Children With Oppositional Defiant Disorder from AACAP

All children are oppositional from time to time, particularly when tired, hungry, stressed or upset. They may argue, talk back, disobey, and defy parents, teachers, and other adults. Oppositional behavior is often a normal part of development for two to three year olds and early adolescents. However, openly uncooperative and hostile behavior becomes a serious concern when it is so frequent and consistent that it stands out when compared with other children of the same age and developmental level and when it affects the child's social, family, and academic life.

In children with Oppositional Defiant Disorder (ODD), there is an ongoing pattern of uncooperative, defiant, and hostile behavior toward authority figures that seriously interferes with the youngster's day to day functioning. Symptoms of ODD may include:

frequent temper tantrums
excessive arguing with adults
active defiance and refusal to comply with adult requests and rules
deliberate attempts to annoy or upset people
blaming others for his or her mistakes or misbehavior
often being touchy or easily annoyed by others
frequent anger and resentment
mean and hateful talking when upset
seeking revenge

The symptoms are usually seen in multiple settings, but may be more noticeable at home or at school. Five to fifteen percent of all school‑age children have ODD. The causes of ODD are unknown, but many parents report that their child with ODD was more rigid and demanding than the child's siblings from an early age. Biological and environmental factors may have a role.

A child presenting with ODD symptoms should have a comprehensive evaluation. It is important to look for other disorders which may be present; such as, attention‑deficit hyperactive disorder (ADHD), learning disabilities, mood disorders (depression, bipolar disorder) and anxiety disorders. It may be difficult to improve the symptoms of ODD without treating the coexisting disorder. Some children with ODD may go on to develop conduct disorder.

Treatment of ODD may include: Parent Training Programs to help manage the child's behavior, Individual Psychotherapy to develop more effective anger management, Family Psychotherapy to improve communication, Cognitive‑Behavioral Therapy to assist problem solving and decrease negativity, and Social Skills Training to increase flexibility and improve frustration tolerance with peers. A child with ODD can be very difficult for parents. These parents need support and understanding. Parents can help their child with ODD in the following ways:

Always build on the positives, give the child praise and positive reinforcement when he shows flexibility or cooperation.
Take a time‑out or break if you are about to make the conflict with your child worse, not better. This is good modeling for your child. Support your child if he decides to take a time‑out to prevent overreacting.
Pick your battles. Since the child with ODD has trouble avoiding power struggles, prioritize the things you want your child to do. If you give your child a time‑out in his room for misbehavior, don't add time for arguing. Say "your time will start when you go to your room."
Set up reasonable, age appropriate limits with consequences that can be enforced consistently.
Maintain interests other than your child with ODD, so that managing your child doesn't take all your time and energy. Try to work with and obtain support from the other adults (teachers, coaches, and spouse) dealing with your child.
Manage your own stress with exercise and relaxation. Use respite care as needed.

Many children with ODD will respond to the positive parenting techniques. Parents may ask their pediatrician or family physician to refer them to a child and adolescent psychiatrist, who can diagnose and treat ODD and any coexisting psychiatric condition.

Identifying the Signs
It's not easy to distinguish oppositional defiant disorder (ODD) from age appropriate normal oppositional behavior. Symptoms of the disorder tend to mirror, in exaggerated form, child rearing problems common in all families. In addition, different families have various levels of tolerance for oppositionality. In some, a minor infraction of the rules produces major consequences, while in more tolerant homes, oppositional behaviors are largely ignored until they cause ongoing difficulties.

In children with ODD, there is a pattern of uncooperative, defiant, and hostile behavior toward authority figures that seriously interferes with the youngsters day to day functioning. Regularly, they lose their temper, argue with adults, actively defy adult rules, refuse adult requests, and deliberately annoy others. The symptoms are seen in multiple settings - at home, at school, in the neighborhood - and are not simply the result of a conflict with a particular parent or teacher.

Blaming others for their mistakes, these children often appear touchy, angry, resentful, spiteful, or vindictive. Although overtly aggressive behavior tends to be limited, some children engage in mild physical aggression. However, their language tends to be aggressive and often obscene.

Children with ODD were, in many instances, fussy, colicky, or difficult to soothe as infants. During the toddler and preschool years, when a certain degree of oppositional attitude is considered normal, ordinary points of contention in the family become battlegrounds for intractable power struggles with these children. These oppositional episodes typically center around eating, toilet training, and sleeping. Tamper tantrums are usually extreme in a child with ODD.

Children with ODD consistently dawdle and procrastinate. Thee claim to forget or fail to hear and, as a result, are often referred for hearing evaluations, only to be found to have normal hearing. The issue is not obeying what was heard rather than a problem with not hearing.

As the child matures, struggles may center on keeping his room neat, picking up after himself, taking baths, going to bed on time, not interrupting or talking back, and doing homework. In all instances, winning becomes the most important aspect of the struggle. At times a child with ODD will forfeit cherished privileges rather than lose the argument.

Milder forms of ODD arc limited to the home environment, while, at school, the child may be more passively resistant and uncooperative. More severe forms involve defiance toward other authority figures such as teachers and coaches.

The child typically has little insight and ability to admit to the difficulties. Rather, he tends to blame his troubles on others and on external circumstances. He is always questioning the rules and challenging those he perceives to be unreasonable.

Before puberty, the rate of ODD is higher in boys than in girls. In adolescence, the disorder is equally shared.

Causes and Consequences
It appears that oppositional defiant disorder arises out of a circular family dynamic. A baby who is by nature more difficult, fussy, and colicky, may be harder to soothe. The parents often feel frustrated and unsuccessful as parents. If they perceive their child as unresponsive or "bad," they may begin to anticipate that the child will be unresponsive or noncompliant. They may then become unresponsive or unreliable in return, adding to the child's feelings of helplessness, neediness, and frustration.

As parents attempt to assert control by insisting on compliance in such areas as eating, toilet training, sleeping, or speaking politely the child may demonstrate resistance by withholding or withdrawing.

As a child matures, increasing negativism, defiance, and noncompliance become misguided ways of dealing with adults. In this way the disorder may be a tenacious drawing out of the "terrible twos."

The more a child reacts in defiant, provocative ways, the more negative feedback is elicited from the parents. In an attempt to achieve compliance, the parent or authority figures remind, lecture, berate, physically punish, and nag the child. But far from diminishing oppositional behavior, these kinds of responses toward the child tend to increase the rate and intensity of non-compliance. Ultimately, it becomes a tug of war and a battle of wills.

When such patterns typify parent child relationships, discipline is often inconsistent. At times, parents may explode in anger as they attempt to control and discipline their child. At other times, they may withhold appropriate consequences which soon become hollow threats. As the child continues to provoke and defy, parents lose control. Then, feeling regret and guilt, especially if they’ve become verbally or physically explosive, the parent may become excessively rewarding and gratifying in order to undo what they now perceive to have been excessive discipline or punitive consequences.

