If your a child is diagnosed with ADHD, Attention Deficit Hyperactive Disorder, you have a difficult decision to make. Do you treat your child with stimulant medications or not? This is a bad spot for parents to find themselves in. The child’s problem is a big one and the treatment seems very drastic. Before deciding on a treatment plan with your doctor, you might want to read a new clinical report from the American Academy of Pediatrics addressing the benefits and risks of treating ADHD with stimulant medications. We have known for a long time that, without treatment, children with ADHD are two and a half times more likely to have an “Substance Use Disorder” or SUD, than non-ADHD children when they become adults, even after accounting for other factors such as family history, gender, age, race, cognitive impairment, and family environment. The good news is that treating children with ADHD at a school-age, as they set their academic course, with stimulant medications reduces their risk of becoming using and becoming addicted to cigarettes, alcohol and other illicit drugs as adults by a whopping 85% according to Pediatrics, the official journal of the American Academy of Pediatrics. The timing of treatment is important however– children who are treated early, at school-age, have a much lower risk of developing SUD than the children who initiate medication treatment in adolescence.
Why might this be the case? We know that stimulant medications themselves have abuse potential. It’s counter intuitive tho think that using a powerful medicine like Ritalin would lower a child’s chance of having SUD in their adult years. How does treatment with these medications reduce the risk of a child growing up to have a substance abuse problem? Let’s take a closer look at the link between ADHD, stimulant medication treatment, and substance abuse to figure it out. Children with ADHD are more impulsive- impulsiveness being a core feature of the diagnosis. Additionally, many of these children have difficulty managing social situations- often having difficulties making and keeping friends during their childhood. Stimulant medications can help some children with both of these difficulties. On a biological level, Adderall and Ritalin increase communication between neurons in a child’s brain, that has the effect of lowering impulsivity and improving judgment. When medicated, their brains are more engaged on one subject. Children with ADHD who are medicated frequently have better attention spans, better impulse control, follow directions better, and perform much better at school. The improvement in the core features of ADHD has the effect of taking a great deal of stress off the child. Less stress, more academic success, better social functioning and less negativity from the teachers and administrators at school, can be a winning formula for many children who suffer from ADHD. Rather than dreading school, a child with ADHD can often begin to build on their successes and actually enjoy school. It is great to watch when it happens for both the child’s family, the child’s teacher, and for his or her pediatrician.
If you or a friend find yourself in the situation of having to decide about medication for a child with ADHD, I am sure you will find the article in Pediatrics helpful. Take a few minutes and check it out. If you have any comments about this article, ADHD, or related topics, feel free to leave your feedback on my blog, www.docsmo.com. Until next time.
Written collaboratively by Rebecca Brenner and Paul Smolen, MD
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Here we go again with another edition of DocSmo.com, the pediatric blog that brings parents portable, practical pediatrics on their schedules. For those listeners who are new to my blog, I am Dr. Paul Smolen, a board certified pediatrician with 32 years of practice experience. Today I am going to continue my book review series with my thoughts on a new parenting book by the (sometimes controversial) psychologist Dr. John Rosemond. I must admit, I never read the old Six Point Plan for Raising Happy, Healthy, Children by Dr. Rosemond. I assume that the “points” are the same as in the original edition, but that the newer book has more supporting research and anecdotes to validate his recommendations. So, first the basics: this “new” edition is well written with clear, approachable language; it is practical in layout, with part of each chapter including a question and answer format; it is not full of psychological jargon, thank goodness; and even though Dr. Rosemond does not provide footnotes, I have to assume that he is accurately summarizing and paraphrasing the research which he references.
Now to some of the solutions to parenting problems that he stresses in the book. Dr. Rosemond provides what he sees as easy answers to many behavior problems parents may encounter. If you have children who don’t listen and are prone to whining, he thinks it is likely that your discipline is failing and that your child is getting too much attention. If you have a child with ADHD, he believes that the TV and video games are likely the culprit; he recommends getting rid of them and the problem may be solved. If your child is self-centered, Dr. Rosemond thinks you are giving them too many “things.” He contends that if a child can’t entertain himself, he probably has too many toys and outlets for amusement. All these circumstances may be true for certain children, but certainly not all.
