Children and Attention Deficit/Hyperactivity Disorder

Nearly eight million children in the US suffer from mental disorders, and attention deficit/hyperactivity disorder (ADHD) is one of the more prevalent. In fact, it is the most commonly diagnosed mental health condition in American children today. According to the Surgeon General’s Report on Mental Health, ADHD afflicts between 3% and 5% of school-age children in any six-month period.

The disorder, which is more common in boys than in girls, often develops before age seven. However, it is usually diagnosed between the ages of eight and ten. Key features of the disorder include hyperactivity, impulsiveness and the inability to focus.

The essential feature of ADHD is a persistent pattern of inattention and/or hyperactivityimpulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development.

Symptoms tend to worsen in situations that require sustained attention or mental effort, or situations that lack intrinsic appeal or novelty. Activities such as listening to classroom teachers or working on monotonous, repetitive tasks are difficult or even impossible for children with
ADHD.

Diagnosis

Diagnosis is based on a collaborative process that involves children and adolescent psychiatrists or other physicians, the child, and the child’s family, and school-based or other health care professionals as appropriate. Deciding what treatment will best benefit the child requires a careful diagnostic assessment after a comprehensive evaluation of psychiatric, social, cognitive, educational, family and medical/neurological factors. A thorough evaluation will take several hours and may require more than one visit to a physician. Treatment should not be started until the evaluation is complete and a diagnosis determined.

Treatment

Psychiatrists develop a comprehensive treatment plan that encompasses major aspects of a child’s life. Treatment for children with ADHD may include the use of special education programs, psychotherapy and medication. Children properly treated for ADHD generally get along better with their teachers, classmates, parents and friends, which leads to a boost in self esteem, while children who go untreated often fall behind in schoolwork, have problems interacting with others and are at increased risk for later drug and alcohol abuse.

Treatment of ADHD requires the support and education of parents, along with appropriate school placement. Strategies such as rewarding positive behavior changes and communicating clear expectations of those with ADHD have also proven effective. Children with ADHD can also benefit from caregivers paying close attention to their progress, adapting classroom environments to accommodate their needs, and using positive reinforcement. Parents should also work with the school district to plan an individualized education program.

Medications

Medications can be extremely helpful for many children with ADHD. Research indicates that between 70% and 80% of children with ADHD respond to medication. But medication alone is rarely an appropriate treatment for complex child psychiatric disorders such as ADHD. It should only be used as a component of a comprehensive treatment plan.

Use of stimulant medicines can result in an immediate and often dramatic improvement in behavior both at school and at home. The benefits and the risks associated with stimulant treatment must be weighed carefully, and evaluated and monitored continually for each child. Stimulants are usually well tolerated by children with relatively few side effects.

There has been public discussion about whether exposure to stimulant medication in children with ADHD increases the risk for substance abuse in later life. A recent study by Biederman et. al. (1999) suggests that rather than inducing substance use in youth with ADHD, such medications may protect children with ADHD from future substance abuse.

Stimulants, including methylphenidate, amphetamine and pemoline, are by far the most widely researched and commonly prescribed treatments for children with ADHD. When effective, these medications, which have been approved by the Food and Drug Administration (FDA) for treatment of ADHD, diminish motor overactivity and impulsive behaviors seen in ADHD and allow the child to sustain attention and improve physical coordination.

The safety and effectiveness of medication such as methylphenidate (Ritalin) is well documented, and typically, it is well tolerated by children. It has minimal side effects and is not addictive when taken according to a physician’s instructions. While extensive clinical use suggests the effectiveness of clonidine, guanfacine, nortriptyline and imipramine, these medicines have not been approved by FDA for the treatment of ADHD.

Managed care has made it extremely difficult for multidisciplinary clinics – that in the past brought together pediatric, psychiatric, behavioral and family dynamic expertise – to obtain adequate reimbursement for their services. As a result, many children with mental illnesses may not be receiving the comprehensive assessments and individualized treatment they need. For optimum results, an informed, multi-modal therapy specifically designed for a specific child’s condition is essential.

Advice to parents

Most children evaluated and treated for ADHD are seen by pediatricians and family physicians. For parents who have recognized symptoms of ADHD in their children, child and adolescent psychiatrists offer the following recommendations:

• Find a physician who has specific training and expertise in the diagnosis and treatment of child psychiatric disorders. ADHD is not an easy diagnosis to make. Many other childhood disorders have similar symptoms.
  
• Only after a physician concludes that your child has ADHD should you discuss treatment. If your physician recommends medication, ask lots of questions. Make sure you get the answers and information you need to make the best decision for your child. Medicines are effective and can be helpful for many children, but only when used after a thorough evaluation and as part of a comprehensive treatment plan. Remember: evaluation before medication.
  
• Talk regularly with your child’s teachers, caregivers and physicians about how your child is doing, especially when medication is first started, re-started or when the dose is changed.
  
• Applaud your child for improvements in behavior (better grades, developed social skills, etc.). The therapy and medications are not responsible for these improvements – they simply make it possible for your child’s own assets and natural skills to shine through.
  
• Find a school or classroom setting that can provide structure and organization beneficial to your child. A child with mental health problems does not need unnecessary pressure or unrealistic expectations.
  
• Help children feel comfortable with their therapy and medication. They need to know that having ADHD is not their “fault” and it doesn’t mean they did anything bad or wrong. They also need to participate actively in the treatment process.