What is it?
Attention deficit disorder (ADD) is just that, a shortage of attention span. Many people use the term hyperactive, but that does not describe the disorder adequately as some kids with ADD are not “hyperactive”. There is ADD with and without hyperactivity / hyperkinesis, abbreviated ADD and ADHD respectively. Some kids with a short attention span will sit quietly staring at the wall, while others act out or are impulsive. In general, those that sit quietly go unnoticed until they start failing school, while those who act out are found pretty quickly. Its a disorder when its disruptive to your life and you have tried everything you know of to help the problem. A good way to think of ADD is the inability to refrain from stimuli that keep you from the task you are supposed to be doing. Most fathers of boys with this disorder feel that the boys are just rambunctious. Another good way to think of ADD in these kids is that they exhibit normal behaviors (active, rambunctious kids), but they cannot control that activity, and it gets them in trouble and keeps them from learning. Everybody likes to have fun, but when you cannot stop having so much fun that it interferes with having a good productive life, then there is a problem. The problem must be present in multiple situations and cause a problem with learning and / or social activities to be considered a true disorder. A concept that might help is to think of someone who wears glasses. Those people have trouble seeing or focusing on an object. The glasses help them see or focus more clearly on what they need to see. This is not a personality flaw or lack of discipline, it is a physical problem related to the shape of the eye. ADD/ADHD is not a personality flaw or lack of appropriate parenting, it’s a true biochemical disorder that has effective treatment and often devastating life long results if not treated adequately.
What causes it?
We don’t have a cause identified at this point. We do feel it is a “chemical imbalance” of some kind. There is a strong inheritance pattern indicating it is a true biochemical disorder. Many parents of these children have had the same problems, but they were not well understood until recently. Also, many parents who have the disorder have it so mildly that it can’t be detected. In 2004, a new type of MRI scan (like a CAT scan of the head, but uses magnetism and radio waves) showed that kids diagnosed with ADD/ADHD have a distinct pattern that can be shown on the scan. Those kids with ADD/ADHD who were treated with proper medication had those same MRI patterns return to normal. There are also EEG (brain wave test) patterns that are different in children with ADD and those without. This and other recent studies show that ADD/ADHD is a real, inheritable disorder of brain chemistry and the medication used for ADHD can restore normal function. True ADD/ADHD is not a lack of proper parenting or discipline.
What does NOT cause it?
Too much or too little sugar, food reactions or allergies, vitamin deficiencies, allergies, vision problems, poor lighting, preservatives, television, and all sorts of strange things have been implicated to cause ADD, but all have been proven wrong. There are plenty of snake oil salesmen out there who take advantage of parent’s lack of knowledge about ADD and will sell them all sorts of unproven remedies. Granted, there are definitely children who become “hyperactive” temporarily with chocolate or caffeine or even red food coloring, but this is temporary and NOT ADD.
When does it show up?
Every child is different. There are kids who will show up with signs of the disorder as young as 3 to 4 years of age. We really don’t like to treat the disorder medically until the child reaches school age, unless it is very severe. Therefore, we diagnose most kids with it during kindergarten and the first grade. Very few kids are diagnosed in the second grade. In the third grade we catch quite a few since the volume of work dramatically increases. A few kids will be diagnosed as late as the 7th to 10th grade., and even into adulthood.
How common is it?
Between 3 to 8% of children have some form of ADD. Remember it’s only ADD when it disrupts the child’s life or function enough to be a problem.
How is it diagnosed?
Typically someone discusses the problem with the parents. Usually this is a teacher, daycare attendant, or the parents themselves feel there is a problem. Most parents think about the issue for weeks to months trying to figure out if there really is a problem and trying typical behavioral modification methods. Eventually, the child is brought to the pediatrician looking for answers. The pediatrician screens the child for other medical problems that can look like ADD, or those that can be affected by the treatment of ADD. If the pediatrician feels the child may have it, then a referral is made to a child psychologist or psychiatrist. The psychologist or psychiatrist does an extensive evaluation over several hours (sometimes several sessions) to make sure the child does not have any other disorder and to ensure this is the correct diagnosis. The evaluation is very thorough and should assure any parent of the proper diagnosis. The MRI scan mentioned earlier is used for research only. There is a qualitative EEG (brainwave test) that has been developed to help diagnose and monitor children with ADD, but it is expensive and not commonly used. IN ALL CASES, A CHILD IS DIAGNOSED WITH ADD / ADHD BY ANOTHER PROFESSIONAL BEFORE I PRESCRIBE ANY MEDICATION.
