By MICHAEL SHAPIRO, PhD
As I was saying at the end of our last episode, because of the myriad of things that look like ADHD but are not, a diagnosis of ADHD should never be made casually, and should never be based solely on opinion, observation, comparison (“My other kids were never this much trouble!”), or a cursory evaluation in a doctor’s office. A proper evaluation for ADHD involves many painstaking components, beginning with a complete history. Since so many things could predispose a child to hyperactivity and attention problems, the skilled mental health professional will be careful to ask about a child’s health history (“Were there any problems with pregnancy and delivery? Does the child have any chronic health problems or take any medications?”), educational history (“Have there been any learning problems?”), family/social history (“Is this an intact family? Has there been any trauma or abuse? Is there anyone else in the family with similar problems?”), and any history of previous behavioral or mental health issues.
Once a thorough history has been obtained, specific tests will be administered in an attempt to verify an attention problem and rule out any other developmental, emotional, or educational issues. The first of these should be a test of intelligence, which will help the psychologist decide whether or not the child’s behaviors are consistent with his level of intellectual development. For example, children who are intellectually gifted may find it difficult to pay attention in a “normal” classroom because they’re bored. Conversely, children with a developmental delay may act impulsive or immature, but those behaviors might actually be appropriate for their “mental age.”
Next, tests of academic achievement (reading, writing, and arithmetic) should be administered in order to rule out a learning disability, or to determine the degree to which a child’s inattention in the classroom has interfered with learning. Last but not least, tests of emotional functioning should be administered to assess the child’s feelings about school, himself, his family, other children, and the world in general. The clinician may ask the child to draw pictures or respond to some open-ended questions. Also, there are surveys and behavior rating scales that can be administered to parents, teachers, and the child himself for the purpose of comparison. In this way, we can get a “360 degree” picture of a child’s behavioral and emotional functioning from many viewpoints.
Once a history has been obtained and all the data has been collected, a proper diagnosis can be made. However, even with all this information at hand, there still may be some overlap with other diagnoses. For example, a child can suffer from both an attention deficit disorder AND a conduct disorder, an anxiety disorder, a learning disability, or a mood disorder like depression! Quite often, a good evaluation will reveal several issues that will need to be addressed at the same time! A good treatment plan will take all of these into account.
Speaking of treatment…let’s start with the Big Kahuna of contentious issues: medication. Typically, ADHD is treated with stimulant medication. Stimulants all work essentially the same way, by “activating” or energizing the brain. To give you a good point of reference, caffeine is a stimulant. The activating effects of caffeine are why we (or is it just me?) can’t even begin to face the day without a healthy dose of morning Joe (injected, preferably, directly into my veins).
Of course, when I propose stimulant medication to parents, their first reaction is something like, “A stimulant? Really? Don’t you think my kid is stimulated enough?” Although no one is entirely certain why stimulants help children with ADHD, the theory is that these medications actually stimulate the self-control centers of the brain to work more efficiently. Another theory is that the brains of ADHD children don’t receive enough stimulation from within, so they crave stimulation from without (by watching fast-changing cartoons, playing stimulating video games, or going from one thing to another). Stimulant medications satisfy the needs of these under-stimulated brains.
Back in the day, there were very few stimulant medications, Ritalin being the most famous and easily recognized. Nowadays, there are many stimulants on the market, as well as non-stimulant medications (which work a little differently and may be better for children with other issues, like aggression). There are also some “natural” preparations that claim to be effective, but please be aware that few of these claims are actually supported by research. In a child whose ADHD has been confirmed by an evaluation (and who has no other “complicating” issues), stimulants can be very effective, and improvement can be seen very quickly, because these medications are rapidly absorbed by the body. On the other hand, these medications don’t usually last very long, and some children may experience a “rebound” (irritability, tearfulness, or fatigue) when they wear off towards the end of the day. If this is the case, there are some long-acting stimulants that can be helpful, or the child’s doctor can make adjustments to the dosage.
I am always careful to tell the parents of children with ADHD that medication is never intended to be a “forever” thing. Because of the way the human central nervous system matures and develops, many children grow out of some of the symptoms of ADHD. After all, you don’t see many 30 year-olds running through Walmart knocking over displays and playing hide-and-seek in the clothing section (or do you?). However, they may still struggle with inattention and feelings of restlessness as an adult. For children on medication, we are careful to re-evaluate periodically, in the hopes that there will come a day when the child—usually at some point in adolescence—no longer needs medication (only 30 to 60 percent of patients diagnosed with ADHD in childhood continue to require treatment as adults).
How old does a child have to be to start medication? Most doctors are hesitant to medicate preschoolers. However, I usually make two exceptions: the first of these applies to children who are so impulsive that they endanger themselves or others…for example, by jumping off tall things or throwing rocks (often not out of maliciousness…just to see if the rocks can fly). The other exception involves preschoolers who are getting in so much trouble that no one likes them; not their preschool teachers, not the other children…and sometimes not their parents. With these children, if their symptoms are not managed with medication, they might develop social problems, a hatred of school, or problems with self-esteem. So, in the cost-to-benefit analysis, it may be advisable to treat these little ones now in order to prevent some more severe problems in the future.
Of course, medication represents only one tool in the ADHD treatment tool kit. It tends to yield the fastest improvement, which is why it’s usually the first to be recommended. Once a child’s symptoms have been brought under control with medication, individual psychotherapy can be used to help the child develop some self-control and self-regulation skills. Also, the research strongly suggests that the prognosis is best when therapy for the child is paired with training for the parent! EVERY parent can benefit from coaching on parenting skills like communication, discipline, encouragement, and the proper balancing of age-appropriate rewards and punishments. So, no therapist, counselor, or psychologist should treat only the child! The best mental health professionals are those who are skilled in both child therapy and parent training.
That brings us to the topic of how to choose an appropriate mental health professional, because the list of degrees, certifications, and titles can be absolutely bewildering. However, I see by the clock on the wall that it’s time for my afternoon Starbucks, without which I will lose my concentration, fall asleep, start daydreaming, or a combination of all three. So, this will have to wait until next month. See you then!