66 Attention-Deficit/Hyperactivity Disorder

Name: Bart Simpson

Source: The Simpsons (Television series, 1989-present)

Background Information

Bart Simpson is an eight-year-old male with no history of a mental health diagnosis. Bart has been labeled an “underachiever” by authority figures and has poor grades in school ranging from D-minus to F. Bart can be ingenious regarding things that interest him such as learning portions of the Talmud to help reunite his idol, Krusty the Clown with Krusty’s father, Rabbi Krustofsky. However, this drive is absent for school-related performance. His academic achievements are behind those of his fourth-grade peers.
He has a history of consistent and sometimes significant trouble making. He also reports feelings of frustration with the narrow-minded people in his town for judging him by his problematic thoughts and actions. His relationship with his father is volatile and dysfunctional. One minute he is being strongly scolded by his father and the next him and his father bond over a collaborative prank. He once told Bart it was not okay to lose a children’s miniature golf tournament and made Bart stare angrily at this opponent for 15 minutes a day. There is evidence that his father forgets his youngest daughter even exists (Bart’s infant sister). Bart’s mother tends to “over-mother” her children and once left the family for a brief period due to a mental breakdown. Despite this, Bart has no significant problems in the relationship with his mother. Bart enjoys skateboarding, bubble gum, Squishees from the Kwik-E-Mart, and a single-handedly bringing a homicidal TV sidekick to justice – twice.

Family Mental Health History:
Marge Simpson is Bart’s mother. She is described as a happy homemaker and mother of three. Marge puts up with the antics of her husband (Homer, Bart’s father) and children in good spirits, for the most part. Though, in 1992 the combined stress of her workload and family’s problems caused her to have a mental breakdown. She went away to spend time at “Rancho Relaxo” before returning home to her overly-dependant family. Marge over-mothers her children and reports staying with Homer because he makes her feel needed. Marge speaks out about issues such as violence and moral hygiene. The townspeople respond with frustration for her disregard of social norms. However, she also has a history of gambling addiction. She worked to overcome this addiction but it always lingers as a possible problem.
Homer Simpson is Bart’s father. Homer’s father Abe raised Homer in the absence of his “radical hippie mother.” Homer has a reported low IQ of 55 accompanied by periods of forgetfulness and ignorance. A crayon was discovered to be lodged in his brain and when removed his IQ rose to 105. However, he did not like his new ability to understand reason so he had the crayon re-inserted. This returned his IQ to 55. Other contributors to his low functioning include his exposure to radioactive waste, his alcohol use, and repetitive cranial trauma. It is uncertain whether his low level of functioning can attributed to genetics or to his life events. Homer works in a nuclear power plant and has remained an entry-level employee longer than any other employee. Prior to that, he attempted other jobs on impulse. At work, he falls asleep constantly and does not perform his duties. Homer displays regular instances of explosive anger. He does not attempt to hide this in public. He is ruled by his impulses. These impulses combined with his intense rage leads him to strangle Bart on occasion. His impulses change frequently affecting his attention span. He pursues many hobbies and enterprises and then quickly changes his mind about them.
Abraham Jay “Abe” Simpson is Bart’s paternal grandpa. He is a grizzled old man who is incredibly long-winded and often ignored. The stories he tells seem wildly inaccurate and often consist of events that are physically, or historically impossible. For example, he reports serving in World War I, although he was a small child at that time. He reports many confrontations with famous figures and writes letters to organizations making unreasonable requests such as asking the president to get rid of three states because there are too many and requesting that Modern Bride Magazine feature more people with wrinkles and toothless grins. He reports homicide attempts of Adolf Hitler via javelin throw in the 1936 Olympics. It appears that Grandpa Simpson suffers from some mental health impairment(s). Without knowing his history, it is hard to tell whether this is a lifelong disease or one that attributed to old age. If he has suffered these delusions for a long period, suffice it to say some of Bart’s mental health problems could be genetically linked to his grandpa.
Bart’s eight-year-old sister Lisa is a high-achieving student who is already a member of MENSA with an IQ of 159. She is smart, witty, and goal oriented. Lisa does not appear to have any limiting mental health symptoms. Bart’s younger sister Maggie and two maternal aunts are also featured on the show but do not seem to have any notable mental health limitations.

