ADHD

ADHD Introduction

Attention-deficit/hyperactivity disorder (ADHD) is a common neurobiologic disorder characterized by developmentally inappropriate levels of (1) inattention, (2) hyperactivity, and (3) impulsivity. Some children may not have the hyperactivity or impulsivity and may primarily exhibit inattention. ADHD is a behavioral disorder, making it difficult to quantify, but it is one of the most prevalent chronic health conditions affecting school-age children.

Since ADHD is such a common diagnosis, we sat down with Dr. Fesmire to answer some frequently asked questions about ADHD and what to do if a child is diagnosed. 

Q&A with Dr. Fesmire

What is your role at Pediatrics East and how long have you been in it?

Currently I am the “senior” partner at Pediatrics East in my 35^th year with the group.

What is the difference between ADHD and ADD?

In 1987 the Diagnostic and Statistics Manual (DSM) combined inattention, impulsivity and hyperactivity into a single type defined as Attention Deficit Hyperactivity Disorder (there currently is no longer the term ADD in medicine, only ADHD).  When a parent says, “but Dr Fesmire, my child is not hyperactive” our response is “maybe not outwardly, but your child’s brain is hyper!)

What causes ADHD?

Both the cause and risk factors for ADHD are unknown but current research shows genetics plays an important role.  ADHD prevalence is roughly 10% of the population with boys:girls  2:1.

How is ADHD diagnosed? 

Currently the utilization of Vanderbilt Parent and Teacher Assessment Scales is the primary tool used to diagnose ADHD. These scales look for the occurrence of 6 or more out of 9 symptoms in two different categories:  inattention and hyperactivity/impulsivity.  To ultimately make the diagnosis of ADHD, symptoms must be present before age 12, must be present in 2 or more settings (such as home, school, during sports or dance) and interfere with the quality of social, school or work.  More simply said, the symptoms must not only be present but they are causing either academic or social problems for the child.  Some families still choose to have full “psychoeducational testing” with a psychologist to not only diagnose ADHD, but to additionally rule out other learning issues such as dyslexia, oppositional defiant disorder (ODD), autism spectrum disorder, etc

Many children have attention issues, so how does a pediatrician tell the difference between a child being a child and one with ADHD?

The best way to answer this question is to acknowledge that many well- functioning adults from my generation have ADHD but have managed to adapt and move forward.  The choice to treat or not is dependent on if the child has problems in the area of school and/or social performance.  When that child’s performance falls significantly below his/her ability or when that child is a constant discipline problem or losing friends due to an inability to control impulses and actions, then it is time to consider treatment.

What are signs of ADHD that parents should look for in their child?

Fails to pay attention to details or makes careless mistakes, difficulty keeping attention, does not listen when spoken to directly, does not follow through or fails to finish tasks, difficulty organizing tasks or activities, avoids dislikes or does not want to start tasks requiring ongoing mental effort, loses things necessary for tasks (books, pencils, homework), easily distracted by noise or other stimuli, and forgetful in daily activities (these are the signs of “inattention”).  Fidgets with hands and feet or squirms in seat, leaves seat when remaining seated is expected, runs about or climbs too much, difficulty playing or beginning quiet activities, acts as if “on the go” or driven by a motor, talks too much, blurts out answers before question has been asked, difficulty waiting one’s turn, interrupts or intrudes on others’ conversation and/or activities (these are signs of hyperactivity/impulsivity).

My child was given an ADHD diagnosis, what now?

Usually the first step is to schedule an “initial ADHD” visit with your child’s pediatrician.  Most of us will take 30-60 minutes to review the diagnosis, discuss treatment options, explain the importance of titrating medication upwards while watching for any side effects.  Set follow-up down the road to review how well the child is responding to treatment.

What does treatment look like for ADHD?

A study published in the 1990s looked at treating ADHD with behavioral modifications alone versus treating with medication alone versus treating with a combination of behavioral modifications and medication.  The study demonstrated that the single greatest improvement in attention, test scores and behavior was due to medication.  Not that behavioral therapy has no place and at times can be very helpful, the medication was the “single” greatest impact on improving the child’s life.  Currently there are over 30 different medications available for the treatment of ADHD. Parents should sit down and discuss the available options along with cost, side effects and tolerance with their pediatrician.

What are the best techniques for disciplining a child with ADHD?

Provide positive attention (ADHD kids always work best when offered one on one attention), give effective instructions, praise your child’s efforts (try to avoid living in a negative environment), use time-out when necessary (especially when basic rules are broken), ignore mild behaviors (pick your battles or you will feel like you are correcting your child constantly), allow for natural consequences (if your child refuses to stop playing to eat lunch, put the food away and when he is later hungry remind him dinner is only a short time away), establish a reward system (set goals for your child that are attainable), work with your child’s teacher (school rules and home rules to try and coincide as much as possible—it gets confusing to a child to live under different rules in different places).

Do you have any suggestions for getting children diagnosed with ADHD to focus, both in school and at home?

