My 7 year old daughter was diganosed with ADHD this year . She has a terrible time in school with reading and math and is below level in both. When having ADHD, can children also have another type of LD with it? And if so what is the most common LD associated with ADHD ? Thank you.
Dr. Karen Miller:
This is an important question to ask as children with ADHD are at high risk for having learning disabilities. ADHD itself is not considered a learning disability though it can interfere with learning, classroom functioning and productivity. There is substantial evidence from brain research that ADHD is related to differences in specific areas of the brain, particularly the frontal lobe, and differences in the functioning of specific brain chemicals (neurotransmitters), particularly dopamine and norepinephrine. These differences are most evident when a child (or adult) must sustain effortful attention, when there are many distractions to filter out, when the task is not highly engaging or there are many details to manage. This situation happens most often in school. Although the studies vary, 25 to 70% of children with ADHD have a learning disability and from 15 to 35% of children with LD have ADHD. Learning disabilities affect other brain areas, such as the temporal and parietal lobes of the brain.
The processing of specific forms of information are impaired and interfere with learning. The most common LD associated with ADHD is a disorder of written expression as writing is a very complicated task that demands sustained attention and organization. Reading comprehension can be affected by ADHD because of impulsive reading and lack of monitoring for meaning. Individuals with ADHD often fatigue during reading and have to re-read text. Inattention to detail (such as operational signs) can impair math. A thorough educational evaluation is indicated.
Resource: Reiff, M.I. and Tippins, S. ADHD: A complete and authoritative guide. (2004) Elk Grove Village: American Academy of Pediatrics Press
Question from Louise Ennesser, West Point Child Development Center:
As I read through what are signs for some LDs, they are the same as the signs for ADD/ADHD. Is there a way to tell if one is a result of the other, behavior wise, or are these children being labeled with both because of the similarities?
Dr. Karen Miller:
Thank you for bringing this up. There is significant overlap in the symptoms of ADHD and learning disabilities. "Inattention" or "off-task behavior" or even "poor reading" are symptoms, not diagnoses. It is rather like saying someone has a fever and a cough. You know something is wrong but not what is causing it. A careful evaluation is needed. You don't just give a random antibiotic and see if the cough gets better. The same is true of medications such as Ritalin. Response (or lack or response) to medication is not a "test" for ADHD. If learning problems are suspected, medication shouldn't be "tried first to see if that fixes things." That would be like putting a bandaid on a wound without taking out the splinter first.
Although there is overlap of presenting symptoms, appropriate testing will help define whether a specific learning disability is present. For example, deficits in phonological processing are seen in Dyslexia but are not part of ADHD. Children with ADHD are often inconsistent and inefficient learners. They often perform better on tests or in 1:1 situations then they do on a day-to-day basis in the classroom. Unfortunately, many children with ADHD also have a learning disability, and management needs to address all their needs.
Question from Anita Gardner, Orton-Gillingham Tutor, Private Practice:
What recommendations do you make to parents of children (middle school age) who have both ADHD & dyslexia who do not chose to use medication for the ADHD symptoms? Parent reports that medication makes no difference in behavior.
Dr. Karen Miller:
Middle-school age children with ADHD and dyslexia can be very challenging to manage. In elementary school teachers knew the individual child well and could modify the environment, the material and expectations. They often communicated with parents. Parents could work with the child at home. In middle school, there are more teachers involved and individualization becomes more difficult. Using a teaching team approach and/or assigning a specific teacher (usually the learning specialist) to act as a mentor or ’champion’ can be helpful for children who have complex learning and behavioral needs. A problem-solving, rather than a blame-finding, approach is critical. Regular meetings should be scheduled rather than crisis meetings only. This allows sharing of strategies that are working and might be applied in other settings. A positive, strength-based, skill-building approach is essential. Demoralization is common and acting-out is often a face-saving strategy at this age. Early adolescents hate being "different" in any way. They would rather be seen as "bad" instead of "dumb." They may resist going to their special classes and refuse parents’ help insisting they can do it themselves "if they wanted to."
If parents/schools take a punitive approach, adolescents may become depressed, gravitate towards peers with lower expectations or self-comfort with drugs or alcohol. Therefore it is critical that the adolescent have an understanding of his/her strengths and challenges, sometimes called "demystification." They can then participate actively in problem-solving collaboratively and creatively. It is often helpful to tie academic tasks to areas of special interest, develop areas of expertise and use strengths to meet expectations in alternative ways (e.g. a video "news report" covering the murders in Hamlet). A weekly monitoring sheet can be very helpful in communicating how things are going, assignments (current/missing/upcoming) and project deadlines or tests.
Medication that made "no difference" may warrant a consultation with a physician with more expertise in complex ADHD, co-morbid conditions and medication such as a developmental-behavioral pediatrician or child and adolescent psychiatrist. Stimulant medication, such as RitalinÂ® (methylphenidate) or AdderallÂ® (mixed amphetamine salts) are highly effective but more than one medication should be tried and at more than one dose level. As the medication may be worn off when the child sits down to do homework, parents may perceive that the medication is "not working." New extended release formulations (Concerta or Adderall XR) and non-stimulants such as StratteraÂ® (atomoxetine) are available and might be helpful.
For some excellent ideas on working with teens with ADHD (and LD) look at "Teaching Teens with ADHD: A quick reference guide for teachers and parents" (2000) by Chris A. Zeigler-Dendy, published by Woodbine House. Also Chris and her son Alex wrote "A Bird's-Eye View of Life with ADD &ADHD: Advice from Young Survivors: A Reference Book for Children and Teens" (2003) published by Cherish the Children Press. They are available at www.chrisdendy.com.
