Attention Deficit Hyperactivity Disorder (ADHD)

Attention Deficit Hyperactivity Disorder (ADHD)

By: ulrickvieux on (0 comments)

Clinical Vignette

"I don't believe in medications for children and I don't feel comfortable seeing a Child Psychiatrist for my child, as far as I am concerned ADHD is over diagnosed in the Black community and everyone wants to medicate our kids. However, I don't know what to do with my child; he is 8 years old and simply can't stay still. He has already had to repeat the first grade and is in danger of having to repeat the second grade, too; all of this despite being a bright child. He doesn't have many friends and I am constantly being called into his school for his behavior. At home he is like a tornado, I know that boys will be boys, but I am at my wits end with this child."

Discussion

The above vignette is an all too common experience throughout the communities of the United States. It is estimated that in the United States, one in 10 youths has a mental illness severe enough to cause some level of impairment. Despite this high number, approximately only about one in five of these youths is receiving specialty mental health services for his or her situation. ADHD is one of the most common psychiatric diagnoses within children. It is estimated that between 3 to 5 percent of children have ADHD, which would be approximately 2 million children in the United States. This condition becomes apparent in children in the preschool and early school years. It is estimated that boys are three times more likely then girls to be diagnosed with ADHD. The hallmark of a diagnosis for ADHD is a child that is impulsive, hyperactive, and is unable to concentrate. These children may intrinsically understand what is being asked of them but have trouble following through secondarily to an ability to sit still, follow directions and pay attention.

The old adage "boys will be boys" is true to an extent. All children, especially the very young will exhibit a certain amount of hyperactive, impulsive behavior but not to the extent of the child with ADHD. What is unique about the child with ADHD is that this behavior has adversely affected the child in a multitude of settings, including home, socially and at school. The child's ability to function is severely impaired. When the child's hyperactivity, distractibility, poor concentration, or impulsivity begin to affect performance in school, social relationships with other children, or behavior at home, ADHD may be suspected.

How is ADHD Diagnosed?

ADHD, was formerly known as Attention Deficit Disorder, or ADD until 1994 when it was renamed and divided into three subtypes, Hyperactivity-Impulsivity, Inattention and Combined, each with its own pattern of behaviors. According to the DSM-IV-TR.

Hyperactivity-Impulsivity type. (A child needs to have six (or more) of the following symptoms for at least 6 months to a degree that is maladaptive and inconsistent with their developmental level):

-Hyperactivity-
1. Often fidgets with hands or feet or squirms in seat.
2. Often leaves seat in classroom or in other situations in which remaining seated is expected.
3. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
4. Often has difficulty playing or engaging in leisure activities quietly.
5. is often "on the go" or often acts as if "driven by a motor".
6. Often talks excessively.

-Impulsivity-
7. Often blurts out answers before questions have been completed.
8. Often has difficulty waiting turn.
9. Often interrupts or intrudes on others (e.g., butts into conversations or games)


Inattention type. (a child needs to have six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with their developmental level):

-Inattention-
1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
2. Often has difficulty sustaining attention in tasks or play activities.
3. Often does not seem to listen when spoken to directly.
4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
5. Often has difficulty organizing tasks and activities.
6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework).
7. Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools).
8. Is often easily distracted by extraneous stimuli.
9. is often forgetful in daily activities.

Combined type: Is a combination of the above mentioned types and is the most commonly diagnosed.

In order to make the diagnosis of ADHD, the aforementioned symptoms must be present prior to the age of seven. Some impairment from the symptoms must be present in two or more settings (most likely school and at home). The behavior must be present for at least six months and the behavior must be more severe than in other kids at the same age.

It is important to note that since a biological test does not exist to make the diagnosis of ADHD at this point, a detailed history is required by the primary care giver and school teacher. Other factors need to be considered such as stress at home, (i.e. divorce, an illness, change in school etc.) in order to avoid a misdiagnosis. A physical exam by a physician is required to rule out other significant causes. The differential diagnosis could include and not limited to undetected seizures, such as petit mal or temporal lobe seizures, a middle ear infection that causes intermittent hearing problems, problems with vision, medical disorder that may affect brain functioning, underachievement caused by learning disability and anxiety or depression.

