Fall 1999 - IP; Passport to Practice/Resnick

PASSPORT TO PRACTICE

Attention Deficit Disorder: They All Don't Outgrow It!/Robert Resnick

Attention Deficit Disorder: Marketing Tips/Kal Heller

**PASSPORT TO PRACTICE**
	Attention Deficit Disorder: They All Don't Outgrow It!/Robert Resnick
	Attention Deficit Disorder: Marketing Tips/Kal Heller

Robert Resnick, Ph.D. ABPP, FAClinP
Past President of APA

APA Council Representative

Kal Heller, Ph.D.
Independent Practice

Needham, MA

Co-Coordinator of Marketing for the Brochure Project

This is one of a series of articles aimed at helping you to develop and market specialty services for specific problems and populations. “Passport to Practice” articles are each based on one of the eight brochures developed and published by the Brochure project, a joint venture of the Divisions of Psychotherapy and Independent Practice. To order brochures or get further information about the Brochure Project call (602) 912-5303 or FAX (602) 957-4828.

Attention Deficit Hyperactivity Disorder: They All Don’t Outgrow It!
Robert J. Resnick, Ph.D.; ABPP, FAClinP

A German physician, Heinrich Hoffman, wrote a nursery rhyme in 1854, that described a restless, fidgety and overactive child during a family meal.

Phillipp, stop acting like a worm.

The table is no place to squirm.

But Phillipp will not take advice,

He’ll have his way at any price.

He turns, and churns, he wiggles and jiggles

Here and there on the chairè

This may be the first “documented” case of Attention-Deficit/Hyperactivity Disorder (ADHD) although, retrospectively, many well known individuals in history have been identified as similarly afflicted - Alexander the Great, Genghis Khan, Theodore Roosevelt, and Thomas Alva Edison to name but a few. Today, approximately 3-5% of children have ADHD; this number reflects only school age youngsters. Not included are the non-hyperactive (primarily Inattentive Type) school age children, teenagers or adults. It has been suggested that there is, at least, an equal number of inattentive ADHD children and somewhere between 14-20 million ADHD adults. The incidence of ADHD among teenagers remains undetermined. It was not until the late 1970’s that research began to surface suggesting and, now verifying, that 30-70% of children with ADHD will continue to have symptoms into adulthood. In children, the ratio of boys to girls is now estimated at between 3-4 to 1; but in adults there is a 1 to 1 ratio. Studies suggest that women, more often then men, seek help for the problems associated with ADHD. ADHD has a very high genetic component and may be seen running in either the extended or nuclear family. Often, in the course of evaluating a child, the parent will report similar problems, but undiagnosed or treated as the diagnostic rubric of attention deficit wasn’t introduced until the DSM-III in 1980.

The Core-Four of ADHD

DSM-IV enumerates inattention, impulsivity with or without hyperactivity as the primary symptom clusters. I would add distractibility to the list as it is frequently mentioned by parents, children and adults. These core-four symptoms are frequently baseline and the underpinnings of the many concerns and complaints of parents of ADHD children, the children themselves, the school, the employer, the spouse and the ADHD adult. Most individuals show ADHD like symptoms on occasion, ADHD suffers, however, have a frequency, intensity and consistency of age inappropriate behaviors in comparison to peers.

Treatment of ADHD

Treatment plans are highly individualized to meet the needs of the ADHD person. The first step, however, is always the same. Educating the patient and other appropriate persons about etiology, course and treatment of ADHD. Dispelling myth with fact and understanding sets the stage for the second phase--an individually tailored treatment that will help to make the world around them ADHD friendly. In this phase of treatment interventions may be put in place in school, home, or workplace to minimize the impact of the ADHD symptoms. For example, a child who is so disorganized and forgetful that school books don’t always come home. Rather than have the ADHD child pay the price for not acting “responsibly,” arrange with the school to have a duplicate set of books at home under the control of the parents. An adult who is inattentive and doesn’t follow through on instructions should not be given verbal requests. Requests should come by memo or E-mail. At home, the child who can’t seem to get the weekend chores done is given a list printed, upside down, and pinned to his or her shirt will facilitate the chores completion without resorting to verbal recriminations and repetition by the parents. For the ADHD adult at home with organizational problems; the others in the household insuring that once a task is started; it goes to completion before another task is initiated. Additionally, when appropriate, conferences with teachers or employers, also, help make the environment more ADHD friendly.

