ADHD awareness week: Impulsivity

One of the most common symptoms for many kids with ADHD is impulsivity. This impulsive behavior leads kids to act before they think. We neurotypical (non-ADHD) people may evaluate a situation for social norm or potential danger and decide to not partake in an action that could be seen as socially unacceptable or dangerous. Those with ADHD who have impulsive characteristics will generally not self-regulate and decide against an unpleasant or potentially harmful situation. This impulsive behavior leads kids to spending extended amounts of time in trouble at home. They may end up in time-out or end up grounded. Of all the symptoms of ADHD, impulsivity is often the most difficult to control.

So what is impulsivity? This is described as behavior without adequate thought. The person with impulsive behavior may have a tendency to act with less forethought than others.  They may react to stimuli without regard to the consequences that could occur.

I recall a story a friend told me about her ADHD son. When he was about 7 or 8 years old and they were riding their bikes in their neighborhood. There was a vicious looking dog barking relentlessly at them from a backyard, behind a chain link fence. Her son got off of his bike and started walking towards the dog. The mom yelled “What are you doing?” In his innocent, sweet voice he said “I’m going to pet the dog.” My friend was in shock! She yelled to him to stop! “That dog might bite you! Get back here!” They had a discussion about the dangers of approaching a dog they don’t know. My friend said they had conversations like this many times in the past, as she always wanted to be sure he respected animals and their space. His impulsive behavior led him to nearly put himself in a potentially harmful situation.

Not only does impulsivity commonly occur in those with ADHD, but it is associated with other mental disorders, such as mania, substance abuse, and personality disorders as well.  The International Society for Research on Impulsivity (yes, there is actually a society dedicated to the research on this characteristic!) studies impulsive behavior that occurs with mental disorders, such as ADHD. This society has developed several rating scales as measurement tools to make research projects more meaningful.

One of the most commonly used tools is a questionnaire designed to assess the personality/behavioral construct of impulsiveness is the Barratt Impulsiveness Scale. There are 30 items on the scale that describe common impulsive and non-impulsive behaviors and preferences. These behaviors are rated as: Rarely/Never, Occasionally, Often, Almost Always/Always. This scale can be viewed at: http://www.impulsivity.org/pdf/BIS11English.pdf

Other scales include the Balloon Analogue Risk Task: http://www.impulsivity.org/measurement/BART

Cued Go No-Go Task: http://www.impulsivity.org/measurement/cued_Go_NoGo

Immediate and Delayed Memory Tasks: http://www.impulsivity.org/measurement/IMTDMT

Okay, enough about rating scales, as I’m sure that has bored many of you!

Impulsivity has for many years been linked to the neurotransmitter dopamine. Neurotransmitters are chemical substances that transmit nerve impulses across a synapse from one a neuron (nerve cell) to a “target” cell. They carry, boost, and modulate signals between neurons and other cells in the body. There have been over 100 neurotransmitters identified. Dopamine is a neurotransmitter that helps control the reward and pleasure centers of the brain. It allows us to see a reward and to take action to move towards the reward. Dopamine also plays a role in movement, sleep, mood, sustained attention, working memory, motivation, learning, and emotional responses.  

For years scientists have believed that one of the primary causes of ADHD is low dopamine levels, but recent research suggested that structural differences in the brain’s grey matter may play a significant role. Structural differences in the ADHD brain and non-ADHD brain include variations in the prefrontal cortex, the caudate nucleus and globus pallidus, and the cerebellum. Nerve pathways, in particular the basal-ganglia thalamocortical pathways have been found to have abnormalities in the ADHD brain. The research will likely continue on the link between chemical and structural differences in the ADHD brain. Regardless of the cause, the symptom of impulsivity can lead the ADHD person to take risky, dangerous actions.

So is impulsivity always considered bad or a negative characteristic? The answer is no. There are times when impulsive behavior is the right response to a particular situation. We may act of off a gut instinct in an impulsive manner. An impulsive action may lead us to seize a valuable opportunity. But high levels of impulsivity is where this characteristic can be maladaptive.

With proper treatment of medication and behavioral therapy, those with ADHD and this prominent symptom of impulsivity can find success in controlling some impulsive behaviors.

There may be those outliers with ADHD who don’t have symptoms such as impulsivity. They may have a little trouble focusing & managed to get doctor to put them on a stimulant medication so they can maintain a greater than 4.0 GPA in school.  I’ve heard colleagues speak of this issue in their practice. This information doesn’t really pertain to them. This pertains to the millions of individuals with ADHD who have presenting symptoms, such as impulsivity, that greatly affects their life on a daily basis. Hopefully, these individuals will receive the care they need to treat this symptom and the others associated with ADHD.  

Dr. Donna Poma Fife, DNP, ARNP

Disclaimer: This blog is meant for informational purposes only and does not constitute or substitute medical care. I speak of generalizations and do not speak to any particular individual with ADHD, so don't feel singled out if it does/doesn't apply to you!  If you think you or your child may have ADHD please see a healthcare provider, preferably a psychiatrist or a neurologist, as they are best equipped to make a proper diagnosis. 

