Perhaps the most common question posed to Lucy Daniels Center clinicians is: "Does my child have ADHD? Should we test for ADHD?" Often, a child's pediatrician or teacher has raised the question. Perhaps the child has trouble controlling himself or herself, problems getting along with classmates at school and completing his work. Questions about medication are almost part of the overall concerns of parents. In order to address properly parents' concerns about ADHD and about medication, we should first discuss some aspects of Attention Deficit Disorder.
General description of ADHD: The primary symptoms of ADHD are in three areas: inattention, impulsivity, and over-activity. If significant impulsivity and over-activity are present, we speak of Attention Deficit Disorder with Hyperactivity. National experts believe that from 3% - 5% - or higher of children preschool age or older have ADHD. And, since most studies estimate that the ratio of "affected" boys/girls is at least 2 to 1 - and as high as 4 to 1 - the percentage of affected boys, according to these statistics, is somewhere between 6% and 20%. What might an estimate of this magnitude mean? There is a range of views about the topic of ADHD, and we will offer here our professional viewpoints about this controversial topic.
The diagnosis is not the final answer: Most children who are excessively inattentive, impulsive, and overly active are having troubles that should be professionally addressed, although we should be careful not to "label" and unnecessarily treat those children who are merely highly active and exuberant. When we find that a child's symptoms fit the diagnosis of ADHD, we believe that our work is just beginning, because the "diagnosis" does not explain why the child is having troubles or what to do about it! There are a variety of explanations for a child's difficulty with attention, impulsivity, or over-activity, and these reasons often occur in combination. One common explanation is physiological, such as a genetic tendency toward inattention or over-activity that a child may demonstrate even in the womb or during infancy. Rarely, there are other physiological causes, such as exposure to certain toxins. However, psychological factors also can be a significant or even major reason for ADHD symptoms. A partial list of emotional factors that can be expressed in ADHD-like symptoms include: difficulties in the attachment relationship with parents, anxious or depressive conditions, post-traumatic stress disorders, as well as environmental stressors including divorce, adoption after six months of age, and abandonment or abuse.
So, the tasks of diagnosis and treatment with children are actually quite complicated. Parents should also be aware children with ADHD may have problems in addition to inattention, impulsivity, and over-activity. For example, they may have trouble with their peers, which could be beginning for Peter. There are various possible reasons for these social problems. Some children with physiologically based ADHD also possess limitations in their inborn, "hard-wired" ability to understand and respond appropriately to social interactions. Other children are excessively vulnerable or reactive to their peers because their own problems with inattention, impulsivity, or over-activity have lowered their self-esteem and confidence. Still other children are struggling with underlying psychological difficulties (such as anxiety or depression) that are being expressed through the ADHD-like symptoms and social problems.
Children with ADHD-like symptoms also may have learning and achievement problems. Again, there are several possible reasons for the learning interference, including physiological, hard-wired limitations (learning disabilities), lack of motivation resulting from self-esteem problems, or underlying psychological difficulties.
The evolution of ADHD symptoms over time: The psychological, social, and educational capacities of children with ADHD-like symptoms change over time. Some eventually seem to "outgrow" their symptoms; others continue to have difficulties, but they gain the tools to manage them and their problems turn into "quirks"; and some have continuing, significant interference from ADHD-like symptoms or from newly emerging symptoms over time. These additional symptoms may include anxiety, depression or, most commonly, problems with impulse control including substance abuse and antisocial behavior. Conservative estimates indicate that one of five children with ADHD-like symptoms develops a second psychiatric diagnosis in adolescence. There are also other children whose adolescent and subsequent difficulties, while not that extreme, prevent them from fulfilling their potential. Of concern is the fact is that improvement from medications during earlier years does not strongly predict whether an adolescent will have significant difficulties. On the other hand, childhood difficulties in socialization and control of aggression are important warning signs of possible later difficulties.
Using medication Having shared this background, we can return the question of medication. There are a number of medications that are used to treat ADHD. The appropriate ones to try first in the usual situation are called "psychostimulants." Psychostimulants will sharpen anyone's concentration and therefore usually reduce at least some symptoms of most children with "ADHD." There is an extremely low incidence of significant side effects with psychostimulants. Appetite suppression and sleep interference are common but can be usually managed with medication adjustments; stomach pain and headaches are occasional problems; and emotional blunting and anxiety do sometimes develop. There are other specialized and rare issues, such as possible interference over time with thyroid function (which should be monitored) and the emergence of "tics" in susceptible individuals. Growth retardation, thought at one time to be a side effect of psychostimulants, is no longer a major concern; if it is even an issue at all, it can be avoided with appropriate management. Although we do not yet have data about the life-long effects of psychostimulant medication (particularly if started at age six or under), physicians have used these medications for decades and have not yet identified significant long-term negative consequences. There are also second line options for treatment of ADHD symptomatology, but space does not permit a full discuss of all of these generally less effective options.
A parental decision about using medication for a child should be part of a larger effort to identify why that child has ADHD-type behaviors, and to design the best treatment program for that child. This program generally should both help parents and teachers to modify or "structure" the child's environment environment, provide effective discipline, and explore the possibility of medication if there is a significant physiological component. Social skills groups and help with physiologically based learning disabilities may be important treatment components. In addition, since many children with physiologically based ADHD have low-self esteem, counseling or psychotherapy for the child may be important. We also believe that counseling can assist a child to take "ownership" of his or her special susceptibilities. With such help, the child will develop the "inside tools" to provide his or her own limits and structure, skills important for a successful adolescence and adulthood.
Medication will probably have less of a role if a child's ADHD symptoms are primarily based in psychological factors. A comprehensive treatment program will include parent counseling, guidance for teachers and additional approaches such as play therapy, family therapy, social skills groups, or cognitive behavioral therapy. Children with a mixed physiological and psychological basis for their ADHD symptoms will likely need some combination of the various approaches. In our professional opinion and experience, most of the many hundreds of children that we have worked with who have symptoms that are sufficient to meet "criteria" for ADHD on the basis of their behavior (e.g., a rating scale,) turn out to have those symptoms for psychological reasons, although there may be some physiological component as well. There is division in the field of mental health, and other professionals would not necessarily see this situation in the same way.
There are many kinds of help that are available for a child, and we recommend that parents consider a treatment program that will support their child's development most fully. With a thoughtful treatment plan and with flexible strategies for additional help as their child's needs change, parents will have reason to be confident that their son or daughter will grow and develop in a healthy and productive manner.
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