ATTENTION DEFICIT DISORDER

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What is it?

Attention deficit disorder (ADD) is just that, a shortage of attention span. Many people use the term hyperactive, but that does not describe the disorder adequately as some kids with ADD are not ďhyperactiveĒ. There is ADD with and without hyperactivity, abbreviated ADD and ADHD respectively. Some kids with a short attention span will sit quietly staring at the wall, while others act out. In general, those that sit quietly go unnoticed until they start failing school, while those who act out are found pretty quickly. A good way to think of ADD is the inability to refrain from stimuli that keep you from the task you are supposed to be doing. Most fathers of boys with this disorder feel that the boys are just rambunctious. Another good way to think of ADD in these kids is that they exhibit normal behaviors (active, rambunctious kids), but they cannot control that activity, and it gets them in trouble and keeps them from learning. Everybody likes to have fun, but when you cannot stop having so much fun that it interferes with having a good productive life, then there is a problem. The problem must be present in multiple situations and cause a problem with learning and / or social activities to be considered a true disorder. A concept that might help is to think of an occasional drink of alcohol versus an alcoholic. An occasional, responsible drink of alcohol is not a problem. For alcoholics, alcohol controls every aspect of their life; driving ability, interpersonal relationships, authority figures, job performance, etc. ADD/ADHD is not a personality flaw or lack of appropriate parenting, itís a true biochemical disorder that has effective treatment.

What causes it?

We donít have a cause identified at this point. We do feel it is a ďchemical imbalanceĒ of some kind. There is a strong inheritance pattern indicating it is a true biochemical disorder. Many parents of these children have had the same problems, but they were not well understood until recently. Also, many parents who have the disorder have it so mildly that it canít be detected. In 2004, a new type of MRI scan (like a CAT scan of the head, but uses magnetism and radio waves) showed that kids diagnosed with ADD/ADHD have a distinct pattern that can be shown on the scan. Those kids with ADD/ADHD who were treated with proper medication had those same MRI patterns return to normal. This and other recent studies show that ADD/ADHD is a real, inheritable disorder of brain chemistry and the medication used for ADHD can restore normal function. True ADD/ADHD is not a lack of proper parenting or discipline.

What does NOT cause it?

Too much or too little sugar, food reactions or allergies, vitamin deficiencies, allergies, vision problems, poor lighting, preservatives, television, and all sorts of strange things have been implicated to cause ADD, but all have been proven wrong. There are plenty of snake oil salesmen out there who take advantage of parentís lack of knowledge about ADD and will sell them all sorts of unproven remedies.

When does it show up?

Every child is different. There are kids who will show up with signs of the disorder as young as 3 to 4 years of age. We really donít like to treat the disorder medically until the child reaches school age, unless it is very severe. Therefore, we diagnose most kids with it during kindergarten and the first grade. Very few kids are diagnosed in the second grade. In the third grade we catch quite a few since the volume of work dramatically increases. A few kids will be diagnosed as late as the 7th to 10th grade.

How common is it?

Between 3 to 8% of children have some form of ADD. Remember itís only ADD when it disrupts the childís life or function enough to be a problem.

How is it diagnosed?

Typically someone discusses the problem with the parents. Usually this is a teacher, daycare attendant, or the parents themselves feel there is a problem. Most parents think about the issue for weeks to months trying to figure out if there really is a problem and trying typical behavioral modification methods. Eventually, the child is brought to the pediatrician looking for answers. The pediatrician screens the child for other medical problems that can look like ADD, or those that can be affected by the treatment of ADD. If the pediatrician feels the child may have it, then a referral is made to a child psychologist or psychiatrist. The psychologist or psychiatrist does an extensive evaluation over several hours (sometimes several sessions) to make sure the child does not have any other disorder and to ensure this is the correct diagnosis. The evaluation is very thorough and should assure any parent of the proper diagnosis. The MRI scan mentioned earlier is still in the experimental stage.

What can look like ADD?

Anything that can interfere with paying attention can mimic ADD, such as; hearing loss, vision problem, seizure disorder (staring spells), allergies, depression, behavior / conduct disorder, learning disability, etc. The first office visit to the pediatrician for ADD and all the well check ups help ensure these are not present. Children who are very intelligent may also be bored in class and appear distracted or become disruptive. 

What disorders can also be present with ADD?

