How to Evaluate Childhood Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder

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Jun 26th, 13
Dr. Michelman provides some excellent insights into understanding the importance of evaluating for childhood attention deficit and hyperactivity disorders along with offering an overview of treatment options available.

How to Evaluate Childhood Attention Deficit 
Disorder/Attention Deficit Hyperactivity Disorder 
John D. Michelman, M.D.  Child and Adolescent Psychiatrist

Doctor, I want to help Jimmy (age 10 and squirming in the chair), but how can you tell if he really needs medicine?”

Does the child have ADD/ADHD?

Attention Deficit Disorder (ADD) is a medical condition with problems in attention, focus, distraction, organization and impulse control.  Attention Deficit Hyperactivity Disorder (ADHD) also has more motor hyperactivity than expected for children of similar age/maturity levels.  Valid, reliable screening forms for ADD like Connors Scale or the free internet available Vanderbilt Scale are much more accurate when filled out by multiple teachers observing children in groups, in addition to rating parental and therapist/nurse/doctor observations.  These multiple observer’s rating scales do as well as specific “on/off task” computer tests especially now that kids are so familiar with video games.  Although we know that certain brain areas mediated by neurotransmitters dopamine and norepinephrine may be the source of impulse and focus problems, we have not been able to translate research into a clear ADD/ADHD test.  No brain image, blood, or neurological test is currently available.  So parents and teachers use observations and rating forms to screen for possible ADD/ADHD.

What to try before medicines?

How helpful an active parent/school evaluation can be!  It is important to find out the child’s academic ability as measured by cognitive and achievement tests.  Are there specific areas of underachievement (eg. just the math) or is there general lack of success? It is necessary to diagnose defiant, manipulative “negative attention” seeking behavior.  Does the child do more homework than texting, video games and phone time?  Parental supports and consequences for school grades should be clarified.  Is the student anxious, frustrated, sick, unable to see well, depressed, hungry, sleepy, worried about home life or using illegal substances?  Once a parent/school evaluation has been done, parents and school can try accommodations to help needy students receive tutoring, prompts, sessions with school counselors, and better communication with parents.  Is there homework and has the homework been done and brought to school?

School accommodations like a 504 Plan and Individual Education Plan have helped many impatient, disorganized, distracted students, but these plans depend on 100% student and parent participation with the school.

Medicines for ADD/ADHD

Try school evaluations, academic extra help, therapy, and good pediatric evaluation first.  Since there are potential benefits and possible major adverse side effects, all custodial “parents” need to be part of the medicine discussion.  Today, this may include married, divorced, or never-married parents or custodial relatives.

Types of medicines

Stimulants are controlled substances.  They are written on a special non-refillable script for medicines with abuse and addiction potential.  Each script is follow by the U.S. Department of Justice Drug Enforcement Administration.  Urine drug screens and Kasper reports (indicate prescriptions from multiple doctors) follow controlled substance stimulant scripts.  Stimulants are increasingly used inappropriately without prescriptions by older students who hope for “cognitive enhancement” or a quick fix at the last minute as they cram for exams or finish papers.

Types of stimulants

Methylphenidates are Ritalin, Methylin, Focalin, Metadate, Concerta and Daytrana.

Mixed amphetamines are Dexadrine, Adderall and Vyvanse.

Possible adverse side effects

1. Cardiac risk, especially for unrecognized pre-existing heart problems. 
2. Increased pulse and blood pressure.  
3. Appetite suppression and rebound binge eating.
4. G.I. upset.
5. Decreased growth.
6. Transient tics or twitches
7. Insomnia
8. Rare brief psychotic reactions or obsessive over-focus.

Non stimulant Strattera:   It can be used with seizure disorder.  Takes 1-2 months for maximum benefit.

Possible adverse side effects:  Similar to stimulants except no tics.

Non stimulants Intuniv (Tenex, Guanfacine) and Kapvay (Clonidine)

Possible adverse side effects:  

1. Sedation
2. May lower pulse and blood pressure
3. Do not discontinue quickly

Thanks for your attention and I hope you were not reading this with one hand on your phone and the other on the steering wheel!  Our whole society is distracted, hurried, over-stimulated, and overstressed.  First, try to set priorities in your own life.  Limit the video games.  Turn off the TV.  Increase your child’s exercise and active learning time.  Second, work with your school, child, and therapist.  See your child psychiatrist when you are already trying the non-medical approaches and we will work with you to coordinate non-medical and possible medical intervention.

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