When a child starts school, this pattern of passive aggressive, oppositional behavior tends to provoke teachers and other children as well. At school the child is met with anger, punitive reactions, and criticism. The child then argues back, blames others, and gets angry.

These children tend to have difficult adapting at school. Their behavior can cause disruption in the classroom and interfere with social and academic functioning. When their behavior and defiance affects their schoolwork and performance, children often experience school failure and social isolation. This, coupled with chronic criticism, can lead to low self esteem. Usually, ODD children feel unfairly picked on. In fact, they may believe that their behavior is reasonable and the treatment and criticism they receive unfair.

In many cases. oppositional disorders coexist with attention deficit/hyperactivity disorder. In fact, the impulsivity and hyperactivity of ADHD can greatly amplify the defiance and uncontrolled anger of ODD. Symptoms of ODD may also occur as part of major depressive disorder, obsessive compulsive disorder, or mania. Some children with separation anxiety disorder may also have oppositional behaviors. Clingy attachment merges into or possibly reflects oppositional defiance. There also seems to be a correlation between ODD in a child and a history of disruptive disorders, substance abuse, or other emotional disorders in other family members.

How to Respond
Parents who are concerned that their child may have ODD should seek a professional evaluation. This is important as a first step in breaking the cycle of ineffective parenting of the "bad child.” During the evaluation process, parents may come to appreciate the interactive aspect of this disorder and look for ways to improve their management of the child. Books and parenting workshops given under the auspices of churches, schools, and community agencies may also help parents respond better to the needs of their children.

Once ODD has been diagnosed, the child and adolescent psychiatrist or other professional may recommend a combination of therapies for ODD. Among the options your clinician may recommend are following:

Parent Training Programs Some parents are helped through formal parent training programs. In these sessions, parents learn strategies for managing their children's behavior. These are practical approaches to dealing with a child with ODD. The emphasis is on observing the child and communicating clearly. Parents are taught negotiating skills, techniques of positive reinforcement, and other means of managing the behavior of the child with ODD.

Individual Psychotherapy The therapeutic relationship is the foundation of a successful therapy. It can provide the difficult child with a forum to explore his feelings and behaviors. The therapist may be able to help the youngster with more effective anger management, thus decreasing the defiant behavior. The therapist may employ techniques of cognitive behavioral therapy to assist the child with problem solving skills and in identifying solutions to interactions that seem impossible to the child. The support gained through therapy can be invaluable in counterbalancing the frequent messages of failure to which the child with ODD is often exposed.

Family Therapy Problems with family interactions are addressed in family therapy. Family structure, strategies for handling difficulties, and the ways parents inadvertently reward noncompliance are explored and modified through this therapy. This approach can also address the family stress normally generated by living with ODD. Sometimes in the course of treatment, a parent is also found to have a psychiatric disorder. Treatment of that parent may be helpful since the adult's behavior can affect how the child responds to treatment.

Cognitive Behavioral Therapy Behavioral therapy can help children control their aggression and modulate their social behavior. Children are rewarded and encouraged for proper behaviors. Cognitive therapy can teach children with ODD self control, self guidance, and more thoughtful and efficient problem solving strategies.

Social Skills Training When coupled with other therapies, social skills training has been effective in helping children smooth out their difficult social behaviors that result from their angry, defiant approach to rules. Social skills training incorporates reinforcement strategies and rewards for appropriate behavior to help a child learn to generalize positive behavior, that is, apply one set of social rules to other situations. Thus, following the rules of a game may be generalized to rules of the classroom; working together on a team may generalize to working with adults rather than against them. Through such training, children can learn to evaluate social situations and adjust their behavior accordingly, The most successful therapies are those that provide training in the child's natural environments - such as the classroom or in social groups as this may help them apply the lessons learned directly to their lives.

Medication Medication is only recommended when the symptoms of ODD occur with other conditions, such as ADHD, obsessive compulsive disorder (OCD), or anxiety disorder. When stimulants are used to treat attention deficit/hyperactivity disorders, they also appear to lessen oppositional symptoms in the child. There is no medication specifically for treating symptoms of ODD where there is no other emotional disorder.

Online Parent Support

ADHD Treatment

by James Chandler, MD FRCPC
Contributing Author for MyOutOfControlTeen.com

ADHD turns out to be the most studied disorder in child psychiatry. There are two major types of interventions, medical and non-medical.

Medical Interventions

Among the Medical Interventions for ADHD are two types of treatments- substances which are derived from natural substances, usually called “natural treatments” and medications.

What is the perfect treatment for ADHD?

It would be be something that is extremely safe, has virtually no side effects now or in the future, and almost always works right away. Natural treatments fit part of this description: they are usually very safe and have very few side effects. The downside is that they don’t work too well. Medications are just the opposite. They work much quicker, but are more likely to cause side effects.

Natural Treatments

There are thousands of natural treatments for ADHD. Almost none of them have ever been compared to placebo, so it is hard to know if they really work. In my reviews of the literature, the only natural treatments that are worth considering in ADHD are those based on increasing certain fats or oils in the brain. Just as the body needs certain vitamins and minerals in the diet, it also needs certain oils called essential fatty acids. These then are turned into a few compounds that are essential for the brain to work right. If babies do not get them, they end up with brain damage. It is quite clear that the It is also fairly clear that there are abnormalities in these fatty acids in the brains of people who have ADHD. There are two families of these compounds, Omega-3 fatty acids and Omega-6. the only source of Omega-3 is fish, flax seed oil, and some greens. Animals fed mostly Omega-6 and not Omega-3 are not as smart.

So the next step has been to try giving people Omega-3 Fatty Acids. From this research, it has been determined that:

Giving Long Chain Fatty Acids and adding it to your food doesn’t work any better than placebo.
Giving a certain Long Chain Fatty Acid called DHA derived from algae doesn’t work better than placebo.
Giving two Long Chain Fatty Acids called Omega-3 and Omega-6 worked better than placebo in children who had behavior problems, attention problems, and academic problems.

What does this mean?

That certain fish oil preparations for ADHD might work. However, there are no big studies that prove this.

That sounds great! Is there any problem?

Yes. First of all, it isn’t clear how much you need and what kind. Also it isn’t clear whether or not the specific form is going to get into your brain or not. Secondly, fish from the North Atlantic that are oily have a lot of toxins in them and it is possible that these toxins, especially Mercury, could get into your child, but no one knows right now if this really is a problem or not.

Secondly, they taste horrible. In my experience, only a quarter of children can tolerate it.

Right now, I am mostly using a local herring product called Omega Gold. It is cheap, has plenty of the right fatty acids in it, but it is unclear how well it is absorbed and whether or not other toxins are present in it.

