To ADHD or not to ADHD, Part 3 Assessments and tools used to diagnose and treat ADHDHofmeyr
In the previous article, we looked at the prevalence rate of ADHD in the South African context, as well as the implications of misdiagnosis of ADHD. The results from various research studies suggest that our prevalence rate and manifestation of ADHD closely resembles that of the US and Europe. In this article, we will look at the different assessment methods that can be used to assist the professional to diagnose ADHD. We will also briefly touch on some of the therapies available in South Africa. Please note that the list is by no means exhaustive.
According to the 2013 guidelines for diagnosis and treatment of ADHD in children and adolescents, published by the South African Society of Psychiatrists (SASOP) (2013), screening for ADHD should be part of the psychiatric assessment of every patient. The guidelines mention two types of instruments used to detect ADHD: clinical diagnostic interviews, such as the Diagnostic Interview Schedule for Children (DISC-IV) and rating scales like the Conners 3 which correspond directly with the DSM-5. Diagnosis should never be based on the rating scales alone. The scales can also be used to monitor response to treatment. The guidelines point out that “There is a significant risk of misdiagnosing other psychiatric disorders as ADHD, particularly anxiety disorders, and it is important to explore the child’s emotional symptoms”. According to the guidelines, psychological and neurological assessments are not helpful in the assessment process for ADHD. The reason being that people with ADHD score low on these assessments due to impulsivity and their inability to concentrate. Results from psychometric testing should be considered conclusive only when the patient is successfully treated for ADHD. Once a diagnosis is established, certain conditions may warrant behavioural treatment as a first-line option. If the client does not respond well, then a trial period on medication should be considered. It is advised that for severe cases, medication should be the first-line treatment. Treatment should be monitored and reviewed every six months.
Guidelines for diagnosing ADHD in adults were published by Schoeman and Liebenberg, (2017). According to these guidelines, screening for ADHD is accomplished by using amongst others, the following screeners: World Health Organization Adult ADHD Self-Report Scale (ASRS), the Barkley Adult ADHD Rating Scale, and the Conners Adult ADHD Rating Scale (CAARS). The clinical interview is viewed as a ”cornerstone” in the assessment process. Various structured interview guides can be used to add some quantifiable dimension such as the Brown Adult ADHD Diagnostic Interview, or the Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID). Measures used to assess the impact of ADHD on daily functioning include the Barkley Functional Impairment Scale for Adults. It is important to obtain information from a third party and/or collateral information, not just from the individual themselves, to safeguard against malingering to obtain ADHD medication. A thorough medical examination will assist to disqualify medical reasons for behaviour. Clinicians are cautioned not to use psychometric assessments in isolation when making a diagnosis. Neuropsychological assessment that measures executive functioning may be useful. It should however only be considered when the client’s functional impairment is more than expected. Neuropsychological tests can be used to develop a personalised treatment plan and to monitor treatment responses. The use of intelligence tests may assist with ascertaining the individual’s potential and to diagnose comorbid learning disabilities. Referral to an educational psychologist is essential.
Another ”cornerstone” is pharmacological treatment of adult ADHD. Treatment should be reviewed at least once a year. Pharmacotherapy should be combined with psychosocial interventions, such as cognitive behavioural therapy (CBT). Other therapies worth mentioning are: mindfulness awareness therapy, dialectical behaviour therapy, psychoeducation, organisational skills teaching, and cognitive remediation programmes. Other therapies often used include neurofeedback (NF) and exercise. NF is thought to reduce behavioural difficulties associated with the core symptoms of ADHD. NF assists the client to self-regulate certain brain activity patterns. Studies yield contradicting evidence for the use of NF in adults. Aerobic exercise seems to improve neuropsychological functioning in people with ADHD. Evidence suggests that moderate to vigorous activity improves various symptoms associated with ADHD in children, such as planning, working memory, and academic performance. High intensity physical activity can improve sustained attention independent of stimulant treatment. Treatments that have not yielded satisfactory results for adult ADHD include dietary changes, the use of food supplements, NF, and attention and working memory training.
