Keeping a sharp and healthy mind isn’t just a concern for the senior population. Mental health disorders encompass a wide variety of issues that affect people of all ages. As we continue our series on mental health, this month we spoke with a psychotherapist about attention deficit disorder and attention deficit hyperactivity disorder – ADD and ADHD. These disorders are commonly known to be a problem for school-age children, and yet you’ll learn it’s not something to simply grow out of.
Tancy Horn-Johnson grew up in Waco and graduated from Connally High School. As soon as she finished her master’s degree at the University of Pittsburgh, she headed back home. That was in 1996, and she was the residential treatment center director at the Methodist Children’s Home, a “wonderful first-time job out of graduate school because I got to do a little bit of everything,” she said, “develop programming, do therapy, hire, train, staff. It was a wonderful introduction at that level.” She worked there for eight years and then moved to Waco Center for Youth. There, she was a treatment team coordinator where she handled things like psychotherapy, family therapy, assessments, diagnosis and treatment planning. She also taught part-time at Baylor University for four of those years.
Since 2012, Horn-Johnson has been teaching for Tarleton State University through the University Center at McLennan Community College. She earned a doctorate in social work from Capella University. She’s served as president of the National Alliance on Mental Illness’ Waco chapter and is adviser for MCC’s NAMI chapter.
WACOAN: When I was a kid, I don’t remember anybody being diagnosed with, or I never heard the terms ADD, ADHD. Is it a recent diagnosis or phenomenon, or was it just called something else then?
Horn-Johnson: The DSM, the ‘Diagnostic and Statistical Manual [of Mental Disorders],’ has been around since the ’50s. But there’s been several versions of it, and the most recent version was in 2013. In 2013, they really began to break ADHD down into more categories and more specificity.
And so I think historically we’ve thought about children, particularly school-aged children, when they get into a setting where they need to sit for a longer period of time than they’ve ever done before – and there could be also some other behavior [like] acting out. That’s oftentimes when it first comes to the surface that, you know, I’m wondering if this child is either inattentive, maybe they’re not up running around, which is the hyperactivity part, but inattentive. And so that’s when children will really rise to the teacher’s [attention] and then the parents get involved, and an assessment begins for that.
And we really recognize that ADHD and ADD doesn’t really ever resolve but kind of follows people on into adulthood. So the latest version of the DSM-5, then, has provided more of a development, life development stages of ADHD and ADD, which is very helpful to people.
WACOAN: I just read this morning about a film that’s going to be shown at the Deep in the Heart Film Festival next month about a former Baylor football player who’s bounced around the pros from team to team and has had trouble sticking with a team because his ADHD gives him trouble in learning the playbook. So it’s not something that you just outgrow.
Horn-Johnson: No. We can learn techniques to deal with it, psychosocial interventions and some medication. You can learn to manage it, but it doesn’t necessarily come naturally.
The difficulty in those settings kind of bring it to light, and then people, parents, teachers will seek help with it, or employers, for someone who’s not functioning well.
WACOAN: Are ADHD and ADD genetic? Is a child just born with it?
Horn-Johnson: It can be any number of things. There can be a genetic predisposition to it. There could be toxins. There could be toxicity, lead or a number of different things in the environment. And also some social issues as well: poverty, discrimination, lack of health care, sexual abuse, physical abuse.
It can have any number of etiologies or a mixture of many of those things.
WACOAN: So, it’s not necessarily genetic. Some external factors could come into play.
Horn-Johnson: They certainly can.
WACOAN: Is there a known cure for ADD and ADHD, or do you just learn to manage it?
Horn-Johnson: I think you learn to manage it. And I think that certainly, more recently, there have been a number of medications that have come out. Now there’s some nonstimulant medication that’s also handy. There’s some patches that you can get. So the medication is coming in a variety of ways that are much more tolerable for youngsters, for teens and for adults.
WACOAN: If a student is on medication, do you think it’s best if the person continues to take the medication on weekends or school holidays, or should parents not give it then?