Studies show that as many 80% of children with ADD have a second diagnosis at some point during childhood. The most common are behavior disorder, anxiety or depressive disorders, learning delays or disabilities or involuntary muscle tics. For most kids with ADD, these associated disorders are mild enough to not be a problem. For a small portion of kids with ADHD, the secondary disorders can be a big problem that requires multiple medications and ongoing behavior therapy.

Frequently I will see kids that appear to have more than just ADHD do very well on the ADHD medication alone. In short, the ADHD just looked more severe, but those ďextraĒ symptoms went away with proper treatment. Occasionally, though, the other symptoms are not helped with the primary ADHD medication and those symptoms become more obvious when the ADHD symptoms get better on the proper medication.

Occasionally some kids will do very well on ADHD medication for several years and then develop increasing behavioral problems as they get close to adolescence (8-12 years of age). In these kids, there is often a family history of Bipolar Disorder (Manic-Depression) and the kids are now showing signs of the same thing. Bipolar disorder frequently looks like ADHD in early childhood and then the classic signs of Bipolar show up in pre-adolescence.

What does not help ADD?

Because ADD is a perplexing disorder that parents are embarrassed about or not even sure their kids have, many have sought unproven treatments before seeking medical help. There are as many of these unproven treatments as there are snake oil salesmen to take your money. The most notable of these are: vision therapy, biofeedback (there is some evidence of improvement in research centers, but this is still in the research stage), vitamin therapies and diet therapies. Most of these have seemed to help some children in anecdotal reports, but none have proven of any benefit when tested according to accepted scientific standards in large numbers of children. Even psychotherapy has not been proven effective at curing ADD. Psychotherapy is very effective at helping diagnose the disorder, rule out similar behavioral problems and to help the parents and child cope with having this disorder. Psychotherapy is also very effective at teaching parents proper discipline techniques for children with ADD. It is important to note that discipline will not fix the disorder, it only helps control some of the symptoms to a certain extent. You can no more discipline a child to concentrate better than you can discipline a child to see better if they need glasses.

How is it medically treated?

Once we are sure of  the diagnosis and have tried behavioral and other techniques, then we can sit down and choose the best medicine to help your child. There are 4 types of medicines used to treat ADD:

ō   Stimulants

        Short acting (multiple doses per day): (Ritalin, Adderall, Dexedrine, Focalin)

        Long acting (usually one dose per day): (Ritalin LA, Adderall XR,  Concerta, Metadate)

ō    Norepineprine Uptake Inhibitors (Strattera) 

ō    Antidepressants

        Tricyclic Antidepressants: Imipramine (Tofranil), Desipramine (Norpramin), Nortryptyline (Pamelor), Amitryptyline (Triavil, Limbitrol), Clomipramine (Anafranil), Buproprion (Wellbutrin, Zyban).

        Selective Serotonin Reuptake Inhibitor (SSRI): Sertraline (Zoloft), Fluoxetine (Prozac), Paroxetine (Paxil), Fluvoxamine (Luvox)

ō    A blood pressure medicine called Clonidine.

 

How do we choose one medical treatment over another?

                Ultimately, we will choose the medicine that has the greatest chance of helping your child based on your childís individual situation. Whatever medicine we chose, the medicine has to be tailored to your childís specific situation and must be monitored over time. As you will see by the following explanation of effects and side effects, this is not always a simple matter of starting on the most commonly used medicine.

Lets start with some concepts.

1.       One out of three (1/3rd) of kids will not do well on the first medication we try. Approximately 1/3rd of the second medication trials will also fail, and so on.  A small percentage of kids will have to try 2 or 3 medications to get to the right one for them, while most will do well on the first medication chosen.

2.       Whatever medication we chose, it will take from 10-30 days to reach the best dosage. With the stimulants, we start at the lowest dose and increase by a small amount each WEEK. We increase the medication slowly to reduce the chance of a side effect. Kids also have good and bad days and we want to judge the medication effect based on the average of several days observations. In doing this we will generally arrive and the lowest effective dose rather than an over-medication issue.

3.       The first line medications can generally be separated into long acting and short acting. Up until mid 2001, the old long acting medications really did not last all day long, nor did they give an even effect all day. The newer long acting medications (Adderall XR, Concerta, Ritalin LA, Metadate, and Strattera) are very successfully used once a day. The old long acting medications had to be dosed higher to last all day, while the newer ones do not. Up until the newer long acting medications came out, I recommended parents use short acting medications, but the short acting medications must be given at school during lunch time and sometimes an after school dose is needed. We generally recommend the newer long acting medications now, as they do not have to be given at school. Each medication is different and some kids do much better on one than another. The problem is finding that one. The only time I currently recommend a short acting medication is if the long acting are not working or have a side effect, especially insomnia or belly pain. Focalin is a purified version of Ritalin, with much less side effects, but it must be given at school. I also recommend short acting medication because they are much less expensive than the newer long acting medication. If your insurance does not cover the long acting ones or it does not cover the one that works best for your child (all insurances have formularies than limit our choices here), then a short acting cheaper medication may appeal to you.