Description of the Problem

Bart displays multiple symptoms that are indicators for several mental health disorders. He shows very consistent symptoms for ADHD. Several problems arise as a result of Bart being distracted by video games. Specifically, he misses important family announcements because he is so distracted by his video games. Similarly, upon getting a satellite dish, Bart and his father became so distracted by the television that he could not study for an important achievement test. During the test, Bart continued to be distracted by daydreaming about things he saw on television the night before. This resulted in him failing the test and being held back a grade. In another instance, Bart got an F on a test so the school psychiatrist recommended he repeat the fourth grade. Out of desperation to avoid being held back, he promises to study but is repeatedly distracted so did worse on the next test. For the third test, Bart tries to focus while he is studying, but is still easily distracted and is forced to slap himself continually to continue his studying. The next day, still slapping himself, he finishes the test to receive a D- allowing him to pass by one point. During another instance, Bart also spontaneously interrupts an important lecture. There are many more instances where Bart becomes distracted, leading him to fail at tasks.

Diagnosis

The most appropriate diagnosis for Bart seems to be Attention-Deficit/Hyperactivity Disorder (under code 314.0). He fits the Inattentive Type meeting the following symptoms: 1, 2, 3, 4, 6, 8. Bart displays many problems with attention and distractibility. His symptoms seem sufficient for satisfying this ADHD, Inattentive Type criteria. However, he also displays some dominant symptoms for ODD and CD. These symptoms undergo dramatic changes from episode to episode creating some difficulties in rendering a diagnosis.

Two types of ADHD: 1) Inattentive Type, and 2) Hyperactive-Impulsive Type.

• DSM-IV-TR criteria:
• Inattentive Type and Hyperactive-Impulsive Type:
  • 1. Inattentive Type:
  • Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:
    1) Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
    2) Often has trouble keeping attention on tasks or play activities.
    3) Often does not seem to listen when spoken to directly.
    4) Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
    5) Often has trouble organizing activities.
    6) Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
    7) Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
    8) Is often easily distracted.
    9)Often forgetful in daily activities.

• 2. Hyperactive-Impulsive Type:
  • Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:
    Hyperactivity:
    1) Often fidgets with hands or feet or squirms in seat.
    2) Often gets up from seat when remaining in seat is expected.
    3) Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
    4) Often has trouble playing or enjoying leisure activities quietly.
    Is often “on the go” or often acts as if “driven by a motor”.
    5) Often talks excessively.
    Impulsiveness:
    6) Often blurts out answers before questions have been finished.
    7) Often has trouble waiting one’s turn.
    8) Often interrupts or intrudes on others (e.g., butts into conversations or games).

Accuracy of Portrayal

A viewer of the Bart Simpson character can see many accurate symptoms of ADHD, but his character has many overlapping symptoms of Oppositional Defiant Disorder and even Conduct Disorder. His problems with attention are displayed in numerous experiences. However, he also displays multiple symptoms of deceitfulness, serious violations of rules, deliberately annoys people, and often argues with adults. These symptoms are found in individuals with ODD or CD. However, Bart does not demonstrate the temper, anger, or aggressiveness problems that can also be found in ODD or CD. The Bart Simpson character does display ADHD symptoms with fair accuracy, over many different episodes but also displays the ability to effectively organize delinquent behaviors in others, which would be less likely for someone with ADHD. So, there are some inconsistencies in his character but that is to be expected for a character with such different dramatic storylines, in weekly episodes for over 20 years.

Treatment

Treatment of Bart should begin with a structured or semi-structured clinical interview discussing developmental and family history, ADHD symptoms, and symptoms of co-morbid problems. Intelligence testing, achievement testing, and reports from parents and teachers will also provide valuable insight. In light of the 2011 study by Dr. Lidy Pelsser of the ADHD Research Centre in the Netherlands, it seems appropriate to begin Bart on restricted, non-allergenic diet to eliminate allergens related to ADHD symptoms. A strictly supervised restricted elimination diet is a valuable instrument to assess whether ADHD is induced by food. This diet should be followed and monitor his symptoms closely for five weeks.
If ADHD symptoms have not drastically improved or disappeared after five weeks, the diet should be ceased and medication will be the next course of action. Medication should be used to treat Bart’s core ADHD symptoms. Central nervous system (CNS) stimulants have a high success rate for ADHD. Bart would begin taking a low dose of Ritalin. It should be taken two times a day; morning before breakfast and at night before dinner. He should begin taking 6mg tablets and then can move up to 60mg a day. A combination of medication and behavior therapy will be used to treat co-occurring problems for the long term. This therapy will promote improvements in the parent-child interactions, aggressive responses, and social skills. Parent training can also provide parents with skills to effectively interact with a child with ADHD.