Horn-Johnson: I would say that parents are really grateful for some time off to get a drug holiday. I’m sure probably the children are as well, or the teens. So many families do subscribe to that, will do a drug holiday and just get a little break from the medication. That’s certainly an option in conjunction with the doctor who’s monitoring the medication.
WACOAN: Besides a child not being able to sit still at a desk or fidgeting – and that’s my son. He’s a drummer, and so if he’s sitting still, he wants to be drumming. It doesn’t matter if he has sticks or pens or pencils or just his hands. Are there other signs that a child has ADD or ADHD?
Horn-Johnson: Well, and the difference between the inattentive type, or the ADD, is you don’t see the hyperactivity.
So I think probably being easily distracted, not getting schoolwork done, moving from one thing to the next, changing the topic – depending on the age, of course, conversations are different – being easily distracted, not finishing things, being pulled away from something just to hear it, to see it, being drawn to it, looking at it, those kind of things.
WACOAN: Yeah, that’s my son. Are the ways to manage it the same in children as they are in adults? Is it a matter of willpower?
Horn-Johnson: A therapist and then parents can reinforce this, can really have the person, say, ‘OK. Let’s stop and think right now.’ And have that therapist or the parent draw the attention to the child about why they’re so frustrated. ‘Well what happened before that? If things were OK there, then what happened before that?’ It’s kind of really breaking it down in a time series so that cognitively that child or that adult or that young adult will really recognize what they can stop.
WACOAN: I’ve seen, especially for children, instead of sitting in a chair, they sit on the exercise balls. They can bounce and work. Or the big rubber bands stretched across the bottom of the chair where they can kind of kick it. Do things like those work, or are they just kind of the latest fads?
Horn-Johnson: I think we’re just now beginning to really hear about some of those, but I’m of the mindset of let’s try it. We don’t know until we try it. And having done all my clinical training at Western Psychiatric Institute and Clinic where there was always good research going on, we don’t know until we get the research on it. So how can we say, ‘Oh, the balls in the classroom, that’s just distracting.’ Well, let’s give it a try. What do we have to lose? I really believe that on so many counts.
WACOAN: Are ADD and ADHD found more often in males or females?
Horn-Johnson: Definitely in males. Probably 2-to-1 in males, so it’s pretty significant. And also in adults, it’s more predominant in males than it is females.
WACOAN: Are ADD, ADHD sometimes misdiagnosed in children? Could it be called something else and we eventually find out that’s what it is?
Horn-Johnson: Yes. And I think moreover maybe a little bit of depression or mood issues could be diagnosed maybe as attention problems and not the ADD or the ADHD, so that’s the reason that the assessment and the diagnosis and the clinical interview is very important if it’s with a child and the parents and the teachers together.
There’s instruments that you can get to kind of collect that data and look at that data and see what area the child is distracted. Is it in all areas? Is it just in one area? Which is also very important to know before you can really diagnose it.
But yes, I think that we have to be very clear and rule out other things before we firmly say, ‘This is ADD’ or ‘This is ADHD’ because depression can look like that and anxiety can look like that.
WACOAN: Do ADD and ADHD often go hand-in-hand with other things, such as autism or anything like that?
Horn-Johnson: Well in this DSM-5, they did move ADHD into the neurodevelopmental disorder category, which is the same category that autism is in. They also allowed in the 5, beginning in ’13, that someone can get the diagnosis of autism and ADHD and ADD. They had never done that before. They were mutually exclusive. So again, and I can’t speak to the medical piece, the brain, you know the firing of things – they made some allowances for that and do see enough differences to be able to diagnose autism and the attention problems, which is new.
WACOAN: Are there any strengths or benefits to having ADHD or ADD?
Horn-Johnson: Oftentimes, people with ADD or ADHD get a lot of things done. Especially once they learn to manage it, they can really juggle a lot of things at the same time. And yes, I think you can learn to manage it, and I think you can use it to your advantage.
WACOAN: Do the symptoms, the outward signs, vary from person to person?
Horn-Johnson: Yes. Yes, yes. But there’s going to be inattentiveness. There’s going to be three different things, and these are kind of the earmarks of the differences and that’s really on some of the scales that you want to see in order to be able to diagnose it.