Giving fish oils scientifically

To determine whether or not fish oils help ADHD, you need to be able to measure how much change there is over time. Since these substances do not work overnight, it can be hard to answer the question, “ Is my child really better than he was 6 months ago?”

First, I use the SWAN rating scale, which is sensitive to drug effects, before we start the trial. Then about 6 weeks later, we check it again. If there is a significant difference, there is a good chance that the fish oil was doing something. If we really want to be sure it was doing something, then I will discontinue the fish oil and check the SWAN scale a few weeks later. However, usually this isn’t needed.

I usually give fish oils for a year and then stop them to see if there is any improvement. There is absolutely no data to know how long it is necessary to give them.

Should everyone receive fish oils before they are tried on medication?

No, there are some people who are so ill with ADHD that the most effective treatment which will hopefully work tomorrow needs to be started right away. However, in most cases, it is probably reasonable to try fish oil first.

Will fish oil help medications work better?

There has never been a study like this done. In my experience, I have not seen an additional effect from adding fish oil to medication.

Are there any side effects?

Some people have indigestion and burp fishy smells. I have seen a few kids become agitiated on fish oil. Otherwise, there are no side effects.

Are there long term side effects?

Probably not, but there is some concern about fish oils that are not purified to get rid of toxins.

Overall-

Fish oils are worth trying, not because they work so well, but because they have so few side effects. However, don’t be surprised if they don’t work.

Standard Medications for ADHD

Looking for just a table about meds? Click here

There is no doubt that medical interventions for ADHD are effective. Not only that, medications are more effective than any other intervention. Furthermore, adding all sorts of non-medical interventions to carefully prescribed medications doesn't work any better than medications alone. Medications are also effective if there is comorbid Oppositional Defiant Disorder, Conduct Disorder, or anxiety disorders.

On the other hand, medications have some real drawbacks. First of all, they can cause side effects. Given how serious ADHD usually is by the time I see it and how safe these medications are, this usually isn't a real reason not to use medications. That is, since the risk of serious side effects is very low and the risk of the disorder causing severe problems for the child is quite high, the balance favors using medications.

The main reason not to use medications has nothing to do with the medications themselves. It has to do with how much parents hate the idea of giving their children psychiatric drugs. There are three types of parents in my mind

Sally - "If it will help, I'll do it"

Sally's daughter is totally out of control. She can not get through a day of school without going to the principal's office. Sally is a nervous wreck. The rest of their family life is on hold since every ounce of energy they have goes for caring for this child. Sally would like to get her child better right now. This hour, if possible. Sally takes home a prescription for medication for her daughter on the first visit.

Jeremy " I hate the idea of giving my son drugs. It would be my last choice"

Jeremy's son is moderately disabled, but most of the problem is at school, not at home, so it doesn’t seem that bad to Jeremy. The fact that Jeremy is not home until about 6:00 pm every night makes it a little easier to bear, as he doesn’t have to deal with his son all afternoon. So Jeremy is going to try a few other non-medical things first. After two months, if things aren't better, we will try medications.

Beth "Nothing would make me give my daughter psychiatric drugs that will affect her brain"

Beth's son is quite disabled by ADHD, but for her the idea of having to give her child medications is worse than dealing with disabling ADHD. Beth tries all sorts of non-medical treatments but will never let her child take pills. Beth is hoping (gambling, in my opinion) that the ADHD will go away on its own. If she is right, she will feel very proud of herself.

Non Medical Interventions

ADHD has been around a lot longer than medications have been. There are a host of interventions that are useful in ADHD that do not involve medications. The usual approach is to use a number of these together. These interventions are not as potent, but in combination they sometimes can be helpful enough to make ADHD go from moderately disabling to mildly disabling. For mild ADHD, this is the place to start. Often times they are combined with medications, although the most recent work would suggest that the non-medical treatments don’t add too much to medical treatment.

Medications

What exactly do the drugs for ADHD do?

These drugs alter the way signals are transmitted in the brain. They work on substances in the brain which help transmit messages. They work at different levels of the brain to alter the core symptoms of ADHD. The different drugs work on different parts of the transmission system. That is why sometimes one drug will work and not another, as they are working on different parts of the transmission system.

Why would anyone want to give drugs that affect the brain to children?

The main reason would be if the non-medical interventions are not working or in more severe cases of ADHD. No one would suggest trying medical treatments before the non-medical interventions are used in very mild ADHD. It is similar to diabetes in that way. If you have diabetes which is not severe, your doctor will first suggest you try diet control. If that doesn't work, only then will the doctor consider medical treatment. However, if your diabetes was severe, you would start on a diet and medication right away. In other words, if ADHD is severe, sometimes we use medical and non-medical treatments together from the start.

If the drug works, how will my child be different?

In cases where the drugs work very well, the three core symptoms of ADHD (inability to pay attention to things they aren't interested in, hyperactivity, and impulsiveness) are brought down to a level which is close to the average for their age group. As a result, people are usually more successful socially, academically, and there are less family problems. Usually a person's self esteem improves. When these drugs work right, the change can be quite amazing. When children take these drugs, in 75 % of the cases they are indistinguishable from normal children and nothing else is really necessary, that is, very few of these other interventions will be needed.

What if it doesn't work?

Sometimes a medication won't work because the dose is too high or too low. Some people will not respond to one medication for the treatment of this problem but they will respond to another. If the drug doesn't work, of course, it is discontinued, and then you and I decide what do next. Try something else? Abandon medical treatment? Both are sometimes reasonable options.

I have heard that these drugs can do a lot of bad things. Is this true?

Yes, it is. Like all medical treatments, there are side effects and sometimes people can have pretty bad side effects. There are two types of side effects. One type is the kind that disappears when you stop the drug. The other kind can last long after the drug is discontinued.

What exactly are the side effects?

It depends on the drug. Some drugs can interfere with sleep and appetite. Others can make you depressed or angry. Some can affect the heart. Others can make you wet yourself or actually make the hyperactivity worse. Others can make people have movements they didn't have before. Or, they can make you like a zombie.

Are they that dangerous??

Yes, when used improperly they can be quite dangerous. However, when used carefully they can be very safe.

How can that be?

Each drug has certain problems that need to be watched for. The current medical literature suggests three basic principles when using psychiatric drugs in children. 1) Start low, 2) Go slow, and 3) Monitor carefully

What do you mean by Start Low?

This means that you do not start any of these drugs at the usual dose, or the maximum dose. When you have pneumonia, it can be a real emergency. You want to give people plenty of medicine right away, and if there are problems, then you reduce it. Unfortunately, many people use this same strategy in the medical treatment of ADHD. The problem is that big doses can cause big problems, and when the problems affect your mind and personality, this usually means trouble for the person taking the medicines. So I start with the lowest dose possible. I start with about 25% of the usual dose. That way, if the child is sensitive to the drug, it only causes little problems. I also find that some children respond to drugs at very low doses, far below the usual recommendations.