According to Meyer (2005), several factors should be taken into account when choosing a battery of assessments to assess for ADHD, as most are not standardised for South African use. Important among these factors are that the assessments should be non-verbal and have no cultural bias. Meyer (2005) selected the Tower of London, the Wisconsin Card Sorting Test, the Grooved Pegboard, and the Maze Coordination Task in her study. According to her study, all of the assessments distinguished between children with ADHD and the control group without ADHD. However, there was a marked effect of ethnicity, suggesting that cultural differences do affect the performance on neuropsychological measures. Meyer postulates that the reason may be that cultural factors are important determinants of child rearing practices which may affect the brain’s organisation of cognition. There is a great need in South Africa to develop/adapt neuropsychological instruments to assess ADHD symptomology.
The treatment of ADHD is as controversial and diverse as the diagnosis. Many professionals advocate medicine first, while many others recommend therapies like neurofeedback, lifestyle and dietary changes first.
Two of the most prominent US experts on ADHD, Dr William Dodson and Dr Russell Barkley, suggest that medicine should be the first port of call for treatment of ADHD in both children and adults.
Dr William Dodson, a psychiatrist in the US, introduces 11 Basic Concepts in his webinar, Medication Management: How to use and adjust stimulants safely. According to the first concept, stimulant medications such as methylphenidate (MPH) and amphetamine are the treatment of choice for ADHD. Certain conditions, such as uncontrolled seizures preclude the use of these medications. It is therefore difficult to predict: (1) which one of the two will work best for the individual; and (2) what the optimal dosage with no side effects is. It is a trial and error process. An important rule to remember is that with the correct dosage, the individual should return to normal levels of functioning and have no side effects. Symptoms that respond well to medication are: procrastination, distraction, daydreaming, impatience, impulsivity, and restlessness. Symptoms which do not respond are: disorganisation, argumentativeness, and oppositional behaviour. The optimal dosage should be the lowest dose that provides optimal performance and no side effects. Adults should be able to take a nap after lunch while on their optimal stimulant dosage, which will prove that taking the stimulant in the evening, will not affect their sleep.
Similarly, Dr Barkley, considered an international authority on ADHD, advises that medication is the preferred treatment for ADHD. He indicates that the different ADHD medications regulate emotions through different pathways. Stimulants like Ritalin and Vyvanse, work by increasing dopamine production and preventing its re-uptake. Stimulants improve executive functioning such as attention and working memory. Stimulants also manage the emotional dysregulation of ADHD by suppressing the limbic system. The limbic system is however not part of ADHD neuroanatomy and is not impaired in ADHD. The higher the stimulant dosage the less activity in the limbic system, which leads to blunting of normal emotions.
In contrast, non-stimulant medication like Strattera, which is a norepinephrine re-uptake inhibitor, has no effect on the limbic system. It activates the anterior cingulate cortex and the executive system, the area that should down-regulate emotions, but which is impaired in ADHD. No emotional blunting is reported for people using Strattera. Intuniv, another type of non-stimulant, is an Alpha-2 regulator that affects the frontal lobes and fine-tunes signals in nerve cells by latching to the nerve fibre and opening or closing the Alpha-2 ports along the nerve fibre. If port cells are closed the signals are stronger, in contrast when the ports are open, the signals are weaker. The executive system is activated by both Intuniv and Strattera and can be used at this level to regulate emotion in ADHD. Both of these non-stimulants are often used in combination with a stimulant in lower doses, to cover a wider spectrum of ADHD symptoms.
