Download Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder
ADHD: DSM-IV Criteria
Inattention
1) Inattention to detail/makes careless mistakes 2) Difficulty sustaining attention 3) Seems not to listen
4) Fails to finish tasks 5) Difficulty organizing 6) Avoids tasks requiring sustained attention 7) Loses things
8) Easily distracted 9) Forgetful
Impulsivity/Hyperactivity
1) Blurts out answers before question is finished 2) Difficulty awaiting turn 3) Interrupts or intrudes on
others 4) Fidgets 5) Unable to stay seated 6) Inappropriate running/climbing 7) Difficulty playing quietly
8) “On the go” 9) Talks excessively
Symptoms must be met for the past 6 months
Some symptoms present before age 7
Some impairment, academically, socially, emotionally or occupationally in 2 or more settings
Symptoms are not exclusively due to other disorder, mental or physical (e.g. mental retardation, learning
disability, pervasive developmental disorder, mood disturbance, sleep disorder)
Behavioral Therapy
A recent large study showed that behavioral therapy by itself or even in conjunction with medication
offered no benefit over medication by itself. But this does not negate the importance of behavioral therapy
as an adjunct to successful parenting of a challenging child. It also is a clear importance in children who
exhibit co morbid symptoms of anxiety, depression, conduct, oppositional or self esteem issues.
Behavioral therapies might include:
Parent training. Learn to respond effectively to your child’s behavior. Learn to minimize distractions, make
good eye contact and to clearly state commands. Learn when to praise, ignore or punish. Learn when to
reward or punish.
Alternate Therapies (“Anything but Ritalin”)
In Bold are some therapies that show some promise or have had some success
Elimination Diets: Feingold – (salicylate free, preservative free, dye free), Sensitizing food diets (gluten
free, dairy free), Sugar free diets, Aspartame free diets, Yeast or fungus free diets.
Oligoantigenic diet (The few foods diet). This diet consists of two meats (lamb and chicken), two
carbohydrates(potato and rice), two fruits(bananas and apples), vegetables and water. It should be
noted that this form of diet is to be followed for 3 to 4 weeks, no longer, or else nutritional deficiencies
can occur. If during the elimination phase children's ADHD symptoms improved then one food a
week can be reintroduced to evaluate for reoccurrence of symptoms. This diet is most useful for
hyperactivity symptoms. It is unclear whether it is beneficial for attention and focus issues.
Food Additives: there have been three studies have examined the effects of eliminating artificial food
colors and other additives from the child's diet. About 8% of children with ADHD may have
symptoms due to these evidence in children who have had these additives removed seem to improved
at least with the hyperactivity. Although eliminating food additives is time-consuming and requires
inspecting food labels closely, it may be helpful in the small percentage of children, especially those
with previous a documented food sensitivities.
Supplements: Megavitamins, Omega 3 Fatty Acids, antioxidants (pycnogenol), ginkgo bilboa among
others.
Omega – 3 and Omega – 6 polyunsaturated fatty acids are found in marine and plant oils are not
made by the human body. Children with ADHD are found to have lower levels of these essential fatty
acids in their blood. Supplementation with these essential fatty acids led to normalized blood levels
and also showed some clinical improvement especially hyperactivity. It appears that the combination
of both omega-3 and Omega-6 fatty acids offer the most benefits. Common formulations of over-thecounter essential fatty acid supplementation are Nordic gummy bears, Nordic fish chews, Nordic proDF a, MegaRed krill oil, Neutra gold in Nature Made.
Multivitamins: given that a common side effect of stimulants is decreased appetite and decreased
intake of required vitamins, some children taking stimulants could benefit from taking a daily
multivitamin. A number of studies have shown improved nonverbal intelligence, concentration,
sustained attention, and level of motor behavior when multivitamins were added to the diet. This
finding was not specific for children with ADHD but seems safe and inexpensive.
Vision, inner ear, auditory integration, sensory integration, optometric therapies: Each theory is linked to a
specific treatment regimen with vocal enthusiasts but none have proven effective to diminish the symptoms
of ADHD
Hypnotherapy, Biofeedback therapy, Guided Imagery
Biofeedback therapy: this therapy provides a computer interactive feedback system with the child's
attention is evaluated and prompts are used to sustain it. This requires at least 40 sessions for success
and also requires ongoing therapy after success is achieved. The process is very expensive. But, the
National Institutes of Health are evaluating this type of therapy. If this evaluation is successful it may
be something that insurance could consider covering in the future.
Applied Kinesiology – cranial realignment
Homeopathy
Medication
Medications have proven to be a safe and effective method of reducing the core symptoms of ADHD.
There are few situations where they may be considered medically inadvisable. A small number of=f
children will find the side effects too intrusive at the doses found to be effective.
