Generally speaking, no matter how ADHD is manifested, all of these children are difficult and demanding, to say the least. One mother summed it up this way: “He wants what he wants when he wants it, and that means now. And everything has the same intensity. When he wants something, there’s no difference between a candy bar and a bicycle.”
THE DIAGNOSIS
We make a diagnosis of ADHD the old-fashioned way, by talking to the parents, the teachers, and the child himself. We learn as much as we can about the child’s functioning since birth, paying special attention to his development, his activity level, and especially his interactions with others. (We know that children with ADHD have more trouble in groups than they do in one-to-one situations.) We compare the level, frequency, and intensity of their symptoms with those of normal children of the same age. Along the way we look for the crucial telltale signs of any disorder: distress and dysfunction.
ADHD is tricky in this regard because children with this disorder don’t always recognize that they’re in distress. Kids with behavioral disorders, as opposed to anxiety disorders, tend to be unreliable historians. As far as many of these kids are concerned, they’re fine; it’s their parents or their teachers who have the real problem. “There’s nothing wrong with me. I’m great,” they tell me, and often they really mean it. One of the best ways we have of persuading a child to acknowledge that something might be wrong is to ask one of the standard child and adolescent psychiatrist’s questions: if you could have three wishes, what would they be? Most kids with ADHD will offer a variation on these three themes:
“I wish I didn’t have to go to school.”
“I wish I had more friends.”
“I wish my parents would stop yelling at me.”
On the other hand, parents make excellent historians when it comes to children’s behavioral disorders. When we ask mothers and fathers about the actions of a child with ADHD, the facts come pouring out: the child has terrible grades; he’s always losing things; he gets into fights with the other kids; teachers complain about him nearly every day. Things usually aren’t too rosy at home either. A child with ADHD rarely has a good, well-rounded relationship with his parents. The relationship often consists in large part of constant criticism of a child’s behavior. Furthermore, the tension created by the disorder in the household may lead to disharmony between Mom and Dad. It’s not easy keeping romance alive when everyone is shouting and upset all the time.
Parents are not always infallible in their observations, of course. Many first-time parents don’t recognize that their youngster is more inattentive or hyperactive than the average child; after all, this is their only child. Other parents think that their child’s inattention is more willful than chemical. “He pays attention just fine when he’s watching television or playing video games, but somehow he just can’t focus on his homework” is something I hear often from cranky, frustrated parents, and what they say is true as far as it goes. What those parents don’t realize is that the type of attention needed for watching TV and playing Nintendo is actually different from the type required for doing homework. Everyone has an easier time paying attention when he is directly engaged. That explains why many children with ADHD are much more responsive when they interact one-on-one than when they are in groups. If an activity doesn’t engage a child or if the setting is distracting, he’ll find it nearly impossible to focus. Willfulness has nothing to do with it.
We look to a child’s teachers for an assessment of his behavior as well. Teachers can be excellent sources of significant facts about how a child is functioning and how his behavior compares with that of others; teachers have a lot of experience with normal children. When we suspect that a youngster has ADHD, we ask teachers to provide information about the child’s academic performance, his behavior in class, and his social interactions. We also ask teachers to fill out standardized rating scales designed to elicit information that’s relevant to this disorder. The form most often used is the Conners Teacher Questionnaire, which helps a teacher to evaluate a child’s hyperactivity, passivity/inattention, and conduct problems. The 28 questions in the form I use ask teachers to assess a child’s behavior, learning ability, and social skills in the classroom. Is he restless? Does he make inappropriate noises? Does he insist that his demands be met immediately? Does he daydream, pout, or disturb the other children? Does he deny his mistakes or blame others for them? Does he make excessive demands on the teacher? Does he fail to finish what he starts? And so on. Because the Conners questionnaire has been used for thousands of normal children as well as those suspected of ADHD, the Conners score provides yet another piece of useful evidence in the diagnostic process. Once a child diagnosed with ADHD is on medication, Conners forms are sent regularly to teachers and used to help monitor the effects of the medicine.
It’s also important to review and interpret correctly any tests given by schools, psychologists, or independent testing services, such as IQ tests, standardized achievement tests, and tests for learning disabilities. Far too often my colleagues and I hear the sad tales of parents who have been misled by faulty test results. One couple in particular got the runaround for several years before their child finally got the help she needed. Here’s the story they tell: “We had an inkling that something was wrong with Carrie well before she was two years old. She was slow to walk and slow to talk compared with her peers and her older brother. And she was difficult. When she started nursery school, we began what we now understand is a typical adventure. First we were told she was okay. Then we were told she had some serious problems. Then we were told she was okay but we had some problems—namely, we were overprotective and neurotic. We had her tested by two different, very reputable places, and they gave us totally different results. One said she was normal, and the other said she had speech delays and learning disabilities. When she started kindergarten, the teacher said she was a perfectly normal kid, but by the end of the year she was saying that Carrie was immature. It took us another two years before we got the right diagnosis and the right treatment. Carrie definitely has ADD.”
