This is the third part in a series about ADHD, especially as it pertains to children in elementary school. For the first two parts, see here and here.
Today’s post comes to you from my husband, who also happens to be a pediatrician. He’ll share his thoughts with ADHD as both doctor and dad. He’s graciously making himself available for questions, so leave a comment if you have anything to ask him!
And now, Dr. Jason:
First, a plug for a great resource online in case you haven’t come across this yet: HealthyChildren.org. This is a website with great articles about many common childhood concerns from healthy eating to mental health issues. It is run by the American Academy of Pediatrics. I agree with the AAP on 99% of issues (happy to discuss the other 1%) and would definitely recommend this resource to all parents.
So you’ve got a kid with “behavior” problems. This could be caused by a large list of issues. Poor sleep, from things like undertreated allergies, snoring, etc. can cause difficulties during the day. Learning difficulties, like dyslexia, can show up as problems in the classroom. When I was in first grade I had trouble completing my daily tasks, and was almost held back a year. Turns out that I needed glasses and couldn’t read the goals/tasks written on the chalkboard.
One thing that can cause behavior problems is Attention Deficit Hyperactivity Disorder. Here I’ll attempt to give a brief overview of what this is and how to recognize it.
What is ADHD?
Different parts of our brain are responsible for different tasks. At the very front of your brain (just behind your forehead) is the prefrontal cortex. This is the part of the brain that is in charge of attention, impulse control and planning. In kids with ADHD, this part of the brain is underactive, relative to the rest of the brain.
If you are on your way to pick up the laundry and get a notification on your phone, your prefrontal cortex says “You need to go get the dirty clothes before you stop and do something else.” If you have ADHD, this doesn’t happen. You get distracted and stop to check your phone. You may end up spending 25 minutes checking Facebook, Instagram and Flappy Bird (apparently no longer supported on iOS 11, RIP little bird.)
In school, kids with ADHD have trouble controlling their impulses; they may get out of their seats at inappropriate times. They have trouble switching their focus and attention and have a hard time changing tasks. They may, like my son did, get up and wander around the room for 10-15 minutes aimlessly.
Symptoms of ADHD
Kids with ADHD can have a variety of symptoms, with some kids having more issues in some areas than others. Hallmark symptoms of ADHD include impulsivity, inattention and hyperactivity. There used to be two separate diagnoses: ADD and ADHD. Currently it is all called ADHD, and is divided into categories such as ADHD inattentive type, or ADHD hyperactive type.
We all have times when our prefrontal cortex is “underperforming.” This is like when you are useless in the morning until you’ve had your coffee or Diet Coke. The difference with ADHD is that this occurs on a very regular basis and interferes with daily functioning.
Treatment of ADHD
It’s counterintuitive, but hyperactive, distractible kids are often treated with stimulants. The idea is to increase the activity in that prefrontal cortex, giving them the ability to focus and control impulses when it’s needed.
There are other groups of medicines that can also be used depending on the type of symptoms the child is having and the response to routine medications. Understanding these meds, how they work and when they should be used goes beyond the basic scope of this discussion. Just be aware that your pediatrician may suggest things outside of Ritalin/Concerta/etc.
Aside from just treating with pills, there is a lot that parents/teachers can do to help kids with ADHD. Primarily, understanding what the problem is and keeping that in mind is a big first step. If your child has ADHD and you keep yelling instructions at them, thinking they just aren’t listening, you could be making their struggle worse. I try to educate parents on how to help a child with ADHD focus and get a task done. Getting the teacher involved is also important. Sometimes an IEP (individualized education plan) is needed to lay out specific plans/goals/consequences.
So when should you try medications? It’s different with every child, but as a pediatrician I always use meds when the potential benefit outweighs the potential risk. This is the case for all medical problems such as ear infections, asthma and ADHD. Some kids are picky eaters and on the low end of the growth chart, so I might be slower to start a stimulant with them, as they can cause decreased appetite. On the other end of things, I’ve seen kids who have seriously needed treatment for mental health issues that parents refused to act on because of the stigma, and my heart breaks for them. So my advice is to be willing to have the discussion with your doctor about what non-pharmacological things you can try, but be open to the use of medication if needed.
Prognosis of ADHD
When recognized and addressed early, kids with ADHD tend to do pretty well. There may be a “transition” period while you figure out what interventions/strategies/meds are right for you. As kids grow up, some of them may outgrow their symptoms or form their career/lifestyle in a way that meds aren’t needed. Some may continue to need some medications as adults.
“When I was your age…”
I have heard many people say they think ADHD is over diagnosed and over treated these days. I don’t have a solid answer for these people. Are there some kids who are having different issues who just get thrown on medications? Absolutely. Are there some kids who struggle longer than they need to because people tend to neglect mental health in children? Absolutely.
What it comes down to is finding a good pediatrician or family physician that you feel comfortable bringing your concerns to, and that spends the time investigating the issue and explaining to you what they are thinking and why.
My experience with ADHD
From a relatively young age, around 3, I noticed my son excelled at many things like language and learning. In terms of gross and fine motor development, he was average. One area he was behind in was attention and focus. This is hard to define explicitly in a 3 year old. As he entered Kindergarten, I mentioned this in passing to his teacher. He was not a “wild child” and didn’t have big issues with hyperactivity, so from a teacher standpoint it wasn’t a big issue. Same thing starting 1st grade, I had my concerns but it wasn’t affecting his daily functioning. My wife, the Premeditated Mama, was maybe starting to see what I was seeing. Then we got an email from the teacher. “Wandering” was the subject. Basically, she was concerned that he often would get distracted and be unproductive.
I TOLD YOU SO
…This is what I silently said. In reality, what I said was “Oh yeah, why don’t we look into that more.”
After getting an evaluation from his actual pediatrician, we started him on a trial of the first-line meds for ADHD, a stimulant called Concerta. I will leave it to Premeditated Mama to describe our experience once we started treatment, both meds and behavioral, for ADHD.