ADHD Awareness All Year Long

Let me start by saying I know ADHD Awareness Month was in September, but I believe it's important to be aware of ADHD all year long. So, in solidarity with ADHDers who procrastinate, here's a round-up of articles and resources I like.

One of the pages on the ADHD Awareness Week - September 13-17, 2010 site is Myths About ADHD. The article, originally from Attitude Magazine, describes seven common myths. My two favorites (italics are mine):

Myth #5: ADHD is the result of bad parenting. When a child with ADHD blurts things out or gets out of his seat in class, it’s not because he hasn’t been taught that these behaviors are wrong. It’s because he cannot control his impulses. The problem is rooted in brain chemistry, not discipline. In fact, overly strict parenting— which may involve punishing a child for things he can’t control— can actually make ADHD symptoms worse. Professional interventions, such as drug therapy, psychotherapy, and behavior modification therapy, are usually required.

Myth #6: Children who take ADHD medication are more likely to abuse drugs when they become teenagers.

Actually, it’s just the opposite. Having untreated ADHD increases the risk that an individual will abuse drugs or alcohol. Appropriate treatment reduces this risk. The medications used to treat ADHD have been proven safe and effective over more than 50 years of use. These drugs don’t cure ADHD, but they are highly effective at easing symptoms of the disorder. The drugs do not turn kids into addicts or zombies.

Both sites have links to a downloadable poster you can use to educate the misinformed.

Pediatrician Claudia Gold, M.D. expresses her concern about the common belief that medication without psychotherapy is sufficient to treat ADHD - With Psychiatric Drugs as an Option, Motivation may be Lost. I often see the results of this belief in my practice. Many of the children and teens with ADHD I see come to me after being on medication for several years as their only treatment. Their parents generally have little understanding of how ADHD affects their child beyond problems paying attention in school. Some have taken their child off medication because it hasn't "worked." Others are frustrated that their child still has academic and behavior problems despite being on medication. Unfortunately, both groups may blame their child for "not trying hard enough."

Let me be clear. I don't blame parents for their uneducated beliefs and misguided attempts to help their children. It's not surprising that parents are influenced by our contradictory cultural beliefs that drugs are the answer to everything or that all these children need is better discipline. Last year for ADHD Awareness Month, I wrote about the child's point of view in The Question ADHD Kids Dread Most and how their parents' frustrations can lead to parent-child conflict and more problems.

Teachers are another group who can use more education. Joan Teach at ADHD and School Success writes about the child with ADD (Attention Deficit Disorder without Hyperactivity) in the classroom--what it was like for her as a student, and what teachers can do to help in I’m In Your Classroom. Don’t Forget Me! She notes:

This child doesn’t make waves, appears somewhat spacey, not intellectually prone, seldom speaks up when called upon, and may not participate or turn in homework. You may be observing the youngster with the inattentive form of ADHD that is more difficult to diagnose.

Her description of herself as a child provides insight into the experience of the struggling, undiagnosed child. As a teacher today, she give specific tips teachers can use to help these children with memory, organization, and writing assignments.

Let's not get caught up in the either-or debate on medication vs. psychological treatment, or placing the blame on children, parents, or schools. It takes medical, psychological, and educational interventions along with parent education to make the difference for many children with ADD or ADHD. Here are some great resources for understanding the effects of ADHD on children and adults and what all of us can do to help:

• CHADD (Children and Adults with Attention Deficit/Hyperactivity Disorder)
• National Resource Center on AD/HD 
• LD OnLine (Learning Disabilities and ADHD)

How Many Children Need Mental Health Treatment and Get It?

Photo by D Sharon Pruitt

There's more evidence that many children have a mental health disorder and not enough get help. The first representative survey of children in the United States found that 13% of children ages 8 to 15 had at least one psychiatric disorders during one year. The data comes from the National Health and Nutrition Examination Survey (NHANES), a collaboration between the National Institute of Mental Health (NIMH) and the National Center for Health Statistics of the Centers for Disease Control and Prevention. Over 3,000 children were evaluated in person, and their primary caretakers were interviewed by telephone shortly afterward. Along with diagnostic questions, the degree of impairment in daily life was assessed in such areas as family and peer relationships and in school performance. The children and their caretakers were also asked whether help was sought in the past year at a hospital, clinic, or professional's office for the child's symptoms.

