Attention Deficit Hyperactivity Disorder (ADHD)
All parents worry:
Will my child be all right?
How can I do what is best for my child?
Parents feel guilty if they have their child on medication and guilty if they do not.
Most parents hunger for information, answers, and most of all,
understanding of their children andhow they can help them.
Patricia Kennedy, Leif Terdal, Lydia Fustetti. The Hyperactive Child Book
Recent information using MRI imaging to compare how the brain functions for students with ADHD and those without ADHD suggests there is a difference.
Characteristics of ADHD:
Three main characteristics must persist over time and in many situations for the diagnosis of ADHD.
- inability to pay attention and
- Most researchers agree 3 to 5 percent of the general population are ADHD.
- ADD and ADHD are not the same disorder, although they respond to the same medications and behavioral management programs.
- The inability to pay attention is also found in Attention Deficit Disorder (ADD)
- Primary ADHD is biophysical (the child is born that way).
- child does things without thinking first:
- running out in the street
- hitting another child
- taking apart a toy
- blurting out an answer in class without being called on
- difficulty waiting their turn and following rules
Inability to pay attention
- are unable to pay attention at home and at school
- the child can be told something "a million times," and still does not seem to understand
Hyperactivity very busy, but s/he do not accomplish much
To confirm ADHD at least two sources (parents, teachers, or doctors) should report:
- That the child has poor attention span, poor impulse control, poor compliance with instructions, poor self-control, and poor rule-governed behavior (the child knows what will happen if he breaks the rules but cannot control himself and breaks them anyway.)
- The behavior problems have placed the child in the top 3 percent for symptoms of ADHD as compared with other children of the same age and sex.
- The child has exhibited symptoms for at least six months to a year.
- The behavioral symptoms began in early childhood and before five years of age.
- The symptoms are ongoing and occur in multiple settings.
- The child has an IQ of 70 or higher; if mentally retarded, the child must be compared with other children of similar mental age for behavioral assessment.
The diagnosis of Primary ADHD excludes the causes of mental retardation, deafness, blindness, gross brain damage, severe language delay, childhood psychosis, autism cerebral palsy, and severe emotional disturbances.
They could have some of the problems on this list:
- Purposeless selection of cues--listens to the air conditioner instead of the math lesson
- Weak resistance to distraction--easily distracted by all types of cues
- Impersistence--is unable to stick with a task (gives up very easily)
- Inefficiencies of motor activity--or unproductive overactivity: on the go, but going nowhere
- Insatiability--wants all the toys in the toy box, but when he has them, demands more
- Impulsivity--acts without thinking
- Academic failure--poor school work
- Social failure--poor peer relations, difficulty making or keeping friends
- Performance inconsistency--has good days and bad days. Some days he understands his math with no problem; the next day, the same material is like a foreign language
- Attention difficulties--has trouble staying on task
- Diminished self-esteem--feels badly about himself
- Disorganized--difficulty in organizing how to do tasks
In general, parents should take the child for evaluation if they feel the child has problems with impulsivity, inattention, and hyperactivity AND if someone else, like the teacher or the physician, also feels the child is having trouble with the same three things in comparison to other children of the same age, sex, and mental ability.
Professionals now think that only 30 to 40 percent of children with ADHD outgrow it as adults, and they are usually mild cases.
ADHD is thought to be associated with a disturbance in functioning of neurotransmitters in the brain. Neurotransmitters like dopamine, norepinephrine, and serotonin are now thought to occur at different levels among individuals who have hyperactivity than among those who have normal abilities to sustained attention and arousal.
- Toxins affecting the fetus during pregnancy: alcohol, heroin, methadone, and cocaine.
- Toxins affecting the child after birth: lead poisoning
- Genetic factors:
- Increased incidence of problems associated with ADHD occurring in siblings of ADHD children.
- Sex differences...boys around the world show rates of ADHD incidence about three times as high as girls.
Head injuries are not associated with ADHD.
Allergies from food additives such as salicylateds, dyes, and preservatives do not cause hyperactive behavior allergic or toxic reactions in children. Well-controlled studies using a double-blind research method do not support the view that diet (Feingold Diet) improves the behavior of hyperactive children. However, some infants and young children clearly show adverse reactions to some foods and the numbers of foods that can cause problematic reactions are much more extensive than suggested by Dr. Feingold. See a study by Dr. S. Allan Bock in The Journal of Pediactrics (1987). If a child has a behavioral reaction, related to an allergic reaction, there will also be a secondary reaction, such as a stomachache, diarrhea, vomiting, skin reaction, nasal congestions, or wheezing. The child's behavior change is most likely a direct response to discomfort from the symptoms of the food reaction.
Research shows overwhelmingly that sugar does not cause hyperactivity. Parents and others may observe overactive behavior during sugarfest like birthday parties and Halloween, but the behavior can be attributed to the emotional excitement of the event rather than the sugar consumed.