What do you mean, Go slow?

ADHD is not an acute illness. Less than 10% of the people I see with this disorder need to be treated very quickly. Most people who I see with this problem have had it for years. As a result, there is no need to increase the dose quickly. By going slowly, it is a lot easier to manage any side effects because things don't happen suddenly. Also, it is easier to find the lowest effective dose.

What do you mean, Monitor?

For each of the medical treatments for ADHD, there are specific side effects that need to be checked regularly. Some common ones (see individual drugs below) are monitoring weight so that people are gaining weight, watch for tics, watch for depression, checking blood pressure and pulse, checking blood tests and EKGs, and making sure parents know what the side effects are of the different medications. In This way, if there is a problem, we can pick it up early and avoid the horror stories, some of which are true, about the medical treatment of this problem.

How often do I have to see you?

At first, it is fairly frequent, but it is mostly by phone. For the drugs which do not require blood levels to figure out the dose, I have people start the medication (low) and then call me in about four days so I can do a phone check up. I then see the child in two or three weeks. Once we know the medication is working and there are no side effects, most kids only have to be seen three or four times a year. Of course, if things do not go smoothly, I will see the child as often as necessary.

How long do you have to take it for?

If there is a big benefit and minimal side effects, then I usually have people take the medication throughout the school year. In the summer I have the person go off the medicine to see what happens. Some people grow out of ADHD. If they are doing well on medicines, the only way you can tell if they still need the medicine is to see them off of it. If they seem to be no different off the drug, I have them start school off the medicine. If there are signs during the summer or at school of relapse, then I restart it and we try again to stop it the following summer.

So what drugs do you use –How to decide?

The medical treatment depends on a few things. From my perspective, I always want to use the drug that is easiest to use, cheapest, and works best. It turns out that about half of the children with ADHD have other neuropsychiatric problems. It is the presence or absence of these other problems that can determine which drug I use. Do they have tics? If so, certain drugs work much better. Are there signs of anxiety and depression? This means certain things will work and other will not. The first choices of drugs for ADHD are the stimulants. The other drugs are all second choice and usually reserved for children who do not respond to the stimulant drugs.

How fast does it work?

Stimulants work immediately, that is within hours. The full effect is seen right away. Non-Stimulants take weeks to see the full effect.

Number of dosages per day

Some of these drugs have to be administered three times a day or more. That means someone has to be very, very attentive to getting the drug in the child at school and usually after school, too. Almost no children that I see will reliably take their own medicine. Besides, some people really object to the stigma of having to go someplace at school and afterwards to get their medicines. The drugs that need to be given three times a day are short acting Ritalin and short acting Dexedrine (not Dexedrine Spansules). All the other drugs are once day or just morning and night.

Can the child swallow Pills?

Some children can crunch up short acting Dexedrine or Ritalin, but the taste is pretty bad. None of the others can be chewed. However, Adderall comes in a Sprinkles format, and the beads can easily be sprinkled on yogurt, apple sauce, etc.

If you can’t swallow pills, Adderall is clearly the best choice.

Cost

Some of these drugs are cheap, others expensive.

A month of each of these drugs is roughly -

Strattera $130.00

Altertec $130.00

Adderall XR $105-115 (all doses are the same price)

Concerta $70-110, depending on the dose

Welbutrin $30-50

Dexedrine Spansules, Ritalin SR $30-50, depending on the dose

Short acting Ritalin and Dexedrine $20-50, depending on the dose

In Summary

Each of these drugs has some good points and some bad points. There is no perfect drug. After the description of each drug is a chart which summarizes all of this.

You can not predict which drug will work in a child and which will not.

You can not predict which drug will cause side effects in a child and which will not.

Stimulants

They are the most commonly used medications for ADHD and include Ritalin and Concerta (methylphenidate), Dexedrine, and Dexedrine Spansules (dextroamphetamine) and Adderall. Others are available in the USA but not in Canada. Sometimes one drug in this group will work for a person but the others will not. They all have the same side effects, but some people will tolerate one drug in the group far better than another. It is currently impossible to know which drug will work or be well tolerated in a certain child. About 90% of children with ADHD or ADD will respond to one of the stimulants. Most of these will be able to tolerate at least one of the stimulants. There is more data to support the effectiveness of stimulants as a treatment in ADHD than in any other medical treatment in medicine! So how do you decide which drug to start with?

Special Populations

Preschool

In some circumstances, drugs are used in this group. Usually it is because the child's behavior is so disruptive that he or she can not attend a structured pre-school program. It is important to get children with severe ADHD into pre-school as it can be very helpful in building their social skills. Other times a child's behavior is so difficult, especially when combined with ODD, that people in the family are getting seriously hurt. Other times the child's behavior is causing a severe impact on parents, relationships, or siblings. Overall, these medications are safe in this age group. However there do tend to be more side effects. In recent studies of preschoolers with ADHD and other common comorbid conditions, 30% had significant side effects when they received Ritalin and 11% had to stop the medication. The most common side effects were appetite problems, sleep problems, and irritability. Unfortunately, these drugs do not work as well in preschoolers as in older children. Only about 20% had a remission of their symptoms, compared to 13% on placebo. Since children at this age are growing rapidly, one of the questions is whether or not these drugs keep children from growing. When this is checked carefully for a year while on medications, some children do not grow as tall as they would otherwise and some do not gain as much weight as they would otherwise. Overall, they are about ½ inch shorter and about 3 pounds lighter than they otherwise would be. It turns out that even over three years, this is not really a problem with older children

How to manage the possibility of reduced growth rates in preschoolers on medications.

There is a special type of growth chart that can be used to see if children are not growing properly. The usual reason in my experience is that they are not eating. Overall, if a child doesn’t grow properly, we stop the medication. I have never seen a child where we had to keep him or her on medication even though they weren’t growing. Remember, it is only the stimulants that cause this.

Teenagers

These drugs are very effective in this group. The biggest problem is with medications requiring multiple dosages a day. A short acting drug like Ritalin or Dexedrine tablets would have to be given three times a day. This is very hard to remember, even if you do not have ADHD. As a result, the first line choice is drugs which can be given once or at most twice a day.

Questions about abusing stimulants

The stimulant medications are closely related to certain drugs of abuse. For example, if you crush Ritalin (methylphenidate) and smoke it, you can get high. Large doses of dexedrine by mouth can be addictive. Some people try to combine these drugs with other street drugs to get high. As a result, these stimulant medications do have some street value.

How often are ADHD medications abused?

In a recent study of children and adolescents with ADHD,

11% sold their medication

22% Used too much medication

10% got high on their medication

Which drugs get abused?