Question from Angela Schieber, Undergraduate, Argosy University:
I am a pre-k teacher. Can you offer suggestions to help the classroom enviroment when a student has been diagnosed with ADHD, yet the child's Pediatrician will not allow the child to take medication because of young age?
Dr. Karen Miller:
Young children with ADHD often present with hyperactivity and impulsivity, oppositionality and emotional regulation problems. Attentional problems emerge later but are the most persistent. Some young children who present with impulsive or inattentive behaviors behavior actually have a language disorder and are pushing others because they can't find the right words or wander off from story time because they don't comprehend the story being read. Inability to sit upright and still in circle or bumping into others may indicate sensory processing or motor disability instead of ADHD. A child may have a stressful homelife with inconsistent parenting or nurturing.
The first step in adapting the environment is to define a child's strengths and weaknesses by obtaining a comprehensive evaluation including hearing and vision screening. Education of the family including training in effective behavior management is the foundation of the treatment of ADHD. Referral to parent support groups, such as ChADD (Children and Adults with ADHD -- www.chadd.org) is often very helpful for information and support.
Young children with ADHD (and all children) benefit from an educational environment that is loving, nurturing, safe and predictable. Expectations should be stated clearly, explicitly and in positive terms. Instead of "don't run," state "we walk in the hall." Practice the behaviors that are important such as lining up or using quiet voices. Use visuals, such as schedules, stop signs (on door or cabinets that are off limits) or to show target behaviors (photos of child seated quietly looking attentive). Keep control of your materials, explain first, hand out stuff second. Give the child with ADHD opportunities to move legitimately (with permission) such as helping to pass things out. Use proximity. Stay close, monitor and redirect before problems escalate. Create situations that increase the likelihood that children 'get it right' and offer praise when even a part of the right behavior occurs (raises hand but then calls out).
I would recommend Clare B. Jones' "Sourcebook for Children with Attention Deficit Disorder: A management guide for early Childhood professionals and parents." (1995) published by Communication Skill Builders, Division of The Psychological Corporation, San Antonio, TX. (800) 228-0752. (birth to 6 years).
With regards to medication in young children, I agree that caution is appropriate. Medication may be appropriate when the ADHD is severe, psychosocial supports have failed and/or a child's safety is at risk. For a thoughtful review of this topic by top experts see: "Pharmacological Management of Preschool ADHD," by Kratochvil, Christopher J.; Egger, Helen; Greenhill, Laurence L.; and McGough, James J. Journal of the American Academy of Child & Adolescent Psychiatry. 45(1):115-118, January 2006.
For scientifically-based information on medication and ADHD see the CH.A.D.D (Children and Adults with Attention Deficit Disorders) website, www.chadd.org, and the federally funded National Resource Center (NRC) website, http://www.help4adhd.org or use their toll-free number (800-233-4050); English and Spanish.
Question from Audrey Zinman, Parent LD/ADD Children:
1. Would you advise getting an EKG for all children taking stimulants? Are they safe given all the negative press?
2. Should I as a parent anticipate that my children will be taking this medication through adulthood or should I be focusing on coping strategies so that they can learn to compensate and function without meds?
Dr. Karen Miller:
Articles in the press about stimulant medication safety have alarmed many families. Stimulant medications have been used for more than 60 years in children and have been shown to be safe and effective. Side effects do occur but they are generally mild and transient when the medications are carefully adjusted and monitored for effects on appetite, growth, sleep and emotions. Rarely stimulants may bring out tics (involuntary twitches) but they do not cause Tourette syndrome (a genetic disorder). Psychiatric symptoms, including hallucinations, have been reported, though very rarely.
It has been known that stimulants can cause slight increases in heart rate or blood pressure and some people may experience fast heart rate (tachycardia) or elevations in blood pressure that require discontinuing the medication. Abuse of stimulants can result in serious side effects including heart attacks and stroke.
In February 2005 Health Canada (the equivalent of the U.S. Food and Drug Administration) banned Adderall XR because of reports of sudden deaths. Between 1992 and 2005 there were 13 deaths of children taking Adderall. Six of the 13 had structural cardiac defects. Others had toxic levels or were exercising in extreme heat. During that time more than 70 million prescriptions had been written for Adderall resulting in a rate of less than 1 in a million. As unpleasant as it sounds, every year children die unexpectedly and for no identifiable cause. The rate is about 1 in 100,000. CDC data indicates that in 1999 there were 226 "sudden unexplained deaths" in children between 5 and 14 years in the U.S. Health Canada and allowed Adderall back on the market in August 2005 as they "cannot prove or clearly associate Adderall with an increased risk compared to available therapies." There was NO media attention paid to this bit of news.
The FDA had already reviewed the data on stimulants in August 2004 and stated that there was already a warning about the risk of abusing stimulants and revised the label to include a warning about using stimulants when there are structural heart defects. They also felt more research needed to be done to investigate safety of ADHD medications.
An FDA panel was convened in February 2006 to discuss cardiovascular effects of stimulants on adults with ADHD. One of the panelists, an adult cardiologist, felt there were too many prescriptions being written for ADHD medication. He convinced the panel (8 to 7 with 1 abstention) to recommend a "black box" warning to "send a message." This ignited the media firestorm. The media ignored the FDA pediatric advisory panel that met in March 2006, reviewed all the data, did not recommend a black box and supported the revised wording. A revised information handout is being developed and further research recommended.