Readers need to be for warned that this book is full of Dr. Rosemond’s own opinions, replete with “in your face” classic Dr.Rosemond style. I am sure his blunt advice will rub many readers the wrong way. I think the reason for this is Dr. Rosemond’s insistence on only paying attention to the limit-setting side of the successful parenting formula and ignoring the leadership-love side. Yes, limits need to be set, I totally agree, and a child needs to provide labor for his or her family, and TV and video games are undoubtedly a negative force in some children’s lives, but equally important to a child’s healthy psychological development are a parents’ ability to provide consistent love and acceptance, making children feel needed, creating an atmosphere where children want to please their parents, and setting a good example for children to model. I am sure Dr. Rosemond understands how important leadership is to parenting, but I think he needs to articulate it more as he gives parenting advice. Maybe he will do exactly that in the New-New Six Point Guide to Raising Happy, Healthy Children… the next edition? In my opinion, that would make a good book into a great one. I give him four Doc Smo stars on this edition. Until next time.
In November of 2011, the Academy of Pediatrics experts revised their guidelines for pediatricians when it comes to the management of children with ADD. In this edition of DocSmo.com, Dr Smolen introduces parents to the new changes when it comes to helping children with ADD along with some of his own insights and opinions. Informed parents will certainly want to listen.
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My partners are really smart people with a lot of experience under their collective belts. I pay a lot of attention when they speak, because I always learn from their wise insights. Such was the case the other day in the lunchroom, when the subject of practical ADD management tips came up. One of our doctors has a child with ADD, so she is speaking from more than doctoring experience, which gave the conversation a whole new perspective. Here are the highlights:
Things are not always what they appear: Dr. Kimberly Riley recalled stories of children whose main problem was not attention span but learning disabilities. She has noticed that after their learning problem had been identified and helped, the impulsiveness and inattention faded away. They didn’t have ADD, simply a learning disability that had not been recognized. Dr. Riley also pointed out that if a child has severe learning difficulties, genetic testing may aid in looking for recognized genetic problems that impair learning. Conversely, Dr. Downing has noticed that in her experience, many of the children that present mood problems like anxiety, depression, or oppositional behavior really have ADD as a core feature dominating these children’s personality. Both the mood problem and the ADD issue need to be addressed for the child to get maximum benefit.
Sleep problems usually seem to accompany the ADD personality: all of the doctors agreed that many children who are diagnosed with ADD have innate sleep difficulties. Certainly, the medications that are used to treat ADD can cause sleep problems on their own, but this is not the root cause. Dr. Plonk has noticed that initiation of sleep can be very difficult for these children, going all the way back to infancy. He believes that this problem has a neurological basis. Drs. Plonk, Riley, Moorman, and Downing all recommend 1-3 mgs. of Melatonin about 30 minutes before bedtime to help children get to sleep; they feel that this OTC hormone is both safe and effective. They also have found that a homeopathic product called Calms Forte can be effective in children with ADD. Both of these products have unfortunately not been tested by the FDA for safety or effectiveness since they are non prescription products. Keep in mind, however, that both parents and doctors are fans of melatonin so I think you can be confident giving it a try.
Beware of the easy fixes: My colleagues believe that ADD is a neurologically based “chronic” disorder. Chronic means just that, chronic. They have noticed that as children mature, they almost always improve in their ability to concentrate and to avoid distractions but often don’t catch up with their age-matched peers until adolescence or beyond. For those who need help, the combination of behavioral therapy, attention to learning problems and associated mood problems, and possibly medication seems to get the best results. The doctors were pretty unanimous declaring that dietary supplements (except fish oil), strict dietary restriction of sugar, gluten and preservatives along with other assorted therapies seem to have limited effectiveness. As you will hear in the Pedcast featuring Dr. Kilbane, other physicians strongly disagree with that contention.
Let’s not forget there is a kid with feelings behind that diagnosis of ADD: Drs. Plonk, Riley, Downing, and Moorman became very animated and forceful when the subject of a child’s self image and self esteem came up. They all strongly feel there is a need to speak directly and honestly to children who have this diagnosis, reminding them that they are not “bad kids” and that to a large degree, they can’t help this impulsive behavior and lack of attentiveness. Dr Downing even noted that one of her patients declared to his mother just after this conversation, “You owe me, Mom” (an apology I presume). Understanding that the ADD behavior pattern is not anyone’s fault can be a huge relief to many families. As Dr. Downing points out, guilt is a strong emotion, and doctors can be very useful in mitigating some of this emotional baggage.
Conclusions of the doctors: My partners feel that the best approach to helping a child with an ADD diagnosis includes: having their learning problem and mood difficulties addressed, managing sleep problems if they exist, making sure that the school they attend provides appropriate accommodations to help the child with behavior and learning, initiating good behavioral management strategies at school and home, and most of all treating the child and his/her family with the respect and patience they deserve. That is the Lunchroom Lowdown for this week.
