September 2010

Is It ADD/ADHD or Just Normal Behavior?

By William "Dr. Bill" Incatasciato

Every year when the new school year begins, many parents contact me to ask if their child may have attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD). Usually these parents have been told by a teacher that their child has been very fidgety, forgetful or inattentive in class. I see this mainly in kids who just started kindergarten or first grade, although I also get more visits later in the year from middle and high schoolers.

ADD/ADHD Basics

Let me start by explaining that ADD and ADHD are basically the same thing, except ADHD adds a hyperactivity component to the diagnosis (see symptoms below). Nationwide, it is estimated that between 1 to 3 million children (3 to 5 percent of the population) have these conditions, which are often inherited from a parent.
Being diagnosed with ADD/ADHD does not mean your child is not smart; quite the opposite, in fact. Many kids with ADD/ADHD are highly intelligent.

Don't panic if a teacher or other professional suggests that your child may have ADD/ADHD. Children are naturally curious and are still learning social rules, especially if they just started kindergarten or first grade. As a result, they may seem to be hyperactive and inattentive but are actually just being themselves. Even middle and high schoolers need time to adjust to new environments. In some cases, these kids will simply outgrow the fidgety stage.

On the other hand, if your child actually does have ADD/ADHD or some other problem, it's important to have him seen by a professional, who will determine exactly what your child is dealing with. For example, there are plenty of other conditions that may mimic symptoms of ADD/ADHD, including learning disorders, hearing problems, vision problems, metabolic problems, toxic exposures, seizures, genetic problems, boredom due to easy schoolwork, and traumatic events. It's important to do a thorough exam and testing to rule out all these other possibilities before pursuing the diagnosis of ADD/ADHD. The work-up for ADD/ADHD includes a history, physical, ADD screeners and blood work. Your pediatrician can do these tests, and/or make the necessary referral to a colleague who will do the work-up.

Symptoms

Children who have ADD typically show the following symptoms:

Patients with ADHD may also have:

Most of these symptoms will surface in children before the age of 7. In order to qualify as ADD or ADHD, the symptoms must cause disruption in the child's daily life in at least two settings, i.e., home and school. Again, don't panic--many "normal" kids have these symptoms at times, and fortunately for some, the symptoms will eventually go away on their own. Note that the hyperactivity symptoms often disappear with time as well.

Girls vs. Boys

When it comes to ADD/ADHD, the traditional belief is that more boys have the disorder than girls. But since boys and girls are different in how they appear with this problem, it is hard to know if this is really so. Boys tend to have more "hyperactivity" signs and get discovered by their teachers early on. Girls tend to be quiet and come across as daydreamers.

Boys and girls also deal with their lack of focus differently. Here is an imaginary scenario: It is 8:30 p.m., and a boy just realized that he forgot to do the homework assignment that is due the next morning. His plan is just to forget about it and accept a zero from the teacher the next day. When a girl realizes that this same homework assignment is due, she promptly tells her parents. Mom or Dad then spends the next few hours working with her to get it done, and the girl receives an "A" on the homework.

Treatment

Once the diagnosis of ADD/ADHD is made, the treatment approach will depend on the severity of the symptoms and if there are any complicating factors. Sometimes, children with ADD/ADHD also have co-morbid conditions, such as oppositional defiance disorder, pervasive development disorder, learning disabilities, anxiety, depression, obsessive compulsive disorder, and auditory/visual processing problems.

Kids with ADD/ADHD will need some environmental adjustments. They do better if placed in the front of the class to minimize distractions. They also do well if given more time for tests and if they can receive assignments in smaller units. If the symptoms are severe or if the child is in danger of failing or being expelled from school, then medications may be necessary. If co-morbid conditions are present, then referrals to the appropriate specialist are needed.

There are two types of medicines used to treat ADD/ADHD: stimulants and nonstimulants. I'm often asked, "Why would a stimulant be prescribed for a person who is hyperactive and can't pay attention?" The answer is that the stimulant activates a center in the brain responsible for filtering information and restoring a sort of balance. Here's an analogy I use when explaining the concept to parents: Imagine being in a large room filled with many people and trying to have a conversation with one person only. The average person can do it because he is able to ignore the other conversations everyone else is having around the room. Someone with ADD/ADHD, on the other hand, hears all the conversations and has trouble focusing on one in particular.

You may have heard of a stimulant called Ritalin, which was commonly used many years ago. Today, there are a wider variety of stimulant medications available. Some stimulant medications currently used are: Adderall XR, Focalin XR, Rilalin LA, Vyvanse and assorted generics. The long-acting stimulants can last most of the day and then wear off by bedtime. They can be given on days that the patient needs control, and parents can opt to not give them on "non-vital" days. Some common side effects include appetite suppression, abdominal pain, insomnia, motor tics, headaches and increased heart rate.

Nonstimulants have also been used with some success. They need to be given daily to maintain certain levels in the blood but seem to have fewer side effects than the stimulants. The two nonstimulants currently being used for control of ADD/ADHD symptoms are Strattera and Intuniv. Each works differently on the brain by affecting how the brain's neurotransmitters work. Some side effects include headache, nausea, drowsiness and constipation.

The Future for ADD/ADHD Patients

ADD is a lifelong condition. (ADHD is not usually lifelong because the hyperactivity component that may have been present at childhood is typically gone by adulthood). Some evidence suggests patients who started on medication at a young age tend to do better later in life. Sometimes, patients refuse to take their meds, either because of side effects or not wanting to be different from their friends or just sheer forgetfulness. However, using ADD meds reduces the risk of drug abuse down to normal adolescent levels.

Most physicians ask their patients to continue taking their ADD medications through college. At that point, the person has hopefully learned how to manage his time and has come up with techniques that allow him to remember tasks to be done. Then, he can hopefully be weaned off the medications.

Don't Let ADD/ADHD Bring Your Child Down!

Failing in school is not the only risk to children with ADD/ADHD. Those with co-morbid conditions can also experience more severe problems, such as depression or anxiety, and suffer from symptoms of those conditions as well as the symptoms from ADD/ADHD. ADD/ADHD patients have a higher risk of drug abuse and trouble with the law and are more prone to auto accidents. Their lack of impulse control and leaping before thinking will also make them prone to doing stunts that are dangerous. These are the kids who would put their tongue on the frozen flagpole!

Don't let ADD/ADHD bring you and your child down. If you see behaviors that you think may be consistent signs of ADHD, visit your child's pediatrician for a proper evaluation. The earlier you know what is going on, the sooner you can do what is needed to help remedy the situation. With an early diagnosis and treatment, there's a high probability that your child will overcome his obstacles and enter adulthood prepared to take on the world!

William "Dr. Bill" Incatasciato is a board certified pediatrician who has been practicing with the Countryside (Sterling) office of Capital Area Pediatrics (www.CapitalAreaPediatrics.com) since 1995. Dr. Bill speaks Spanish and Italian, teaches regular baby classes for Reston Hospital, has served on many boards and committees and is also a clinical instructor for the Georgetown University pediatrics program.