So what am I doing? I am reviewing patient and family cardiovascular history, I look for a family history of sudden death or cardiac death before 50, a history of heart rhythm disorders or fainting with exercise. I am not getting EKGs on everyone. I am referring selected patients to see a cardiologist as structural heart problems may not be detected by an EKG or listening for a murmur.
With regards to taking medication through adulthood, it needs to be remembered that most children with ADHD will continue to have symptoms into adulthood. ADHD in adults can be a very serious disorder. There is a significantly increased risk of automobile accidents and deaths, lower educational attainment, poorer occupational functioning and higher rates of divorce, trouble with the law, substance abuse, depression and suicide. Will medication alone prevent these negative outcomes? No. Some adults do continue to benefit from medication and other treatments including coaching because life only gets more complicated. Some adults find that when they can find things to do that they are passionate about and have people who support them, they can use their differences to make a difference in the world.
- Villalba, L. Safety Review: Sudden death with drugs used to treat ADHD. February 28, 2006
- American Academy of Pediatrics, Subcommittee on Attention-Deficit/Hyperactivity Disorder and Committee on Quality Improvement, Clinical practice guideline: treatment of the school age child with attention-deficit/hyperactivity disorder. Pediatrics 2001;108:1033-44.
- Barkley, R.A.; MCMurray, M.D.; Edelbrock C.S.; and Robbins, K. Side effects of methylphenidate in children with attention deficit hyperactivity disorder: a systematic, placebo-controlled evaluation. Pediatrics 1990:86:184-92.
- Gutgesell, H.; Atkins, D.; Barst, R., et al. American Heart Association Statement: Cardiovascular monitoring of children and adolescents receiving psychotropic drugs. Journal of the American Academy of Child Adolescent Psychiatry (1999); 38(8), 1047-1050; http://circ.ahajournals.org/cgi/content/full/99/7/979.
- Findling, R.L.; Short E.J.; and Manos, M.J. Short-term cardiovascular effects of methylphenidate and Adderall. Journal of the American Academy of Child Adolescent Psychiatry. 2001;40:525-529
Question from Rose Mary Morris, teacher, Hancock County Schools:
I have a student who has Math/Reading LD and ADHD. Sometimes his mother doesn't have the money to buy his mediciine. So when he comes to school without it, he is very disruptive. When he doesn't take his medicine, what am I to do with him all day at school? I co-teach with a specialist who comes in during Math and Reading. We can get through the instruction while she there. But when she leaves it is very difficult to teach the other subjects. What do you suggest??
Dr. Karen Miller:
One resource that might be helpful to this parent is the Partnership for Prescription Assistance, which brings together America's pharmaceutical companies, doctors, other health care providers, patient advocacy organizations and community groups to help qualifying patients who lack prescription coverage get the medicines they need through the public or private program that's right for them. Many will get them free or nearly free. Its mission is to increase awareness of patient assistance programs and boost enrollment of those who are eligible.
Through their Web site, the Partnership for Prescription Assistance offers a single point of access to more than 475 public and private patient assistance programs, including more than 150 programs offered by pharmaceutical companies. To access the Partnership for Prescription Assistance by phone, you can call toll-free, 1-888-4PPA-NOW (1-888-477-2669).
I do not have an easy solution to handling him when he's off-medicine all by yourself. I would consider requesting a Functional Behavioral Assessment and have a behavioral specialist consult to your classroom as there are many positive behavioral strategies and supports that might be helpful. Certainly a classroom aide should be considered and the FBA could document the need.
My favorite resources for teachers are:
- How to Reach and Teach ADD/ADHD Students: Practical techniques, strategies, and interventions for helping children with attention problems and hyperactivity revised. Reif, Sandra. (2005) Jossey-Bass.
- All about ADHD: the complete practical guide for classroom teachers by L.J. Pfiffner. (1999)Scholastic Paperbacks.
Question from Cindy Baumert, Education Advocate:
To qualify for OHI eligibility under IDEA 2004, can the ADHD diagnosis be made by a psychologist based on rating scales done by parent/teacher and classroom observation, or must it be done by a medical doctor? I understand that in order to obtain medication as a treatment for ADHD, it can only be prescribed by a medical doctor. My question is not regarding treatment, but who is able to diagnose ADHD for the purposes of eligibility for IDEA 2004. My question stems from the fact that I've seen school district procedures that dictate that the child is not eligible to receive services until the school receives a diagnosis from a medical doctor, even if the school psycholgist has diagnosed the child with ADHD based on rating scales and observation.
Dr. Karen Miller:
According to the U.S. Department of Education, children diagnosed with AD/HD who meet the eligibility criteria under "Other Health Impaired"(OHI) have always been eligible for special education services. While this was clarified by the 1991 Policy Memorandum issued by the U.S. Department of Education, the regulations implementing the Individuals with Disabilities Education Act (IDEA) Amendments of 1997, issued March 12, 1999, for the first time explicitly incorporate AD/HD within the definition of "Other Health Impaired."
Children with ADHD do not automatically qualify for special education services under OHI. In order for a student to qualify the following criteria must be met:
a) the student must be diagnosed with AD/HD by the school district, or the school must accept the diagnosis rendered by another qualified professional;
b) the AD/HD must result in limited alertness to academic tasks, due to heightened alertness to environmental stimuli;
c) the effects of the AD/HD must be chronic (long-lasting) or acute (have a substantial impact);
d) this must result in an adverse effect on educational performance;
e) the student must require special education services in order to address the AD/HD and its impact.
