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Why Is ADHD On The Rise?-My Opinions

25 Apr

rising-graphThere have been a few studies and reports highlighting the rise of the diagnosis of ADHD in our children…

Here’s one of the more popular ones from the NYTimes if you haven’t seen one yet:

A.D.H.D. Seen in 11% of U.S. Children as Diagnoses Rise

Historic estimates have put the incidence at 3-7% just to give you an idea of what 11% means.

So, I expect if you’ve read this far, you are expecting my opinion of why this is…Remember that this is my opinion from a few years of pediatric practice and counseling many families on the the diagnosis (or not) and treatment of ADHD.

I think there are multiple factors but I will handle them in categories…

Doctors

Doctors have become more and more comfortable prescribing stimulant medications for ADHD.  There is a quote in the article above where a doctor states that he used to tell his families that the stimulant medicines are “safer than aspirin.”  Because of this, I believe doctors will be a bit lax in their requirements that children actually meet criteria for ADHD.

Couple this together with a developing medical marketplace that favors competition and convenience as well as online ratings, etc and it makes standing up against a families demands more difficult.  I’m definitely not saying that this is the right thing to do but you can certainly see how a doctor is put in a difficult place.

It is important as physicians that we consider the information carefully and evaluate the child in front of us based on appropriate criteria.  Treatment decisions should be made based on this information and not based on the pressure from the family.

Parents

I have to remind my families in diagnostic consultations and follow up appointments to evaluate treatment that talking back, aggression and “being bad” are not the core symptoms of ADHD.  It is not uncommon for me to be sitting with parents who tell me that I need to “fix this kid.”  Well, unfortunately, there isn’t a medicine that can fix a child.

ADHD can be managed but many of the behaviors that parents want fixed need to be addressed with counseling and parenting skills.  I commonly refer the children of this type of parents for counseling because they need it but also because my counselors will help the parents come up with more effective parenting techniques.

Because of the growing awareness of ADHD, parents are more pushy about getting their children diagnosed and treatment started and I believe that this increases the incidence of ADHD.

Society

In some arenas, there is a still a small stigma associated with having ADHD.  This is sad and I wish it weren’t true.  But, in reality, this has significantly decreased even in the past couple of years.

It used to be common for parents to give their children “vitamins” each morning that were actually stimulants to keep from having to explain to their children about the diagnosis.  Things are different now and I almost feel like it’s to the point that ADHD is a trendy diagnosis.  I have teenagers that come in wanting to be diagnosed and start treatment and you can almost feel they are there because “everybody else is doing it.”

While I’m proud that any mental illness carries less stigma than it did in the past, it does create a problem when ADHD becomes so commonplace that it’s almost “cool” to have it.

Schools

Schools are different now than even 20 years ago when I was in junior high and elementary school.  We didn’t start phonics until 1st grade, most kindergardeners finish reading now.  Early school used to be about centers and getting up and moving around but now it has become much more about sitting still for lectures and worksheets.

Don’t get me wrong…I’m not saying that individual schools or teachers are to blame.  Many of our teachers feel tied to doing things a certain way in order to prepare their students for standardized tests, etc.  School ratings are dependent upon performance on these tests as well.

However, because of this culture, there is little flexibility for the little boy who is smart but is bouncing around the room like a bouncy ball. I hope no one takes this the wrong way, I’m not blaming schools.  This is simply just the way it is.  The requirements for sitting still and paying attention for longer periods have changed and have gotten younger and younger.

So, as you can see, I have lots of opinions about what might be contributing to the increase in ADHD diagnoses.

Is there anything to do about all this?  Probably not.  We just need to be aware of what’s going on and make sure that diagnoses are appropriately made based on the child’s symptoms and not the result of some outside pressure or trend.

Here is the full table of contents for the ADHD Series:

ADHD-What is it?

ADHD Behavioral Treatment-8 Tips

ADHD-Medical Management Concepts

ADHD-Medication Types and My Thoughts

Preschool Child with ADHD Symptoms

Why Is ADHD On The Rise?-My Opinions

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Preschool Child with ADHD Symptoms

22 Apr

I am not kidding when I say that I had a mother of a 6 month old ask me if her child was going to be ADHD, “Because he just moves all the time!”