The percentage of children who met diagnostic criteria for the following disorders is listed from most to least common.

• Attention-deficit Hyperactivity Disorder (ADHD)  8.6%
• Depression (Major Depression or Dysthymia)  3.7%
• Conduct Disorder   2.1%
• Anxiety (Generalized Anxiety Disorder or Panic Disorder)  0.7%
• Eating Disorder (Anorexia or Bulemia)   0.1%

Similar to the results of other studies, boys were twice as likely as girls to have ADHD. Girls were twice as likely as boys to have one of the two types of depression. There was no difference between boys and girls in the other disorders. The rates of depression and conduct disorder were higher in young adolescents ages 12-15. All but the anxiety disorders were reported more often in poor children. Higher rates of the two types of anxiety disorders were found in children from higher income families.

Only half of the children with diagnosed disorders sought help for their symptoms in the past year. Children with disruptive behavior (ADHD and Conduct Disorder) were most likely to seek treatment. Only a third of children with an anxiety disorder received services. The children with more severe symptoms were only slightly more likely to get help. There was no information reported about type (medication, therapy, or both), length (one or more visits), or response to treatment. As a result, we don't know how many children were receiving adequate treatment.

How do the current study's estimates differ from older findings? As I noted in Children's Access to Mental Health Care, the Surgeon General's 1999 Report on Mental Health found that 1 in 5 children and adolescents had a diagnosable mental illness. This was a higher rate (20%) than is found in the NHANES study (13%). The difference is likely due to the broader range of disorders included in the Surgeon General's report.

The major strength of the NHANES study is that it provides the first estimates of the overall prevalence of specific mental disorders in children in the United States. Because the researchers used a standardized method of diagnosing the children, the results can be directly compared with local and international studies that use the same criteria. As the lead author Kathleen Merikangas, Ph.D. concludes, "Until now, there has been a dearth of reliable data on the magnitude, course and treatment patterns of mental disorders among U.S. youth. When combined with data from other nationally representative surveys, the data will provide a valuable basis for making decisions about health care for American youth."

Merikangas, K., He, J., Brody, D., Fisher, P., Bourdon, K., & Koretz, D. (2009). Prevalence and Treatment of Mental Disorders Among US Children in the 2001-2004 NHANES PEDIATRICS, 125 (1), 75-81 DOI: 10.1542/peds.2008-2598

ADHD and Sleep Problems in Children

It probably comes as no surprise to parents that their ADHD children have trouble getting to sleep at night. It's hard for them to rev down and resist the impulse to play one more video game, text one more friend, post on Facebook, or start(!) their homework. But what do we really know about sleep problems and ADHD, and more importantly, what can you do about it?

What Research Tells Us

Several studies published in the past year by sleep medicine researchers have found significant differences in sleep problems between children with and without ADHD. Some of their findings include:

• Approximately 45% of children with ADHD are reported by their parents to have moderate to severe sleep problems.  Some of the most common problems were difficulty falling asleep, resisting going to bed and tiredness on waking. According to the authors "compared with [ADHD] children without sleep problems, those with sleep problems were more likely to miss or be late for school, and their caregivers were more likely to be late for work." They contend that successful intervention to improve sleep may reduce the need for medication for some children with ADHD.
• Children with ADHD may be chronically sleep deprived and have abnormal REM (rapid eye movement) sleep. Results show that they have a total sleep time that is significantly shorter than that of children without ADHD. The authors note that partial sleep loss on a chronic basis accumulates to become a sleep debt, which can produce significant daytime sleepiness and neurobehavioral impairment.
  
• A review of 47 studies of ADHD and sleep problems in children and adolescents, suggests increased nighttime activity, reduced rapid eye movement sleep, and significant daytime drowsiness in unmedicated children with ADHD when compared to controls. Data also suggest a possible increased prevalence of periodic limb movements during sleep but little differences in sleep-disordered breathing.

An excellent, free full-text article by Judith Owens, MD, MPH, a leading sleep medicine expert, describes the diagnosis and treatment of sleep problems in children with ADHD. She notes:

The relationship between sleep problems and ADHD is hardly a straightforward one, and may present clinically in a number of different guises. For example, psychotropic medications used to treat ADHD or comorbid psychiatric conditions associated with ADHD (i.e., mood disorders, anxiety) may themselves result in sleep problems in some patients, daytime manifestations of primary sleep disorders such as obstructive sleep apnea may “mimic” ADHD symptomatology in others, comorbid sleep problems may exacerbate ADHD symptoms, and/or sleep problems may in some cases represent an “intrinsic” dysregulation of sleep and wakefulness associated with ADHD-related CNS dysfunction.