ADHD Awareness: Getting the diagnosis

ADHD Awareness Month #ADHD #ADHDawareness #Seekahealthymind 

So my previous blog brought awareness to the symptoms of ADHD, but how does a person get diagnosed with the disorder? Well, I’m here to tell ya!

Making the diagnosis of ADD/ADHD:  

One of the most important steps in getting a proper diagnosis of ADHD is selection of a healthcare provider. Who can diagnose ADHD? Well, family doctors, pediatricians, psychiatrists, psychologists, and neurologists are all licensed to diagnose. However, when it comes to a neurodevelopmental disorder, such as ADHD, seeking evaluation by a psychiatrist and/or neurologist is often your best bet. These specialized healthcare providers are trained in diagnosing and treating this disorder, whereas many family doctors and pediatricians are not.

Diagnosing ADHD is done according to the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders or DSM-V. This book provides diagnostic criteria for mental disorders.  The criteria for diagnosing according to the DSM is that the patient has to show six of nine symptoms of inattention and/or hyperactivity/impulsivity before the age of seven. I had listed those symptoms in my last blog, so refer back if you need to.  The symptoms should have persisted for at least 6 months, and must impair the person’s functioning in settings such as the home, school, and work.

 A clinical interview utilizing a standardized ADHD rating scale should be used in the diagnostic process. This scale rates the symptoms into classifications of inattention, impulsivity and hyperactivity.  The ADHD rating scale can be found at: http://www.fmpe.org/en/documents/appendix/appendix%201%20-%20adhd%20rating%20scale.pdf

There are common mistakes that occur in the diagnostic process. These mistakes may occur when seeking a diagnosis from a family or pediatric doctor. I’m not downing these types of providers, they are generally highly educated and experienced in general or pediatric practice. But many have limited knowledge in diagnosing and treating ADHD. Diagnosing is best accomplished by a neurologist or psychiatrist. Common mistakes include:

·         Length of time of an exam: A diagnosis of ADHD should not be done in a 15 minute office visit with a family/pediatric doctor. This is a complex disorder and a thorough evaluation is essential.

·         Diagnosing secondary symptoms as the primary problem. Many of those with ADHD have coexisting conditions of anxiety, depression, or other mood disorders. These may be secondary symptoms caused by the primary diagnosis of ADHD/ADD.

·         Academic success: Just because a person isn’t failing or doing poorly in school doesn’t mean they don’t have ADHD. Some kids with ADHD may do very well in school.

·         The child has a high IQ, therefore they can’t have ADHD. Many of those with ADHD have an average or higher than average IQ score.

Finding the right clinician is important. If I had listened to the first pediatrician who told me Nevia doesn’t have ADHD, we would have never received a proper diagnosis or treatment. This can really make a kid suffer unnecessarily. Of the three pediatricians Nevia has been to, none of them utilized the ADHD rating scale to evaluate for this diagnosis. She received a diagnosis of ADHD from doctor #2, and #3 carried on treatment after we switched providers for insurance purposes. While prescription of the medication to treat ADHD was not an issue, neither of the pediatricians referred us to a psychiatrist or psychologist for counseling or behavior therapy.

A friend of mine told me a story of a coworker who asked another coworker who has ADHD what symptoms she has with this disorder. She mentioned that she wants to get a prescription for ADHD because she heard it acts as an appetite suppressant. So this young lady went to her primary care doctor complaining of inattention & difficulty focusing. She even acted the part by staring out the window & losing her attention when the doctor was talking. After her 15 minute encounter with her primary care provider, she walked out of the office with a prescription for a Schedule II narcotic, Focalin. This medication is commonly prescribed to treat ADHD. It is a HIGHLY abused medication by those who don't actually have ADHD, but somehow managed to get diagnosed with it. A more socially acceptable form of drug abuse, I suppose.

Many of those with ADHD/ADD have coexisting learning disabilities, as well. While ADHD is not considered a learning disability, it is important to evaluate for learning disabilities in those diagnosed with ADHD. Some disabilities that may coexist include; dyslexia, dyscalculia, dysgraphia, dyspraxia, and executive functioning. By the way, I dislike the term ‘disability’. I really wish they would change the wording to Learning Differences. Those with learning disabilities have the capacity to learn. They just learn differently. Additionally, other screening tests may be conducted in those with ADHD to assess for coexisting conditions, such as anxiety, depression, and other mood disorders. This particular testing can take about 4 hours for a psychologist to complete. Yes, my daughter Nevia sat through FOUR hours of testing. Quite an accomplishment for an ADHDer!

So in some circumstances, getting a diagnosis of ADHD may be quite simple. However, it is a complex disorder with many variables and the potential for coexisting conditions. This is why a thorough evaluation by a licensed psychiatrist and/or psychologist is important.

Mental health does not receive the attention that it should. We have a tendency to undervalue the importance of a healthy mind. With ADHD Awareness Month, hopefully more focus will be shed on this mental disorder that over 15 million Americans have been diagnosed with and many others live with without a proper diagnosis.

