DocSwiner's Superwoman Complex Blog

Back to school‐‐ADHD

Attention Deficit Hyperactivity Disorder (ADHD) is a condition I see and treat often

in my practice as a Family Physician, and it is a controversial and passionate topic

for a lot of my patients. I have those parents and children who do not agree with the

opinions and impressions of teachers and school leaders who suspect the condition,

seemingly too quickly and too frequently. And in terms of treatment, I have those

parents who question the safety and effectiveness of the medicines used to treat the

condition.

A fairly representative depiction of this discussion usually goes as follows:

Elementary school aged child is brought in my Mom or Dad, frustrated by their

behavior at school and constant comments or calls made to them by his or her

teacher. He or she was doing well in school until 2

nd or 3rd grade, when Teacher

began to notice what she described as “fidgetiness.” Now, a perfectly intelligent,

previously well‐behaved child is slipping in his or her grades and is earning

demerits for bad behavior. He or she has begun interrupting class by talking, passing

notes frequently, and keeps forgetting his or her homework assignments. Teacher

has suspicions for ADHD and suggests an evaluation.

Or this: Mom or Dad brings elementary school child into the office to ask about his

or her being “yperactive” He or she won’ listen to directions, talks back, and can’

sit still. He or she does well in school otherwise, and the parents have become

frustrated when usual discipline no longer works.

There are 3 general types, including inattentive, hyperactive‐impulsive, or

combined. It was originally thought that boys have it more than girls, but more

recent studies have not shown a clear predominance. There are nine following

criteria must be present in both the home and outside of the home, must be present

for at least 6months, and must be identified before the age of 7. They also need to

have clear disruption of school or social functioning and cannot be due to another

mental or emotional condition, such as anxiety, depression, or a personality

disorder of some sort. These criteria are too many to list, however, they include:

‐difficulty paying close attention to direction

‐difficulty maintaining a level of attention

‐being “n the go”and talking excessively

‐interrupting or intruding often.

From recent studies, ADHD is a chronic disorder that may be associated with levels

of dopamine, nor‐epinephrine, and serotonin chemicals in the brain. (Am Fam

Physician. 2009;79 (8): 657‐665) Due to the imbalance of these chemicals, patients

with ADHD may suffer from academic, behavioral, emotional and social issues. Also,

because these chemicals have been identified, the medicines used to treat ADHD are

directed toward these chemicals. Most medications are called “timulants” which

are the medicines that interestingly have a calming effect on the child. These

include, Ritalin (methylphenidate), Concerta, and Adderall, among others. If used

correctly at the smallest needed dose, these medicines are very effective but can all

come with possible side effects of appetite suppression, weight loss, insomnia and

headache. I often am asked about their effect on growth of kids, and I explain it has

been shown that these medicines have had association with the trajectory of

growth, but not the amount of growth. This means, if a child’ growth spurt is to be

1‐2feet within a year, it may take a little longer for him or her to reach that 1‐2 foot

growth spurt yet it does not mean he or she will only grow half as much.

Non‐stimulants include Strattera and then other medicines you may have heard of

in treatment of depression or anxiety, such as Wellbutrin (bupropion), Clonidine,

and Imipramine, among others. The other important part of treatment is the nonmedication

based methods, or behavioral methods. Evidence has shown great

benefit from behavioral approaches with reward and consequence methods,

support groups for parents and patients, and parenting skills training. These things

should be done under the guidance and support of clinical providers. Studies show

the combination of both medicine and behavioral therapy of some sort has much

more success than either method alone.

This is how I usually proceed with most of my patients:

1. A patient and parent(s) present with one of the 2 questions I noted at the

beginning of this discussion.

2. I ask if there is any family history (parents, brothers, sisters) of ADHD and

what treatments helped them.

3. Can they identify problems starting before the child turned 7 years old?

4. I make sure there are no problems with hearing, vision, or other medical

issues (anemia, diabetes, thyroid disease among others) with the child. Are

they overeating sugary or caffeinated snacks or beverages?

5. Has there been any other traumatic event (death or illness of loved one,

divorce, abuse) to which the child is responding? Any signs of depression or

other emotional condition?

6. How much sleep does the child get at night? Is it restful, do they snore or wet

the bed? (Bed‐wetting and ADHD seem to occur often together. Snoring or

sleep apnea in kids can cause daytime fatigue and sleepiness).

7. Does the child like school and his or her teachers? If not, why?

8. If ADHD seems plausible, I then ask parent to answer a questionnaire about

patient’ behavior at home (there are various versions, such as Connors

Rating Scale, Vanderbilt Assessment Scales, etc.). Then, we give one to

patient’ teachers.

9. If there is concern from these questionnaires, I then refer to Child

Development and Psychology professionals to confirm our diagnosis, test IQ

and for learning disabilities, and offer treatments options.

10. If parents are comfortable, we can try a medication. If not, we can try

conservative methods and re‐evaluate.

Notice that number one was not “ut child on medicine” This is rarely the right first

thing to do without a thorough investigation. Seek medical advice if concerned

about your child.

Be healthy and be blessed (Have a good school year!),

Dr. Swiner