Early identification of ADHD and early intervention are extremely important. There’s a huge difference between diagnosing a child early, when all he has is a little impulsivity and inattention, and seeing him later, when his parents are angry at him, his teachers are fed up with him, and his every encounter since early childhood has been negative. It’s not unusual to see kids of 12 or 13 with ADHD who don’t want to be in school anymore. It’s also not difficult to understand why they feel that way. If I were being picked on and berated at the office every day, I’d want to quit my job too. Studies have shown that teachers are not only more short-tempered with kids who have ADHD; they’re less patient with everyone in the class.
THE BRAIN CHEMISTRY
Too much sugar and too little discipline: those are just two of the things that do not cause ADHD, no matter what Uncle Frank says he thinks he read in last week’s Parade magazine or what the well-meaning but ill-informed math teacher announced at the last parent-teacher conference. I’ve never met parents of a child with ADHD who haven’t been told, somewhere along the line, that their child wouldn’t be acting this way if he just got a little discipline at home.
ADHD has nothing to do with diet or with parenting. It’s also not caused by chronic exposure to lead, another theory that has been proposed but not substantiated. ADHD is a disorder of the brain. Children are born with a vulnerability to the disorder.
There is a great deal of evidence to suggest that ADHD is genetic. For one thing, parents of children with ADHD tended to show symptoms associated with the disorder when they themselves were kids. For another, ADHD is more prevalent among the siblings of kids with ADHD than in the general population. And finally, there is a higher rate of hyperactivity and restlessness between identical twins than between fraternal twins.
There’s a strong suspicion that brain chemistry, and specifically the level of the neurotransmitters dopamine and
norepinephrine, is an important determining factor for ADHD. All of the medications that have been effective in the treatment of ADHD affect the regulation of one or both of these chemicals. Neuroimaging techniques—especially magnetic resonance imaging (MRI), positron emission topography (PET) scans, and single photon emission computer topography (SPECT)—have demonstrated that children with ADHD have brains that are different from the brains of kids who don’t have it—specifically, dysfunction in the areas of the brain that have high concentrations of dopamine. PET scans performed on adults with ADHD have shown some evidence that a particular area of the brain is undermetabolizing or underutilizing energy. When those adults were treated with Ritalin, a dopamine-increasing stimulant discussed in detail later in this chapter, the PET scan returned to normal. This result indicates—indirectly, to be sure—that dopamine plays a part in ADHD.
THE TREATMENT
The good news is that ADHD is relatively easy to treat. There are more than 200 studies showing that a stimulant called Ritalin (generic name: methylphenidate) works wonders for children with ADHD. Stimulants have been used in the treatment of ADHD for more than 90 years. Adults feel more focused and alert after a cup of coffee in the morning. That’s roughly how Ritalin works on children. Ritalin and other stimulants increase the alertness of the brain and nervous system, stimulating it to produce more dopamine and norepinephrine. The medication increases the child’s attention and reduces excess fidgetiness and hyperactivity, allowing him to focus on his work. Children with ADHD who take Ritalin make fewer errors on a variety of tasks than untreated children do. They are less impulsive and more attentive, both in the classroom and in social situations. They’re better able to control themselves. Kids with ADHD taking Ritalin receive more praise and less criticism from parents and teachers, and they get along a lot better with the other kids. Their grades go up, they become more popular, and they feel better about themselves.
A myth surrounding the treatment of ADHD is the “paradoxical calming effect” of stimulants such as Ritalin. It is a commonly held misconception that if a stimulant calms a child, then he must have ADHD; if he didn’t have the disorder, the thinking goes, the medication wouldn’t have any effect. That is categorically not true. Stimulants increase attention span in normal children as well as those with ADHD.
The recommended dosage of Ritalin varies widely. I’ve seen kids who respond to as little as 10 milligrams of the medicine and others who require 80 milligrams. Most children I see take from 30 to 70 milligrams of Ritalin; we start with the low doses and build up if necessary, taking into account the decrease in symptoms and the occurrence of side effects. Children nearly always take their Ritalin twice or three times a day: first thing in the morning, at lunchtime, and right after school. (This third dose helps kids to focus as they do their homework.) A dose of Ritalin lasts about four hours.
A child should have had a complete physical examination within the last year before a stimulant is prescribed. (We want a baseline of a child’s physical condition before the medication begins, so that we won’t mistakenly conclude that the stimulant is causing adverse effects.) Ritalin usually decreases appetite and may affect a child’s growth, so we pay special attention to a child’s height and weight, checking both every four to six months to monitor his growth rate. Most kids take ADHD medication for a minimum of nine to twelve months.
A decrease in a child’s rate of growth is a possible side effect of Ritalin, but that doesn’t happen very often. Most youngsters experience minimal negative side effects or none at all. The most common side effects are reduction in appetite, delay in falling asleep, headaches, and tearfulness. These side effects almost always disappear over time or with an adjustment in either the timing or the dosage of medication. Stimulants have been known, rarely, to cause tics, usually in children whose families have a history of tics. When a child is genetically vulnerable to tic disorders, particularly Tourette syndrome (described in Chapter 13), we look to other medications for treatment.
