Parenting a Child With ADHD (cont.)
John Mersch, MD, FAAP
Dr. Mersch received his Bachelor of Arts degree from the University of California, San Diego, and prior to entering the University Of Southern California School Of Medicine, was a graduate student (attaining PhD candidate status) in Experimental Pathology at USC. He attended internship and residency at Children's Hospital Los Angeles.
William C. Shiel Jr., MD, FACP, FACR
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
In this Article
- Childhood ADHD facts
- What are the signs and symptoms of childhood ADHD?
- What should parents do if they suspect their child has ADHD?
- What are the causes of childhood ADHD?
- What should parents of children with ADHD expect from their child?
- What type of medical specialist can help diagnose and treat a child with ADHD?
- What treatment options exist for a child with ADHD? How can parents help their child with ADHD?
- What are the risks of the use of stimulant medication and other treatments?
- What are other therapeutic approaches for children with ADHD?
- Is childhood ADHD on the rise?
- What is the outlook for a child with ADHD?
- What can parents of children with ADHD do to help themselves?
- Find a local Psychiatrist in your town
What should parents of children with ADHD expect from their child?
Children experiencing ADHD should be held to the same expectations as their peers of the same emotional developmental level. Assuming the child has no learning disturbance, children with ADHD will have both academic strengths and weaknesses like all non-ADHD classmates. Athletic ability will vary in a similar manner as will social interaction; some children with ADHD are very outgoing while others are more reserved. Children with ADHD are often noted to be emotionally delayed, with some individuals having a delay in maturity of up to 30% when compared with their peers. Thus, a 10-year-old student may behave like a 7-year-old; a 20-year-old young adult may respond more like a 14-year-old teenager.
What type of medical specialist can help diagnose and treat a child with ADHD?
The initial evaluation of a child whose behavioral issues may be indicative of ADHD can generally by managed by the pediatrician. A current physical examination is indicated to rule out potential medical issues that may either reinforce a potential ADHD diagnosis or rule out the condition. Further history regarding the various behavioral and academic strengths and weaknesses of the child are elicited and it is imperative to gather feedback from both the parents and teacher. If any concerns are developed regarding potential learning disorders (for examples, dyslexia, auditory processing disorders, etc.), specialized testing should be obtained. This evaluation may be secured either through the child's school district or private agencies. Standardized questionnaires (such as Connors Rating Scales) are often used to provide objective evaluations in both the home and school settings. In addition, these scales commonly have sections to evaluate for other mental-health issues (including depression, anxiety, etc.) that may also be present in a child with ADHD. Once a diagnosis is established, a pediatrician can discuss with the patient and the parents the various treatment options. Children whose physical or mental-health history is more complicated may warrant an evaluation by either a pediatrician with specialty training in developmental disorders, a pediatric neurologist, a psychologist, or a psychiatrist. Should a patient have a poor response or excessive side effects to commonly used medications, a pediatric neurologist or psychiatrist consultation may be especially helpful.
What treatment options exist for a child with ADHD? How can parents help their child with ADHD?
The two major components of treatment for children with attention deficit hyperactivity disorder (ADHD) are behavioral therapy and medication.
- Home and school interventions: Parents can help their child's behavior with specific goals such as (1) maintaining a daily schedule, (2) keeping distractions to a minimum, (3) setting reasonable goals, (4) rewarding positive behavior, (5) using charts and checklists to keep a child "on task," and (6) finding activities in which the child will succeed (sports, hobbies). Children with ADHD may require adjustments in the structure of their educational experience, including tutorial assistance and the use of a resource room. Many children function well throughout the entire school day with their peers. However, some patients with ADHD will benefit from a "pull-out session" to complete tasks, review specific homework assignments, and develop "management" skills necessary for higher education. Extended time for class work/tests may be necessary as well as assignments written on the board and preferential seating near the teacher. An IEP (Individualized Educational Program) should be developed and reviewed periodically with the parents. ADHD is considered a disability falling under U.S. Public Law 101-476 (Individuals With Disabilities Education Act or IDEA). As such, individuals with ADHD may qualify for "appropriate accommodations within the regular classroom" within the public-school system. In addition, the Americans With Disabilities Act (ADA) indicates that secular private schools may be required to provide similar "appropriate accommodations" in their institutions.