According to Dr Katya Rubia (2015), a meta-analysis of long-term effects of medication on brain structure and chemistry in ADHD, indicated that the brain adapts to medication in the space of one year. Positron Emission Tomography (PET) scans on adults indicated that the dopamine transporters in the basal ganglia increased – which suggests that the brain adapts to stimulant medication. Increased dopamine transporters in the basal ganglia in ADHD are associated with inattention. Adults treated with stimulants have an increased and not a normalised amount of dopamine transporters. People who have never used any kind of stimulant have low numbers of dopamine transporters. It is assumed that the same happens to a child’s brain, in which case Dr Rubia suggests that a drug holiday should be considered during the summer holiday so that the brain does not adapt to stimulant medication. Longitudinal studies are needed to confirm these preliminary findings. Clinical studies have not shown long-term efficacy of stimulant medication – it does however work well in the short term. Ideally a more objective measure is needed to identify children with ADHD. The brain patterns should assist with diagnosis in especially difficult cases.
Dr Daniel Amen, founder of the Amen Clinics and SPECT scanning pioneer, states that ”when the brain works right, people tend to work right; when the brain is troubled, people tend to struggle being their best selves”. SPECT (Single Photon Emission Computed Tomography) is a nuclear medicine procedure widely used to study heart, liver, thyroid, bone and brain problems. According to Dr Amen, brain SPECT imaging is a proven, reliable measure of cerebral blood flow. Because brain activity is directly related to blood flow, SPECT effectively shows us the patterns of activity in the brain and allows us to observe three things in the brain: areas of the brain that work well, areas of the brain that work too hard, and areas of the brain that do not work hard enough. Ideally, when we concentrate, blood flow should increase in the brain, especially in the prefrontal cortex; this increased activity allows us to focus, stay on task and think ahead. However, according to Dr Amen the ADD brain works differently, blood flow actually goes down when they concentrate, making it harder to stay focused.
The Amen Clinics (https://www.amenclinics.com) use, amongst other therapies, neurofeedback to treat ADHD. Before the tailor-made treatment is initiated, a Quantitative Electroencephalogram (qEEG) is conducted. The qEEG is a painless, non-invasive diagnostic tool which measures electrical activity in the form of brainwave patterns. The qEEG helps to:
- Identify cognitive and psychiatric problems
- Predict medication response
- Track progress with different therapies and treatments
According to the Amen Clinic’s website, the American Academy of Pediatrics gave neurofeedback a high scientific rating with relation to ADD/ADHD. Neurofeedback has been used successfully to improve many conditions including, but not limited to:
- Autism spectrum disorder
- Sleep problems
The effects and benefits of neurofeedback training last long after the training itself has stopped. Because the brain has actually learned (or relearned) a more efficient way of performing, it will continue in this way as new neural pathways are created, thus making lasting change the path of least effort.
According to a short video posted by Biofeedbacknews (2013), Marco Congedo, a neurofeedback research scientist at the French National Centre for Scientific Research, awareness of ADHD in schools and the community is growing. This also means that children are being identified with ADHD earlier and treatment can also be provided earlier. Every case is different and brain functioning should be assessed in all. The major treatment for ADHD is medication, but medication does not solve the problem, it only masks the problem. Another disadvantage of medication is that the child does not learn to do anything about the ADHD. With neurofeedback, the child learns to change brain patterns, and by applying the knowledge the change becomes permanent. Neurofeedback is a lengthy process, which needs about 40 sessions. Improvement can take up to 1 month. There is now enough literature and control studies to prove that the technique is effective.
Arns, et al. (2014). Evaluation of neurofeedback in ADHD : The long and winding road. Biological Psychology, 95, 108-115.
Baumeister, et al. (2016, September 19). Neurofeedback training effects on inhibitory brain activation in ADHD: A matter of learning? Neuroscience.
In the same video, Prof Leon Kenemans, Professor of Biopsychology and Psychopharmachology at Utrecht University in The Netherlands, is also of the opinion that the effect of medication is short-term, and repeated use is necessary to maintain its effect, whereas neurofeedback is a possible long-term solution. Neurofeedback can reduce healthcare costs as repeated use is not necessary. He however emphasises that more studies about the effectiveness of neurofeedback are needed.
More detailed information about the application can be found on the website of The International Society for Neurofeedback & Research (https://www.isnr.org/neurofeedback-introduction).