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So, the establishment has come to you and said there is something wrong with your child’s behavior. They say that he or she is not meeting the school’s expectations. Maybe he or she doesn’t pay attention well in school. Perhaps they are more active than other children. Or, maybe they are simply more impulsive than their friends. What next? Where do you turn? How should you react? In this post I am going to give you my advice–and hopefully some insight–about how to handle this situation should you find yourself faced with it.
First, I think you need to understand that your child’s teachers have his or her best interests at heart. They want your child to succeed and learn as much as possible. Most likely, your child’s teachers are coming to you with concerns and observations that are important for you to know. Try not to get angry or defensive, because this will not help. I recommend that you listen and evaluate what you are being told, but keep in mind that the teacher’s opinion is just one of many. As you will see from this discussion, input from as many sources as possible is essential. The teachers are simply reporting a pattern of behavior that they are observing in the classroom. Your child’s behavior is complex with many factors that have influence. Many of life’s twists and turns can make a normal child exhibit ADD behavior, including: stress of family problems, an impending big life change such as a move, a medical issue, or a sleep problem, just to mention a few. You know your child best. Give all these factors consideration when trying to evaluate his or her behavior.
If the school establishment believes that your child has ADD or ADHD, it is useful to back up and recall the definition of ADD and ADHD. All of the following criteria must be met to justify the diagnosis:
– A child who is healthy and of schoolage (less than 7 years) who is found to have a shorter attention span than normal and to be more impulsive than his/her peers.
-These impairments need to be seen across many settings such as school, church, camps, etc.
-These impairments must be chronic, which is defined as at least 6 months in duration.
-These impairments must be affecting the child’s ability to learn in a classroom setting.
Without ALL these features, an ADD or ADHD diagnosis is not justified. So ask yourself, does my child fit all these criteria? If so, you need to proceed. If not, maybe watching and waiting is in order.
Assuming that you and the school feel that the above criteria are met, it is time to proceed to the level of professional help. After all, this is your child’s academic success we are talking about. At minimum, standardized measures of attention and other factors should be completed by both parents and teachers, the two most common of which are Conner’s and Vanderbilt scales. Even better is a full psychological assessment by a psychologist including an actual classroom observation. At the same time, your child should also visit a healthcare provider who knows them and your family. During this visit, your child’s doctor will be trying to find things that are known to interfere with learning such as chronic sleep problems, difficulty with mood, family stress such as alcohol abuse or violence, genetic problems, vision or hearing problems, or any other factors that could be affecting learning.
If your child made it to this level of inquiry and met the initial criteria, it’s time to make some decisions and recruit as much help as possible. ADD is considered a disability under the 1990 Americans with Disabilities Act. Schools must provide accommodations to help your child if they have an ADD diagnosis. These can be very helpful. More testing time, quiet test areas without distractions, closer supervision by the teacher, and special academic tutoring are a few examples of accommodations that can be made to help your child succeed in school. Take advantage of them. Also make sure that your child’s school sets up a formal behavior program to address troublesome behaviors that get in the way of his or her learning.
My experience and research confirms that the most successful approach to assist a child with ADD is what is called the multimodal approach; that means the combination of school accommodations, behavior management, counseling for the family, and medication for the child. Many families are very leery of the strong medications that are used for children with ADD. It is a big step, but the results can be amazing. Keep an open mind when this subject is discussed. Your child’s doctor needs to do the same and recognize that not all children with ADD either need or can tolerate these medications. If you have access to an integrative pediatrician, I recommend you get their input as well. If your child has a disturbance of mood, is oppositional, or has major learning disabilities, I think a pediatric neurologist or psychiatrist should be in the mix.
Here is an important thought I want you to consider if you have a child with ADD–don’t despair, the news is not all negative. Remember, children with this pattern of behavior have many advantages over their non ADD friends such as high energy, enthusiasm, and sometimes, incredible creativity. Unfortunately, their learning style does not fit well in a traditional classroom. This fact is something that you and your child are going to need to deal with but can overcome. Remember, slow and steady wins the race, always has and always will. School is likely to be more difficult for your child as well as for your family, but success can and will be yours if you persist. I see this everyday. Families where education is valued, learning is made fun, intellectual stimulation is plentiful, hard work is encouraged, and failure is not an option will have success.
I also want you to remember that there is a person inside that child who is struggling to meet the school’s expectations. Despite their academic difficulties, they are most likely very intelligent! They are going to need a lot of encouragement and praise whenever possible. Not fake praise, but the real thing. Make sure you notice and compliment progress, determination, and creativity. Eventually, your child’s impulsiveness and inattentiveness will wane, but we want to be left with a confident and self-assured adult, not someone who feels like a longtime failure. You are your child’s best advocate. Be relentless!
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