Nuances in Assessment and Treatment of ADHD

Differential Diagnosis of ADHD
Differential Diagnosis of ADHD

The treatment of ADHD requires consideration of many nuances during the assessment process. The debate on whether ‘ADHD is a cultural construct’ as proposed by Sami Timimi or a biological condition as suggested by Eric Taylor (full article) rages in some quarters. UK Psychiatrist have always been conservative and prescribing rates for ADHD remains behind many other Nations but is picking up with growing research and evidence.

In our practice we see significant meaningful change for the better with treatment of ADHD in many young children and adolescents, a proportion of whom experience transformational improvement. It could be a difference between high B’s getting converted to As or being stopped from permanent exclusion from school.

We need to look at the nuances when assessing, a clinical process, though there are diagnostic questionnaires and the computerised QB test, these are not diagnostic by themself. The key criteria that one should evidence during the assessment are – 1) Directly observed demonstrable abnormality of core symptoms that are relentless, pervasive across settings, for the age and developmental level of the child. 2) Onset of some of the symptoms have to be before age 7 (11 as per DSM 5).

Let’s take a case example: A 9-year-old boy, raised by single mother who herself was excluded from school and spent time in foster care. The father had substance use problems, in-out of prison and grew up in an orphanage. The child presents with a clear history and the ADHD questionnaires supported a diagnosis with suspensions from school and closing on getting excluded. Such a case can be inferred by those with psychodynamic leanings as stemming from disrupted attachment. On the other hand, with substantial hereditary influences at play with ADHD, could we assume the parents may have had ADHD as well but this was never diagnosed! Are the two hypothesis ie. Attachment Disorder Vs. ADHD mutually exclusive, can they not co-occur? Research evidence does show that disruptions in attachment can affect orbito-frontal cortices leading to ADHD and this can make a case of ‘both and’ rather than ‘one or the other’.

Attachment patterns / overlap with ADHD – there is as you will note below a considerable overlap between attachment disorders and ADHD. Careful assessments can help draw the distinctions and in some cases a genuine co-occurrence.

Avoidant – watchful, wary (hypervigilant), ‘slow-to-warm-up’; difficulty maintaining emotional closeness to others, difficulty directly expressing feelings, show limited engagement in emotionally arousing situations.
Ambivalent/Resistant – both clingy & angry, rejects contact, refuses to be comforted; heightened arousal and exaggerated emotional expression; easily frustrated, overstimulated, impulsive and overly anxious.
Disorganized/Disoriented – fearful and confused: infants may exhibit an array of seemingly undirected behavioural responses, i.e., ‘freezing’, hand-flapping, and stereotypies; older children may take control of the parent by punitively controlling the parent or, alternately, caring for and comforting the parent.

An example of the above was a child who was barely 5, deemed unmanageable at home and described to be high energy, bouncing off the walls, this child was described as a gem of a boy by the teachers. At home, one of the parent was battling cancer for past 4 years, going back to infancy with disruptions to not only the attachments but implementing parental boundaries and authority. To conclude this as ADHD would have been a mistake as the treatment needed required re-establishing parental authority and mending the relational dynamic.

We routinely see patients with anxiety, depression, conduct problems, substance use, PTSD where at times as the header image displays, the symptoms mimic ADHD. On the other hand a sub-cohort of people with ADHD are prone to experiencing these conditions in adolescence and late adulthood and will often have underlying undiagnosed ADHD. Treating the latter (ADHD) can often make a positive difference to the other psychological difficulties.

Let’s look at another case – 22, female with harmful substance use, self-harm, reckless-impulsive behaviours through indiscriminate sexual activity, labile mood, angry-hostile and at worse jumping for roof-tops. This young lady had been passed off as having an emotionally unstable personality disorder (Borderline Personality Disorder) by some clinicians. Crucially her early childhood history had not been looked at in sufficient detail. This early life history showed significant behavioural disturbance at school, bright but below potential academic performance, oppositional defiance and considerable inattention. The school reports typically suggested an ‘attitudinal issue’ and little if any help was offered during the formative years. Adult Conners questionnaires and DIVA assessment tool supported likely underlying ADHD as an alternative formulation. Treatment of ADHD was described as ‘life changing’ by the patient. This example is of significance as we have seen many children and young adults deemed to show ‘bad behaviour’ end up getting excluded, gravitate to offending and land in youth justice systems. It is now recognised that a sizeable proportion of people in the prisons have untreated ADHD.

In our next writeup we will look at medication as well as non-pharmacological approaches to management of ADHD. Early treatment and continuing it results in much better outcomes in terms of academic grades, job and financial prospects as well as overall quality of life.

To go back to the process of assessment of ADHD and what it entails click here.

Click here to read about Pharmacological treatment of ADHD

Find out more about ADHD coaching and non-pharmacological approaches