Not all stimulants are alike. In the study above, of those who sold or misused their medications, the only two drugs that were sold and abused were short acting Ritalin and Dexedrine.

Which persons abuse them?

In the above study, all the patients who abused ADHD medications either had Conduct Disorder or a Substance abuse problem, or both.

In summary –

There is no risk of abuse with long acting ADHD drugs.

There is no risk of abuse if the child does not have Conduct Disorder or Substance Abuse

There is a very high risk if the child is taking short acting drugs and has There is no risk of abuse if the child does not have Conduct Disorder or Substance Abuse

If my child uses Ritalin or Dexedrine now, will he be more likely to use street drugs and alcohol later?

No. In fact there is some evidence to suggest the reverse. That is, teenagers with ADHD who are treated with stimulants are less likely to end up abusing drugs than teenagers with ADHD who do not take stimulants. That is, it seems like stimulants might actually protect children from drug abuse.

My son has ADHD but also abuses drugs if he can get a hold of them. Are stimulants safe?

No. The usual approach is to make sure people are clean with urine drug screens and then make sure that they do not have access to the supply of medication.

Specific Stimulants

Short acting Stimulants

These are drugs which last 3-4 hours per dose and have to be given 2-3 times a day to work. They used to be the standard drugs for ADHD. Now they are only used in special circumstances such as

A preschooler who is just too small for the long acting pills. Since these drugs are given by weight, sometimes the smallest long acting size is still too big.
A child can't swallow the long acting pills. The short acting pills can be crushed, but not the long acting ones.(except Adderall)
As an add on to another ADHD drug, especially Welbutrin.

Note: Ritalin (methylphenidate) - It is confusing, as there are three drugs which all have the same chemical in them, but with different names. The chemical is Methylphenidate. The three pills are called Ritalin, Ritalin SR, and Concerta. To help keep that straight, everything with Methylphenidate in it is in blue.

Ritalin tablets (methylphenidate)

This is certainly the most frequently used drug for ADHD. It requires no special monitoring. It comes in 5, 10, and 20 mg sizes. They are easy to crush and can be given in anything sticky for children who can not swallow pills. It is usually given at breakfast, lunch, and after school. The usual dose is 1mg/kg, or half your weight in pounds. For example, a 60 lb. child would take roughly up to 30 mg a day total. However, the dose can be up to 2mg/kg, or about your weight in pounds. They are quite cheap

Dexedrine

This is the oldest drug used for ADHD. The tablets last about 6 hours at the most. That means two or three doses a day. There are some children who will respond to short acting Dexedrine and nothing else. In fact they might respond to Short acting Dexedrine but not the Dexedrine Spansules! The tablets come in 5 mg size. The dose is .5mg to 1.5 mg per kg.

Long Acting Stimulants

This is the first choice for stimulant treatment in most children with ADHD. There are two drugs in the category which last about 12 hours. There is another older drug, Ritalin SR, which lasts 6-7 hours.

Dexedrine Spansules (long acting Dexedrine)

The Spansules are tiny pills in a capsule like a cold capsule. The Spansules last about 12 hours. The Spansules come in 10 and 15 mg sizes. The drug is twice as potent as Ritalin, so you are usually taking about a quarter of your weight in pounds. That means that if you weigh less than about 40 lb., The 10 mg spansule will probably be too much to start with. However, you can make a 5 mg spansule (roughly) by pouring out the medicine into the two halves of the capsule and then dumping out one half and putting it back together. Of course the pharmacy and the Drug Company do not approve of this. They are quite cheap. The maximum dose is about 1.5mg/kg/day

Concerta (long acting Methylphenidate)

One of the problems of Ritalin is that your body gets used to it throughout the day, so that to get the same effect, the pill needs to release more, not less, drug later in the day. The old form of Ritalin (Ritalin SR - see below) didn’t do this. This pill is different and actually does release the drug in a way so that it is just as effective as Ritalin tablets three times a day, but with one dose. The side effects are the same as with the short-acting Ritalin three times a day. (36) the dose is usually between .5 to 2 mg/kg/d.

It sounds Great! What is the catch??

Cost. This drug is more expensive than the other stimulants. At Lawtons, with a prescribing fee, the cost of 100 18mg Concerta is about $230.00, or $2.30 a day. One hundred of the 36 mg Concerta is about $300, or 3.00 a day. One Hundred of the 54 mg size is $370, or about $3.70 a day.

And if you need to take over 54mg a day, the cost can be even higher- for example a 150 lb child, about 75 kg, who is taking a full dose, about 75 mg a day, is going to have to take a 54 mg plus a 27 mg Concerta each day. So that is about 7-8 dollars a day!

This drug comes in 18mg, 27mg, 36mg, and 54 mg size. You can not break or crush them. If a person has never been on Methylphenidate, then I would start with 18mg.

Biphentin (another long acting Methylphenidate)

This is the newest form of methylphenidate available in Canada. It works about like Concerta, but does not probably last as long. The advantage is that it is a capsule and it can be sprinkled on things like applesauce, yogurt and ice cream. The other advantage is that it is cheaper than Concerta. How cheap is not clear yet, as it was only released in September 2006. It comes in many sizes from 10 mg to 60 mg, so you would only have to take one or two pills maximum. The main disadvantage is there are no published data about this drug, and no information that is not from the drug company that makes it. (64)

Adderall XR

This is actually two different forms of amphetamine together. They are mirror images of each other. The combination has been around for about 30 years, but has only been carefully studied in the last 15 years. It has recently been re-released here in Canada. It had been removed because there was a concern it was associated with sudden death, but it turned out that Adderall was extremely unlikely to be the cause. If you have the dose right, it should easily last 12 hours. It careful studies, it has been shown to be at least as effective as Methylphenidate. It comes in 5, 10, 15, 20, 25, and 30 mg forms. Studies on 10 year olds have shown that the 30 mg size is better than placebo for 12 hours, while the smaller sizes either don't last quite as long or take longer to start working in the morning. Blood tests have shown that there is a wide variance in the blood level from the same dose, so you need to start at the bottom and work up, just like with the other drugs. It can cause all the same side effects as the other stimulants. It is $105-115 a month and it doesn’t matter what size the pill is, the price is the same. It is different than the other drugs for ADHD because the capsule can be taken apart and sprinkled on apple sauce for those who can not swallow pills. The maximum dose is usually 1.5mg/kg. The cost issue is the same for high doses. Above 30 mg a day, the cost is double, about $230 a month.

Long acting stimulants and sleeping in

If you get up every morning all week long before 8 and always have breakfast before 8:30, you don’t have to worry about this. However, if you like to sleep in on weekends, holidays, snow days… there is a problem here.

