child exhibiting any of the symptoms she describes. But if the appointment took two hours, he would notice everything she spoke about.”

But since everyone occasionally exhibits traits found in people with ADHD, diagnosticians look for entrenched patterns of behavior that fall outside the range considered normal for their age.

Complicated Undertaking

Clionsky opened the ADD Center in the ’90s with four partners, who planned to provide all the services people with the condition might need. But they soon discovered most clients simply wanted a diagnosis, and when the evaluation was complete, they returned to their own physicians and counselors for medication and help.

So, today, the ADD Center has become primarily a neuropsychological diagnostic practice.

“We evaluate about 200 people each year and have seen more than 4,000 patients since we opened,” Clionsky told HCN, explaining that children must be at least 6 years old because, prior to that age, there is not enough evidence for a diagnosis to be conclusive as most young children have short attention spans and are very active.

Testing done on the first visit takes one to two hours and begins by collecting in-depth information.

“We get a comprehensive history that includes the person’s academic, medical, psychiatric, and family background, and they fill out a detailed questionnaire and are asked to rate a variety of symptoms on a scale of one to five,” said Clionsky. “We also interview the individual who is being studied as well as their parents or spouse.”

In addition, the person suspected of having ADHD takes a 15-minute, computerized performance test, which is purposely designed to be boring. “It compares their vigilance and ability to focus and respond consistently against people of own their age, and is used to determine how capable the person is of staying on task,” Clionsky explained.

When those tests are complete, the results are tabulated. However, if the case is complicated by medical or psychological issues, several more hours of evaluation may be needed that include testing the person’s reasoning and looking at their learning and problem-solving skills, their ability to memorize things, their intelligence, and their emotional state.

In order to be diagnosed with ADHD, six out of nine diagnostic symptoms must be rated ‘moderate’ or ‘severe,’ and they have to have been present since before age 12 and have created problems in more than one area of the person’s life.

“The symptoms have to have interfered with their academic, occupational, or social functioning and can’t be due to another cause such as anxiety, depression, a trauma, or a concussion,” Clionsky said, explaining that the symptoms of a concussion can mimic ADHD, but are typically temporary.

He added people with ADD fall into two categories. The first group has attention-impairment problems that lead to disorganization.

“It’s not that they can’t pay attention, but they are easily distracted or lose focus if something is boring, routine, difficult to understand, or has too many variables,” he explained. “Adults with ADD often become distracted or impatient during lectures where there is no interaction. They also have trouble completing tasks; they begin one thing, get distracted, and start another, which leads to something else, without ever realizing their primary objective.”

The second group has problems related to hyperactivity and impulsivity. “It predisposes them to a higher likelihood of auto accidents, orthopedic injuries, and head traumas because of their risk-taking behaviors. They tend to engage in activities that stimulate the release of dopamine, such as motocross or mountain biking, and are more likely to be in trouble with the law,” Clionsky said. “They also tend to speed, jump red lights, and do things such as leaping off the walls of a quarry without knowing its depths.”

If a person is diagnosed with ADHD, Clionsky talks to them about the condition and how it is affecting their life. He also suggests appropriate medication, which they can get from their own physician, and may recommend counseling to improve their organizational skills. Educational planning is included in the center’s services for students, and academic accommodations are usually recommended, which may involve having them take tests in a separate classroom and allowing them extra time to complete the work.

“We also tell students with ADHD to sit as close to the front of the room as possible,” he explained. “Most tend to sit in the back, which makes it really difficult, because there is an ocean of activity in front of them, which can be distracting.”

The testing is repeated during a six-month follow-up exam, but the medication usually works. Side effects are minimal, and negative long-term effects of the drugs are almost unheard of, Clionsky said.

Coping Mechanisms

ADD is a developmental disorder that starts in childhood, and even though some young people learn to compensate with help from adults, in many cases, it catches up with them.

For example, adolescents who get extra help from their teachers or have parents who carefully monitor their schoolwork often do well in high school. But once they enter the adult world or go to college, they are unable to manage on their own.

“I see many clients who have left law school or college; they’re bright, but they are failing,” Clionsky says, adding that they miss class, don’t allow themselves enough time to complete assignments, and are often distracted and thrown off track during exams by something as simple as someone dropping a pencil.

He added that many small-business owners who work in the trades, including landscapers and contractors, have come to the ADD Center for help.

“They may be really good at their job, but they are not good business people. They are working 70 to 80 hours a week, but are in debt because they fail to collect payment for their bills or have too many things going on at once, which keeps them from ever finishing anything,” Clionsky noted. “People with ADHD are the most wonderful people in the world, but they frustrate others because they don’t return calls, are late coming home because they make too many stops, and are disorganized. They make dates and promises but forget about them, and although their spouses love them, they can’t count on them. So, resentment builds up, their home lives become very disruptive, and they have trouble retaining jobs or relationships.”

However there is an exception: If the person with ADHD is working on something they really enjoy, they can block out everything else, and many adolescents and adults exhibit this behavior when they are playing video games because they are fast-moving and demand total attention.

But Clionsky says it’s never possible to know for sure if someone has the disorder until a full evaluation is done. He recently diagnosed a 20-year-old with anxiety disorder whose mother was sure she had ADHD.

“She couldn’t seem to pay attention to anything or finish filling out college applications,” he explained. “But the real problem was that she was so anxious, she worried constantly.”

The example points out the importance of examining every factor of an individual’s life that could cause symptoms commonly seen in people with ADHD.

“Some children and people just have bad habits. They procrastinate or are disorganized, so we are very careful about what we diagnose,” Clionsky said. “But if it is ADHD, it’s a real medical problem, and treatment can and will make a difference.”