While that was an easy question to answer, I do get more difficult questions about young children with hyperactivity.

In order to start this conversation, it is important to remember the core ADHD symptoms: inattention, impulsivity and hyperactivity.

Based on appropriate diagnostic criteria, you cannot diagnose ADHD until age 4.  It is also difficult to diagnose children until they are in school because the diagnosis requires that symptoms be present in more than one environment.

As with any type of behavioral problem, the degrees of severity present a wide spectrum of the various symptoms of ADHD.

Inattention-Some children can focus for hours at time but some jump from one activity to the next very quickly, seeming to never really focus on one thing for a significant amount of time.

Impulsivity-Some children are very cautious and don’t do anything dangerous, while others jump from my exam table across the room to the chairs on the other side.

Hyperactivity-Some children can sit still for long periods of time, while other are constantly fidgeting and restless.

So, how does this look in a 3-4 year old child?

All 3 and 4 year olds show signs of inattention.  There are a select few children in this age group who can maintain focus for extended periods of time.  Because of this, it’s hard to get too excited about concerns about a 3 year old’s attention span.

I have definitely seen varying levels of impulsivity in this age group.  Those that are highly impulsive, in my experience, often go on to meet criteria for ADHD as they get older.  Remember, however, that talking back and aggression are not necessarily impulsivity.  In fact, these two behaviors are more commonly a result of insufficient supervision or inappropriate boundaries. Without appropriate supervision and boundaries for significant amounts of time, these behaviors will show up more and more often, but that’s not necessarily impulsivity.

Finally, the most common symptom that parents interpret as ADHD is hyperactivity.  There is definitely a difference between the general restlessness of a typical 3 year old and a child that truly becomes ADHD in the future.

Children at this age are often described by parents who report, “Their motor is just always running” or “They just go non-stop from the moment they wake up.”  Because I see so many children of this age group every day, I also have some subjective sense of what is normal or abnormal for the age group and this can help my assessment over time.  However, I never make snap judgments because any child can act like they have ADHD on a particular day.

So, what if you are concerned that your young child may be showing some signs of hyperactivity?  A great place to start is here: ADHD Behavioral Treatment-8 Tips.  

Here are some basic things to remember:

1) Try to stay patient.

Because so many of these young children will outgrow these symptoms, it is important to stay patient with them.

2) Try to stay calm.

Anxiety only makes hyperactivity worse.  Yelling at a kid to sit down and shut up will most likely just make your problems worse.

3) Try to stay consistent.

Children with hyperactivity do their best with structure and clearly defined boundaries.  If these children don’t know what to expect from minute to minute, they cannot adjust as easily as most kids.  If they are not disciplined consistently, they do not know where the boundaries lie.  With any behavior problem, I ask my families to pick out what 1 or maybe 2 behaviors that they want to extinguish and be consistent in the their punishment for those.  It is not feasible to fix all of your child’s problems at once.  Also remember to praise them when they do the proper behavior.  If a child is only getting negative reinforcement, they will often choose that over positive reinforcement.

4) Try not to ask if your 6 month old has ADHD.

 

Here is the full table of contents for the ADHD Series:

ADHD-What is it?

ADHD Behavioral Treatment-8 Tips

ADHD-Medical Management Concepts

ADHD-Medication Types and My Thoughts

Preschool Child with ADHD Symptoms

Why Is ADHD On The Rise?-My Opinions

ADHD-Medication Types and My Thoughts

18 Apr

If you have issues with children being on medicine for ADHD, please see my previous post…ADHD-Medical Management Concepts.

In this post I want to discuss the different classes of medications for ADHD including how they work and how they are used.

Stimulants

Stimulants are the most commonly used class of medicines for ADHD.  They have the longest track record because they have been around the longest.  The most famous (or infamous) in the class is methylphenidate (or Ritalin).  Many people have some experience with some family member or friend who was on methylphenidate and hated it for one reason or another.