But there’s some conduct problems that can occur, like in a classroom setting. The hyperactivity for the ADHD, and then the inattentiveness, which is kind of more passive. The hyperactivity is [apparent], you can see that. But the passive piece on the inattentiveness, you know, would be that distinguishing mark.
And I think the conduct problems are oftentimes the pieces that the children and the adolescents are like, ‘I don’t want to keep getting in trouble.’ But they’re not quite sure what it is yet. The adults are clamoring [for answers], and so when those two things meet, that’s when the teaching can come in about the more self-awareness of how to manage that better and differently.
WACOAN: What are some things teachers can do to help a child? For instance, my son’s teacher would just tap on his desk when he was fidgeting.
Horn-Johnson: Well, I think that’s a very good one, kind of just a little code. And maybe it’s not even a word set, but it’s just a gesture, a tap that’s set up and meaningful between the teacher and the student. And I think that’s what can make dealing with these types, with ADD and ADHD, successful in the classroom.
Now to the extent that other modifications need to be made for a child, such as an ARD meeting, an Admission Review and Dismissal [committee to form] an individual education plan. I’ve also done many of those, been there for the child and the family during those meetings. But it could be some other interventions need to be in that IEP, such as moving a child to where they can’t see the rest of the classroom, and they’ve got something that they can kind of focus on.
I think that there are some tools and some agreements with the teachers and the diagnostician and whatnot to put those things in place for a child and an adolescent.
WACOAN: When students say, ‘Yeah, I can’t pay attention in class, I get distracted. I have ADD.’ That’s not the same as ADHD, obviously.
WACOAN: But if a student just can’t pay attention in class, is it necessarily ADD, or could it be something else?
Horn-Johnson: It could be something else, and I think that’s where we kind of go back to a very good assessment from the teachers maybe in a Sunday school class. Maybe if it’s an adolescent, and they’re doing some volunteer work, maybe something in that area. Because what we would want to do is to have that inattentiveness or that hyperactivity generalizable to more than one area. Otherwise, how do we know that it’s not one thing in this area that’s very distracting when it doesn’t occur in other areas? So the generalizability is what you really want to understand and factually have evidence to back that up.
WACOAN: So if a student says, ‘I can’t pay attention in class,’ then through meeting with teachers and counselors, it would have to be shown that the student doesn’t pay attention in other settings as well, not just in class?
Horn-Johnson: Yes. And most likely, if a child is playing at home and has friends over or whatnot, you’re probably going to see some of that. Now if they love to do one certain thing, it doesn’t matter how much inattentiveness they have, if they love Legos, they can sit for hours at a time with Legos. So there’s kind of some splinter interests that you have to be able to really discuss and talk with the parent or talk with school to find out what those areas are.
WACOAN: OK, back to the student who can’t pay attention in class. I’ve read that our attention spans are getting shorter just because there’s so much stimuli. Do you think that’s contributing to inattentiveness or ADD?
Horn-Johnson: Well I think if someone is already predisposed to it, that would certainly provide more of a setting for that to reveal itself.
We’re definitely a social media culture, and I really am always so in awe of families who put limits around the social media, whether it be the handheld or the games or whatever. So I do think that there needs to be parental guidance with that and carried out in the home with that in mind. I do think it influences our teens.
WACOAN: That’s so easier said than done.
Horn-Johnson: Yes, it is.
WACOAN: How have you seen ADD, ADHD affect relationships? Friendships, romance, parent-child relationships.
Horn-Johnson: Yes, often starting in elementary school or when a child is in a classroom setting, if they are getting negative attention from other people, from the teacher and from others, if they’re disturbing people – Not intentionally. They’re not aware that they’re doing it – that can cause social issues.
I think that for a parent, I mean it’s taxing. First of all, even getting to the point where a parent may be thinking, ‘You know I think my child has some ADD. Or there has to be something that is causing this.’ And so, just that whole dilemma of where do I go and dealing with, is there something wrong. And, you know, with two-parent families working, oftentimes it does become stressful to manage that.
