A Social Worker’s Guide to
Attention Deficit/Hyperactivity Disorder:
What is it? Who has it? And what should we do about it?
By Susan Kottler, LICSW
Knowledge of this wide-spread disorder is beneficial to social workers in varied settings in the detection, assessment, treatment and referral of people struggling with symptoms of ADHD, as well as in broader areas of program planning and implementation.
Picture yourself in the following common situation. It’s time for your appointment with a new client, but she is late. You begin some paperwork, only to hear the door to the waiting room fly open. There she is! She fills in your registration form, but within her large totebag and pocketbook can’t find her insurance card. She knows it’s in there somewhere. Her appointment book falls, spilling a profusion of scraps of paper.
After she enters your office, you listen carefully to her reasons for the visit today. Based on your observation of her arrival, you begin to wonder about the overall level of disorganization in her everyday life. She speaks quickly, sometimes jumping from topic to topic. Twice she rises from her chair, once to retrieve her gloves which have fallen, and then again to pick up her appointment book and its ever-spreading contents. You find that she is a busy and seemingly competent person, managing a job, a family, and a relationship with an ill, elderly mother. As she continues to talk, you realize that it is not so much the circumstances of her life that seem unusually difficult, but her manner of responding to the demands of everyday life that makes her feel ineffectual and overwhelmed.
Does this woman have Attention Deficit/Hyperactivity Disorder?
Beginning to think diagnostically, we must first consider whether she exhibits the major characteristics of ADHD as defined in the Diagnostic and Statistical Manual (DSM-IV): impulsivity, hyper-activity or restlessness, and difficulty with attentional processes. There are two types of ADHD listed: ADHD, hyperactive-impulsive style, and ADHD, inattentive style. The DSM IV lists nine characteristics of ADHD, hyperactive-impulsive style, of which six must be endorsed for a diagnosis. Included are fidgeting, being often "on the go," talking excessively, interrupting or intruding on others, blurting out answers to questions before they are finished, having difficulty waiting for a turn, leaving one’s seat in a situation where being seated is expected, difficulty playing or relaxing quietly, and excessive running or climbing, which, in adolescents and adults, can be simply an internal feeling of restlessness.
There are nine additional items related to ADHD, inattentive style, outlined in the DSM IV. Similarly, six items are required for diagnosis. ADHD, inattentive style, requires the presence of problems in attentional processes only, including: difficulty paying sustained attention to tasks or play, forgetfulness in carrying out activities, losing things necessary for tasks, being easily distracted, having difficulty being organized in work or other activities, seeming to not listen when spoken to, not following through on instructions then not finishing tasks, avoiding work that requires sustained mental effort, and failing to attend to details or making careless mistakes. If criteria are met for both inattentive and hyperactive-impulsive styles, the disorder is called ADHD, combined type.
To meet diagnostic criteria, symptoms are required to have been present over time (for at least six months in children), and to have been noticeable before the age of seven. They should be present in at least two settings (home, school or work, social settings, etc.), clearly impair adjustment, and be inconsistent with developmental level. Other reasons for the symptoms must be ruled out.
However we may choose to understand and categorize ADHD, a great deal of research has shown that there are neurobiological underpinnings to the disorder. Some theorists blame faulty neurotransmitters in the brain, specifically dopamine and norepinephrine. In addition, there is definite evidence from Positron Emission Tomography (PET) and Magnetic Resonance Imaging (MRI) scans implicating the brain’s frontal lobe in ADHD. The general consensus is that in at least some forms of ADHD, an underactive frontal lobe is unable to provide the usual "executive functions." These "executive functions" normally assist in areas including planning, organizing and regulating behavior over time and in accordance with internalized norms, and, attending to and monitoring information. Possibly both dysregulation of neurochemicals and frontal lobe dysfunction are important in causing ADHD, and lower brain structures have been implicated in its etiology as well. There is evidence from many studies of a hereditary predisposition to ADHD.
It may be that ADHD is not one unified disorder, but rather a number of related and unrelated disorders, with differing etiologies, all under the "umbrella diagnosis" of ADHD. Future research is likely to further develop subtypes of ADHD.
Detecting ADHD throughout the Lifecycle
At all ages there are characteristic traits and behaviors seen with ADHD. Generally, ADHD, inattentive style, is the more difficult to detect. Inattentive people may function reasonably well, with their organizational and attentional issues invisible to the casual observer. Those with the impulsive, hyperactive version of ADHD can be easier to identify. In addition to organizational and attentional issues, they may exhibit the characteristic restlessness, impulsivity and overactivity, plus related symptoms such as low frustration tolerance, temper outbursts, mood lability, and, a seeming insatiability for attention, especially in children.