First off, sit down with your pediatrician and discuss the role of medication as that can be the difference maker for most children.  It literally becomes like “eyeglasses for concentration.”  Routine and structure are vital to the functioning of a child with ADHD.  This will help them to develop time-management skills. Bedtime should remain the same over summer, weekends and holidays to ensure as much rest as possible and maintain stable routines. Accountability is crucial.  Check behind your child and make him keep a notebook that has all assignments and mark those completed.  Provide a “two-minute” warning when transitioning to new activities.  Limit screen time and assure no screen time later than one hour prior to bedtime.  Allow 5-10 minute breaks during homework (but no screen time or playing outside during this time).  Chores help a child develop responsibility and work on task completion.  Help your child recognize his strengths to develop a sense of pride and accomplishment.  Involve your child in activities that will help build on these strengths.  Set up an IEP or 504 plan with your school so that your child has appropriate accommodations, program modifications and services offered that will maximize your student’s ability to learn.

Is there anything else about ADHD that you want to tell us? 

I think the most important thing everyone should understand is that treating ADHD in your child is not a “sign up” but rather a process that sometimes is lifelong. There is no single “one best medication” or “one single way” to deal with children having ADHD.  What works best for your child is “what works.”  And follow-up and ongoing communication between the school, parents and your pediatrician is the best way to optimize your outcome.

If you think your child shows signs of ADHD, talk to your pediarician about getting an evalutation done. 

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What is ADHD & How is it Diagnosed?

ADHD is defined as a mental health disorder in the Diagnostic and Statistical Manual 4th Edition (DSM IV) (Table 1). The diagnosis requires a comprehensive clinical evaluation based on identifying children who have the core symptoms of inattention, hyperactivity, and impulsivity. No single ADHD test is available to establish the diagnosis, but rather a physical examination and battery of standardized psychological tests are preformed to rule out other causes, either physical or psychological, for the child’s difficulties.

Studies show that as many as 67% of children who have ADHD may have a coexisting condition such as a psychiatric problem, learning disorder, or social immaturity. The most common comorbid psychiatric conditions that have been described include oppositional defiant disorder (35%), conduct disorder (30%), anxiety disorder (25%), and mood disorder (18%). It is important that any coexisting conditions be identified and treated.

The diagnosis is reported 2.5 times more frequently in boys than girls, with 9.2% of males and 2.9% of females found to have behaviors that are consistent with ADHD. According to a 2003 national survey of children’s health, 56% of children with ADHD were treated with medication and problems in school were the primary difficulty.

Table 1: Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder

A. Either 1 or 2 Six or more of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Inattention Often fails to give close attention to details or makes careless mistakes in schoolwork, or other activities  Often has difficulty sustaining attention in tasks or play activities  Often does not seem to listen when spoken to directly  Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)  Often has difficulty organizing tasks and activities  Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)  Often loses things necessary for tasks or activities (toys, school assignments, pencils, books, tools)  Often is easily distracted by extraneous stimuli  Often is forgetful in daily activities   Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity Often fidgets with hands or feet or squirms in seat Often leaves seat in classroom or in other situations in which remaining seated is expected Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)   Often has difficulty quietly playing or engaging in leisure activities quietly  Often is "on the go" or acts as if "driven by a motor"  Often talks excessively  Impulsivity  Often blurts out answers before questions have been completed Often has difficulty awaiting turn Often interrupts or intrudes on others (eg, butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before 7 years of age.

C. Some impairment from the symptoms is present in 2 or more settings (at school or at home)

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (mood disorder, anxiety disorder, dissociative disorder, or personality disorder).

What does ADHD treatment look like?

In 2001, after extensive review of the scientific literature, the American Academy of Pediatrics (AAP) published an evidence-based clinical practice guideline for the treatment of school age children who have ADHD. Pharmacologic intervention for ADHD was found to be more effective than behavioral treatment alone unless the child had coexisting conditions, such as anxiety or oppositional defiant disorder, where combination (medication and counseling) therapy was found to be more effective.

What medications are used for ADHD treatment?

Stimulant medications are the first line agents for the treatment of ADHD and are effective in reducing symptoms in 80% of children. Two categories of stimulant medication are available: (1) methylphenidate and (2) amphetamine compounds.

Most pediatricians have found that, for some children, a few medication trials may be needed to find the most effective medication. The primary mode of action of the medications is to enhance central nervous system catecholamine action increasing the availability of dopamine and norepinephrine in the frontal cortex of the brain that regulates attention, arousal, and impulse control.

Children who have ADHD and are treated with stimulants show improvement in attention to task and decrease in impulsivity and hyperactivity. These medications may also improve parent/child and teacher/ child interactions, reduce aggressive behavior, and improve the child’s academic productivity and accuracy. 

What does ongoing ADHD treatment look like?

Children who have a diagnosis of ADHD require longterm follow up because evidence is increasing that ADHD does not resolve as a child gets older. With aging, their hyperactive and impulsive symptoms improve. However, most children continue to meet criteria for ADHD as adolescents and adults.

Children whose ADHD is untreated are at increased risk for developing substance abuse problems, high risk behaviors, poor self esteem, and school/work failure. As a parent, if you feel that your child is having difficulties with any of the three core areas of ADHD, inattention, hyperactivity, and impulsivity, and it is adversely affecting their life in several areas such as school, home, social activities, you should discuss this with your pediatrician and make plans for a comprehensive ADHD test and physical exam with their doctor and psychological evaluation by a qualified psychologist or social worker experienced with ADHD.

As pediatricians, we have seen the success stories of properly diagnosed and treated ADHD and will help you work out a plan that is best for your child. 

Contact Your Pediatrician

 

This page was authored by Dr. Edward C. Davis.