ADHD: diagnosis and treatment

I have a five-year-old who has been diagnosed with ADHD. He is currently on Ritalin, 10 mg. twice a day and 5mg. in the afternoon. I realize that many of the other stimulants out there may be more effective. Can Adderall be used for a child of this age?

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Robert Steele

Robert W. Steele, MD, is a board certified pediatrician at St. John's Regional Health Center in Springfield, MO. He graduated from medical... Read more

Let me first address your question by briefly discussing the diagnosis of AD/HD.

Attention deficit/ hyperactivity disorder (AD/HD) is a diagnosis, which has increased substantially over the last few years. This issue has both a medical and substantial emotional side to it making discussion of the topic sometimes difficult. There are many children who seem to be uncontrollable both at home and in the classroom who have teachers and parents clamoring to have these children placed on medication. And, there are many doctors who feel this disorder is over-diagnosed and that children are being placed needlessly on mind-altering medication. The answer to this probably lies somewhere in the middle, in that, AD/HD is a very real problem that can often be substantially minimized with medication and other interventions. However, to have the right cure, you must have the correct diagnosis. There are many reasons for children to have poor impulse control and poor attention. One reason is AD/HD, but there are various others. Therefore, understanding some of the other things that may mimic AD/HD is crucial.

SOME THINGS THAT MAY MIMIC AD/HD

Learning Disabilities
This is probably one of the most important things to rule out when considering AD/HD. Imagine sitting in class for an hour discussing a book, but everyone is speaking Portuguese. Unless you know Portuguese, you will become bored pretty quickly. If a child has difficulty learning for whatever reason, he too is going to become bored, and he is not going to be attentive or cooperative. And having a learning disability does not mean the child couldn't also have AD/HD. It is estimated that up to 40 percent of children with AD/HD also have some other learning disability. Formal testing for learning disabilities is crucial to make sure it is not playing at least some role if not the entire role in his apparent impulsivity and inattention.

Hearing or Visual Impairment
Anything hampering the child's ability to learn is going to result in decreased attention in the classroom. Significant hearing impairment may, unfortunately, go undiagnosed for years. Therefore, the usual hearing screen performed in the preschool years should be done. A vision screen may be done at the doctor's office or at school.

Behavioral/Psychiatric Disorders
Behavioral problems due to social stressors (divorce, poverty, poor limit setting, etc.) may manifest as behaviors which may be confused with AD/HD. And these psychiatric problems may run hand-in-hand with AD/HD as well. Therefore, treatment of any co-existing behavioral or emotional problems must also be addressed for treatment of the AD/HD itself to be effective.

Medical Causes
Side effects of certain medications, chronic medical illnesses, and sleep disorders may also cause children to behave in such a way as to be confused with one afflicted with AD/HD.

Increased Intelligence
On the other hand, an increased intelligence may facilitate boredom in the normal classroom setting. This actually is a relatively uncommon cause of behavior mimicking AD/HD but one that should be kept in mind.

These are just a few examples of other things that may either coincide with or completely mimic AD/HD. Obviously, the treatment for a learning disability is not medication but a specific learning environment tailored to the child. Giving Ritalin to a child with a hearing or vision problem will not cure the behaviors. Behavior disorders require counseling both for the child and the family, not medication for AD/HD. The point is, one must first be sure the child has AD/HD to correctly treat it.

SO, HOW DO YOU ACCURATELY DIAGNOSE AD/HD?

The short answer to this is there simply is no quick, easy test to diagnose AD/HD. There are certain check sheets that may be filled out by parents and teachers to get an idea of what behaviors are occurring, but they are far from perfect in diagnosing AD/HD. The best way is by careful and consistent cooperation between, the parents, the teachers, a professional trained in testing for learning disabilities, and the pediatrician. Because the diagnosis of AD/HD is so very often unclear, it requires all these team members working in concert to get to the bottom of the cause of the child's inattention, impulsivity, and apparent hyperactivity.

The parents and teachers are the best judges as to which children seem to behaving significantly differently from the other children. Their job is to identify what the child is actually physically doing that is out of the ordinary. The educational testing professional is there to make sure there are no learning difficulties occurring. And the pediatrician is there to take in all the information in order to form an opinion as to the cause of the child's difficulty. Together, as a team, hopefully the following questions can be answered:

  1. Do the symptoms of impulsiveness, inattention, and hyperactivity occur in all settings? A child with AD/HD usually has problems regardless of where he is. If it only occurs at school or only in one person's classroom, this may suggest there is something else going on.
  2. Is there any specific medical, psychiatric, social, or developmental reason that could account for these behaviors?
  3. Are the expectations placed on the child consistent with his overall ability?
  4. Have any educational or behavioral interventions been tried? What worked and what didn't?

Once the diagnosis of AD/HD is made, there are many aspects to helping the child, that don't involve medication, which are necessary. These include increasing the consistency of the learning environment, identifying behavior modification strategies (both praise and discipline), and addressing any low self-esteem the child might have. And then medication is tried.


MEDICATION FOR AD/HD

About fifty years ago, it was noted that a certain amphetamine had a calming effect on those with hyperactivity. Since that time, amphetamines have been used as the primary medical treatment for AD/HD. There are other medications that may be used in conjunction with the amphetamine when the diagnosis of AD/HD is certain and the use of amphetamines alone has not worked. While these medications have proved valuable as part of a treatment plan in AD/HD, there are a couple of things that must be kept in mind.

  1. Medication will allow for a better attention span and greater impulse control. It does not treat poor self-esteem, learning disabilities, or behavior disorders. These must be treated as well.
  2. Amphetamines can improve anyone's school performance in the short run. Therefore, an improvement early on in treatment does not necessarily mean the diagnosis of AD/HD was correct. Long-term, ongoing reevaluation of the child must take place with all team members stated above taking an active role.

To date there have been no studies that show any one particular amphetamine is better than any other in treating AD/HD. The differences in medications are primarily found in how often the pills must be taken and their side effects. Adderall has two types of amphetamines in their one pill and has been approved for children three years and older. However, like all other amphetamine formulations, it has not been shown to be any better in treating AD/HD. If you are unhappy with your child's response to medication, I suggest you talk with his doctor about the problem. Specifically, address whether your son has any other problems (as outlined above) which need to be investigated. Other medications being added to his regimen may also be an option. However, the diagnosis of AD/HD ought to be certain if this is chosen.

Good luck to you.

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