Name: Clark Griswold

Source: National Lampoon’s Christmas Vacation (movie, 1989)

Background Information

Clark Griswold is a forty-four year old male patriarch of a traditional middle-income family with a wife and two teenage children (one son and one daughter). Clark works as a food additive designer for a large firm. His achievement is inconsistent and fluctuates from high level (creating a new “varnish” to keep cereal crispy in milk) to minimal effort and being “invisible” to his boss. Although Clark proclaims himself as “a regular family man, trying to do what’s best for his wife and kids,” his actions contradict his behavior. On more than one occasion, Clark has introduced his children as “Rusty and what’s-her-name”. This verbal outburst demonstrates a subconscious disconnect between beliefs and actions. Clark’s wife, Ellen, does not display outwardly noticeable symptoms of mental health disorder. She demonstrates a loving relationship to her husband (a.k.a “Sparky”) and children, although she tends to enable the household behaviors and live in a state of denial about Clark’s eccentricities until his behavior is extreme. The children both display typical teenage angst and disinterest in family situations. Both minor children have past experience with illegal substances, but do not present addictive behaviors (see National Lampoon’s Vacation, 1983). Clark’s cousin Eddy displays a possible genetic link to maladaptive behaviors. For example, when Clark does not receive his anticipated Christmas bonus from work, Eddy kidnaps Clark’s boss. Clark displays poor coping skills and reacts abruptly and inappropriately in both public and private settings. Although he lives in constant pursuit of the ultimate family vacation, his overall achievement goals are shallow and limited to materialistic gain.

The close proximity of relatives that may or may not always get along under normal circumstances, increases tensions and exacerbates Clark’s ADHD symptoms. Family support and understanding for display of symptoms is minimal and inconsistent, although time spent together is abundant. Most of Clark’s outbursts or behaviors are dismissed as normal for him. As of 1989, Clark has received no official mental health diagnosis but has displayed multiple symptoms that his family normally dismisses as “part of his character.” Individuals from the outside view Clark as impulsive and prone to quick outbursts. It is possible that Clark displayed symptoms before age seven but went undiagnosed due to the lack of information regarding ADHD prior to 1970. Subsequent controversy and downplay of ADHD from critics may have interfered with proper diagnosis and treatment.

Description of the Problem

Clark presents with several significant symptoms pointing to Attention-Deficit/Hyperactivity Disorder. Clark is easily distracted and demonstrates an inability to stay on task with everyday items. However, he does overindulge on items he deems important. Clark becomes so involved in his quest for the perfect family vacation and Christmas lights for the house that he misses quality family time and activities with the group. Clark has a tendency to behave in an overly energetic manner and is unable to rest or at times maintain an even temperament. He is quick to anger at even mundane situations and consistently holds extreme grudges. Furthermore, he shows inappropriate affect and significant impairment in both personal and professional settings. For example, while Christmas shopping for his wife; Clark is unable to maintain composure with the female working the counter. He also displays inappropriate affect and coping behaviors with anger towards his boss by demonstrative and abrupt outbursts.

Diagnosis

Clark’s symptoms fit best with a diagnosis of Attention-Deficit/Hyperactivity Disorder (314.0) from the DSM-IV-TR, with the specific subtype of Inattentive Type best describing his symptoms. Clark meets the following symptoms for Inattentive Type: 1, 2, 3, 4, 5, 8, 9. Although he presents with symptoms for Hyperactive-Impulsive Type, he does not display the required six or more for a complete diagnosis. Clark’s hyperactive and impulsive behaviors may be caused by environmental factors. The following symptoms must be met to be diagnosed with Attention-Deficit/Hyperactivity Disorder:

1. Inattentive Type:
Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:

1) Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

Clark overlooks specific details in personal activities with an elevated risk such as driving or home improvement. During a family trip to choose a Christmas tree, Clark became distracted by his frustration with another driver and drove the car directly parallel under the bed of a semi-truck. He was unaware of his wife’s warnings to stop or that he was pulling under the truck until after the action was complete. His home improvement skills lack detail such as the time he stapled his shirt sleeve to the top floor guttering while precariously balanced on a ladder.

2) Often has trouble keeping attention on tasks or play activities.

