Pediatrics in Brevard: Does your child have ADHD? Here's how to tell and how to help them
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Attention Deficit Hyperactivity Disorder (ADHD) is the most prevalent neurobehavioral disorder in childhood.
The disorder affects at least 8.4% of the student population and 2.4% of the adult population.
Children with ADHD have difficulty with inattention, distractibility, impulsivity and hyperactivity.
The disorder not only affects their ability to do well in academics but has an impact on social relationships and daily family life.
Adults with ADHD who are left untreated as children have a lower self-esteem and poor self-worth because they felt excessively criticized growing up.
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What causes ADHD?
Although researchers have not identified any single cause for ADHD, genetic links in families have been identified, and often, parents with ADHD will have one or more children with ADHD.
Research on children’s brains with ADHD have found reduced grey and white matter volume, and their brains’ have different regions that activate when presented with mental tasks.
The prefrontal cortex (PFC) of the brain near the forehead regulates attention, behavior and emotional responses.
Brains of children with ADHD have slower PFC development and alternation of catecholamine signaling, which causes ADHD symptoms.
Other possible links to ADHD that were not genetic include low-birth weight, premature birth, exposure to toxins, such as alcohol, smoking, lead exposure during pregnancy and extreme stress during pregnancy.
How is ADHD diagnosed?
Although it would be ideal to have a comprehensive neuropsychological evaluation on every child, there is a nationwide shortage of clinical psychologists and psychiatrists.
With over 8% of the student population having a diagnosis of ADHD, having every child evaluated would be impossible.
A pediatrician or other primary care provider can diagnose ADHD using standardized assessment tools that teachers and parents complete.
Parent and child interviews should be done as well. It is important to get as much information from at least two different settings, such as home and school, to make a diagnosis.
ADHD does not occur only at home or only at school.
The Diagnostic and Statistical Manual of Mental Disorders (DSM)-5, has set criteria to make the diagnosis of ADHD. The child’s symptoms must be present for at least six months and must begin prior to 12 years of age.
There are three main subtypes of ADHD: inattentive, hyperactive-impulsive or combined.
The child has to have six out of nine symptoms if under 17 years of age and five out of nine symptoms if over 17 years of age, in respective categories.
ADHD: Inattentive
For the inattentive type, the child:
• Doesn’t pay close attention to details or makes careless mistakes in school or job tasks.
• Has problems staying focused on tasks or activities, such as during lectures, conversations or long reading.
• Does not seem to listen when spoken to (i.e., seems to be elsewhere).
• Does not follow through on instructions and doesn’t complete schoolwork, chores or job duties (may start tasks but quickly loses focus).
• Has problems organizing tasks and work.
• Avoids or dislikes tasks that require sustained mental effort, such as preparing reports and completing forms.
• Often loses things needed for tasks or daily life, such as school papers, books, keys, wallet, cell phone and eyeglasses.
• Is easily distracted.
• Forgets daily tasks, such as doing chores and running errands. Older teens and adults may forget to return phone calls, pay bills and keep appointments.
ADHD: Impulsive/hyperactive
For the impulsive/hyperactive child:
• Fidgets with or taps hands or feet, or squirms in seat.
• Not able to stay seated (in classroom, workplace).
• Runs about or climbs where it is inappropriate.
• Unable to play or do leisure activities quietly.
• Always “on the go,” as if driven by a motor.
• Talks too much.
• Blurts out an answer before a question has been finished (for instance may finish people’s sentences, can’t wait to speak in conversations).
• Has difficulty waiting for his or her turn, such as while waiting in line.
• Interrupts or intrudes on others (for instance, cuts into conversations, games or activities, or starts using other people’s things without permission). Older teens and adults may take over what others are doing.
The combined type would include both inattentive and impulsive-hyperactive types with at least six out of nine in each type for children and five out of nine for teens over 17 years of age.
Is it always just ADHD?
It is important for the clinician to rule out other coexisting problems with ADHD.
Boys are more likely to have oppositional or conduct disorder, and girls are more likely to have some anxiety and depression.
In teens, especially presenting after 12 years of age, drug-seeking behavior or substance abuse needs to be ruled out.
Additional assessments need to be done to rule out developmental conditions, including learning disabilities, language disorders, speech delay, Tourette's syndrome and autism spectrum disorders.
Certain disorders can mimic ADHD.
Children with obstructive sleep apnea or restless leg syndrome may not sleep well and be inattentive during the day.
Children may have had a history of abuse or neglect and have poor coping skills in school. In addition, unresponsive staring off into space could be a sign of seizures and not just daydreaming.
Rarely, a thyroid disorder may also cause hyperactive behavior.
How can we help children with ADHD?
The gold standard for treating ADHD has been the use of stimulant medications that work on the neurotransmitters in the brain.
Studies have shown that anywhere from 70-90% of students will have success with a stimulant medication if dosed correctly.
In the past few years, several new medications have been developed.
A good website to review is www.ADHDMedicationGuide.com.
For young preschoolers, 4-5 years of age, the first treatment is Parent Training in Behavior Management (PTBM).
This may be the only treatment that is needed.
After the six years of age, a single dose long-acting stimulant can be added.
All medications have the potential to cause side effects.
It is also difficult to determine how the child will respond to a particular medication, so the child should be followed closely until the correct dose is found.
There are also some nonstimulant medications available too, but they are not as effective as the stimulant medications.
What about alternative treatments?
Behavioral therapy at school and at home has been helpful in reducing some of the oppositional and defiant behavior seen in children with ADHD.
School-based support with a 504 plan or Individual Education Plan (IEP) should be instituted to give the child extra time for assignments and tests and may include tutoring for learning difficulties.
However, in research studies, mindfulness, chiropractic manipulation of the spine, cognitive training, diet modification, biofeedback, vision therapy, interactive metronome training and sensory integration training have not been helpful for controlling the symptoms of ADHD and are expensive.
Parents should look at research documentation in controlled studies, not just anecdotal success stories when considering therapy.
The use of cannabidiol oil (CBD) has not been looked at in rigorous studies and therefore, could not be recommended as a reliable treatment method.
Although it is FDA approved, the efficacy of external trigeminal nerve stimulation has not been extensively studied.
Some supplements for ADHD, including Omega-3’s, have shown limited success and are mainly used as adjunctive therapy.
ADHD is a chronic life-long disorder with varying degrees of severity.
Close follow-up with the child’s primary care provider is imperative for success.
The Chadd.org website is a wonderful resource for parents beginning the journey to help their child succeed in school but also in life.
Margaret Nemethy, ARNP, PPCNP-BC, has been a Certified Pediatric Nurse Practitioner for more than 27 years. She presently works out of the Pediatrics in Brevard, Melbourne office.
This article originally appeared on Florida Today: Everything you need to know about ADHD and the type of help available