If you take Dexedrine Spansules at 9am, it won't be out of your system untill 9pm, which means you probably won't fall asleep until at least 11pm. But if you don't get up until 10, and don't take your medication until after your late breakfast at 1030 am, the drug will not be out of your system until 1030 pm, and you probably won't fall asleep until 1am. This is a real problem for teenagers and adults.

Ben becomes a night owl

At 14, Ben is really happy about taking Concerta instead of Ritalin three times a day. With a school inservice on Friday, a weekend, and a snow day on Monday, he has four days in a row without school. So He stays up late Thursday night and gets up at 9am and takes his Concerta. Friday he is up even later and gets up at 10am Saturday and takes his medication. Saturday night he has trouble sleeping and doesn’t get to bed until about 1am, and barely is up in time to go to mass at 11:30 and takes his medication as he goes out the door. Sunday night he has more trouble, but falls back to sleep after school is cancelled and doesn’t wake up until noon. Then he takes his medication. Tuesday morning his Dad gets up to go lobstering at 330 am. Ben greets him and tells him he hasn’t been asleep yet.

Solutions:

If you sleep in past 9am, don't take your long acting stimulant (but what if you need to take it to survive?)
Never sleep in. (this leads to sleep deprivation and wore quality of life)
Wake up at 7am and take your medicine and then fall back to sleep (you won't sleep long, as these are stimulants, remember?
Never stay up late (Impossible for most of us!)
If you sleep in, take a shorter acting version of the drug you are taking or a lower total daily dose. For example, Ben is taking 36 mg of Concerta. If he sleeps in and doesn’t take his medication until 10, he should try taking just 10-15mg or short acting Ritalin, or maybe 20mg of Ritalin SR.

Ritalin SR - medium acting methylphenidate

At one time this was the state of the art for stimulants in ADHD. That time was 1965. A lot has changed for the better in the world of drugs since then. The good thing about slow release Ritalin is you can give it once a day and it works for about 6-8 hours, but not 12. The bad thing is it comes in 20mg pills and you can not cut them in half, so it is very hard to "start low". This drug has a place in these circumstances:

A child has insomnia with Concerta, and really doesn’t need to be on medication 12 hours a day to thrive. This way the medication is out of their system sooner.
Some children will have more mood symptoms with Concerta and not with Ritalin SR
Some people can't afford Concerta

So exactly how do you give these drugs?

I start with a dose that is quite low and watch the child for a few days.

One of these things will happen:

Absolutely nothing. Then we increase the dosage
Amazingly better and minimal side effects. We thank God and leave things alone.
A little improvement and no side effects. Then we increase the dosage.
Lots of side effects. Then we stop the drug and consider something else.
Some side effects and some benefit. Then we try to figure out whether the benefit is worth the side effects.

After each dose increase I check things out and we see what happens. I am after a dosage that will control the symptoms and not cause a lot of side effects.

Once a drug is working, there is no guarantee that the dosage is going to stay the same. In fact, over 70% of children have to have their dosages adjusted over the span of a year. Of those dose adjustments, 60% were increases in dosage, 30% were decreases in dosage and a few (7%) were changes to different medication. If one stimulant doesn’t work, you should try the others.

Side Effects of Stimulants and their management

Remember, all the stimulants have the same side effects. Some people will have no side effects on one stimulant, and many on another. You can not predict who will have what side effect on which stimulant.

Sleep

Many children with ADHD have insomnia. Sometimes the stimulants actually improve sleep. Sometimes they don't. A child may be able to go to sleep, but awaken a few hours later ready to go. More commonly, the child just can't fall asleep. This is very serious business for a number of reasons. First, the child will become sleep deprived leading to irritability, poor concentration, and fatigue. Second, since most parents do not go to sleep before their children do, the parents are sleep deprived with the same problems as the child. This is a very bad combination!

Management - If it is mild, sometimes attending to sleep hygiene or good sleep habits will do the trick. Things like an earlier bed time, certain foods, no TV or computer, quiet activities in the evening and no naps sometimes will do the trick. More often they do not. What to do depends on how well the child is doing on the drug at that particular dose. If the child isn't that much better anyway, I discontinue the stimulant and try another stimulant or another drug for ADHD. If the child is markedly better, often I will add one of two drugs, Clonidine or Trazadone. Both of these drugs have been safely used in young children. They are not addictive. They are not related to sleeping pills. They do not, when used properly, make a child dull the next day. The key thing is to do something. Sleep deprivation will undo every intervention you have made.

Medical Treatments for stimulant induced insomnia in ADHD

Melatonin

This is a hormone that every person actually makes. By giving the hormone, children will go to sleep earlier. When compared to placebo in children with sleep problems, some of which were taking stimulants for ADHD, the children fell asleep about an hour earlier, and fell asleep about 30 minutes faster. They didn’t tend to sleep much later in the morning though. As a result of getting more sleep, they were healthier and felt better. The dose was 5 mg at about 7:00 pm. A more recent and larger study showed that it worked quite well and was safe and better than placebo. In that study, nearly everyone responded. Melatonin has also been used for a number of years for other sleep problems in adults and children. This is not a prescription drug. It is available at the Yarmouth Natural foods store in Yarmouth and perhaps over the counter elsewhere I would suggest using their more expensive brand as it may be more pure. It comes in 3mg sizes.

Clonidine (Catapress, Dixarit)

This drug was originally developed for treating blood pressure in children and it is very safe. It turns out to be useful for a lot of things. Indications for Clonidine are; tics, severe ADHD, severe aggression, sleep disturbances in ADHD, detoxifying Heroin addicts, menopausal flushing, and sometimes autism. The good thing about this is that it never aggravates tics, works well when autism is present, and works in very aggressive kids whom never sleep. It is safe for pre-schoolers and comes in a pill called dixarit that is sweet tasting and looks exactly like smarties. As a result, kids will easily take it. It also comes in a larger size. It is a good choice when tics are present, in autism, preschoolers, and very aggressive kids with ADHD and severe insomnia.

And the bad side of Clonidine?

About one out of every 10 to 20 people who take this will get depressed. It comes on within about 3-4 days and after the drug is stopped, it can take 3-4 days to clear. However, if you are not watching for this, you might think the child is depressed for another reason, and never stop the drug, thus leaving the child depressed. With careful monitoring, that never happens. You have to check a person's blood pressure when you are starting this. It will make some children sedated, but usually by cutting back the dose you can avoid this. As it can affect the heart, I check an ECG before using it and after the child has been on it.

Trazadone (desyrel)

This drug was developed in the 1980s to treat depression. It works for that, but the reason it is used in children has nothing to do with depression. It turns out to be a very safe drug for helping children sleep. It has virtually no side effects. It is not addictive at all. The problem? In less than one in 1000 men, this drug can lead to prolonged erections (priapism) which can be so severe that it requires surgery. It has never been reported in male children, however, I have read some unofficial reports of one or two cases in the USA. It has been used for years in Autism in children. If a child has a history of depression and has stimulant induced insomnia, I use this.