Fortunately, we have a better understanding of ADHD and its treatment than when it was the only option available.  One of the major advancements we have made is in the development of longer acting medicines that require only a single morning dose (Ritalin required taking a dose twice per day.).

Some of the other major players in the stimulant class of medicine are Concerta, Vyvanse, Adderall XR Daytrana and Focalin XR.  In my practice, I most commonly use Concerta and Vyvanse because those are the ones I picked early and have become very comfortable with.

One of the great things about these medicine is that they are given in the morning, peak around lunch time and are gone by the afternoon/evening.  You can see the discussion about the benefits of this by clicking the link above to the previous medication post.

I generally have my parents start by giving the medicine seven days a week and through the holidays but after the dose has been established and things are going well, I will allow them to take drug “holidays”, which is where the child doesn’t have to take the medicine on days when focus is less important. This is not true for all doctors, so please ask your doctor before you do this.  I often find that parents realize how significantly these medicines help their children and continue to give them every day.

One of the major factors in determining which medication to start with is the delivery method.  Many of the medicines come only in pill form.  Daytrana comes in a patch form and can be placed each morning and removed at the end of the day.  I find that getting the child to keep the patch on is difficult and for this reason I tend not to use it very commonly.  For my children who cannot swallow pills, I tend to recommend Vyvanse because the capsules can be opened and sprinkled.  There is a new liquid version of a stimulant medicine being released but I am still researching and learning about it at this time.

Non-Stimulants

There are three major medicines in this class that I will discuss here: atomoxetine (Straterra), Intuniv (guanficine) and clonidine (Kapvay).

Straterra was initially developed to be an anti-depressent but it was a terrible anti-depressent and got a second life as an ADHD medication.  It works very similarly to a group of antidepressants called SSRIs and needs to be taken every day.  You cannot take days off because the level of medicine in your body drops and you start over at the bottom when you start to take it again.  I personally have found this medicine to be more effective in children with mild ADHD or with mostly inattentive subtype of ADHD but generally not as effective as the stimulants for either.  I find myself using it most commonly in children who cannot tolerate stimulants because of side effects or in children whom their parents choose not to use a stimulant.

Intuniv and Clonidine are both old blood pressure medicines that are currently used for ADHD. They can both be used individually as treatment for ADHD but I most commonly use them as add-on therapy for children who need a little more help than their stimulants are providing.  Kapvay (long acting clonidine) and Intuniv are both long acting and provide benefit through the whole day.  Short acting clonidine can be used at bed time to help children go to sleep who are having difficulties with this on their stimulants.

Now that we’ve looked at the different cases, here’s my summary on dosages:

  • My preference is to start with a stimulant unless there is a concern from the family or myself about how the child will tolerate the medicine.
  • If there is an issue with the stimulants, I will switch to non-stimulants.
  • If I cannot increase the dose of stimulant medicine because of side effects, I will add on a non-stimulant such as Intuniv or Kapvay.

ADHD-Medical Management Concepts

15 Apr

Ok, for those of you out there who disagree with using medicine…save your comments for yourself.  I am usually very open minded to people who disagree with me on various topics, but this is an issue I feel have to protect my well meaning parents from.

If you have a child with ADHD and have chosen to go for a non-medical route…more power to you and if it is working well for you, that is awesome.  However, I also have families that have stressed for years because of something they have heard in the media or from their friends and suffered because they didn’t want to place their child on medicine for whatever reason.

Let me first address some of the most common concerns about the medicines:

Won’t They Get Addicted to the Medicine?

Children on ADHD medicines are not addicted and are not more likely to have addictions later in life.

Here is the definition of addiction: “compulsive need for and use of a habit-forming substance (as heroin, nicotine, or alcohol) characterized by tolerance and by well-defined physiological symptoms upon withdrawal; broadly   : persistent compulsive use of a substance known by the user to be harmful.”