What can look like ADD?
Anything that can interfere with paying attention can mimic ADD, such as; hearing loss, vision problem, seizure disorder (staring spells), allergies, depression, behavior / conduct disorder, learning disability, etc. The first office visit to the pediatrician for ADD and all the well check ups help ensure these are not present. Children who are very intelligent may also be bored in class and appear distracted or become disruptive.
What disorders can also be present with ADD?
Studies show that as many 80% of children with ADD have a second diagnosis at some point during childhood. The most common are behavior disorder, anxiety or depressive disorders, learning delays or disabilities or involuntary muscle tics. For most kids with ADD, these associated disorders are mild enough to not be a problem. For a small portion of kids with ADHD, the secondary disorders can be a big problem that requires multiple medications and ongoing behavior therapy. Frequently, I will see kids that appear to have more than just ADHD do very well on the ADHD medication alone. In short, the ADHD just looked more severe, but those “extra” symptoms went away with proper treatment. Occasionally, though, the other symptoms are not helped with the primary ADHD medication and those symptoms become more obvious when the ADHD symptoms get better on the proper medication. Occasionally some kids will do very well on ADHD medication for several years and then develop increasing behavioral problems as they get close to adolescence (8-12 years of age). In these kids, there is often a family history of Bipolar Disorder (Manic-Depression) and the kids are now showing signs of the same thing. Bipolar disorder frequently looks like ADHD in early childhood and then the classic signs of Bipolar show up in pre-adolescence.
What does not help ADD?
Because ADD is a perplexing disorder that parents are embarrassed about or not even sure their kids have, many have sought unproven treatments before seeking medical help. There are as many of these unproven treatments, as there are snake oil salesmen to take your money. The most notable of these are: vision therapy, biofeedback, vitamin therapies and diet therapies. Most of these have seemed to help some children in anecdotal reports, but none have proven of any benefit when tested according to accepted scientific standards in large numbers of children. Even psychotherapy has not been proven effective at curing ADD. Psychotherapy is very effective at helping diagnose the disorder, rule out similar behavioral problems and to help the parents and child cope with having this disorder. Psychotherapy is also very effective at teaching parents proper discipline techniques for children with ADD. It is important to note that discipline will not fix the disorder, it only helps control some of the symptoms to a certain extent. You can no more discipline a child to concentrate better than you can discipline a child to see better if they need glasses.
How is it medically treated?
Once we are sure of the diagnosis and have tried behavioral and other techniques, then we can sit down and choose the best medicine to help your child. There are multiple types of medicines used to treat ADD:
STIMULANTS
- methylphenidate (Ritalin) - there are many versions, short and long acting
- amphetamine (Adrenal) - there are many versions, short and long acting
NON-STIMULANT
- Norepineprine Uptake Inhibitors - (atomoxetine / Strattera), viloxazine (Qelbree)
- Blood pressure medication - clonidine and guanfacine
- Norepinephrine and dopamine uptake inhibitors: buproprion (Wellbutrin),
How do we choose one medical treatment over another?
Ultimately, we will choose the medicine that has the greatest chance of helping your child based on your child’s individual situation. Whatever medicine we chose, the medicine has to be tailored to your child’s specific situation and must be monitored over time. As you will see by the following explanation of effects and side effects, this is not always a simple matter of starting on the most commonly used medicine.
Let’s start with some concepts.
1. One out of three (1/3rd) of kids will not do well on the first medication we try. Approximately 1/3rd of the second medication trials will also fail, and so on. A small percentage of kids will have to try 2 or 3 medications to get to the right one for them, while most will do well on the first medication chosen.
2. Whatever medication we chose, it will take from 10-30 days to reach the best dosage. With the stimulants, we start at the lowest dose and increase by a small amount each WEEK. We increase the medication slowly to reduce the chance of a side effect. Kids also have good and bad days and we want to judge the medication effect based on the average of several days observations. In doing this, we will generally arrive and the lowest effective dose rather than an over-medication issue.