Neurofeedback has gained popularity as part of a treatment plan for ADHD – especially for children. Studies are still conflicting on its efficacy and it is not always readily available. According to Schoeman and Liebenberg (2017), there appears to be insufficient data to support the use of an electroencephalogram-based assessment to diagnose ADHD in adults. However, the US Food and Drug Administration (FDA), has approved the use of such an assessment as part of the diagnostic process for children. The data seem to indicate that children with possible ADHD demonstrate higher resting theta:beta waves.
In South Africa, a qEEG can be done at a few facilities. I have experience from the ADD Lab (http://addlab.co.za/choose-a-solution/qeeg/) in Randburg. Here a type of neurofeedback is done to teach the brain to alter its own electrical waves to regulate itself.
Another relatively new neurofeedback method is known as HEG (hemoencephalography). HEG is a method of monitoring and regulating blood flow in the brain. According to The Brain Resource Center, through this method voluntary control over blood flow or oxygenation in specific regions in the brain is regulated. Since the brain needs to supply extra blood to those modules in current use (blood provides oxygen, nutrients and glucose to various parts of the brain), the regulation of blood flow is extremely important for proper functioning of various brain regions. Use of HEG for activating the prefrontal cortex as well as other lobes has been very useful in the treatment of various disorders including ADHD, migraine headaches, and other neurobehavioral disorders. This method is also very useful in conjunction with neurofeedback in improving auto-regulatory functions of the brain. Thermal Passive Infrared HEG (pirHEG) and Optical Near Infrared HEG (nirHEG) are the two methods of HEG that use thermo-modulations and changes in brain tissue colour as a method of measuring blood flow and oxygenation in the brain.
In South Africa, Brain Gain (http://www.braingain.co.za) conducts a Test for Emotional Stability and Cognitive Ability (TESCA) to determine a baseline of the individual’s blood flow to their brain. A type of neurofeedback is then done for approximately 40 sessions to teach the brain to increase blood flow as needed.
The professionals all have their preferred method of assessing and treating ADHD, but what do parents of children with ADHD say? What do they think are most effective? According to a survey conducted by ADDitude, parents of children with ADHD reported that they try multiple therapies and continue to adjust the treatment plan long after an ADHD diagnosis has been made. No single treatment works for all individuals. Interestingly enough, parents report that the treatment they find most useful, is most often not the one suggested by their doctor, or frequently used by others.
Many factors, such as budget, geography, access to information, lifestyle, and medical aid, influence which treatment/s are chosen. Some parents feel that the trial and error phase for finding the correct treatment is like a full-time job. Frequent doctor’s visits, co-payments, expensive alternative treatment like NF, and coaching, are aspects that parents take into consideration when choosing a treatment. Parents also feel that professionals do not always provide all the treatment options or expert advice and guidance needed. Parents report that 92% professionals recommended medication. Parents are then left to search for answers and alternatives themselves. Exercise was rated as ”extremely” effective by 50% of the parents using this treatment, but only 13% said their doctor recommended it as a treatment option. 60% of parents surveyed indicated that they were not satisfied with their child’s treatment plan. Likewise, only 44% of adults were satisfied with their treatment. Exercise, behaviour training classes and ADHD coaching, were rated as most effective by parents and adults with ADHD. These three, in combination with meditation, NF, and CBT ranked higher than medication for efficacy. Yet, most people used medication for convenience and the fact that it brings immediate relief from symptoms. The majority of parents tried other treatment options before considering medication. Many parents view medication as a last resort. Adults with ADHD were less reluctant to try medicine.
From the above information it is evident that diagnosing and treating ADHD is a mine field. Ample information about the condition and treatment is available, but consensus between professionals is lacking. Treatment is definitely not clear-cut or an easy or speedy process. In the meantime, while treatment is in its trial-and-error phase, children with ADHD struggle with daily functioning.
In the next article we will look at the controversy around whether ADHD exists at all.
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