An adverse effect on educational performance can be an impact on any aspect of a child's functioning at school, including educational performance as measured by grades or achievement test scores. Failing grades may be evidence of a disability, but are not a required to establish a disability. Conversely, the fact that a child is getting failing grades does not automatically mean the child has a disability or is entitled to special education. Adverse effect can also be manifested through behavioral difficulties at school; and impaired or inappropriate social relations; impaired work skills, such as being disorganized, tardy, having trouble getting to work on time and difficulty with following the rules. Schools are required to address the effects of a child's disability in all areas of functioning, including academic, social/emotional, cognitive, communication, vocational and independent living skills.
For educational purposes, local school district policy determines whether a medical evaluation is required. Most states and school districts require a medical diagnosis of ADHD and a physician's statement of such to qualify a student under OHI. Some states/districts do not require a medical diagnosis and may utilize its multidisciplinary team, including a psychologist or other professional qualified to diagnose AD/HD, to make the determination for educational purposes. Of course, a medical evaluation may also be desirable, as it can rule out other causes for the problem and determine if medication would be an appropriate of the child's treatment.
Speaking of medication, IDEA 2004 specifically states that a school district cannot require a student to be on medication as a condition of attending school, receiving an evaluation or receiving services. It permits school personnel to consult and share classroom based observations with parents or guardians regarding child's academic or functional performance or behavior or regarding need for evaluation for special education or related services.
Finally, if the student with ADHD does not qualify for special education services under IDEA, he/she may be eligible to receive accommodations under Section 504 of the Rehabilitation Act of 1973 if there is an identified physical or mental impairment that substantially limits a major life activity. The diagnosis of AD/HD is not enough; the AD/HD must significantly impact learning or behavior.
For more information on IDEA 2004, Section 504 or special education law, go to NCLD's Parent Center and also www.wrightslaw.com. In addition to their guide to IDEA 2004, Pam and Pete Wright's "From Emotions to Advocacy: The Special Education Survival Guide" is very useful.
Question from Leslie Miller, Program Manager, Reach Out Morongo Basin:
Good Day Dr Miller, thank you for presenting this topic. While these children are being diagnosed for disabilities are they also evailuated for their areas of strength too, areas of talent, special abilities, and are these included into the treatment plan? Thank You.
Dr. Karen Miller:
Thank you Leslie, you bring up an important point. It is critically important that evaluations described strengths as well as areas of challenge. Everyone has uneven skills as well as traits that can be a liability in one setting but an asset in another. For example, whether we call someone "stubborn" or "persistent" depends on if we like what they are doing or not! I often "reframe" teacher or parent concerns into positive terms to help them change how they think about the child. I may talk about a child having "high energy" and discuss how we can direct that energy towards useful activities. Saying he's "hyperactive" sounds like there is nothing you can do about it and discourages problem-solving.
Talents and special interests are extremely valuable skills to use when designing a treatment plan. If a child knows a lot about bugs, she might be allowed to read, write and do math problems about bugs. She knows the content and so she can focus on practicing the target skills with more interest. She can develop expertise and be recognized for it. She might be called on to consult on a particularly large bug crawling up the wall and gain social status for her knowledge. That's the way it works in the adult world. We value expertise, special knowledge and unique talents. We need to be sure that we nurture those areas of expertise or what Dr. Robert Brooks calls "islands of competence." We need to value diversity of talents in our classrooms and in our daily lives.
- Raising Resilient Children: Fostering strength, hope and optimism in your child, by Robert Brooks, and Sam Goldstein. (2004) McGraw Hill: NY.
- One Mind At A Time, by Mel Levine MD. (2002) Simon and Schuster, Inc.
Question from Addie Cusimano, Semi-retired, Diagnostician and Reading Specialist:
When one of my clients was in kindergarten, her teacher complained about her lack of attention to the task at hand. She had multiple problems with hearing, tubes, etc. at the time. She was tested by the school psychologist and also by me as an outside source. Both evaluations were in agreement. The child has a very high IQ. She had no weaknesses in reading or math readiness, but weaknesses in visual sequential memory and serious weaknesses in auditory sequential memory. Her teacher and parents were asked to assess the child's activity for possible ADD or AD/HD by filling out the Conner Questionnaire. Based on the responses, the child was diagnosed by the pediatrician as a child with a "mild attention deficit disorder." My feeling was that her lack of attention and focus was primarily due to her serious auditory memory (attention, listening and recall) deficiencies, not an attention deficit disorder. However,the pediatrician decided to put her on Adderall.
I have worked with her on a one to one basis expanding her basic skills and developing her visual and auditory sequential memory skills. In addition, an operation to correct a mild hearing loss had added to her ability to be able to focus and attend in class. It is a delight to work with her and she has blossomed! The child is now at the end of third grade. Her reading is well above grade level, her comprehension and reasoning skills are excellent, her math skills are good, her visual and auditory memory skills are now well above average and she performs very well in a challenging private school.
My question for you is, should this child be weaned now from the medication? The parents are concerned that she will slide backwards if the medication is discontinued, while I feel that medication, in this case, was not warranted from the beginning. I also feel that now that the child has very good basic and listening skills, she will be able to perform well on her own, without medication.
What has your experience been in weaning children with mild attention deficit disorder from medication once their learning skills are well developed? Thank you.
Dr. Karen Miller:
For purposes of this discussion, let's assume this child had mild ADHD complicating some learning issues. ADHD is a chronic disorder in the majority of cases with 70% of children continuing to qualify for the diagnosis in late adolescence and 50% as adults. The more obvious signs, hyperactivity and impulsivity, diminish over time but attentional and organizational ("executive function deficits") are often persistent. When learning problems are added, mild attentional problems can make it very hard to compensate. Imagine having a reading disorder and needing glasses to focus on the page. Finishing your reading assignment will be very difficult. Getting glasses (like taking medication for ADHD) may help the focusing, but that doesn't teach the skill. Educational and behavioral supports will still be needed.