ADHD is frequently underdiagnosed, particularly in adulthood. Estimates of the incidence of ADHD range from 3% to 9% in school age children, and between 2% and 6-7% in adults, depending on the study cited. In clinical populations, the percentage is much higher. A 1996 research review finds that over 50% of out-patient child mental health evaluations involved a diagnosis of ADHD.
Here is a typical situation that might come to the attention of a social worker. Brian’s mom is concerned that he might "flunk out" of nursery school. The teachers say he grabs things from other children, pushes if he’s not the first in line, talks during story time, and bothers other children when they are playing quietly. He never settles on an activity during free time, but wanders around the room, sometimes making silly noises. The teachers have spoken with him about appropriate classroom behavior, and he seems to understand, but his behavior doesn’t improve. Last week they asked his mom if there’s anything going on at home that’s troubling Brian and making him angry. She’s beginning to feel that she might not be a very good mother.
Does Brian have ADHD?
In the preschool years, when most children are active, curious explorers, children with ADHD show markedly short attention spans and often very high activity levels. They seem to be continually on the go, easily frustrated, and sometimes with more severe temper tantrums than their age-mates. One typical picture of the ADHD child at this age is that of an energetic whirlwind, moving from one activity to another, driven to touch, explore, and react to much in the environment. The care of such children presents challenges to parents, as these youngsters can be in need of almost constant monitoring and redirection. It is interesting to note that some symptomatic pre-school children appear to make significant maturational gains after age four, and then catch up developmentally.
For other children, diagnostic questions are not raised until the school years, when they are required to sit still in the classroom and focus attention on learning. Those with ADHD, inattentive style, can appear dreamy and spacey, and are easily overlooked in a busy classroom. For children with ADHD hyperactive/impulsive style, restlessness, high activity level, and talkativeness, as well as difficulty with concentration, are at odds with classrooms requiring quiet, focused attention to tasks. Unstructured or unsupervised times are taxing, since internal self-regulation is deficient. Completing work assignments, doing homework, and for some, negotiating social situations, are problematic.
In third or fourth grade, when school work calls for increasingly complex learning sequences, these children underperform and are blamed for being lazy or unmotivated.
They may be seen as "class clown," or perhaps as not very bright. Undiagnosed ADHD causes problems between parent and child, when the child can’t focus on chores or homework, can’t complete schoolwork in spite of adequate intelligence, and can’t master age-appropriate social skills. Mustering the skills needed for longer-range projects - research papers and book reports, for example - that require on-going planning and organization, can cause troublesome conflict for parent and child.
Here is another situation that might come to the attention of a social worker in any number of settings. Jessica asked her parents to find someone to help her. She’s 13, in the eighth grade, and is no longer getting A’s and B’s as in elementary school. Her parents worry that she’s "lying." During the fall semester, she told them she was diligent about her homework, yet she got warning notices for multiple missed assignments in two subjects. When a long book report was due, although her mother tried to help her budget her time, she put it off, doing it hastily and poorly at the last minute. Her parents have tried punishing her, but she still doesn’t do her work. Lately, she’s been complaining of headaches and stomach aches, and crying at home. She told her parents, "I’m stupid. I can’t do anything right."
Does Jessica have ADHD?
Demands on children become even more complex when they enter junior high/middle school, and many pre-teens are brought for clinical evaluation at this time. With maturity, some of them may gain control over their outward manifestations of hyperactivity, while remaining inwardly as restless, disorganized, and inattentive as ever. In other words, although they appear capable of coping with age-appropriate demands for more autonomous social and academic functioning, this may not be the case. Unlike elementary school, there is no one teacher to help undiagnosed ADHD junior high/middle school students make sense of the multiple demands on their time and organizational skills.
All teens feel the age-appropriate need to be part of the peer group. Those with ADHD may respond by assuming a negative identity, banding together with other poor achievers, sometimes with considerable downward drift, to avoid feelings of failure and humiliation. This only increases parent-child conflict. In high school, students with undiagnosed ADHD often perform well below their intellectual capacities, but may not be noticed as having attentional issues.