Dr. Donna Poma Fife, DNP, ARNP

 Disclaimer: This blog is meant for informational purposes only and does not constitute or substitute medical care. If you think you or your child may have ADHD please see a healthcare provider, preferably a psychiatrist or a neurologist, as they are best equipped to make a proper diagnosis.

ADHD Awareness month

Welcome to October! At this time of the year, the kids are back in their routine of school, autumn is well under way, and we may be enjoying the cooler weather that is coming our way. In addition to the changing colors of leaves, shorter, cooler days, and pumpkin lattes, October also brings ADHD awareness month. Those individuals living with ADHD or living with a child with ADHD, are well aware of this disorder on a daily basis. But with a month dedicated to ADHD, hopefully many more will gain awareness of this disorder that affects more than 15 million Americans.

The terminology Attention Deficit Hyperactivity Disorder (ADHD) and Attention Deficit Disorder (ADD) are often used interchangeably. So you may see either of these recognized variations of the name and abbreviation being used. Either way, it is the same disorder, just with varying symptomatology.

ADHD is one of the most common neurodevelopmental disorders of childhood. The causes and risk factors for this disorder are unknown. Research points in the direction of genetics, brain injury, environmental exposure to toxins such as lead, alcohol/tobacco use during pregnancy, premature delivery, and low birth weight as possible causes/risk factors. But more research needs to be done.

A common misconception is that other factors, such as high intake of sugar, watching too much TV, poor parenting, and lower socioeconomic status contribute as causes to this disorder, but these factors have NOT been supported by research.  While they may not contribute to the diagnosis of ADHD, limiting sugar intake and TV time are good choices for everyone!

The CDC lists that as of 2011, approximately 11% of kids age 4-17 have been diagnosed with ADHD. This number continues to rise. Another common misconception is that ADHD occurs more commonly in boys than in girls. However, girls hold the same risk for the disorder, but are often not given the proper diagnosis like their male counterparts. The average age at diagnosis of ADHD is 7 years of age. However, many parents notice symptoms of the disorder well before the child’s 7^th birthday.

 This disorder affects adults as well. Many adults with ADD/ADHD have never received a proper diagnosis of the disorder. While ADD has been recognized in the medical community for many years, those with ADD in generations before the 1980s didn’t usually receive this diagnosis. They may have been labeled as bad kids, lacking discipline, unintelligent, lazy, or defiant. Imagine what these labels do to the self-esteem of a person. Think about how the self-esteem of the individual could have been supported, rather than diminished, if a proper diagnosis was made early on in life.  

Adults with ADD may have trouble with organization and remembering appointments and important events. They may have trouble completing the tasks to get out of the house in the morning, often making themselves and/or their kids late for work/school. They often have a history of difficulty in school during childhood & adolescence, and they may have a history of issues with employment and sustaining relationships.  Thankfully, healthcare providers are more aware of the disorder and the prevalence in adults, and with proper diagnosis and treatment, adults with ADD can find success and lead a productive, organized life.

So what are the symptoms of ADHD/ADD?

 Many may think that lack of focus and/or distractibility are what constitute a diagnosis. However, these symptoms are only the tip of the iceberg. Adults and children with ADHD/ADD generally have many of the following symptoms:

·         Trouble paying attention

·         Makes careless mistakes

·         Seems to not listen when being directly spoken to

·         Has trouble following instructions and finishing tasks

·         Trouble planning and organizing work/activities

·         Trouble completing and/or turning in homework

·         Avoid tasks, in particular those that require sustained mental effort

·         Loses things often

·         Becomes easily distracted, misses details, frequently switches from one activity to another

·         Forgetful, forgetful, forgetful

·         Fidgets and can’t seem to sit still

·         Gets up and moves around when they are expected to stay seated

·         Is often ‘on the go’ or acts as if ‘driven by a motor’

·         Talks too much or blurts out answers

·         Can’t wait his/her turn

·         Interrupts or intrudes on others’ conversations

Wow, that’s quite a list! Now some may read this and say “well I have trouble paying attention and am forgetful, perhaps I have ADD”. Well what human doesn’t fit some of these descriptors? Most all of us can think of times that we were sitting in class and started daydreaming or thinking of a plethora of other things we wish we were doing. I’m forgetful at times. I lose things at times. That doesn’t necessarily constitute an ADD diagnosis. Individuals with ADD/ADHD live with many of these symptoms, often to a VERY high degree, and deal with these on a daily basis.  While some individuals may outgrow the symptoms of ADHD, for many the symptoms are lifelong.

As a parent of a child with ADHD, I have a great passion for learning about this complex disorder.  In honor of ADHD awareness month, I hope to pass on some of the education that I have gained through my endless reading about this disorder and my life experiences gained with a child with ADHD!

Dr. Donna Poma Fife, DNP, ARNP

Disclaimer: This blog is meant for informational purposes only and does not constitute or substitute medical care. If you think you or your child may have ADHD please see a healthcare provider, preferably a psychiatrist or a neurologist, as they are best equipped to make a proper diagnosis.