Now lets looks at individual medications.

1.       Stimulants (Short acting): The stimulant medicines have been the first line therapy for over 30 years and we have a lot of experience with them. Some kids can do well on any of these medications, but the majority will do much better on one than another. One problem is that there is now way to tell which is the best medication for a specific child until they are tried.

a. Ritalin was the first choice of the short acting stimulants as we have the most experience with it and it is available cheaply. Regular Ritalin must be given in multiple doses through the day since it only last 3-5 hours. Almost all kids on regular Ritalin need a lunchtime dose. If homework is an issue or the child requires medication for social function in the evening, then we often will give an afternoon dose at approximately 3-5pm to cover the evening. Giving this later dose increases the chance for problems getting to sleep.

b. Dexedrine was the second most commonly prescribed medicine up until the newer long acting medications came out. There really isnít a good long acting Dexedrine that will last all day yet. It is longer acting than plain Ritalin, with some kids needing only one dose in the morning. Dexedrine is also used in weight control, and many insurance companies demand a letter of explanation for why the child requires the medicine (despite the fact that it was the second most commonly used medicine in ADD/ADHD before the long acting medications came out). Since the long acting Ritalin medication came out, Dexedrine is rarely used.

c.  Adderall is a mixture of the active ingredients of Ritalin and Dexedrine. Some children are able to take one dose of Adderall in the morning rather than multiple doses, but the majority of kids will take multiple doses like with plain Ritalin.

2.        Stimulants (Long Acting): The long acting stimulants were released soon after the turn of the century. The long acting stimulants all contain the same basic ingredient, Ritalin. Each long acting stimulant has a different mechanism for slowly releasing the Ritalin through the day. Since there is a different release mechanism for the medication, some kids will do much better on one of these than another. In the vast majority of cases, the long acting stimulant can be given as a single dose in the morning with no other doses needed. They generally last 10-12 hours and usually last long enough to allow homework to be completed with ease in the early evening. Even though these long acting stimulants last much longer than short acting Ritalin, they cause much less problems with getting to sleep as compared with multiple doses of short acting Ritalin being given throughout the day.

a.  Ritalin LA: This medication can be sprinkled on food or swallowed as a capsule. The medication comes in 10mg, 20mg, 30mg and 40mg pill sizes. If the child requires higher doses, we simply give combinations of the smaller pills. Ritalin LA releases 1/2 of the total dose in the morning with the rest slowly spread through the day.

b. Concerta: This medication is a special type of capsule with precise laser holes drilled in the sides. There is Ritalin coated around the capsule to release an immediate dose in the morning, and then the medicine is slowly leaked out of the laser holes in a precise manner through the day. Because the release mechanism uses these holes, the pill must be swallowed whole and cannot be sprinkled. This medication comes in 18mg, 27mg, 36mg and 54mg sizes. Concerta releases approximately 1/4th of the dose in the morning and then slowly releases the rest slowly through the day.

c. Metadate: This medication can be sprinkled on food or swallowed whole as a pill.  Metadate comes in 10mg CD, 20mg CD, 30mg CD, 10mg ER, 20mg ER.

3.       Strattera:  In December 2002, a new class of medication was approved. Strattera is a Norepinephrine Uptake Inhibitor, which affects nerve signal transmission in the brain. Strattera is meant as a first line medication for ADD/ADHD, is not a stimulant, is taken once daily, does not usually need adjustment of the dose, has no abuse potential, and has less potential for side effects. Now less potential does not mean the stimulants are horrible and does not mean Strattera has no side effects. Strattera only has been released since 12/2003 and only has 4 years worth of studies prior to its release to back it up, while the stimulants have been successfully used for over 30 years.  Strattera comes in 10mg, 18mg, 25mg, 40mg and 60mg pills. The pills are best swallowed whole as the medicine does not taste good sprinkled on food (I do have a few patients that have taken it this way). Strattera can be formulated into a liquid by a formulating pharmacist (Travilians in Kanawha City or Loop Pharmacy in St. Albans).