Appetite

The stimulants can reduce a person's appetite. After all, these are the same family of drugs used for weight loss. Often a child will not be quite as hungry on one of these drugs. Other children are finally able to sit down long enough to eat something and actually gain weight. Problematic weight gain is very rare, but weight loss is common. I weigh children regularly who are taking these drugs. If there is substantial weight loss in an already thin child, we try something else. Some children will eat no breakfast lunch or afternoon meal but not lose weight because they spend their evenings eating. Usually, children have other complaints then like stomach ache. Sometimes with a little encouragement a child will be able to eat enough at mealtimes to not loose weight. Sometimes things like Ensure, Boost and instant breakfast can help. If this has been tried and a child is still losing weight, it doesn't matter how well they are doing. It is time to stop that particular drug.

Rebound

The short acting drugs often can cause this (regular dexedrine, regular ritalin). What this means is that as the drug is wearing off the child does not return to their usual severity of ADHD, but to a much worse state. They will stay this way for 1-3 hours before returning to their old selves. The usual story is a child who is taking Ritalin at breakfast and at lunch with great result. The drug wears off right after school and the child behaves like are a monster until evening. If this is severe, something has got to be done, no matter how well they might be doing in school. It is better to be consistently hyper than Dr. Jeckyl at school and Mr. Hyde at home. Sometimes, you can get around this by giving a small dose of the short acting drug (usually ritalin) in the afternoon.

Unwanted psychiatric signs and symptoms

Perhaps 30-50% of children will have this on stimulants to one degree or another. These signs and symptoms are all reversible when you stop the drug. Everyone involved in the medical care of children with ADHD needs to be watchful for these. It is important to remember that even if this happens with one stimulant, it does not necessarily mean it is going to happen with a different stimulant.

Decreased activity - some children will become very, very still on these drugs, especially in the first few hours after they take them. Often they are perfectly behaved, but are taking in next to nothing. This is usually due to the dose being too high, but can happen in low doses in susceptible people.

Increased hyperactivity - some children will actually become more hyper, not less with these drugs.

Mood changes - Occasionally these drugs will make a person sad, angry, and very easily upset. Irritability is also possible. The child appears to cry at the drop of the hat. Even less commonly, a child will be giddy and actually seem high.

Language - Occasionally a child who has a problem with speaking or understanding will actually go backward on one of these drugs and speak even less than usual.

Movements and compulsions - occasionally these drugs will make people have what appears to be nervous tics as in Tourette's syndrome. At times these can be compulsive, such as new onset of nail biting, licking the hand, or having to touch certain things.

The possibility of the above things happening to a child who is already having psychiatric problems is often scary to contemplate as a parent. It is another reason to start low, monitor, and go slow. These are all reversible, and most children do not have these side effects which affect the mind.

Other mild side effects

Besides these, there are sometimes some mild nuisance side effects of the stimulants. Occasionally mild head ache, abdominal pain, and other mild physical symptoms are reported by children taking these drugs. Often they go away with time and most research has found that this type of side effect is as common in ADHD children treated with placebo as with the actual stimulant drug.

Serious Side effects- Sudden Death, Stroke, Heart Attacks

Over the many years that these drugs have been around, there have been a few cases of the above things happening, not counting suicides and drug abuse. This is how frequent they are in children and adolescents:

Sudden death while taking stimulants 1.6 to 3 deaths per 10 million

Other serious heart problems while taking stimulants1.8 to 5 per 10 million.

The question is, is that any more than you would expect in children not taking stimulants? The answer is probably not. The best estimate of the chances of a child dying suddenly is that each year close to 13 per million children will suddenly die, usually of heart problems.

As a result, the risk is very, very slight for most people. However, if you have a history of sudden death in your family or serious heart problems, you probably should not take a stimulant for ADHD.

Side effects and the school

The side effects of the stimulant medications are rarely seen at school. Studies have shown that while teachers are good at determining how effective a drug is, there are not accurate in determining side effects. As a result, it is not uncommon for teachers to be more enthusiastic about medical treatment or suggesting that the dose of the medication be increased.

Example

Ryan is 6. He has quite severe ADHD and it impairs him everywhere. His parents don’t know of any other first graders who got suspended in October. Ryan has taken medications (Ritalin) in preschool when he was biting everyone and they helped. He lost a few pounds, was whiney, and didn’t go to sleep until about 9 pm, but he was able to get through preschool without getting thrown out. During the summer we tried dexedrine and the side effects were even worse. We were able to figure out that at 10 mg a day, the side effects were mild, and he was better. Not great, but not getting thrown out. Once the dose went above that, his behavior was super at school. Except the rebound was horrible, he didn't eat and he whined all evening. Since his teacher never saw the side effects, she felt they were being too cautious. Even after discussing it with me, they still think the parents are exaggerating the side effects.

Non-Stimulant Drugs

These drugs are all second line because there have not been as many studies and there is no long term follow up data so we can not answer the question, “ If my child takes this drug now, will it lead to some problems years from now?”

Strattera (Atomoxetine)

This drug has been used in the USA since 2003. It is not a stimulant. It is related to antidepressants. It increases the amount of dopamine in the front of the brain, but has less effect on the dopamine in other parts of the brain. It is quite different than the other drugs that are currently used for ADHD. A couple of advantages are:

1. One dose will last for 24 hours.

2. It is not a controlled substance and is not abusable.

How does it compare to the stimulants like Ritalin?

There was not difference in effect between the two drugs.

What are the side effects?

In a study of Ritalin vs. Strattera, there were no differences between the two drugs. That is, the most common side effects were the same as with stimulants: headaches, insomnia, decreased appetite, mood problems and anxiety. Overall, 5-10% of the children who were taking either drug stopped it due to side effects.

Are there other side effects?

Yes, in a very few cases, children can become very agitated. About .37% will consider suicide, but in no drug trial has anyone ever committed suicide.

Does it stop working after awhile?

After nine months of treatment, half were still doing well, and half were doing worse.

Can it make tics worse like stimulants?

Yes.

What is a reasonable dose?

The usual dose to start with is .5mg/kg. So if a child weighs 60lbs, that would be about 18mg a day. I will have children take that dose for a week, and then, if they are tolerating it, increase it by .5 mg/kg every week until there is an positive effect or side effects. That is actually slower than the drug company recommends. The usual top dose is 1.5mg/kg, however it has been tested up to 1.8 mg/kg. The higher doses seem to be necessary when Oppositional Defiant Disorder is also present. A person needs to take it every day. You can’t skip weekend days. It is available in the following sizes:10mg, 18mg, 25mg,40mg, and 60mg. You can not chew it. You have to be able to swallow pills to take this drug, at least at this point.