ADHD often persists in adult life; estimates are that 50-65% of children do not outgrow their symptoms. This means that there are a great many restless, easily distracted, sometimes impulsive, sometimes inattentive adults bravely trying to manage busy, fast-paced twenty-first century lives. In many circumstances, ADHD symptoms can make completing ordinary cognitive processes a complex and extraordinary challenge. Life with adult ADHD might feel frantic. Houses are messy, chores aren’t done, relationships suffer, and careers are stymied when ADHD is undiagnosed. Adults with ADHD are more likely than their peers to have trouble managing interpersonal issues and controlling their impulses. In particular, many struggle with raising children, managing finances, driving responsibly, and resisting drug use and alcohol abuse.
The adult with ADHD can often be described as intelligent enough, but chronically underorganized, and often overwhelmed by ordinary daily demands. Picture the energetic, successful contractor who can’t manage paperwork and is frequently overbooked, the working mother with a structured job who falls apart under the more amorphous demands of running a household, or the bright college student brimming over with creativity who doesn’t remember to finish or hand in assignments — all could be showing signs of ADHD.
Restlessness or overactivity, impulsivity, and difficulty with attentional processes—these are the hallmark traits of Attention Deficit-Hyperactivity Disorder. Part one of this article, published in the April issue of FOCUS, outlined common issues in under-standing ADHD and in recognizing the disorder as it is manifested in different stages of the life cycle.
Why is Diagnosis Difficult?
Issues leading to underdiagnosis—or overdiagnosis— of ADHD:
A vignette about a woman appearing late for her first interview with a social worker began part one of this article. The woman was disorganized. She appeared to be restless, she spoke impulsively, and her attention wandered from topic to topic. Can we assume that she has ADHD?
In fact, any time we hear about or observe the symptoms of ADHD, we should, depending on the social work setting, assess for its presence or refer for assessment.
Whichever we do, the process of diagnosing ADHD is complex and challenging, and there is no physiological or psychological test in general use to give a definitive diagnosis.
Historically there has been some unwillingness to recognize attentional diagnoses, since many of the behaviors associated with ADHD have long been thought to be under volitional control. In addition, ADHD was thought to be an affliction of childhood which was believed to be "outgrown" by adolescence. Outcome studies in the 1980s proved that attentional symptoms do often persist into adulthood. Thus only in recent years has it become clear that ADHD can be a life-long issue. More recent research indicates that 60-70% of children with ADHD are still symptomatic in adolescence, and that at least 50% still have ADHD in adulthood.
It is easy for clinicians to overlook the symptoms of ADHD in diagnostic work, since these symptoms can seem indistinguishable from ordinary daily reactions. Most people, at some time in their lives, exhibit some restlessness or distractibility, or, report difficulty focusing attention. Anyone can have lapses in memory, act impulsively, or find concentration waning.
On the other hand, any number of frequently diagnosed mental disorders, as well as stress, can create a similar symptom picture and obscure the presence of ADHD as a separate disorder. Many of these diagnostic categories, such as depression, anxiety, and post traumatic stress disorder, share some characteristics with ADHD. A comprehensive evaluation with multiple sources of information, even for adults, will ensure that those with other reasons for restlessness, inattention, or impulsivity, or those whose symptoms are of recent onset, do not mistakenly receive the diagnosis of ADHD. A number of ADHD rating scales and other assessment tools exist to aid in determining a proper diagnosis. Russell Barkley, PhD, presents a detailed discussion and samples of rating scales in his 1998 book, Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment.
The hallmark inconsistency of ADHD can present a confusing picture, as there are varying manifestations and degrees of symptomatology from person to person, and even in the same person across different situations and settings. Someone with ADHD may appear calm and organized in a relatively structured one-to-one meeting, yet ADHD is still a possibility if symptoms that interfere with smooth functioning are reported in other areas of life.
Co-Morbidity: Another Diagnostic Complication
To further complicate diagnostic matters, a large percentage of people with ADHD also have one or more co-morbid conditions. This means that other constellations of complex symptoms exist, sometimes overlapping with the symptoms of ADHD. It is crucial for social workers evaluating ADHD to be familiar with a range of DSM-IV diagnoses, since each condition must be separately assessed and treated.