The diagnosis of ADHD should be made by a professional with training in ADHD or in the diagnosis of mental disorders. Child psychiatrists, developmental/ behavioral pediatricians, behavioral neurologists and family practice physicians are those most often trained in diagnosing and treating ADHD. Non physician disciplines with experience in diagnosing ADHD would be Child psychologists and Clinical social workers.

Choosing the Right Clinician

Understanding the differences in qualifications and services can help the family choose the clinician that best meets their needs. For example, Child psychiatrists are physicians who specialize in diagnosing and treating childhood mental and behavioral disorders. Child psychiatrists can provide therapy and prescribe any needed medications. Child psychologists can provide therapy but are not physicians and must rely on the child physicians to do medical exams and prescribe medications. Neurologists, family doctors and pediatricians are physicians who can prescribe medications but may not provide therapy for the emotional aspects of the disorder like a child psychiatrist or psychologists.

What is the Treatment?

At this point, ADHD cannot be cured but can be successfully managed. The landmark study for ADHD was the "Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (MTA)" which was founded by the National Institute of Mental Health (NIMH). The results of this study were that long term combination therapy of medication and behavior therapy led to the best results.

Medications:

1. Stimulants: Best known treatment and have been in use for over fifty years. These medications when used under the supervision of a physician are usually very safe. It is found that the stimulants dramatically reduce the hyperactivity, impulsivity and improve the ability to focus, work and learn. A review of long term studies on stimulant medication conducted by researchers at Massachusetts General Hospital and Harvard Medical School, found that that teenagers with ADHD who remained on their medication during the teen years had a lower likelihood of substance use or abuse than did ADHD adolescents who were not taking medications. (1) Speak to your psychiatrist about the many types of medications on the market.

2. Non-stimulants: Recently approved in 2003 for treatment of ADHD. Less side effects then stimulants, but may not be as effective.

3. Antidepressants: Considered a second choice for treatment of adults with ADHD. Concern about increased suicidiality with children.

Behavioral Therapy:

The goal of Behavioral therapy is to change negative behavior patterns by:

1. Reorganizing the child's home and school environment.

2. Giving clear directions and commands.

3. Setting up a system of consistent rewards for appropriate behaviors and negative consequences for inappropriate ones.

Social Skills Training:

A child works with the therapist to learn new behaviors that will help foster more effective social skills such as, like waiting for a turn, sharing toys, being mindful towards others needs etc.

Support Groups and Parenting Skills training offers opportunities to learn more about ADHD and connect with other families that are suffering from ADHD.

Enpowerment Points:

ADHD is a serious disorder that can lead to profoundly negative consequences if not treated. Research has shown that the cause of ADHD is not due to bad parenting and contrary to public opinion it is not over diagnosed, yet in certain communities (such as the Black community) it is under diagnosed. The key thing is to be informed and to know where to go for help when it is suspected that a love one may be suffering from this ailment.

References:

1. National Institute of Mental Health
http:// www. nimh.nih.gov/publicat/adhd.cfm

2. Kids Health for Parents. Nemours foundation

3. Concise Textbook of Clinical Psychiatry. Second edition. Benjamin J. Sadock, MD, Virginia A. Sadock, MD.

4. Martin L. Korn, MD. Effective treatment for ADHD. Medscape today.
http://www.medscape.com/viewarticle/418614

5. Child and Adolescent Psychiatry. The Essentials. Keith Cheng, MD and Kathleen M. Myers, MD. Lippincott Williams and Wilkins.

6. Children and Adults with Attention Deficit/Hyperactivity Disorder.
http://www.chadd.org

Copyright © 2007 ALL RIGHTS RESERVED. No part of this article may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from Dr. Ulrick Vieux.

Author: Ulrick Vieux, DO, MS

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