Dr. Owen also discusses the importance of screening all children with mental health problems for sleep disorders and gives clinicians suggestions for doing so.

Tips for Parents

If your ADHD child or teen has problems sleeping, don't assume there is nothing you can do about it. Consult her pediatrician about possible sleep disorders. If your child is taking stimulant medication, ask the prescribing physician whether the type or dose of medication could be affecting his sleep. Ask a child psychologist to help you develop behavioral strategies to deal with bedtime struggles. If none of this helps, you may want to take your child to a sleep specialist. You can search for an American Academy of Sleep Medicine accredited sleep center here.

Other Resources:

Sleep Tips for Children from the National Sleep Foundation

ADHD Health: Shuteye Strategies for Children | ADDitude Magazine

The Question ADHD Kids Dread Most

September is National Attention-Deficit Hyperactivity Disorder Awareness Month. Most activities will happen during AD/HD Awareness Week (September 14-20). I think there may also be an Awareness Day in there somewhere. This gives everyone multiple chances to celebrate if they forget to pay attention the first time around.

I'm starting off the month by raising awareness of what it's like to be a kid with ADHD. Parents frequently express their frustrations about managing their ADHD children. But unless they have it themselves (and there is a strong likelihood that one parent does), it is very difficult to imagine what it's like from a child's point-of-view.

Let's begin with the question kids with ADHD dread most......WHY?!!?!?

• Why didn't you turn in your homework?
• Why don't you pay attention in class?
• Why didn't you come home in time for dinner?
• Why didn't you do your chores after school?
• Why didn't you do what I asked you to do?
• Why didn't you finish your project?
• Why don't you stop and think before doing (fill in the blank)?

Children quickly learn that the following answers are not what parents want to hear:

• I forgot.
• It's too boring.
• I didn't know what time it was.
• I was going to do them later.
• I didn't hear you.
• I didn't feel like it.
  
• I don't know!!

Of course this is frustrating for parents. It's easy to interpret their child's behavior as carelessness, defiance, laziness, or inconsideration. As a result, parents react with reprimands, lectures, and punishment. Children may apologize and promise not to do it again, but this stops working after the 20th, 30th, or 50th time. They then try denial, blaming others, and elaborate "stories" to avoid parents' anger and further punishment. Parents eventually catch on and stop trusting their child. Increasing conflict and lack of trust (on both sides) makes it impossible to engage in constructive problem-solving. These negative patterns of interaction are often well-established before a child is diagnosed. The resulting damage to family relationships and a child's self-esteem is hard to reverse. This is why an early diagnosis and professional help are so important.



This brings us back to ADHD Awareness Week. The goal this year is to "raise awareness about the importance of identifying and treating this potentially debilitating disorder early in life." (See more about CHADD's campaign here.)

Here are 10 more reasons CHADD members give for why an early diagnosis is important.

Parents Are Concerned about Psychiatric Medications

Popular press coverage has once again raised concern about the use of psychiatric medications to treat emotional and behavioral problems in children. A recent study has linked the use of stimulant medication (such as Ritalin) with 10 deaths in a sample of 564 children and adolescents who died suddenly for unexplained reasons. It's important to note that the study was unable to demonstrate that stimulant medication was the cause of the deaths. For an explanation of the study see Questions Raised About Stimulants and Sudden Death from the National Institute of Mental Health.

Each wave of negative news reports about rare side-effects increases mistrust of psychiatric medications. Previous examples include the long-standing controversy over anti-depressants' effects on suicidal thoughts and behavior. As a result, parents reject medication despite substantial evidence of beneficial effects. Parents are already concerned about whether medications are safe and effective for treating their children's problems. Sensational headlines and profiles of tragic cases only serve to raise fears and provide little helpful information. Seldom is sufficient attention paid to the larger context of risks and benefits for using, and for not using, medication. Stories that end with the usual caveat "these results may not apply to individuals" and a recommendation to "consult your physician" do little to reduce parents' anxiety and confusion.