Whenever I put a child on stimulant medication I conduct a systematic medication trial. I start with a lower dose than I expect to work and increase weekly usually trying 3 different doses of one of the shorter acting medications. I use a simple rating scale such as the Child Attention Profile scale. I obtain a baseline rating before I start medication and then home and school ratings on each dose tried. I also get a baseline assessment of problems such as sleep, irritability and appetite so that I can determine if there is a true change on medication. Medication must be substantially beneficial with no significant side effects to be continued. Longer-acting medications can tried once the correct dose is determined. Doses and schedules are very individualized.
At each medication check we discuss the role of medication and the appropriateness of continuing. It should be noted that individuals with ADHD are notoriously poor at assessing effects of medication. If it is adjusted correctly, they feel normal. People don't notice feeling normal and alert. Most children and adolescents stop medication too soon. I discuss stopping medication often because it is best to do a systematic trial off. Timing is important. I never do a trial off at the start of the school year. My rule is if you finish the school year on medication, you start the new school year on medication. We wait for 6 weeks for things to stabilize or at the beginning of a quarter. Ratings are obtained while still on medication and then off medication at the 2, 4 and 8 week marks.
The inconsistent performance associated with ADHD may take some time to become problematic especially at the upper grades where teachers are less aware of student slumps. This is often a good time to be working with the child on organizational strategies which will continue to be an issue on or off medication. Remember that medication acts like eyeglasses, they help you focus on what's in front of you but don't tell you what to do next or what's due next week.
Question from Dr. Sheldon Horowitz:
Part of the 'mythology' about ADHD is that it is a male thing, that is to say, many people think that ADHD is more prediominent in boys than in girls. Differences in attention-seeking behaviors, verbal expressive skills, motor skill development and adult expectations are clearly important considerations when looking at (and for) ADHD in boys vs. girls. Can you share some thoughts about special challenges when it comes to the diagnosis and treatment of ADHD in girls?
Dr. Karen Miller:
Great question! When ADHD was primarily described as "hyperkinesis" and focused on the obvious behaviors of hyperactivity, impulsivity and acting out, the majority of children REFERRED for evaluation were boys. In some clinical studies the reported prevalence was 9 boys for each girl. We now know that ADHD is an equal opportunity disorder and in adults the ratio is just about equal male:female! Girls can be as hyperactive and impulsive as boys but more often they are quietly inattentive, "too social" or written off as being less academically capable. There has been a great deal of interest in this area led by experts such as Patricia Quinn, MD and Kathleen Nadeau, PhD who started a wonderful website and resource www.ADDvance.com. It has resources including a checklist for girls and women of "red flags" for ADD in females. Women have a higher incidence of depression and anxiety that often mask the underlying ADD. They may do well in the structure of the office but fall apart when overwhelmed by the details of being a mother and running a household. Treatments are similar but ADD coaching and support groups can be extremely helpful. Medication response is similar though PMS is often increased in ADHD women! I recommend the book: Understanding Girls with AD/HD. (1999) Nadeau K., Littman E.B., and Quinn P.O. Advantage Books, Silver Spring, MD, 1-888-238-8588.
Question from Ruth Kalton, teacher, Ramaz Lower School, Manhattan:
At what age is it advisable to have children tested for attentional concerns? What criteria are necessary to advise parents to have their children evaluated?
Dr. Karen Miller:
Between 3 and 7% of school-age children have AD/HD according The Diagnostic and Statistical Manual, 4th edition Text Revision (DSM-IV TR). AD/HD is the most current term for children (or adults) who experience levels of inattention and/or hyperactivity and impulsivity that are excessive for their age and causes serious problems for them in more than one setting (home, school, friends, play or work).
Symptoms of ADHD typically arise in early childhood with hyperactivity and impulsivity becoming problematic between 2 to 5 years of age. Some mothers (who already had one child with ADHD) swear they knew when they were pregnant that this child would also have ADHD. They were usually right. Some children with primarily inattentive issues may not come to anyone's attention until elementary school or later, especially if they are bright. It often becomes evident when the assignments get longer, the details increase and there are more organizational demands. They can no longer "half-listen" or rely on their background knowledge. Sometimes an adult first realizes their life-long struggles were due to ADHD when their own child is diagnosed.
Symptoms of inattention can include:
- Often fails to give close attention to details or makes "careless" errors
- Often has difficulty sustaining attention in tasks
- Often does not seem to listen
- Often does not follow-through on tasks or instructions
- Often has difficulty with organization
- Often avoids or dislikes tasks that require sustained mental effort
- Often loses things
- Often easily distracted
- Often forgetful
Symptoms of hyperactive/impulsivity can include:
- Often fidgets or squirms
- Often leaves seat when sitting is expected
- Often runs or climbs excessively for situation
- Often has difficulty playing quietly
- Often acts as if "driven by motor"
- Often talks excessively
- Often blurts out answers
- Often has difficulty waiting for turn
- Often interrupts or "butts in" to others' activities
Many children have attentional problems but only some of them will have ADHD. Some will have other problems contributing to their inattention. Others will have a temperament that is a little more active but doesn't interfere with their functioning. If a child is experiencing difficulty with behavior, focusing, social interactions or learning, then an evaluation that looks at all aspects of development should be initiated. If the child is less than 3 years of age and having self-regulation problems, they should undergo Early Intervention evaluation. If they are over 3 years of age then the school district is responsible even if they are not in a public school setting.
