Dr. Swiner’s Medical Note of the Month-August 2009-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 2nd 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 “hyperactive”. He or she won’t listen to directions, talks back, and can’t 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 “on 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 “stimulants”, 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’s 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 non-medication 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’s behavior at home (there are various versions, such as Connors Rating Scale, Vanderbilt Assessment Scales, etc.). Then, we give one to patient’s 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 “put 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

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