3. The first line medications can generally be separated into long acting and short acting stimulants. Up until mid 2001, only short acting medications were available and they really did not last more than 4 hours. The newer long acting medications (Adderall XR, Concerta, Ritalin LA, Metadate, Vyvanse, Strattera, etc) are very successfully used once a day. Up until the newer long acting medications came out, I recommended parents use short acting medications, but the short acting medications must be given at school during lunch time and sometimes an after school dose is needed. We generally recommend the newer long acting medications now, as they do not have to be given at school. Each medication is different and some kids do much better on one than another. The problem is finding that one. The only time I currently recommend a short acting medication is if the long acting are not working or have a side effect, especially insomnia or belly pain. There are generic versions of almost all of these medications. Insurance formularies and yearly changes of these has become a significant issue. We electronically prescribe these medications and the computer can often tell us what is covered and what is not. Brand and generic almost always work the same, with few exceptions usually specific to a single child. These are all issues we will handle if necessary. There is a separate page on starting ADHD medications that covers individual medications in depth and the intricacies of fine tuning a medication to a specific child.
Side effects of the medicines
Most children do very well on these medicines without any side effects. The most common side effect of the stimulant medicines is appetite suppression. The majority of these kids will drop a growth curve on the growth chart, but then will gain weight as fast as any child in that growth curve. The majority of kids we start on stimulants are overweight to begin with and simply drop their weight into a more normal growth curve. The stimulant medicines CAN but do not always also worsen involuntary muscle tics. If you remember the TV comedy Cheers and the barmaid Diane, she had a facial muscle tic where she twitched her right eye lid and facial muscles. Some children have this disorder so mildly you cannot tell they have it, then after starting the medicines it worsens. We used to stop the stimulant medications if tics occurred, but now think the medicine is ok to use with tics. ADD tends to start at 4-6 years of age and tics tend to start at 6-8 years of age. Stimulant medicines can increase blood pressure, but this is usually only a few points. We are very careful to watch for this and slowly increase the medicines. In my first 30 years of private practice, I did not see a single child get high blood pressure from the medicines. The Antidepressants can affect the heart rhythm in children whom already have one they may not know about. These sound impressive, but are not common. We check an EKG before starting some medications and repeat the EKG 3 weeks later to ensure no change. This is only with a few medications and is only done once unless the child has an underlying heart rhythm issue. Clonidine can cause orthostatic hypotension, or getting lightheaded if you stand up too quickly. We almost never see this in children, while it is much more common in adults. When we start and adjust this medication slowly, it almost never happens. Drinking more water and getting up slower helps at first, but the body adjusts this almost always stops after the first week or so of a dose change.
Will my child grow out of it?
About 80% of children will still have some of the symptoms of ADD into adulthood, but it won’t look the same as the childhood form. Most children will have less of the impulsive problems as they go through adolescence and into adulthood. Some children will have interpersonal skill problems, such as problems relating to authority figures (employers, police), problems relating to loved ones (divorce), procrastination, mood swings, low stress tolerance (hot temper) and hyperkinesis (restlessness).
ADD/ADHD causes kids to not respond to the typical discipline that most parents give. This can lead to an ever-increasing division between the child and the parents. Over time, this division can cause the child to develop abnormal social skills. When kids with ADD/ADHD grow into adolescents and adults with interpersonal skill problems, its often difficult to figure out whether the ongoing problems are due to adult ADD/ADHD or are due to the lack of adequate social / personal growth caused by the ADD/ADHD in childhood. Therefore, I occasionally recommend ongoing therapy with a child psychologist or family therapist to help in these situation. Children with ADHD whom are treated appropriately through childhood are substantially less likely to have those problems in adulthood. While untreated children have significantly higher adulthood and lifelong problems with interpersonal skills, keeping a job, unwanted pregnancies, trouble with authority figures and failed relationships. Much more than half of prison inmates have untreated ADHD.
Logistic issues with ADD medication
There are a few logistic issues with stimulant medications due to state and federal regulations that you should be aware of.
- We can only write for a 1 month supply at a time. The only exception is for 90 day supplies to mail out pharmacies once the patient is stable on a medication.
- We cannot write for refills or call in the medicine if it is a stimulant. We must send in a new prescription monthly
- The prescription must be filled within 3 days of the date on the prescription and can’t be filled sooner than 27 days from the last one, unless the dose has changed.
- The medications must be slowly increased with close monitoring by phone to get to the right dose.
- Make sure to keep the medicines locked up away from small children as an overdose of any of these can cause serious harm.
- By federal law, we must see your child in the office at least every 6 month for controlled substances. A check up counts as one of these visits.
We will cover much more about the medicines if your child is diagnosed with ADD/ADHD. Our main goal is to help your child concentrate for learning in school. A secondary goal is to help your child with social interaction if that appears to be greatly affected also. We will be in touch by phone frequently to ensure that your child is doing the best he or she can by adjusting the dosage as necessary.