In the course of an evaluation for depression, fourteen year old Andrew and his parents answered a series of questions about his concentration, restlessness, and impulsivity, all agreeing that any current restlessness or difficulty concentrating was of recent onset. Before moving from a small town to a city with a more demanding school system earlier in the school year, he had gotten all A’s and had done homework and schoolwork easily. Andrew was treated for depression, and by the end of the school year, was more comfortable and successful academically and socially. Occasionally he seemed overwhelmed by homework, especially when long papers or final exams loomed. Andrew and his parents presented this difficulty as resulting from unaccustomed demands on a youngster who never before had had to work hard to succeed. He seemed to respond well to support and to tips on organizational strategies. The following year, he developed depressive symptoms several times, always in the context of a disappointment, such as not making the basketball team, and sporadically felt unmotivated to do schoolwork.
Given the information from his evaluation, both his therapist and psychopharmacologist attributed his academic struggles to his fluctuating depression. Then Andrew appeared for a therapy appointment to say that he had been up most of the previous night, trying unsuccessfully to write a long paper. "Could he have that attention thing?" his mother asked. As it turned out, Andrew did have ADHD, never visible when his high intelligence enabled him to complete easier work in earlier grades, then co-morbid with, and somewhat masked by his depressive disorder.
Among the most common co-morbid diagnoses are learning disabilities, anxiety disorders, substance abuse, mood disorders, and, in addition, oppositional defiant disorder and conduct disorder in children and adolescents. It is important to note that most people with ADHD experience at least some transient depression as they recognize themselves as unable to function optimally at some times and in some areas of their lives. This type of depression might fall into the category of adjustment disorder, and should be differentiated from more pervasive depressive disorders.
ADHD: What do we do about it?
Since ADHD is comprised of a set of variable symptoms, differing in their expression from person to person and changing over time, it makes sense that there is no one recommended treatment. Multi-modal treatment is indicated and may include some or all of the following: medication management, individual therapy, family therapy, support groups, parent counseling, coaching, and consultation to schools or other settings. Multiple theoretical frameworks can be effective, including ego psychology, family systems theory, and cognitive behavioral interventions.
All effective therapy for ADHD has a strong educational component. Once an accurate diagnosis has been reached, it is the job of the social worker to educate the adult, or the adolescent or older child and parents, about the basics of ADHD and its effect on behavior. For many it is empowering to have an explanation for the difficulties they or their children have endured, and to know that the manifestations of ADHD are no one’s fault. It is important to highlight the positive traits often seen with ADHD, such as high energy, optimism, creativity, and an engaging personality. We can generate hope by explaining that people learn to live with, and to compensate for, attention-related deficits. Social workers can give examples of positive outcomes for people who have ADHD. Traditional psychotherapy, while useful in treating co-morbid conditions, is not useful in changing the essential troublesome characteristics of this disorder.
Social workers are often the first members of the treatment team to come into contact with the individual with ADHD and frequently must make a referral for a medication evaluation. The referral process includes an explanation about the team approach to treatment, in which both issues of day-to-day living and neurobiological components of ADHD are addressed through talk as well as medication. Since we are often the professionals who see the person most frequently, we need to have knowledge of the medications commonly used for ADHD, as questions may arise about their effects and side effects, as well as about the necessity of adhering to the medical regime. Numerous books detail the indications for medication, medications used for ADHD, and common side effects (Barkley, 1998; Dendy, 1995; Hallowell and Ratey, 1994).
For the vast majority, medication helps improve at least some symptoms related to restlessness, attention regulation, and impulsivity, and is sometimes helpful with related issues such as mood lability, anxiety, and irritability. Everyone with ADHD deserves a careful trial of medication to attain the most symptom relief possible.
Another important piece of our work with ADHD involves emphasizing, and then supporting, the skills and self-regulation needed for the stage of life of the person in treatment. Over time, people can learn to subject their impulsive or unfocused decisions and life patterns to more deliberate thought, to increase and improve their behavioral repertoire.
With children, the work includes parents, who must provide a sort of treatment milieu at home. First, social workers must help parents decrease friction and "wear and tear" that might have built up in the parent-child relationship through a long series of frustrating interactions, to restore a more positive atmosphere. Parents need to understand how the whole gamut of traits associated with ADHD — restlessness, poor attention regulation, impulsivity, distractibility, low frustration tolerance, emotional overreactivity, and disorganization — causes behavioral, social, and academic problems. The standard reward and punishment schemes that are useful with many youngsters to shape proper behavior have limited effectiveness in improving the adjustment of children with ADHD, and often lead instead to stalemates. Because the symptoms of ADHD make it difficult for children to learn from their mistakes or to generalize from one behavioral situation to another, their parents are most successful when they employ parenting techniques specifically designed for the ADHD population. Such techniques work toward changing the child’s environment, whether home or school, to increase chances for success in behavior and performance. Rules are clear, tasks are broken down into smaller and more manageable components, and success is rewarded immediately. Most schemas for improving childhood adjustment with ADHD stress consistency, a positive and empowering outlook, and when necessary, appropriate use of sanctions (Barkley, 1995).