In addition to the environmental support system, the use personal prompts such a daily planner, sticky-notes, check-lists, mini-cassette recorders and “Voice-It” are all helpful in addressing the inattention and disorganization in ADHD individuals. Very recently, an attractive wrist watch has become available with several alarm settings that cause the wearer’s wrist to vibrate at preset times and, by looking at the face of the watch, a brief message cues the individual on the task that must be performed at that time.

Making the world more ADHD friendly is, also, accomplished by individual therapy, family therapy and couples therapy alone or in some combination. Because ADHD is a chronic disorder both environmental and personal issues arise throughout the life span. Entering middle school or high school, attending college, job changes, getting married or a change in marital status, becoming a parent, a move, etc may have deleterious effects on the ADHD person. It is not that the ADHD person has gotten worse but that change coupled with no greater control over the ADHD has caused additional stress and problems coping to the extent that further treatment and fine tuning are necessary. In my practice there is an adult with ADHD that I have seen intermittently over 25 years; each time he comes in for treatment, it is in response to a major change in his life. As he puts it, “I need my battery charged.” Three to twelve sessions later he is done with this episode. However, with some ADHD persons co-findings of depression and other psychological problems require longer term therapy.

Additionally, ADHD people frequently have difficulties with social situations. They tend to misperceive what others say and may not interpret the subtle nuances of other people’s non-verbal behavior. Consequently, they often feel on the periphery of social situations, or worse, react erroneously to what they think they have heard and seen. Needless to say, such ADHD behavior reaps havoc on a marriage or any ongoing relationship. Such social skills building, is thus, a relatively common component of the treatment plan. Anger management and conflict resolution can be integral parts as well.

A Word About Pharmocotherapy

Medication is almost always considered as one part of the ADHD treatment plan for children, teens and adults. It is effective in controlling some of the symptoms of ADHD. The improvement is state dependent and, when the drug wears off, a return to symptom baseline will occur. But with proper challenging of the drug dose and timing of the dose, some symptom reduction is apparent. It must be emphasized that drug therapy should be only one part of a multi-modal plan. Indeed, all the manufacturers of the stimulant drugs used to treat ADHD state that pharmocotherapy is but one component of a treatment plan.

Why Work With ADHD?

First, it almost impossible to not work with this population given their ubiquitous nature. Second, they frequently make great personal strides under our care--they get better and are appreciative. Often, they become part of your informal referral network. Third, a recent issue of Psychotherapy Finances mentioned ADHD in their list of the best niche practices. And fourth, you won’t regret it!

Robert J. Resnick, Ph.D. ABPP, FAClinP is a Past President of APA and is an APA Council Representative.