Ritalin is unquestionably the medication of choice—the first line of attack—with ADHD; but when Ritalin doesn’t get results or when the negative side effects are such that it must be discontinued, several other medications are routinely prescribed. The other stimulants that have proven to be effective are Dexedrine, Adderal, and Cylert. Dexedrine lasts longer than Ritalin and has similar, more frequent side effects: decrease in rate of growth, decrease in appetite, and delay in onset of sleep. Both Ritalin and Dexedrine are available in sustained release (SR) pills, which have the advantage of not requiring a school nurse to give the lunchtime dose. Frequently children taking Ritalin SR will also need to take regular Ritalin with their morning dose and an additional dose of regular Ritalin after school. Adderal is long-acting and similar to Dexedrine spansules. It lasts for about six hours, and since it comes in tablet form, it is easy to adjust the dose. Cylert lasts about ten hours, so it can be given once a day. Unlike the other stimulants, which work very quickly, Cylert may require two weeks before the full effects are felt. Cylert’s side effects are a little different from the others; appetite, sleep patterns, blood pressure, and heart are less often affected, but inflammation of the liver may occur in a small number of children. The manufacturer of Cylert recently reported on a series of youngsters who developed liver failure while on Cylert. At this time, it is not clear if this is a side effect of the medicine or a coincidental finding; however, given the serious nature of this side effect, Cylert should be used only for youngsters who have been nonresponsive to other medications.
Wellbutrin, a new antidepressant, has proven to be effective in children with ADHD who have had a poor response to stimulants. The side effects are similar but less frequent than those associated with the stimulants. There are three tricyclic antidepressants (TCAs) that psychiatrists turn to in treating ADHD, especially when the child being treated is vulnerable to tics: Norpramin, Pamelor, and Tofranil. These antidepressants have their own side effects, of course. They may cause tiredness, dry mouth, and constipation. More important, they may have an effect on heart rate; a child taking any of these medications must have an electrocardiogram before starting the medicine and before the dose is increased. Until recently Norpramin was the TCA used most frequently because it has fewer of the bothersome side effects, but over the last year or so several sudden deaths have been reported in children taking this medicine. Although there is not sufficient evidence to link those deaths with the Norpramin, it is rarely prescribed; Pamelor and Tofranil are now the medications of choice. The doses of Pamelor and Tofranil that are prescribed for children with ADHD are lower than those prescribed in the treatment of depression, and they need from one to four weeks to take effect. Because the medicine lasts a long time, it is taken in the morning and at bedtime.
Two antihypertensives, Catapres and Tenex, have been used when children have tics as well as ADHD. (An antihypertensive is frequently given in combination with a stimulant.) The medicine lasts a short time, so children must take it three or even four times a day. Catapres is available in a skin patch, which eliminates the necessity for the multiple doses. Side effects of Catapres and Tenex are minimal—sedation, headaches, nausea, dry mouth, and constipation—and they usually disappear with time. Antihypertensives don’t have the same cardiac effects on children as they do on adults, who take the medicine for high blood pressure, but an electrocardiogram is necessary before the medication is started. The child’s blood pressure and heart rate should be checked on each visit.
BuSpar, an antianxiety medicine, is currently being studied for use in children who have Attention Deficit Disorder and symptoms of anxiety. Some antipsychotic medications, especially Haldol, Thorazine, and Mellaril, reduce the symptoms of ADHD, but their side effects are such that they’re not ordinarily prescribed for this disorder.
We prescribe “drug holidays” for children who take stimulants, suggesting that parents discontinue the medication for at least four weeks each year. There are two reasons for
a drug holiday: first, it allows kids whose rate of growth or weight has been affected to catch up; and second, it lets us know if the medicine is no longer necessary. (Some children with ADHD do get better.) Most parents are inclined to declare the drug holiday in the summer, when a child’s school work won’t suffer, but it’s harder to assess a child’s progress in the summertime, because there is relatively little pressure on him to perform when school is not in session.
No matter when the drug holiday comes, most parents dread it. “I have a very hard time with drug holidays,” said one mother of a 10-year-old boy being treated for ADHD. “My whole life turns upside down, and the rest of the family goes a little crazy too. He is so different off the medicine, and by different I don’t mean better. July is the longest month of the year.”
Another mother wanted to give her son the summer off between fifth and sixth grade, but the child’s baseball coach pleaded with her to put him back on. The medication made a critical difference in his performance. Since playing the game well also made a critical difference in the child’s happiness and self-esteem, the mother gave him back his Ritalin after two weeks.
I’ve known parents who flat-out refuse to give their children a drug holiday. “We just couldn’t take drug holidays,” said one such mother, whose 11-year-old daughter has been taking Dexedrine for five years. “It’s not just that she’s incredibly unpleasant. We could deal with that. It’s that she’s so reckless. She gets into terrible trouble. She can’t make rational decisions and get on with her life without the medication. We worry about her too much to take her off it for any length of time.”
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