Yet parents must rely on the professional opinions of physicians--either their child's pediatrician or a child psychiatrist. (My bias is towards the latter--see my previous post.) Research on safety and effectiveness is incomplete, especially, for newer medications. Factors that must be considered in choosing a medication include accurate diagnoses, appropriate and effective dosage, common and uncommon side effects, and interactions with other medications. The effects on children's long-term development may not be known because studies are not completed until long after approval by the U.S. Food and Drug Administration. "Off-label" use of medications that have not been approved for children or other conditions is common with little or no evidence of safety or effectiveness.

Don't get me wrong, I am not advocating the wide-spread use of psychiatric medications. I understand parents' reluctance to consider medication and I am also cautious about recommending it's use. I generally don't suggest medication unless a patient's symptoms are severe (for example, Major Depression), it's a standard treatment for a particular condition (such as ADHD), or there has been insufficient response to psychological therapies. In addition, research has demonstrated for certain conditions that medication or psychotherapy is equally effective, but it is the combination that is most effective. In any case, a careful evaluation is needed to determine what is the best course to take for a particular child or adolescent.

I also believe an underlying factor in negative public response is lack of acceptance that serious mental illness exists among children and adolescents. Popular myths continue to undermine efforts to identify and treat children before their conditions become disabling and affect their long-term development. Contrast the sometimes hysterical public rejection of psychiatric medications associated with very rare serious side effects to the continued acceptance of medications that treat "real" conditions like pain despite much more common side effects. Tara Parker-Pope's blog post Reasons Not to Panic Over a Painkiller and Dr. Rob's Tylenol can Kill are examples of more balanced responses to the recent concerns over acetaminophen.

Besides relying on professional opinions, parents can also educate themselves about psychiatric medications. Here are some good sources of information:

• Mental Health Medications - National Institute of Mental Health
• How can I get information about medications? - Mental Health America
• Medications - National Alliance on Mental Illness
• Psychiatric Medication For Children And Adolescents: Part I-How Medications Are Used, Part II - Types Of Medications, Part III: Questions To Ask - American Academy of Child and Adolescent Psychiatry

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This post was featured in Grand Rounds, Vol. 5, No. 46: Emergiblog

Kindergarten Attention Problems Affect High School Achievement

A new study published in the June issue of Pediatrics (The Impact of Early Behavior Disturbances on Academic Achievement in High School) provides evidence of the long-term negative impact of attention problems in kindergarten on standardized high-school achievement tests. Six-year-old children who were rated by teachers as having problems paying attention performed more poorly at age seventeen in reading and math when compared to children with internalizing (depression and anxiety) or externalizing (aggression and rule-breaking) problems.

In a press release from the University of California at Davis School of Medicine, the lead author Dr. Joshua Breslau states:

Many children have behavioral problems of the types we examined in this study, but we don’t know which types of problems have the most serious long-term consequences. By identifying attention problems as the most consequential for academic achievement over the long term, this study helps us decide where to put our clinical resources.

One of the co-authors, Dr. Julie Schweitzer, points to the importance of having young children evaluated when they show problems paying attention in school. She suggests that parents start by talking to their child's pediatrician and determine the need for an evaluation by a psychologist.

A careful evaluation of medical and psychological factors related to poor attention is necessary to determine the best interventions. Although attention problems are often caused by attention-deficit hyperactivity disorder (ADHD), other causes include learning disabilities, depression, anxiety, post-traumatic stress disorder (PTSD), poor nutrition, sleep problems, lead poisoning, and a variety of medical illnesses.

For more details on the study's design and results, see Peter West's article at HealthDay.

Howie Mandel on Stigma and Children's Mental Health

According to Mental Health America, 1 in 5 children and adolescents have a diagnosible mental health condition, yet only 1/3 of them get help. One reason is the stigma associated with having a mental illness.