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		Robert Resnick, Ph.D. ABPP, FAClinP Past President of APA APA Council Representative	Kal Heller, Ph.D. Independent Practice Needham, MA Co-Coordinator of Marketing for the Brochure Project
This is one of a series of articles aimed at helping you to develop and market specialty services for specific problems and populations. “Passport to Practice” articles are each based on one of the eight brochures developed and published by the Brochure project, a joint venture of the Divisions of Psychotherapy and Independent Practice. To order brochures or get further information about the Brochure Project call (602) 912-5303 or FAX (602) 957-4828.
	Attention Deficit Hyperactivity Disorder: They All Don’t Outgrow It! Robert J. Resnick, Ph.D.; ABPP, FAClinP A German physician, Heinrich Hoffman, wrote a nursery rhyme in 1854, that described a restless, fidgety and overactive child during a family meal. Phillipp, stop acting like a worm. The table is no place to squirm. But Phillipp will not take advice, He’ll have his way at any price. He turns, and churns, he wiggles and jiggles Here and there on the chairè This may be the first “documented” case of Attention-Deficit/Hyperactivity Disorder (ADHD) although, retrospectively, many well known individuals in history have been identified as similarly afflicted - Alexander the Great, Genghis Khan, Theodore Roosevelt, and Thomas Alva Edison to name but a few. Today, approximately 3-5% of children have ADHD; this number reflects only school age youngsters. Not included are the non-hyperactive (primarily Inattentive Type) school age children, teenagers or adults. It has been suggested that there is, at least, an equal number of inattentive ADHD children and somewhere between 14-20 million ADHD adults. The incidence of ADHD among teenagers remains undetermined. It was not until the late 1970’s that research began to surface suggesting and, now verifying, that 30-70% of children with ADHD will continue to have symptoms into adulthood. In children, the ratio of boys to girls is now estimated at between 3-4 to 1; but in adults there is a 1 to 1 ratio. Studies suggest that women, more often then men, seek help for the problems associated with ADHD. ADHD has a very high genetic component and may be seen running in either the extended or nuclear family. Often, in the course of evaluating a child, the parent will report similar problems, but undiagnosed or treated as the diagnostic rubric of attention deficit wasn’t introduced until the DSM-III in 1980. The Core-Four of ADHD DSM-IV enumerates inattention, impulsivity with or without hyperactivity as the primary symptom clusters. I would add distractibility to the list as it is frequently mentioned by parents, children and adults. These core-four symptoms are frequently baseline and the underpinnings of the many concerns and complaints of parents of ADHD children, the children themselves, the school, the employer, the spouse and the ADHD adult. Most individuals show ADHD like symptoms on occasion, ADHD suffers, however, have a frequency, intensity and consistency of age inappropriate behaviors in comparison to peers. Treatment of ADHD Treatment plans are highly individualized to meet the needs of the ADHD person. The first step, however, is always the same. Educating the patient and other appropriate persons about etiology, course and treatment of ADHD. Dispelling myth with fact and understanding sets the stage for the second phase--an individually tailored treatment that will help to make the world around them ADHD friendly. In this phase of treatment interventions may be put in place in school, home, or workplace to minimize the impact of the ADHD symptoms. For example, a child who is so disorganized and forgetful that school books don’t always come home. Rather than have the ADHD child pay the price for not acting “responsibly,” arrange with the school to have a duplicate set of books at home under the control of the parents. An adult who is inattentive and doesn’t follow through on instructions should not be given verbal requests. Requests should come by memo or E-mail. At home, the child who can’t seem to get the weekend chores done is given a list printed, upside down, and pinned to his or her shirt will facilitate the chores completion without resorting to verbal recriminations and repetition by the parents. For the ADHD adult at home with organizational problems; the others in the household insuring that once a task is started; it goes to completion before another task is initiated. Additionally, when appropriate, conferences with teachers or employers, also, help make the environment more ADHD friendly. In addition to the environmental support system, the use personal prompts such a daily planner, sticky-notes, check-lists, mini-cassette recorders and “Voice-It” are all helpful in addressing the inattention and disorganization in ADHD individuals. Very recently, an attractive wrist watch has become available with several alarm settings that cause the wearer’s wrist to vibrate at preset times and, by looking at the face of the watch, a brief message cues the individual on the task that must be performed at that time. Making the world more ADHD friendly is, also, accomplished by individual therapy, family therapy and couples therapy alone or in some combination. Because ADHD is a chronic disorder both environmental and personal issues arise throughout the life span. Entering middle school or high school, attending college, job changes, getting married or a change in marital status, becoming a parent, a move, etc may have deleterious effects on the ADHD person. It is not that the ADHD person has gotten worse but that change coupled with no greater control over the ADHD has caused additional stress and problems coping to the extent that further treatment and fine tuning are necessary. In my practice there is an adult with ADHD that I have seen intermittently over 25 years; each time he comes in for treatment, it is in response to a major change in his life. As he puts it, “I need my battery charged.” Three to twelve sessions later he is done with this episode. However, with some ADHD persons co-findings of depression and other psychological problems require longer term therapy. Additionally, ADHD people frequently have difficulties with social situations. They tend to misperceive what others say and may not interpret the subtle nuances of other people’s non-verbal behavior. Consequently, they often feel on the periphery of social situations, or worse, react erroneously to what they think they have heard and seen. Needless to say, such ADHD behavior reaps havoc on a marriage or any ongoing relationship. Such social skills building, is thus, a relatively common component of the treatment plan. Anger management and conflict resolution can be integral parts as well. A Word About Pharmocotherapy Medication is almost always considered as one part of the ADHD treatment plan for children, teens and adults. It is effective in controlling some of the symptoms of ADHD. The improvement is state dependent and, when the drug wears off, a return to symptom baseline will occur. But with proper challenging of the drug dose and timing of the dose, some symptom reduction is apparent. It must be emphasized that drug therapy should be only one part of a multi-modal plan. Indeed, all the manufacturers of the stimulant drugs used to treat ADHD state that pharmocotherapy is but one component of a treatment plan. Why Work With ADHD? First, it almost impossible to not work with this population given their ubiquitous nature. Second, they frequently make great personal strides under our care--they get better and are appreciative. Often, they become part of your informal referral network. Third, a recent issue of Psychotherapy Finances mentioned ADHD in their list of the best niche practices. And fourth, you won’t regret it! Robert J. Resnick, Ph.D. ABPP, FAClinP is a Past President of APA and is an APA Council Representative.
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