Here are some helpful resources:
- Diagnostic and Statistical Manual of Mental Disorders, 4th ed- text revision.: DSM-IV-TR. (2000) Washington, DC: American Psychiatric Association.
- The Office of Special Education Programs (OSEP) within the Department of Education's Office of Special Education and Rehabilitative Services (OSERS) has put together a free guide entitled Identifying and Treating Attention Deficit Hyperactivity Disorder: A Resource for school and home. The document can be found online or by phone at 1-877-4-ED-PUBS.
- Reif, S., How to Reach and Teach ADD/ADHD Students: Practical techniques, strategies, and interventions for helping children with attention problems and hyperactivity. (revised, 2005). San Francisco: Jossey-Bass.
Question from Shira Nahmias, Special Education Itinerant Teacher, Cooke Center for Learning and Development.:
As a special educator working with young children with special needs, it seems that often times in working with children with ADHD, the aspect of learning disabilities can be overlooked. Parents and teachers alike seem to be concerned with the ADHD aspect and how to address impulsivity while working on ways to help the child academically sometimes takes a back seat. Is there any advice you can offer on how to address both issues simultaneously? Also, are there diagnostic tests or screeners that address both LD and ADHD?
Dr. Karen Miller:
ADHD, particularly if there is significant impulsivity and hyperactivity, is a noisy and irritating problem for the adults. They want the troublesome behaviors that they can see to stop because of the disruptive effects on the adults and other children. Learning problems are mainly a problem to the child, and they often just struggle quietly. It has been shown that the reason boys are identified with learning disabilities is because they tend to be more disruptive when they struggle and get referred for evaluation. Children with ADHD or LD benefit from:
- Structured, calm and emotionally-safe learning environment
- Highlight key information. Preview to give big picture, teach the lesson and then review important points
- Alternate lesson types, active/sedentary tasks and easy/difficult material
- Speak clearly, at a moderate pace with animation, emotion and emphasis
- Breakdown tasks
- Provide visuals (checklists, written notes, schedules)
- Teach strategies and problem-solving
- Praise EFFORT, not just product or grade
- Check for comprehension but discreetly; avoid humiliation
- Find a "helper role" for the struggling child; either a classroom chore or working with younger children.
With regards to screeners, red flags may be found for learning and attention problems on some behavioral questionnaires but as the symptoms often overlap a complete evaluation is usually needed.
- A good review of screening rating scales is available at the Massachusetts General Hospital School Psychiatry website
- >DuPaul G.J., and Stoner, G. ADHD in the Schools: Assessment and intervention strategies. 2nd ed. , (2003) New York: Guilford Press.
- Swanson, H. Lee; Harris, Karen R. Handbook of Learning Disabilities. (2003). New York, NY, US: Guilford Press.
Question from Yolanda Font, Mtg Loan Shipping Specialist:
Hi, I have a child 7 years of age. She was diagnosed with ADHD by her pediatrician. She had a psychological exam done in her kindergarden year. Her pediatrician recommends to give her Concerta medicine, but I want to wait for later years to see if she gets better. I researched Concerta and it is like a amphetamine drug and it's habit forming. Please advice as to what other options I may have for my daughter. Thank You.
Dr. Karen Miller:
Treatment of ADHD begins with comprehensive diagnosis and interventions that address all the areas of needs. Research has documented the helpfulness of certain interventions including education about ADHD for the child and the family, academic modifications, positive behavior modification and management strategies, treatment of any associated conditions (learning disabilities, depression, anxiety, etc) and often, medication.
It is excellent that you are trying to get more information about your child's condition and asking questions about what you read. There is a lot of misinformation about ADHD around. I would suggest starting with the following reliable, scientifically-based resources:
- Reiff, M.I. and Tippins S. ADHD: A complete and authoritative guide. (2004) Elk Grove Village: American Academy of Pediatrics Press.
- Wilens, T.E. Straight Talk about Psychiatric Medications for Kids. (revised edition 2002). Guilford Press, NY (800-365-7006).
- CH.A.D.D (Children and Adults with Attention Deficit Disorders) website. The federally funded National Resource Center (NRC) website, http://www.help4adhd.org, toll-free number (800-233-4050); English and Spanish.
Just to comment on your concerns about Concerta. ConcertaÂ® is a long-acting form of methylphenidate which is the same medicine that is in RitalinÂ® and MetadateÂ®. Methylphenidate and other stimulant medications have been used to treat children with attentional problems for more than 60 years. They have been the subject of hundreds of rigorous scientific studies that show they are highly effective in improving the core symptoms of ADHD-inattention, impulsivity and hyperactivity. There are now several different medications (and brands) that can be useful. When stimulant medications like Concerta are taken by mouth and in the doses prescribed by a doctor they are not habit-forming or addictive. Adolescents and adults can misuse these medicines by taking very high doses, snorting medication or mixing it with other drugs or injecting it and can become addicted and do harm to themselves.
However, studies have actually shown that treating ADHD with medication may actually reduce the risk of substance abuse when the child becomes a teenager. This is because when children are appropriately treated for their ADHD they do better in school, are more successful with peers and have higher self-esteem. This makes them less likely to self-medicate with drugs of abuse or alcohol to feel better.
Research studies on stimulant medication and risk of substance abuse
- Beiderman J., Wilens T.E., and Mick E., et al. Pharmacotherapy of ADHD reduces risk for substance abuse disorder. Pediatrics. 1999:104(2):e20.
- Fischer M., Barkley R.A., Childhood stimulant treatment and risk for later substance abuse. Journal of Clinical Psychiatry. 2003;64 (suppl II):19-23.