ADHD medicine do not form compulsions in children who actually need them and they are not habit forming.  Just like any other medicine, parents will forget from time to time and the only effect they see from missing a dose is that their child’s behavior is not as good that day.  There are no other side effects.

Tolerance is the effect whereby a person develops a bigger and bigger need for a substance in order to develop the desired effect.  While there are times when I do have to increase a dose of medicine it is typically more related to the size of the child increasing and the changing stressors (increasing difficulty, etc) at school that require the increase.

There is no withdrawal symptoms when a person comes off their stimulant ADHD medicines.  In fact, the child comes off their medicine every night and can take weekends or summers off without issues.  By definition, this means that there is no withdrawal.

So, without compulsion and habit, tolerance or withdrawal, there is no single characteristic about these medicines that make them addictive.

As for the question about children with ADHD going on to have more addictions later in life, it seems that this is more related to the ADHD than the medicine and adequate treatment may actually help prevent some of these later behaviors.

I Don’t Want Them to Act Like a Zombie!

I hear this complaint or concern with just about every consult that I see.  Understandably, parents don’t want their children to act differently or have a change in personality because they are on medication.  Guess what? Me neither.  If I were to see personality changes in my patients, I would change their medicine or come up with other treatment strategies.  However, this is a very uncommon complaint.  In fact of my 4 years of practice, I have seen it only twice and both of the parents were extremely worried about this prior to starting medicines, which makes me wonder if they weren’t looking too hard for it.

It is my opinion that this was a bigger problem earlier with the short acting medicines as you saw a more rapid peak and fall than with our newer/better treatment options that allow for a more gentle change the drug levels over the day.

Will This Stunt My Child’s Growth?

While there have been some studies showing a slight decrease in weight and height growth over the first years of starting a medicine but these differences disappear when you recheck the children at 2 and 3 years out from starting medicine.

So, What are the Common Side Effects?

The most common side effects I see from the ADHD medication (primarily stimulants) are loss of appetite and difficulty going to sleep.

Loss of appetite-This symptom typically starts right off the bat and can improve over time.  The child usually has the biggest problem with lunch time as that is the when the medicine is at it’s highest level in the blood stream.  Usually, you can make up for this problem by making sure the child eats a good breakfast and dinner and eats what they can at lunch.  I follow my patient’s weights closely especially when there is a concern about the child’s appetite.

Difficulty with sleep-Occasionally, we will have a child who has a difficult time going to sleep especially when they first start the medication.  My first treatment for this is to make sure that are taking care of doing the right things to help themselves go to sleep: no food or drink with 1-2 hours of bed time, no screens on in the room 1 hour prior to bed time, etc.  If that doesn’t work we can do a trial of melatonin or other options are available if this doesn’t work.

Some more rare side effects that I want to discuss are mood instability and tics.

Some of the medicines are worse that others about this but we will sometimes have a child who is very emotional and tearful when first starting the medicines.  This typically happens in the afternoon or evening as the medication is wearing off.  Usually, with just a period of observation, this will improve after about 1 week on the medicines so I first have my families continue trying for a bit to see what happens.

Tics are involuntary movement disorders that result in a short jerking of the head, lip smacking or some other short, quick motion.  These medicines do not cause tics but in a child who is already predisposed to them for some reason can cause them to become much more obvious and frequent.  If the tics are disruptive or concerning, we will usually need to switch medicine to something else as this does not usually improve over time.

Summary

1) Children do not become addicts because of ADHD medicines.

2) Children do not become zombies because of ADHD medicines.

3) Children do not become short because of ADHD medicines.

 

Here is the full table of contents for the ADHD Series:

ADHD-What is it?

ADHD Behavioral Treatment-8 Tips

ADHD-Medical Management Concepts

ADHD-Medication Types and My Thoughts

Preschool Child with ADHD Symptoms

Why Is ADHD On The Rise?-My Opinions

ADHD Behavioral Treatment-8 Tips

11 Apr

Screen Shot 2013-04-10 at 11.53.46 PMIf you haven’t read the first post in this series about ADHD.  You can find it here:

ADHD-What is it?