4.        Other medications: The rest of the medications mentioned here are not used by themselves. These medications are often added to the stimulants to help them work better or to help a symptom that the stimulant was not able to fix by itself. The vast majority of kids with plain ADD or ADHD will not need one of the medicines mentioned in this section.

a.  Antidepressant medications also appear to be quite effective for ADD, but they have more of a potential for side effects than the stimulants. Blood work and an EKG are required before starting, and periodically while taking, the medicines. The antidepressant medicines are rarely used alone for ADD. Typically we try stimulant medicines first. The stimulant medicines have a mild antidepressant effect, and depression frequent occurs with ADD. If the stimulant medication is not effective enough at the proper dose, then an antidepressant may be added. Antidepressants also seem to help with aggressive behavior and sleep disturbances.

b. Clonidine appears to help a large number of children with ADD, but it also, has a higher chance of side effects than the stimulant medications. Blood work and an EKG are required before starting, and periodically while taking, the medicines. Clonidine appears to help with aggressive tendencies and also wonít cause involuntary muscle tics that some kids have along with ADD.

Side effects of the medicines

Most children do very well on these medicines without any side effects. The most common side effect of the stimulant medicines is appetite suppression. The majority of these kids will drop a growth curve on the growth chart, but then will gain weight as fast as any child in that growth curve. The majority of kids we start on stimulants are overweight to begin with and simply drop their weight into a more normal growth curve. The stimulant medicines can also worsen involuntary muscle tics. If you remember the TV comedy Cheers and the barmaid Diane, she had a facial muscle tic where she twitched her right eye lid and facial muscles. Some children have this disorder so mildly you cannot tell they have it, then after starting the medicines it worsens. We used to stop the stimulant medications if tics occurred, but now think the medicine is ok to use with tics. ADD tends to start at 4-6 years of age and tics tend to start at 6-8 years of age. Stimulant medicines can increase blood pressure, but we are very careful to watch for this and slowly increase the medicines. In my first 13 years of private practice, I did not see a single child get high blood pressure from the medicines. The Antidepressants can affect liver function and blood cells and therefore require monitoring of blood tests. The antidepressants can also affect the heart rhythm, cause dry mouth, dry eyes, blurred vision, constipation, drowsiness, sleep changes, dizziness and change heart rhythms. These sound impressive, but are not  common. Clonidine can cause many of the same side effects as the antidepressants and require similar blood tests and EKG monitoring.

Will my child grow out of it?

About 80% of children will still have some of the symptoms of ADD into adulthood, but it wonít look the same as the childhood form. Most children will have less of the attention problems as they go through adolescence and into adulthood. Some children will have interpersonal skill problems, such as problems relating to authority figures (employers, police), problems relating to loved ones (divorce), procrastination, mood swings, low stress tolerance (hot temper) and hyperkinesis (restlessness).

ADD/ADHD causes kids to not respond to the typical discipline that most parents give. This can lead to an ever-increasing division between the child and the parents. Over time, this division can cause the child to not develop socially in a manner most of would feel is healthy. When kids with ADD/ADHD grow into adolescents and adults with interpersonal skill problems, its often difficult to figure out whether the ongoing problems are due to adult ADD/ADHD or are due to the lack of adequate social / personal growth caused by the ADD/ADHD in childhood. Therefore, I occasionally recommend ongoing therapy with a child psychologist or family therapist to help in these situation.

Logistic issues with ADD medication

There are a few logistic issues with stimulant medications due to state and federal regulations that you should be aware of.

  1. We can only write for a 1 month supply at a time. The only exception is for 90 day supplies to mail out pharmacies once the patient is stable on a medication.
  2. We cannot write for refills or call in the medicine, but we can mail you a prescription. The only exception is Strattera, which is not in the same DEA control category.
  3. The prescription must be filled within 3 days of the date on the prescription.
  4. The medications must be slowly increased with close monitoring by phone to get to the right dose.
  5. With any medication increase, the blood pressure should be checked within a few days after the change.
  6. Make sure to keep the medicines locked up away from small children as an overdose of any of these can cause serious harm.

 We will cover much more about the medicines if your child is diagnosed with ADD/ADHD. Our main goal is to help your child concentrate for learning in school. A secondary goal is to help your child with social interaction if that appears to be greatly affected also. We will be in touch by phone frequently to ensure that your child is doing the best he or she can by adjusting the dosage as necessary.

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