Links on medication:
- National Resource Center for ADHD "Medication Management"
- Information on ADHD is also available in Spanish at http://www.help4adhd.org/espanol.cfm.
Question from Judith D McGarry, elementary teacher:
Do you recommend anything in the vitamin/herbal/holistic area? We have used L-Tryptophan in the past for our son. A good multiple with an added B-50 Complex seemed to help for the ADHD. We also used Valerian at night for our son to go to sleep.
Dr. Karen Miller:
Many families would like to avoid using medications to treat ADHD and explore complementary and alternative treatments feeling they are more safe and "natural." Dietary supplements are not subjected to the same requirements for safety and efficacy as medications. Potency and purity vary. Some supplements have been associated with serious side effects (such as tryptophan) or are toxic when taken in "mega doses" such as vitamin A or iron. Although there have been some intriguing preliminary studies, the scientific evidence varies from fair to none for most supplements.
Personally, I think Omega-3 supplementation may be reasonable as our diets tend to be poor in omega-3s. There is some evidence that it may be helpful for ADHD, mood and anxiety but research is still limited. Most children with a well-balanced diet don't need supplements. If they are very picky, a multi-vitamin may be considered. There have been some studies suggesting Melatonin can be helpful for sleep problems in ADHD and autism. Special diets have not been shown to be helpful in general though perhaps up to 5% of children may benefit from elimination diets, primarily preschool children with irritability and sleep problems.
Careful studies have not shown elimination of sugar to be helpful for ADHD though most children would benefit from less refined sugar in their diet. There is some emerging data supporting EEG biofeedback (neurofeedback) but well-controlled studies are needed before this expensive and time-consuming intervention can be recommended. There is a study showing that children with ADHD benefited from playing in natural, green spaces compared to concrete play areas. I often recommend yoga and martial arts (with appropriate instructors and programs). There are some preliminary data supporting yoga.
Parents should consider traditional or complementary approaches as experiments. Each child and their situation has unique characteristics. Try one thing at a time. Collect data, preferably from more than one source to objectively assess response. Tell your physician about any supplements used as there can be interactions and reactions that can be serious.
- FDA and dietary supplements
- Complimentary and controversial treatments:
- National Center for Complementary and Alternative Medicine
- Chan, E., Rappaport L.A., and Kemper K.J., Complementary and Alternative Therapies in Childhood Attention and Hyperactivity Problems. Journal of Developmental and Behavioral Pediatrics. (2003) 24(1):4-8
- Arnold, L.E., Treatment Alternatives for Attention-Deficit/Hyperactivity Disorder. In: Jensen, PS & Cooper, J (Eds.). Attention Deficit Hyperactivity Disorder: State of the Science; Best Practices. Kingston, NJ: Civic Research Institute, 2002.
- Richardson, A.J; and Puri, B.K. A randomized double-blind, placebo-controlled study of the effects of supplementation with highly unsaturated fatty acids on ADHD-related symptoms in children with specific learning disabilities. Progress in Neuro-Psychopharmacology & Biological Psychiatry. Vol 26(2), Feb 2002, 233-239.
Question from Ana Pacheco, graduate student:
Hi, I was diagnosed with a reading disorder while I was studying to become an attorney and was told I had "borderline" ADD as well. My question is whether reading disorders are categorized as learning disablilities or physical/psychological disabilities? I would also like to know if it is possilbe to have borderline ADD and how much it can affect functioning. Thank you.
Dr. Karen Miller:
Thank you Ana for this question. When the term ADD or ADHD is used it sounds like it's one thing. I like to use the term Attention Deficit Disorders because of the broad spectrum from severe and very disabling to mild and only intermittently affecting function. To qualify as a Disorder with a capital "D", symptoms must be substantially impairing function in more than one setting. Otherwise I call it an "attention PROBLEM" but not Attention Deficit/Hyperactivity DISORDER. We all have times when we can't focus or are disorganized. It is only considered ADHD if the symptoms are significant, chronic and pervasive. Even mild symptoms can be real problems and are important to address. Figuring out where the breakdown points in your day or task might be is critical to problem-solving about how to be more successful. Even things like having a large wall calendar that has the whole year at a glance rather than month by month can be very helpful and could prevent missed appointments. Putting your keys in the same spot or having a box by the door to collect "stuff to go" may help the day start better. See the www.chadd.org website for more information on ADD in adults. Good luck!
Question from Genie Taylor, Mother:
Is there suppose to be some type of monitoring for a child with ADD taking Concerta, other than annual blood tests? The pharmacist sends us letters stating that my child’s dosage should be checked, because she has been taking the same dosage for four years now. When I speak with her pediatrician, he states that everything is fine. Her schoolwork remains at a constant C average, and she is frustrated that she studies and pay attention in school, but her grades stay the same. The psychiatrist who evaluated my child four years ago referred her to see a social worker once a week for about six months. After that, they both said that she no longer needs it, and that her pediatrician could write her monthly prescription. What can I do to help my child?
Dr. Karen Miller:
You asked two good questions. First, there is the question of monitoring. Routine monitoring for children who are doing well on a stable dose involves visits about every 4 months or 3x a year to check progress (bring report cards, test results and a note from the teacher), physical exam (height, weight, blood pressure, heart rate), interview of the child and parent and if possible, rating scales, such as the Vanderbilt ADHD Rating Scale which is in the public domain. Your pediatrician can obtain an ADHD Toolkit for Clinicians from the American Academy of Pediatrics which includes information on diagnosis, treatment, monitoring as well as rating scales and handouts in English and Spanish. (http://www.aap.org/bst/showdetl.cfm?&DID=15&Product_ID=3970.