While Christmas gift shopping for his wife, Clark was distracted by the counter attendant and unable to focus on the task at hand. He continuously rambled, stumbled on words, or changed sentence syntax by saying “hooter” instead of “hotter”. Clark displayed difficulty staying on task or keeping his attention on the purpose of his trip.

3) Often does not seem to listen when spoken to directly.

Clark’s daughter, Audrey continuously updated him of her “freezing” body parts during a trek to find the family Christmas tree. He remained unaware of the situation, even after his wife expressed concern that Audrey’s eyes were frozen. He dismissed the problem once he realized he was being addressed.

4) Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

Failed to latch the ladder placed against his house and slid down to the ground from the second floor. Clark also overlooked the directions for the “twinkling” holiday lights and was unable to change them from the constant on position.

5) Often has trouble organizing activities.

Clark forgets to bring the saw necessary to cut down the tree on the family Christmas tree trip and also manages to freeze most of his daughter’s body by leading them through massive snow and freezing temperatures without adequate preparation. His son, Rusty, spends most of the time during the Christmas light installation retrieving items from various locations or untangling the jumbled mess of string lights.
6) Often avoids, dislikes, or does not want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).

7) Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).

8) Is often easily distracted.

Clark asks his wife about his mother-in-law waxing her lip during a serious conversation about holiday tension. He becomes trapped in the attic and becomes distracted by the case of home movies he found while searching for warm clothing. He proceeds to watch the movies instead of trying to find a way out of the attic.

9 )Often forgetful in daily activities.

Clark is easily distracted and forgets basic activities or the involvement of others.

Some symptoms that cause impairment were present before age 7 years. There has to be an onset of symptoms prior to 7 years old, but a diagnosis can occur much later.

Unable to find medical history confirming childhood diagnosis but this could be due to the lack of information regarding ADHD prior to 1970.

Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

Clark’s behavioral problems are consistent at both home and work, with home being his largest source of symptomatic display.

There must be clear evidence of significant impairment in social, school, or work functioning.

Clark displays inappropriate affect and displays attentional deficits at work and home.

The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Clark’s does not demonstrate the symptoms associated with other disorders to warrant a full diagnosis of Mood Disorder, Anxiety Disorder, Dissociative Disorder, or Personality Disorder. He does present with OCD like symptoms and should be observed to assure an accurate diagnosis.

Accuracy of Portrayal

Clark’s ADHD oriented behavior traits are consistent over the course of each movie. His excessive talking, trouble organizing activities, trouble staying focused when spoken to directly, and forgetfulness of daily activities are just a few of the direct ADHD symptoms that Clark displays. However, He does not consistently display the passiveness normally associated with Inattentive ADHD. Clark is compliant and passive during some events, yet he is also prone to outbursts and demonstrates a quick temper. ADHD shows a high comorbidity with Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD), but Clark’s temper and outbursts are more likely caused by environmental and psychological factors, thereby presenting an inaccuracy in the portrayal. The average viewer watching Clark Griswold may consider his behaviors are more consistent with Obsessive-Compulsive Disorder (OCD). Clark displays an inability to curb impulses and recurrent thoughts and is prone to act according to his own volition, regardless of the outcome on others. Although these attributes illustrate OCD, they are just a few of the many symptoms of ADHD that Clark exhibits.

Treatment

The best course of treatment should begin with a structured or semi-structured clinical interview to obtain Clark’s family and medical history, and pervasive symptoms pertaining to ADHD and co-morbid disorders. Empirically supported treatment includes stimulant medication to relieve core symptoms. FDA-approved medications are useful for reducing physical symptoms. Specifically, ADHD responds best to stimulant medications such as Ritalin, Cylert, and Dexedrine. Due to the severity and inability to predict side effect occurrence from Cylert, the better pharmaceutical choice is either Methylphenidate (Ritalin) or Destroamphetamine Sulfate (Dexedrine) for Clark’s symptoms. Potential stimulant medication side effects include insomnia, decreased appetite, and potential dependence. Dosage is prescribed based on patient age, weight, and medical history. Clark should begin with the lowest possible dosage and gradually increase prescription strength only at the advice of a therapist or doctor. Behavior therapy is preferred as the primary treatment choice in conjunction with pharmacotherapy and can be useful for improving social skills, modifying behavioral deficits, and reducing aggression. Additionally, family support methods are vital to effective treatment plans.