So, your child is showing signs of or has been diagnosed with ADHD…what do you do next?

The first line treatment for children with ADHD are behavioral options.  I never ask a family to jump first to medication that hasn’t tried some of the techniques I’m going to describe below.

What are the goals of treatment?

1) Improved interaction with parents, teacher, classmates and siblings

2) Improved grades

In my opinion, the goals are simple and should be taken in that order.  It is important to consider these goals and re-evaluate them frequently during the treatment course.  Perfection should not be the goal.

I recommend these behavioral techniques before medication for all children, especially those who are young or who have milder ADHD:

1) Make a schedule daily-All kids have difficulty and waste time with transitions.  Children with ADHD have more trouble with this than most.  If these transitions are scheduled and the child knows what comes next it can speed up the transition.  Things that should be included on the schedule are homework time, daily chores and self-care items (shower, brushing teeth, etc).

2) Make separate areas in the house for necessary tasks-Keep toys and video games out of the space where homework needs to be completed.  These helps limit the child’s distractions so that they can finish the task at hand.

3) Set small goals that are attainable-Don’t ask the child who is failing to make the A honor roll in the next six weeks.  Start with turning all assignments in and complete, then slight increases in grades, etc.

4) Use charts and checklists-Children with ADHD are often very visual and concrete.  If you can put a list in front of them that can be checked off, they are much more likely to complete what needs to be done.  I find this to be helpful for me as well…

5) Keep choices to a minimum-Don’t tell them to go to the closet in the morning and pick out something to wear.  This is a sure way to start a huge fight as they stand in front of the closet for hours while you are trying to wrestle them out the door.  Pick out 2 options ahead of time for them to choose from.

6) Don’t discipline them impulsively-Remember that one of their biggest problems is that they don’t stop to think about consequences before they act.  If your discipline follows the same pattern, how can we expect them to learn to act differently?  Plan out your discipline plan in advance and be consistent.  As tempting as it may be, corporal punishment is rarely effective.  I’m not a touchy-feely, don’t ever spank your child pediatrician but time outs and restriction of privileges seem to be more effective for children with ADHD.

7) Help your child with organizational skills.  Developing a system that helps them keep track of all the papers is a way to keep them from getting thrown away, having them sit in the floorboard of the car or (more infamously) avoiding having the dog eat them.  If you need some help establishing this system, check out this amazing book called That Crumpled Paper Was Due Last Week.

8) Get help-Raising a child with ADHD can be very frustrating and quite exhausting.  There will be lots of times when you will feel like there is nothing left to do to help.  Talk with your pediatrician about options for treatment.  Find a family counselor that can work with your child but, more importantly, that can help you develop a plan for your child and help you cope with the struggles you will face.

I hope that you find these tips helpful as you begin to think about how you can help your child with ADHD.

Here is the full table of contents for the ADHD Series:

ADHD-What is it?

ADHD Behavioral Treatment-8 Tips

ADHD-Medical Management Concepts

ADHD-Medication Types and My Thoughts

Preschool Child with ADHD Symptoms

Why Is ADHD On The Rise?-My Opinions

ADHD-What is it?

9 Apr

There has been lots of news this week about ADHD…reports and studies have shown increasing rates in children and teenagers as well as news about how many cases of ADHD persist into adulthood.

So, what is ADHD?

ADHD stands for attention deficit hyperactivity disorder.

There are 3 core symptoms of ADHD:

1) Inattention

2) Impulsivity

3) Hyperactivity

Inattention

Inattention can present itself in many ways.  Some of the most common complaints that I hear about are daydreaming, forgetting assignments and inability to complete a short list of chores at home.

Often children who mostly have inattention do not become recognized until they are older because they are not the ones causing all kinds of problems in the kindergarten classroom.  They will often skirt by making OK grades and not getting in trouble until they get a little older and the requirements to sit still and complete assignments on their own increase in the 2nd-3rd grade.