Howie Mandel, host of "Deal or No Deal," often talks about his own mental illnesses of obsessive-compulsive disorder (OCD) and attention-deficit hyperactivity disorder (ADHD). As ambassador for National Children's Mental Health Awareness Day (May 7, 2009), he speaks on the stigma of seeking help:

Because children and adolescents often don't tell anyone about troubling thoughts and feelings, it is up to adults to notice symptoms of possible mental illness. The U.S. Dept. of Health & Human Services' on-line publication Child and Adolescent Mental Health lists the following warnings signs:

A child or adolescent is troubled by feeling:

• Sad and hopeless for no reason, and these feelings do not go away.
• Very angry most of the time and crying a lot or overreacting to things.
• Worthless or guilty often.
• Anxious or worried often.
• Unable to get over a loss or death of someone important.
• Extremely fearful or having unexplained fears.
• Constantly concerned about physical problems or physical appearance.
• Frightened that his or her mind either is controlled or is out of control.

A child or adolescent experiences big changes, such as:

• Showing declining performance in school.
• Losing interest in things once enjoyed.
• Experiencing unexplained changes in sleeping or eating patterns.
• Avoiding friends or family and wanting to be alone all the time.
• Daydreaming too much and not completing tasks.
• Feeling life is too hard to handle.
• Hearing voices that cannot be explained.
• Experiencing suicidal thoughts.

A child or adolescent experiences:

• Poor concentration and is unable to think straight or make up his or her mind.
• An inability to sit still or focus attention.
• Worry about being harmed, hurting others, or doing something "bad".
• A need to wash, clean things, or perform certain routines hundreds of times a day, in order to avoid an unsubstantiated danger.
• Racing thoughts that are almost too fast to follow.
• Persistent nightmares.

A child or adolescent behaves in ways that cause problems, such as:

• Using alcohol or other drugs.
• Eating large amounts of food and then purging, or abusing laxatives, to avoid weight gain.
• Dieting and/or exercising obsessively.
• Violating the rights of others or constantly breaking the law without regard for other people.
• Setting fires.
• Doing things that can be life threatening.
• Killing animals.
  

The presence of one or more of the above symptoms indicates a need for further evaluation. Pediatricians and family physicians can refer families to psychiatrists or psychologists in their area who specialize in treating children and adolescents. For other resources, see Mental Health America's factsheet How Do I Find Treatment?

ADHD Medication Improves Test Scores

Recent research published in the May issue of Pediatrics--Official Journal of the American Academy of Pediatrics--shows improved standardized reading and math scores in a nationally-representative, longitudinal sample of 594 school children from kindergarten through grade 5.

As reported by Tara Parker-Pope, in her New York Times' health blog (A.D.H.D. Drugs Linked to Higher Test Scores, April 27, 2009):

Children with attention deficit problems make bigger academic gains if they are taking stimulant medications compared to similar kids who aren’t receiving drug therapy...

She quotes the study's first author, Richard Scheffler, Ph.D., from the University of California, Berkeley's School of Public Health:

I think the findings are important because this is the first time that we’ve had objective educational performance measures, to look at whether kids who are taking medications for A.D.H.D. compared to kids who are not, that actually show that they are doing better.

For details, see the journal article's abstract -- Positive Association Between Attention-Deficit/ Hyperactivity Disorder Medication Use and Academic Achievement During Elementary School. The full article is available on-line to journal subscribers or for a single-use fee.

Teens, Distracted Driving, and ADHD

Here in Maryland, there’s been much ado about texting while driving. Although it was already banned for teenagers, there’s been a surprising amount of debate among legislators on whether to include adults in the ban.

Regardless, texting is just the latest activity (soon to be replaced by Twitter?) that has been tagged as a driving distraction along with cell phones, multiple passengers, changing music, and eating.

Until now, only teen drivers with graduated licenses were required to limit distractions after a series of highly publicized fatal crashes related to cell phone use and multiple passengers. It also made sense to target teens because being distracted by friends, entertainment, and other pastimes, instead of attending to the task at hand, is their normal state of being.

Debate about ADHD Multimodal Treatment Study

A recent front-page article from the Washington Post "Debate Over Drugs For ADHD Reignites: Long-Term Benefit For Children at Issue" by Shankar Vedantam examines the 8-year follow-up of the Multimodal Treatment Study of Children With ADHD and the differences of opinion among the study's researchers about what the results might mean.

The study looked at which of three intensive ADHD treatments was best--stimulant medication, behavior therapy, or the combination of both. All three were compared to usual community treatment. The initial results showed a clear superiority of medication (whether alone or combined with behavior therapy) over behavior therapy or community treatment. But when the children were followed-up three years later, medication seemed no better than the other treatments.