- Psychotherapy: ADHD coaching, a support group, or both can help teens feel more normal and provide well-focused peer feedback and coping skills. Counselors such as psychologists, child and adolescent psychiatrists, behavioral/developmental pediatricians, clinical social workers, and advanced practice nurses can be invaluable to both the children and families. Behavior modification and family therapy are usually necessary for the best possible outcome.
The medications used to treat ADHD are psychoactive. This means they affect the chemistry and the function of the brain.
Psychostimulants are by far the most widely used medications in treating ADHD. When used appropriately, approximately 80% of individuals with ADHD have a very good to excellent response in reduction of symptoms. These medications stimulate and increase activity of areas of the brain with neurotransmitter imbalances.
The exact mechanism of how these drugs relieve symptoms in ADHD is unknown, but these medicines are linked to increases in brain levels of the neurotransmitters dopamine and norepinephrine. Low levels of these neurotransmitters are linked to ADHD.
Learn more about: dopamine
- The most common adverse effects are short term. They include reduction of appetite, sleep disturbances, rebound (for example, agitation, anger, lethargy as the last dose starts to wear off), and mild anxiety. Most individuals who take psychostimulants for ADHD build up tolerance to adverse effects within a few weeks.
- Individuals with certain coexistent psychiatric disorders (for example, psychosis, bipolar disorder, some disorders of anxiety or depression) are particularly vulnerable to adverse effects if they do not receive appropriate concurrent treatment for the coexistent condition.
The psychostimulants most often used in ADHD include the following:
- Methylphenidate (Ritalin, Concerta, Daytrana patch, Quillivant XR)
- Dexmethylphenidate (Focalin, Focalin XR)
- Dextroamphetamine and amphetamine mixture (Adderall, Adderall XR, Vyvanse)
Atomoxetine (Strattera) is a newer nonstimulant used to treat ADHD. Less is known about its long-term side effects. This drug has several benefits over stimulants, but its use may also carry several negative aspects.
- It is not a controlled substance and is not considered a drug of potential abuse by the U.S. Food and Drug Administration (FDA). Since it is not a controlled substance, pharmacies may accept phone-requested medical refills.
- It is usually taken only once a day for full 24-hour effectiveness.
- It is much less likely than stimulants to disrupt eating or sleeping.
- For some children, atomoxetine is not enough to control their ADHD symptoms. Many other children do very well on this medicine alone.
- Specialists treating individuals with ADHD have found Strattera seems to best help improve the problems associated with a disruption in executive function skills. Inattention and hyperactivity symptoms are less responsive.
- When starting atomoxetine therapy, a gradually increasing dosage schedule is recommended. It may take up to three weeks before full therapeutic benefit is achieved. For this reason, patients may need to remain on previously prescribed stimulant medication during the "build up" phase. In addition, atomoxetine must be taken daily; short-term "medication holidays" (for example, school vacations and weekends) will limit its efficacy.
- Studies have indicated a higher than expected incidence of suicide ideation during early treatment. This occurred in patients with pure ADHD as well as in those patients with ADHD accompanied by other emotional disorders (for example, depression, anxiety, bipolar disorder).
Learn more about: Strattera
Some medications originally developed to treat depression (antidepressants) also have important roles in treating some individuals with ADHD. Since these medicines have been used for many years to treat other mental-health conditions, their adverse effects are well understood.
- Imipramine (Tofranil): an antidepressant that increases levels of neurotransmitters norepinephrine and/or serotonin in the brain
- Bupropion (Wellbutrin): an antidepressant that increases levels of neurotransmitters in the brain, especially dopamine
- Desipramine (Norpramin): an antidepressant that increases levels of the neurotransmitter norepinephrine in the brain
Other medicines that were originally developed to treat high blood pressure (alpha agonists) may also be useful in the treatment of those having ADHD. Again, due to widespread and long-term use, their side effects are well known to doctors.
- Clonidine (Catapres): an alpha agonist that stimulates certain receptors in the brain stem. The overall effect is to "turn down the volume" of hyperactive movement and speech.
- Guanfacine (Tenex, Intuniv): another alpha agonist with an effect similar to that of clonidine. These medications are designed to be used in combination with other medications listed above. They are not effective when taken as a single and only medication.
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