Health News • ADD or ADHD?

Most mothers of ADD/ADHD (Attention Deficit w/wo Hyperactivity Disorder) children will admit that they have noticed short attention spans, impulsivity and constant motion in their child’s behavior since infancy. But somehow these Moms also know that their child, although disorganized and easily distractible is also of reasonable or even above average intelligence.

These parents are also not surprised when their wiggly, bright child cannot accommodate himself to the classroom setting. Indeed as the child goes from kindergarten to grade school, more self-control is expected and these core symptoms (inattention, impulsivity & hyper-activity) of ADD/ADHD get in the way of learning and socialization. He cannot sort out the massive number of stimuli entering his brain.

ADD/ADHD has replaced outdated terms such as hyperkinetic syndrome and minimal brain dysfunction both of which unduly imply delinquency and/or low intelligence. This disorder occurs more frequently in males than females and in left-handers more than right-handers. Obviously there are family tendencies where one can trace behavior disorders and their consequences. Girls tend to be more ADD while boys tend to be more ADHD, although these conditions are not mutually exclusive. Comorbid conditions include oppositional-defiant disorder, conduct disorders and learning disabilities.

Because he cannot follow directions, the ADD/ADHD child entertains himself with other activities usually distraction classmates as well. Teachers are now trained to handle such students and know how to continually “cue him” to stay on task. Because of this constant “cueing”, teachers often become exasperated, the ADD/ADHD student feels inadequate and the child can be labeled as “lazy” or a “bad kid”. Hence, if good intervention is not initiated the child’s confidence and self esteem begin to suffer.

Most physicians, psychologists and educators now recognize that this scenario can be treated with medication and proper psychological counseling. ADD/ADHD is a condition of the nervous system where the chemical dopamine is somewhat deficient. This chemical helps inhibit motor activity so that the child’s overloaded circuits can concentrate on the task at hand and allow learning to occur.

Behavior modification techniques along with medication can do much to rebuild such a child’s self esteem thus furthering his motivation for learning and positive socialization. Many psychologists, schools and mental health departments hold group sessions for parents of ADD/ADHD children. These sessions seem to help families deal with their child not only through better understanding of ADHD but also in assisting with structuring the home environment.

Families and their ADHD patients learn how to do personal behavior management whereby their attention deficit child learns how to respond to demands. He will better respond predictably to a given situation. He will adapt better to changing demands and approach his peer and authority figures more appropriately. And of course, his will be better able to look out for his own safety (i.e. curb sometimes dangerously impulsive behavior).

Psychometric testing is essential when eliciting help from the school system. These test include IQ, Weshsler, Connors Parent-Teacher Questionnaires (or its shortened form) and child behavior checklists. Such testing can be done by the school or by the psychologist’s or psychiatrist’s office as part of the child’s evaluation and final IEP (Individual Educational Plan). It would be important to bring these results to the pediatrician when the child is being considered for treatment of ADD/ADHD.

Medication is complex. Stimulants (eg: Dexadrine,Ritalin, Focalin, Metadate, Concerta, etc) are very effective. As seemingly incredible or paradoxical as it may be, these drugs work by actually stimulating the brain to focus on the task at hand by shutting out unnecessary stimuli that may distract the patient. Dextra-amphetamines can be used in preschool children while methyl-amphetamines are used in older children and adults. Because of the “upper” effect of stimulants, these drugs are often abused and thus the DEA (federal Drug Enforcement Agency) closely regulates their manufacturing and prescribing. Amoxotime (Strattera), on the other hand, has an altogether different pharmacomechanism by encouraging the brain to use its own circulating endogenous dopamine and is not as heavily regulated as are the stimulants.

Both medications have their benefits and disadvantages. Parents should know that long term effects may include short stature with prolonged use of stimulants and possible liver damage with the use of amoxotime. Hence, the pediatrician will require frequent visits to monitor growth and even lab work. Changes in blood pressure and heart rate have been observed and may be reason to discontinue the medication. Short term effects are frequent but often short lived. These include emotional lability (a downer effect whereby the child seems depressed, is tearful) or the child suffers headaches, nightmares or insomnia as well as loss of appetite subside after proper dose adjustments. Although tics were thought to worsen or even originate with the use of stimulants, recent studies have shown this to be false. The appearance of hives or hallucination is cause for immediate cessation of the drug.

Any drug therapy of ADD/ADHD requires titration (adjustment of the drug) with frequent office visits especially at the outset with the pediatrician and psychologist. Parents, teachers and doctors will review the “Connors” (shortened form of teachers/parents assessment of the child’s behavior) with the patient and/or parents. Timing medications is important in encouraging good compliance. Most of the stimulants are now available in long acting preparations, eliminating the need to the need to take medicine at school. A patient with gastrointestinal problems may be a good candidate for the patch system of delivery. The “wearing off” of the medication becomes a significant factor especially with homework or sports in the late afternoon, when more brain activity and attention is required of the patient. A “homework” dose of a short acting stimulant may be in order.

Whether or not there should be a “drug holiday” is an individual decision. It is thought that the home environment is also an important learning experience (especially in emotional development) and that if medication aids in better socialization, then it should be continued on the weekends, holidays and summer vacation. Sometimes a patient may require a combination of medication. All this takes close collaboration with the teachers and parents. Once a stable dose regimen has been established, usually follow-up visits will only be needed every 3-6 months.

Many ADD/ADHD do outgrow their difficulties by maturing out and developing coping mechanisms to compensate for their inattention. Presently there is a growing trend to treat adults with prolonged medication and the results are quite rewarding.

But medication is not a cure all, other reasons for short attention span should be ruled out simultaneously. Many ADHD patients also have learning disabilities which require testing in the school setting. If a proper IEP(Individual Education Program) is worked out, reactive hyperactivity (eg: child with an exceptionally high IQ who is bored is acting out in class) can be avoided or minimized allowing the child to properly cope with learning difficulties and elimination the need for medication.

Proper diagnosis and proper treatment along with lots of love go a long way in helping these children to cope and to assimilate into our society as productive adults.