Brain Evaluation

ADHD, QUESTION OF MOTORIC OVERFLOW

There is a recent finding that ADHD children have motoric overflow and difficulty with motor cortex inhibition.  This is cited in Neurology Today 2-11-2011.  The study took children diagnosed with ADHD and found excess motoric activity and signs of impaired inhibition.  However the question remains as to whether these children were not ADD plus some additional disorder which then constitutes ADHD.  We have found in our research that the greater percentage of the ADHD population has attention as the primary variable and when ADHD or the H for hyperactivity or I for impulsivity is involved, that the result is ADD or attention plus some additional disorder (which could be anything from a sleep disorder to the complication of another brain disorder).

 

The low fliers

What to do about the low fliers; the ones who are clearly out of sync with their environment, at home and at school? They are unhappy, alternating between poor behaviors and upsetting everyone, then feeling badly and asking if they are still loved or are they still going to get the treat that was promised to them or are they okay. They are reactive emotionally, often intolerant of everyday situations; their behavior is impulsive and the first thing everyone thinks is ADHD and they certainly fit the characteristics of this disorder.

But here is the problem, you test them and they have symptoms of executive reasoning.  Attention problems that seem to follow the pattern of ADHD inattentive type suggests a genetic disorder that has been exacerbated. So what is the problem of labeling ADHD when we see characteristics that are more related to executive processes? Because the label leaves them at risk for a lifetime of medication and no resolution; tired parents, low self esteem in the child and continuing unresolved problems. You refer them for a sleep study with all the symptoms of apnea and they come back okay and you ask the question, well, how close were they to sleep apnea? Or how well was this measured; or was the CAP scoring used or were other methods used to determine sleep disordered breathing? You can’t question the professional especially if they are a big deal in their field so what to do? You ask the treating physician about an EEG which comes back normal: But how normal? The pediatric neurologist is well known.  How dare you question his read on things, but you can’t help but think there has to be some differentiating factor that creates this unmanageable kid who is so difficult for himself to deal with along with his parents and everyone else. So now you begin to treat and you do what you can with many of the causal factors remaining untouched. You are criticized for thinking critical thoughts about other professionals when your only concern is that something was missed that could be treated and could make a huge difference now:  But all you can say to the parents is, “well there does not appear to be anything but lets do some treatment of the symptoms we know are clearly there and maybe discuss with your treating physician repeating these tests in a year”.

 

ADHD in Adulthood

Recently the wall street journal published an article on Adult ADHD (4-6-2010) providing the estimate of ten Millon US adults and 4.4. percent of the adult population as exhibiting symptoms that have been historically thought to disappear in childhood.  Untangling ADHD from symptoms of psychological disorders of depression, bipolar illness, anxiety, sleep disorders requires the use of neuropsychological evaluation as opposed to relying upon self-report measures.  Involved in testing the adult ADHD population for over twenty years I can tell you that there is a distinct pattern seen in the testing that allows ADD as a genetic biochemical disorder to be differentiated from these other disorders as well as brain injury.  Reliance upon self report measures as the only defining criteria to diagnoses this commonly misunderstood disorder only serves to create more confusion and misdiagnosis in my opinion.  Not to mention that adults are more at risk for undiagnosed sleep apnea and heart disease as well as the long term effects of poor sleep.   We as a facility have found tremendous improvement in functioning of adults using our non-medication treatment program fostering the belief that people do not have to grow old fighting attention symptoms.  The key being accurate diagnosis and accurate treatment.

Attention Deficit Disorder Associated with Neurotransmitter Deficit in the Brain

Research supports the long held theory that ADHD is the result of abnormal chemical activity of the neurotransmitter, Dopamine.  Lower availability of the dopamine receptor was noted in ADHD but not in controls using PET scans.  Regions revealed signficantly lower dopamine transporter availability in specific brain areas providing confirmation of the important role of dopamine deficiencies in a specific brain circuit.  The question is how this transmits clinically.  The study alluded to the motivation system in the brain targeting the ADHD Impulsive, Hyperactivity but not the Inattention symptoms.  This can become very convoluted in terms of understanding the symptoms of ADHD.  If the subjects diagnosed with ADHD actually had symptoms of ADD plus meaning the impact to frontal processes then these findings would make sense however this then contributes to the continually held theory that ADHD involves the frontal processes which research studies have yet to clearly identify. Article from Neurology Today, 11-5-2009

So Really, What is ADD?

Anyone who uses testing as opposed to self-report measures to diagnose ADD/ADHD knows that this is a disorder of leftovers.  Leftovers are the scraps saved from a meal that may be the vegetables, the meat or main entree or even the desert.  ADD has become a bin of leftovers.  The diagnosis to give when a child is overly active, falling asleep in class, non-attentive, non-responsive or even a poor reader.  However, the sleep world continues to document a vast assortment of sleep disorders that would account for the symptoms we so quickly assume are manifestations of an attention disorder.  Case in point is the recent research article by Dr. Konofal (Relationship Between ADHD and Sleep Disturbances, Int. J Sleep Wakefulness, Vol 1 No.3, 2008) who points to disorders such as Restless Legs Syndrome (RLS) Delayed Sleep Phase Syndrome, Sleep apnea, and I would add Periodic Limb Movements in Sleep and childhood insomnia as precursors to daytime hyperactivity and inattentiveness.  Sleepy children are hyperactive children, a well known documented fact.  Sleepy children are inattentive, another well known fact. We really need to do our homework and use testing (neuropsychological evaluation from my perspective) to document a disorder such as ADD or ADHD before jumping to an incorrect conclusion and incorrect treatment. 

Evaluating ADHD

Too often a child, adolescent or adult is diagnosed with ADHD based upon only self report measures that is completed by a parent, teacher, spouse or symptoms are self-reported.  However any symptom listed under ADHD such as distractibility could be the result of ten different reasons, only one of which would actually be an attention disorder.  ADHD is commonly misdiagnosed for seizures, brain injury, behavior problems, sleep disorders, anxiety, stress, low blood sugar- the list is endless. Unless testing is done, testing of the brain if you believe it is a brain disorder, which means neuropsychological evaluation, the diagnosis is always suspect. Worse yet disorders such as sleep apnea, a brain injury, dementia, cardiovascular disease, PTSD remains undiagnosed.   

ADHD and Sleep Disorders

It is well known that hyperactivity is a symptom of sleepy children. The more tired the child, the more sleepy they are. Undiagnosed sleep apnea, sleep disordered breathing problems is running rampant in the ADHD population which is already overdiagnosed and a comfortable "bin" to place any child who is a behavioral problem in school. In competition with the "bin" for Autism Spectrum Disorders, it seems easier for professionals to typecast children based upon their behavior with these common disorders rather than spend the extra time to look beyond the child's behavior to figure out what the problem really is.  It is easy to make a mistake on an emotional issue however to miss a disorder such as is to risk injury to a child's brain that cannot be undone later. Neuropsychological evaluation reveals the impact upon frontal processes when there is sleep apnea or any kind of injury to the brain and these cognitive deficits create the symptoms seen in the hyperactive or combined subtype child who experiences learning problems as well.