Medication classes:
Stimulants (methylphenidate, amphetamines)
Methylphenidate
Short acting (3-5 hours) (Methylin, Ritalin, Focalin)
Long acting (8-12 hours) (Concerta, Ritalin LA, Metadate CD, Daytrana patch, Focalin XR
{dexmethylphinadate}, Quillivant (liquid), Aptensio XR
Amphetamines
Short acting (3-5 hours) (Adderall, amphetamine salts, Dexedrine, Dextrostat)
Long acting (8-12 hours) (Adderall XR, Vyvanse)
Side effects
Both groups of stimulants share similar side effect profiles. But if your child experiences a significant side
effect with one there is a good likelihood he/she may not with the other. Rarely. a child experiences a
“disaster” i.e. fussy irritable, aggressive, moody with the first dose. If this occurs with one class of
medication it is extremely unlikely with the other. Fortunately this is uncommon. Headaches or stomach
aches also can occur and lead to medication discontinuation, but also are uncommon.
Side effects that occur with good frequency that we usually tolerate or “work around” include:
1.
Appetite suppression Reduced appetite is common to both medication groups and occurs in
almost all children. It requires creative parenting to get the necessary calories in at the nadirs of medication
effectiveness to maintain good growth. Good breakfasts, afterschool snacks and bedtime treats are some
examples.
2.
Difficulty falling asleep Trouble settling down to sleep occurs in about half of the children taking
these medications. A technique like soothing bedtime stories, sipping warm milk (not chocolate) or using
the over the counter medication melatonin might be useful A good night’s sleep is critical to the subsequent
day’s performance. Sleep problem from medications frequently wear off with time but may reappear after
medication holidays (weekends, holiday breaks or summer break)
3.
Tics Sudden muscular jerks that might include snorts, eye blinking or throat clearing can occur in
small numbers of children on medication. We almost never see this in older children who have no previous
history of tics off medication. In the younger child it is believed that medications only uncover p previous
propensity to tics. They are usually infrequent and seem to bother the parents more than the child.
4.
Rebound phenomenon As medicine starts to wear off (6-9 hours with long acting meds, 2-3 hours
with short acting meds) some children experience irritability, headaches and anger. This can be avoided by
adding a very small dose of short acting medication at the tail end of the involved dose.
5.
Dysphoria While small numbers of children can become depressed or quite anxious on the
medications this is fortunately rare, easy to note and responsive to discontinuation of therapy. But more
subtly, and frequently only over time patients develop a flattening of mood. They may complain of or
appear not as cheerful and full of life. It may not be apparent to people (teachers) who do not know
him/her well. Parents will miss it because their next contact with the child after medication administration
is not until medication is wearing off. And, this may occur in conjunction with the dramatic improvement
in school performance expected from the medication further masking the effect from inobservant parents.
We recommend parents administer medication on the weekends at least from time to time (unless they are
already doing so) so they may observe their child and the effects of medication from the time it takes effect
until it wears off. With dyphoria we will try to change medication or sometimes need to add a medication
to improve mood.
Addiction does not occur with these medications even though they are controlled substances. Taken,
correctly, for even 10 years, then discontinued does not lead to any withdrawal symptoms.
There are no long or short term affects on organ systems requiring any blood work to check for toxicities.
Growth and blood pressure should be checked regularly.
Stimulants are the most effective medications for ADHD. 90+% of children will respond to one of the
above medications. Alternate but likely less effective medications include Strattera, Intuniv, Wellbutrin and
Buspar. Each of these medications might be a reasonable substitute if side effect profiles of stimulants are
too severe. SSRI’s and some antihypertensive medications have an adjunctive role in the treatment of
ADHD.
Agenda for your child’s follow up visits
1.
Discuss and review your own observations of your child, most recent teacher reports and the
results of any rating scales since the last visit.
2.
Share information about target behaviors and how they might have changed since the last visit
3.
Screen for new co-existent conditions
4.
Review side effects and our role in alleviating them
5.
Review your child’s function at home, including behavior and family relationships
6.
Review your child function in school, especially related to academics, behavior and social
interactions. Make sure information is available directly from your child’s teacher.
7.
Discuss your child’s self esteem and review his academic, behavioral and emotional self
management scheme.
8.
Assess and supplement your child’s understanding of ADHD, coexisting conditions and treatment
strategies
9.
Discuss any current problems organizational and study skills, homework, anger and selfmanagement.
10.
Review and revise your child’s treatment plan
11.
Make sure there is system in place for communication among you, your child, his educators and
the clinician between visits.
More Information
www.chadd.org
www.add.org
www.aap.org
Books on alternative therapies
Buzz: A Year of Paying Attention
Katherine Ellison