Attention Deficit Disorder Misdiagnosis: Approaching ADD From a Brain-Behavior/Neuropsychological Perspective for Assessment and Treatment Fathering the ADHD Child: A Book for Fathers, Mothers, and Professionals
The first of these two books, Attention Deficit Disorder Misdiagnosis, addresses attention-deficit hyperactivity disorder (ADHD) and attention-deficit disorder without hyperactivity (ADD) from a neuropsychological perspective. Dr. Barbara Fisher argues that these disorders represent two distinct subtypes of attention-deficit disorder that are structurally and neurochemically quite different from one another and that lead to differing co-occurring disorders.
For example, ADHD seems to be correlated more with learning disabilities and "true" dyslexia, while the language problems of the ADD population seem to be more related to spatial inattention or problems with information processing or both. Also, central processing disorders have been found to be associated with ADHD. Dr. Fisher likens this disorder to a plane being operated without its pilot or control panel, whereas ADD is primarily a sustained-focus disorder resulting in severe academic underachievement.
In addition, Dr. Fisher notes that attentional problems may be secondary to other medical problems, such as hypo- or hyperthyroidism, pituitary problems, narcolepsy, hypoglycemia, and seizure disorders, and that bipolar disorder, depression, and other emotional symptoms may mimic ADHD or ADD. Medications taken for allergies or seizure disorders may result in attentional problems. Thus the diagnosis of ADHD becomes quite complicated, and the clinician not only needs to distinguish between ADHD and ADD but also must address other possible neurological or emotional variables that would present similar behavior.
Attention Deficit Disorder Misdiagnosis is a very comprehensive text that discusses such topics as the manifestations and consequences of attentional deficits, the anatomic structures implicated in this disorder, the pharmacology of attention, the role of information processing in attentional functioning, and the functioning of specific portions of the brain, including the frontal and parietal lobes. It also covers genetic influences and comorbidity factors, cognitive differences between ADHD and ADD, comorbid disorders associated with ADD, and the developmental span of the disorder.
Most useful from my perspective as a practicing clinician are the chapters on stimulants, antidepressants, and other medications. The book contains highly detailed descriptions of the variety of medications available, with lengthy discussions of stimulant medications as well as some of the less typical medications currently being used to treat ADHD, including buspirone, third- and fourth-generation antidepressants, mirtazapine, antihypertensives, neuroleptics, amino acid supplementation, and antiseizure medications. In discussing her own experience with stimulant medications, the author notes that she has found generic brands and sustained-release preparations to be ineffective; the formulation of generic brands often leads to negative, variable, and unpredictable responses, and sustained-release preparations may be overmetabolized, resulting initially in overmedication and later in undermedication.
It is Dr. Fisher's discussion of medications that will draw me back again and again to her text. I believe that clinicians will find much useful information in this book that will prove valuable in their work with children and adults with attentional disorders.
Fathering the ADHD Child addresses the needs of fathers who want to do a better job of parenting the child with ADHD and of professionals who face the task of involving these fathers in treatment. Dr. Edward Jacobs notes that addressing fathers' needs requires an understanding of how their parenting skills differ from mothers' skills and a realization that they are more difficult and less immediately gratifying to work with than mothers, more often failing to attend sessions or dropping out of family treatment prematurely.
Difficulties that children with ADHD bring to parenting include their lower ability to be motivated by rewards; their lack of a well-developed sense of the future and difficulty in regulating their behavior toward future goals; their difficulty in delaying gratification; and the limited value language has in affecting their behavior, as they are driven by their immediate wants. Fathers and mothers deal with their ADHD children differently. Fathers tend to see their children's problems as being less serious. Fathers tend to be instrumental and linear thinkers and problem solvers, defining goals and keeping track of progress but often overlooking emotional and interpersonal factors that make behavior management more complicated; they tend to overlook their own emotional reactions and conflicts with their child. In addition, fathers often misuse punishment, sometimes favoring it to the exclusion of praise and rewards for desirable behavior or using it for retaliation.
Particularly valuable in this discussion is the common reaction of disbelief fathers express when their child receives a diagnosis of ADHD. Dr. Jacobs attributes this skepticism to several factors, such as fathers' greater acceptance of a high activity level and imperfect social behavior—the "boys will be boys" perspective—and to fathers' seeing themselves in their children and needing to view themselves as "normal." Another factor is the variability of their children's behavior, making it often seem less severe or due to willfulness or laziness. Fathers also may want to avoid the narcissistic injury or shame that might be experienced from seeing their child as damaged, and they may find it difficult to accept someone else's authority, especially when it involves control over their own child.
The author gives many practical recommendations for what fathers can teach their ADHD children, including helping them develop better sequencing skills through charting and reviewing events, structuring homework, developing a social skills report card identifying social behaviors to be worked on, and many others. One recommendation concerns how to keep the father-child relationship in the child's mind when the father is not present, through the use of index cards, pictures, or calendars that illustrate what the father is doing and when he will be returning home.
This book is especially valuable for helping fathers better understand attention-deficit hyperactivity disorder, for eliciting their interest in becoming partners in the treatment process, and for encouraging them to become more active in implementing behavioral management strategies and working with their children at home. Too many times I have found myself seeing ADHD children with their mothers, but without their fathers. I am hopeful that recommending this book to fathers at the time that a diagnosis of ADHD is made will lead them to greater participation in the process of working with their challenging children.
Dr. Sexton is a clinical child psychologist in private practice and staff psychologist in the early intervention program in the department of pediatrics at the University of Massachusetts Medical School in Worcester.