Impulsivity

Do you know that split second where you think about telling someone off but you stop yourself?  Or you think about driving 100 mph because you’re running late but don’t because you realize it will be dangerous?  That split second is another thing that children with ADHD are lacking.  They push right through that pause and act before thinking about the consequences of their action.

The best summary for this problem is that they lack the ability to determine if the upcoming action is: safe or appropriate for time and place.

Hyperactivity

The hyperactive symptoms are the ones that most people (even strangers) will notice about children with ADHD.  They are not even necessarily bad kids, it’s simply that they have a significant struggle with staying seated, staying still when seated and not talking out of turn.  These symptoms are usually noticed by 4 years of age and progressively worsen until about 7 years.

ADHD Subtypes

There are 3 major types of ADHD and they are characterized by which of the core symptoms your child demonstrates: predominately inattentive, predominately hyperactive-impulsive and combined.

Diagnosis

The diagnosis of ADHD can be made by multiple practitioners: pediatricians, psychologist, psychiatrists and some counselors are trained to diagnose ADHD.  I prefer to make my own diagnosis in my clinic unless the case is particularly challenging or there is something complex about the presentation.

There are many different modalities that can be used to diagnose ADHD but it is mostly made by parental history, teachers reports and screening scales.  I prefer to use the Vanderbilt scale but there are many other scales out there that can be used.

Diagnostic Criteria

Diagnostic criteria for ADHD start at age 4 so younger children are generally not diagnosed with ADHD.  This is due in part to the complexity of trying to decide what is normal and what is hyperactive or inattentive for a child younger than 3.

The following criteria are used:

1) Be present in more than 1 environment (home and school)-this is important because children who have issues only at home or only at school are usually having more of a problem with the structure at one place than actually having a tendency towards ADHD

2) Be present for more than 6 months

3) Be present before age 7-this is becoming more of a problem as adolescents and adults are becoming more aware of the problem but demonstrating that there were symptoms prior to age 7 can be difficult

4) Impair function-see below

5) Be excessive for the developmental level of the child

Impair Function

My main point when I am discussing a child’s ADHD with the family is focused upon this aspect of the diagnosis and treatment.  For most children, impairment of function means that they are not progressing through school appropriately, are in trouble at school regularly for hyperactive or impulsive behaviors or have difficulty performing regular function at the house because of their ADHD.

As I work on treatment, I also discuss regularly how the child is functioning in home and school.  I am not aiming for perfection and this should never be the goal.  Improving function to a tolerable level for the parties involved (child, parents, teachers) while avoiding any side effects from treatment is the goal.

Here is the full table of contents for the ADHD Series:

ADHD-What is it?

ADHD Behavioral Treatment-8 Tips

ADHD-Medical Management Concepts

ADHD-Medication Types and My Thoughts

Preschool Child with ADHD Symptoms

Why Is ADHD On The Rise?-My Opinions

When Your Child Is The Biter…

24 Mar

First off, this happens ALL THE TIME…

You’re child is not the first child who has bitten and won’t be the last so let’s be calm.

There’s really just a few things you can and need to do in these situations…

When The Bite Has Already Happened

Separate biter and the bitten child.  This helps the “victim” feel safer and diffuses whatever frustration caused the biting in the first place.

Try to talk it out.  Often you are dealing with a pre-verbal child but it is still important to try and talk about the situation that led up to the biting.  Usually the child who bit is just as scared as the child who was bitten.  You are typically dealing with young toddlers with limited verbal skills but talking with them about their frustration/anger that led up to the biting can help them to understand that there is a better way to express these emotions.

Preventing the Problem

The ultimate goal in helping with biting is to prevent the situation that leads to biting in the first place.  The key to this is: distraction, distraction and distraction.  Keep the frequent biters from their trigger situations or be prepared to intervene quickly before the frustration levels begin to rise.

Or, Just Bite Them Back

Of course, everyone has had a family member or someone tell them that this is the best way to get a biter to stop and while it may have worked for them in the past, I feel that this strategy is simply modeling the behavior you are trying to extinguish.  Toddlers learn best through seeing their parents’ actions and having your parent bite you only makes you think that is appropriate behavior.

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