So I think, seeking some advice, maybe a therapist, a pastor who can really assist in the psychoeducation of it and the social, the psychosocial side of that to better understand it and put some things into place so that everyone, so that the family understands it better and the child feels better.
And then for teens, I think the same thing. I think that oftentimes teens with the ADHD, depending on the family setting, if there are other environmental factors – poverty, discrimination, living environment -those teens can certainly be more predisposed to other more severe things developing. And so I think the earlier intervention is always going to be the best.
I think in relationships, you know, hopefully, like the [football player] who’s going around in different places with the team, I’m sure that would have to be difficult as well. So I think being very transparent and being very honest, getting understanding about it, and learning how to deal with that. Perhaps some medication as well is always a typically good, not the medication first without some intervention and learning about it, but yes. There are things that would have to be worked through, recognized and talked about a worked through.
WACOAN: How does an individual or parent decide that medicine is the right route to go?
Horn-Johnson: Sometimes that can take a while. And I’ve worked with families who didn’t want to do it at all, and as the momentum built and, particularly the school setting became more negative, there was more pressure on the parent too, then it’s time for medication.
So it’s a good balance of getting a good therapist and a good doctor who are going to really walk that with the family and not feel pushed into the medication piece and get the learning, psychosocial piece as well, not one over the other. And balancing that until there’s more of a homeostasis for that child. But that can take a while. So it’s a balance. I don’t think we can force families to do things.
WACOAN: It would be easier not to give the child medicine, not to have to remember it and have the expense and all that. But then the parents don’t see the effect of not giving medicine, and the child suffers, and the class suffers. And the teacher has to deal with that.
WACOAN: I’ve read that you’re involved with NAMI. First, what is that?
Horn-Johnson: The National Alliance on Mental Illness is the largest grassroots organization that really fights the stigma of mental illness, and it does that through free trainings, webinars, focusing on certain populations. Our executive director goes out to the high schools and does a suicide awareness to the high schools, works with the school counselors and goes out to do that.
We’ve got a family-to-family, 12-week session that we offer to families who have a loved one with a mental illness. There’s much stigma around that. Families get tired. They need respite and those types of things. So NAMI provides free education services on so many counts. NAMI Basics, just learning where the resources are in Waco.
I recently did a three-hour discussion with [Heart of Texas Counseling Association] here in Waco talking about the services of NAMI and ways that the counselors can partner with NAMI in their family therapy process – so sending families, telling them about NAMI and where they can go for some of the workshops. There’s a Facebook site, Twitter site where things are posted. And we’re visible around town through those webinars and workshops.
WACOAN: You said free trainings. So it’s not free trainings just for professionals within the field but also for families?
Horn-Johnson: Correct, and they really look at a model of peers. So it’s parents delivering those services and talks and workshops for other parents who have teens or a loved one who suffers from mental illness. So there are professionals in it, but it’s also about hearing from someone who’s lived it and kind of that one-on-one. So it has that extra piece to it with that.
WACOAN: And NAMI has a fundraising gala coming up, is that correct?
Horn-Johnson: We do, on May 3. It will be at the Hilton from 6 to 10 p.m. We have Brian Cuban coming in, that’s Mark Cuban’s brother from the [Dallas ] Mavericks.
He is an attorney in Dallas and has suffered with eating disorders and also body dysmorphic disorder for many years, alcoholism. He’s written a book, and he will be doing a book signing with that. We’ll be hearing him speak about his story.
WACOAN: That’s got to take courage. I assume the gala is a fundraiser. And so those funds will be used for?
Horn-Johnson: More education within our Waco community. To put back into the community for services. I happen to be the adviser of the NAMI on campus there at MCC, so we have students who are fundraising and raising awareness of talking about mental illness on college campuses. Many issues on college campuses, stress levels and so on and so forth.
WACOAN: Is there anything else I need to know about ADD, ADHD that I haven’t asked?
Horn-Johnson: It can be managed. And it’s certainly not a sentence. You can learn to manage it and actually do very, very well.