Once children reach the adolescent years, new challenges face clinicians and parents. The balance of power in the parent-child relationship changes, and parents no longer have the power to insist upon or dictate the rules for required behavior. While families must have some non-negotiable rules for day-to-day living, many of the concerns which surface in the treatment of adolescents with ADHD will be solved most readily through parent-adolescent negotiation. Both Phelan (1993) and Robin and Foster (1989) present useful models from which we can learn the details of improving communication and problem-solving with adolescents.
Social workers can be most effective by having a "bag of tricks" from a variety of sources to use in work with parents and teachers who deal with children with ADHD. There is a wealth of appropriate literature. Additional helpful resources are available in the literature of temperament (Greenspan, 1996, Kurcinka, 1998, Turecki, 1985) and in books addressing work with more difficult, defiant children who might have ADHD plus co-morbidities, especially oppositional defiant disorder (Barkley,1997, Greene, 1998).
Implications for Social Workers
In health, mental health, judicial, educational, and community-based programs, social workers come into daily contact with children, adolescents, and adults with ADHD.
These people may be experiencing great difficulty in managing their lives, yet may be completely unaware of the possibility that their functioning is limited by ADHD. They need our assistance in understanding the cause of their troubles, in locating helpful resources, and in learning new skills for more effective living. It is not unusual for those with ADHD who receive appropriate treatment to become more capable at work or school, more successful in social relationships, better able to balance the demands of work and family life, and more satisfied with themselves.
In the broader helping community, social workers knowledgeable about ADHD can perform a valuable service, not just to our clients, but also in our collaborative professional relationships. We can act as informal educators, bringing state-of-the-art information on the detection, diagnosis, and treatment of ADHD to other professions, fulfilling a consultative role in promoting understanding of this multi-faceted syndrome.
Our knowledge of ADHD can also provide valuable input to program planning. Since a sizable percentage of those seeking social work intervention struggle with disorganization and poor attention regulation, we must consider the importance of planning programs in which expectations and protocols are clear and easy to follow. Participants will derive the most benefit if skill building in areas of self-care and personal life management is included in all elements of program implementation, regardless of program content.
When social workers in any setting come in contact with unfocused lives, people suffering from lack of organization, acting impulsively, and accomplishing little, we must do our best to see a broader picture, and to see it correctly. We just might find that part of the picture is ADHD, a very common disorder, and one which is highly amenable to treatment.
- Barkley, R.A.(1995). Taking Charge of ADHD: The Complete Authoritative Guide for Parents. New York: Guilford Press.
- Barkley, R.A. (1997). Defiant Children: A Clinician’s Manual for Assessment and Parent Training. New York: Guilford Press.
- Barkley, R.A. (1998). Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (2nd edition). New York: Guilford Press.
- Dendy, C.A.Z. (1995). Teen-agers with ADD: A Parents’ Guide. Bethesda, MD: Woodbine House
- Greene, R. (1998). The Explosive Child. New York; Bantam Books
- Greenspan, S.I. (1996). The Challenging Child. New York: Addison Wesley.
- Hallowell, E.M., and Ratey, J.J. (1994). Driven to Distraction. New York: Simon and Schuster.
- Kurcinka, M.S. (1998). Raising Your Spirited Child. New York: HarperCollins.
- Phelan, T.W. (1993) All About Attention Deficit Disorder. Glen Ellyn, IL: Child Management, Inc.
- Robin, A.L., and Foster, S.L. (1989). Negotiating Parent-Adolescent Conflict: A Behavioral-Family Systems Approach. New York: Guilford Press.
- Turecki, S., and Tonner, L. (1989). The Difficult Child. New York: Bantam Books.
Self-Help/Parent Support Groups
- Attention-Deficit Information Network (AD-IN), 475 Hillside Ave., Needham, MA 02492, (781) 455-9895
- Children and Adults with Attention Deficit Disorder (Ch.A.D.D.), 499 NW
70th Street, Plantation, FL 33317, (305) 587-3700.
Susan Kottler, LICSW, is in private practice at Comprehensive Psychiatric Associates in Wellesley, MA, and is a social work consultant to Wild Acre Inns, Arlington, MA.
FOCUS Newsletter - April and May 2000
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