Important Aspects of Medical History to Consider
- Medications: such as theophylline (which can cause jittery behavior or inability to concentrate) for asthma, or phenobarbital (which can cause overactivity) for epilepsy.
- Drugs the mother took during pregnancy.
- Does the child have metabolic problems, such as phenylketonuria (PKU), or has there been lead poisoning or an ongoing illness? Has he had congenital heart disease leading to hypoxia (low oxygen levels in the blood), or has his heart ever stopped and been revived?
- Or any of the following conditions: under-or overactive thyroid, recurrent diabetic problems, diabetic coma, hypoglycemia (low blood sugar), ongoing anemia, and food allergies.
Also might want to know:
- His or her developmental history. When did s/he sit up, walk, say first words?
- Family history: blood relatives of the child who have allergies, autoimmune diseases, seizure disorders, learning problems, or instances of retardation. Are other people in the family hyperactive?
- Social history: Changes in the child's life. Is there a fun parent and a wicked witch of the west parent? Do the parents have realistic expectations?
- Medical history:
- General temperament and emotional health such as anxiety, phobia, oppositional behavior, anger, sadness, depression, abuse, bizarre behavior, autism, and psychotic disorder.
- Physical health such as speech and hearing problems, visual difficulty, neurological disorders like muscular dystrophy, evidence of any minor seizures, heart disease, hypoglycemia, and food allergies.
- Has there been a recent neurological exam? This is important because sometimes a child is misdiagnosed as having being hyperactive when s/he has other neurological problems or delays. A neurological exam will test: coordination, memory, ability to put things in sequence, and fine-motor skills.
- School functioning:
- Can s/he follow directions? Wait his or her turn? Finish work? Listen? Stay on-task?
- Is there any learning disabilities? Perception (visual or auditory or both), listening comprehension, basic reading skills, reading comprehension, memory (both short-term and long-term), sequencing, oral expression, written expression, spelling, math calculation, math reasoning, and fine-motor skills (in handwriting or other skills).
- What are the child's fine-motor skills, eye-hand coordination, and tracking skills. Skill, or lack of skill, when coloring, drawing, cutting paper, and throwing a ball and catching it can indicate possible learning difficulties. A talented teacher takes time to observe and check each child's skill level without students knowing.
Rating Scales to collect information:
- Achenbach Child Behavior Rating Scales
- Barkley's Home and School Social Questionnaires
- Conners Rating Scales (Teacher's Questionnaire and Parent's Questionnaire)
- Vineland Adaptive Scales
Seven Kinds of Attention
- State of Arousal: alertness and excitability
- Impulsivity/Reflectivity: The length of time a person thinks before acting. Fast reaction time is somtimes appropriate (Sports, Nintendo)
- Cognitive Tempo: rate that it takes to complete a task
- Filtering Distractions: ability to ignore background activity and focus on a task
- Purposeful Focus: ability to identify what is important to attend to.
- Persistence: the length of time a person can pay attention to a task
- Self-monitoring: the abilitiy of a person to control their attention
Over 75% of children with ADHD can be helped with medication.
Stimulants like Adderall, Concerta, Strattera, Ritalin, Dexedrine, and Cylert stimulate neurotransmitters in the brain, like dopamine, to help the brain work better. The word stimulant applied to these medications does not mean they increase the user physical active. Instead they stimulate the brain to:
- improve the attention span
- reduce impulsive behavior
- reduce disruptive behavior
- increase compliant behavior
Dosage should be set according to body weight. Some physicians use set dosages of 5 mg, 10 mg, 15 mg, and 20 mg of medication instead of calculating for body weight. Dosages should be individualized, based on an individual's response to the medication. Also there are sustained-release forms that maintain a constant release for eight to twelve hours.
Market shares in 2006: Adderall 36%, Concerta 28%, Strattera 23%, Ritalin 8%, and all others 5%.
Stimulant medications are usually not effective before age five. Preschool children usually respond better to behavioral management strategies than to medication, but there are exceptions. If stimulants were tried and they were not effective, the parents may not be willing to try them again when the child is older and the central nervous system matures so medication may be helpful. If medication works, it is likely it will be need for many years.
It is important that parents understand that for most children with ADHD that when the school day is over the effects of a stimulant medication are over as well. Thus, not relieving parents of the problems associated with ADHD.
Side Effects: To determine if a child is having a negative reaction from the medication baseline data should be collected for a week or so before the start of treatment. Rating scales like the Conners may be used. Possible side effects of stimulant medications are:
- Difficulty sleeping, especially if medication is given later in the day.
- Stares or daydreams
- Lack of interest in activities
- Decreased appetite
- Increased irritability
- Body complaints (headaches, stomach aches, dizziness)
- Increased crying or signs of anxiety
- Increased blood pressure and heart rate
- One child in a hundred develops tics (involuntary motor and vocal spasms)
- Stimulant medications are not addictive.
A hyperactive child needs a structured environment. See
Dr. Robert Sweetland's Notes ©