Although the medications labels state that periodic CBC testing should be done, there is little evidence that this blood testing is needed. As part of the diagnositic workup it is appropriate to check for anemia and lead if indicated. I only do blood work if clinically indicated. I only do electrocardiograms, brain wave tests, brain scans when there are suspicious symptoms or history. With regards to your second question, once a correct dose of medication is achieved many children are stable on that dose for a long time. However, it is important to consider trials of higher doses as studies have shown that most children and adolescents are underdosed. It is rather like eyeglasses, your prescription may change unpredictably and have nothing to do with how big you are. You want the right eyeglass prescription and also the right dose of medication. Stimulant medications should not be automatically prescribed on a weight basis.Some adolescents may need a lower dose than they did when younger because of brain development. Work closely with your child, teaching team and physicians to get maximum benefit and be sure that other issues (learning, emotional, medical problems, etc) are not being ignored.
Question from Sue Bradsher - 5th Grade Teacher - Oakwood Elermentary School:
Would you please discuss the common characteristics of ADHD and Sensory Integration Disorder? Can sensory needs mask as ADHD symptons? Can sensory seeking behaviors exaserbate ADHD behaviors? What role does Ritalin play in calming/decreasing sensory seek behaviors?
Dr. Karen Miller:
As your question implies there is a good deal of overlap between some of the symptoms associated with ADHD and what has come to be called Sensory Processing Disorder (SPD). There are no globally accepted criteria for SPD but there is more research being done which will help it be more accepted in the scientific community. Shared characteristics may be feeling "wound up" in busy environments, seeking sensory input (needing to touch things or move around) but also having variable arousal/alertness levels or withdrawing in confusing settings. A comprehensive history and careful evaluation are critical. Many families find the methods used by occupational therapists to be helpful and practical while others derive little benefit. One resource to look at might be The Out-of-Sync Child: Recognizing and coping with sensory integration dysfunction by Carol Stock Kranowitz; New York : Perigee Book, 1998. (800) 788-6262 http://www.penguinputnam.com. Also: The Out-of-Sync Child Has Fun: Safe activities for home and school.
If a child has ADHD, Ritalin seems to help tighten up the "filter system" of the brain so that unimportant stimuli get filtered out and it is easier to pay attention to the really important things. It is like the difference between studying in Grand Central Station versus the library. Ritalin also helps with the "brake system" and allows a child to inhibit or stop their first reaction and choose whether it is the right action or emotional response. Ritalin does not act as a tranquilizer. In fact it stimulates areas of the brain that are underactive so they can function correctly.
On the correct dose of Ritalin, a child with ADHD can be as active as the other kids on the playground but can also settle down when it is time to come in and do paperwork. Ritalin improves the regulation centers of the brain (executive functions). ADHD really isn't about an attention deficit (they can pay attention to videogames just fine!) but it is a disorder of the regulation/allocation of attention - what they pay attention to and for how long. Hopefully with adult support they will be better able to choose the right thing to pay attention to and be more successful and comfortable in more situations.
Question from: Anonymous
How can a parent with ADD help their child be organized and have daily routines? I feel I need to learn, before I can help my child. Is there help available for adults with ADD? My child and I both suffer with ADD as well as severe depression.
Dr. Karen Miller:
I admire your determination to seek help for yourself and your child. Both ADHD and depression often run in families and can make day-to-day functioning challenging. Obtaining a comprehensive assessment for yourself and your child is essential. The results can feel somewhat overwhelming and you will want to work closely with mental health professionals to support your needs and those of your child. Family therapy can be very useful in helping families change negative interaction patterns and focus on building loving and positive relations and collaborative problem-solving instead of blaming. Medications may be needed that address both the ADHD and the depression. Finding the right medications can be tricky but don't get discouraged. Be sure to find FUN things to do as a family. Laugh a lot and keep your eye on the long term goals of having a loving, healthy family whose members are making progress in their lives.
There is help for adults with ADHD. CHADD is one organization for children and adults with ADHD, but there are others such as ADDA that focus more on adults. They can provide links and resources in your community. Support groups are very helpful. Many adults find ADD coaching to be very useful as it focuses on the practical aspects of daily life. The coach might help you prioritize, set up simple routines and work towards doable short term goals. Being kind and forgiving to yourself as you work to make changes is key. Celebrate the small victories in life!
Question from Diane Lavin, Teacher Middle School, The Agnon School, Beachwood, Ohio:
Are you aware of any studies linking ADD with working memory and if so, is there any treatment for ADD that boosts working memory?
Dr. Karen Miller:
There is a great deal of interest in ADHD and the role of executive functions which are the self-regulation processes of the brain. Working memory is the ability to hold information in mind while working on it (remembering why you walked over to the closet). It is that space where you can think about things before making a choice. When working memory is impaired, you tend to make choices too quickly or without considering the options or consequences. Dr. Russell Barkley has written extensively about executive functions and ADHD. Although stimulant medications improve short term memory (in everyone, as in caffeine) the effects on working memory are less clear. There are some computer-based programs that have been researched for use in cognitive rehabilitation of the brain injured patient that may have some utility. An interesting resource is The Memory Factory by Dr. Mel Levine, Cambridge, MA: Educator's Publishing (www.epsbooks.com.) This text describes memory to children and adolescents and provides down-to-earth examples of how we use memory functions in our daily activities, and suggests areas for discussion and strategies for overcoming memory difficulties.
Dr. Sheldon Horowitz (Moderator):
The hour is up and we need to bring this LDTalk to a close. Thank you to everyone who submitted questions and to all who joined in and followed the discussion.
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