Is it expensive?

All the sizes are the same price - $95.00 US for 30. As long as you do not have to take more than 60 mg a day, it would probably not be any more than Adderall or Concerta.

How fast does it work?

Within a week you can see a response, but a full effect may take 12 weeks.

Can it cause withdrawal if it is stopped suddenly?

No.

I have heard that it will damage your liver.

In December, 2004 the drug company said that of the two million people who have taken the drug, two have had liver damage which returned to normal after the drug was stopped. This included one adult and one teenager. Liver tests were not checked in all two million people. In a separate study, 6000 people on strattera did have liver tests done and none were abnormal. At this point, routine tests for liver damage are not necessary except in people who are at risk for liver problem already. It is important to watch for any signs and symptoms of liver disease if your child is on this drug. These include:

Severe Itchiness
Yellow skin
Dark urine
Upper right-sided abdominal tenderness
Unexplained "flu-like" symptoms

If there is any question, I would check the liver tests before I ever started the drug.

There is more information about this drug on the drug company site. But remember, that is not an unbiased source!

Why isn’t it a first line drug?

Because nobody knows if there are any long term side effects. The drug has only been around since about 2000. As a result, even if you have lots of money, it is a good idea to start with something that has long term follow up data, like stimulants.

Bupropion (Welbutrin)

This drug has been available in the USA for about 10 years. It is used primarily as an antidepressant. However, it affects the same chemicals in the brain (dopamine and norepinephrine) that other drugs for ADHD effect. As a result, it has been tried in ADHD in children and adults. There are only a few studies of this drug in children. However, all of them have found it to be effective. In the one study which compared it to Ritalin, it was found to be almost, but not quite, as effective as Ritalin. It has been used in children who have Conduct Disorder, Substance abuse problems and Attention Deficit Hyperactivity Disorder and it has been found to be helpful. It comes in a slow release form, which means there is no need for a middle of the day dosage. The average dosage is about 3-4 mg/kg. The drug is available only as a slow release preparation in Canada. It comes in 100, and 150mg sizes. The pills can be safely cut in half, but they don’t last longer than 24 hours in the cut form. Usually it is given once or twice a day and it is not recommended that any dose be greater than 150mg.

Since this drug is also an antidepressant, it is a first line choice if a child has both depression and ADHD. It is also a good choice if people have had problems with depression from stimulants. A recent study has shown that in children with depression and ADHD treated with Bupropion (Welbutrin) the drug worked quite well. Depression improved in 88% of the children and ADHD in 63% of the children. In 58% of the children, the drug helped both the ADHD and the depression.

Side effects

Rashes are not uncommon, about one out of 6 children can get one which usually resolves over 3-4 days. Nausea and vomiting can occur. About 1/3 of children will lose a little weight. Less common side effects include irritability, sleep problems, and head aches.

There is only one serious concern. It can cause seizures. This is most frequent in over doses and when patients also have bulimia. In adults, 4 out of 1000 people will have a seizure using the short acting form of the drug. However, the long acting form used in Canada only causes seizures in 1 in 1000 people. This is about the same as most of the drugs used for depression. Seizures have occurred in children, but usually at higher doses. It is still unknown if the seizure rate in children is lower, higher, or the same as in adults. There are no other long term side effects or risks. On the other hand, it has not been around a long time. Over all, the early data suggests the side effects are slightly less than stimulants, but not a lot less.

Good points about Bupropion

Compared to the other non-stimulant drugs for ADHD, the monitoring necessary is minimal. No ECGs or blood tests are necessary. It can be helpful when depression is also present. It has been used a lot in the USA for ADHD without any major problems. If a child has failed to respond or tolerate the first line drugs it is the next choice.

Bad points about Bupropion

There has been some, but not a lot of research on this drug. It seems quite safe in adults, and it probably is in children. However, there is a possibility that something will come up which is a problem with this drug in the future. More importantly, it is hard to use in little children. Since the smallest amount you can give is one half of a 100mg tablet, that means if the child weighs 20 Kg (45 lbs) or less, you are going to be starting the drug at the maximal dose. This is something I always try to avoid doing, so it is not a good choice in children under 50 lbs.

Modafinil (Provigil)

This drug was released in 2004 for narcolepsy, a disease where people suddenly fall asleep in the day. Since it increases the amount of dopamine in certain parts of the brain, it has been tested in ADHD, too. It is not a stimulant. In fact, no one is exactly sure how it increases dopamine. It is been tried in adults and children with ADHD. There have now been a number of studies where it was compared to placebo. The largest found that it worked quite well, and 56% of children responded, but not as many as with Concerta. It took almost 9 weeks to see a full effect. The dose ranged from 200-400 mg a day, and the side effects were mild. The side effects were sleep problems and some mild headache. It comes in 100mg and 200mg size. It can be taken once or twice a day.

The good news about Modafinil

A new, probably safe drug for ADHD that works differently than stimulants. It will certainly be a drug to consider in people who have not responded to stimulants

The Bad news about Modafinil

There has been only a few studies done. There is no information on long term effects, good or bad, and it is very expensive. It can cause problems with other medications.

Third line Drugs

All of the medications below involve more risk. That is, in rare cases, people can have serious side effects. This means that there is additional monitoring required. On the other hand, they have been around a long time so we know everything they can do to a person.Why do you use these drugs?

Because the drugs above have not worked.

Except in a few cases (comorbid severe tic disorders, some mood disorders, some substance abuse disorders) both the drugs above are tried first before considering the drugs below.

Because the risk of ADHD is far greater than the risk of the medication.

ADHD is not always a mild disorder. People with ADHD sometimes engage in very risky behaviors. These are risky to themselves and others. ADHD can totally demoralize a child and put them at significant risk for depression. The risks of things like substance abuse related accidents, motor vehicle accidents, demoralization, other psychiatric disorders and even suicide is not that small. If you look at a group of children with ADHD that go to see a pediatric psychiatrist and then see how they are doing four years later, 51% will have required tutuoring, 34% will have repeated a grade, 15% will be in special classes, and 16% will have been diagnosed with a learning disability. Compared to children without ADHD, they will be 10 times more likely to have manic-depressive disorder, 8 times more likely to have depression, and 4 times more likely to have major anxiety problems. ADHD can be a very serious illness.

The risk of serious problems with the drugs below is on the order of 1 in 10,000 or less. To put that in perspective, your chance of being killed in a car accident on the way to my office is .7 in 10,000. Compared to the risks of ADHD, most people would say the risks of these medications are worth taking.

Your job is to learn about how these medications are monitored and what the risk is and then, with a pediatric psychiatrist, decide what to do.

Clonidine (Catapress, Dixarit)

This drug was originally developed for treating blood pressure in children and it is very safe. It turns out to be useful for a lot of things. Indications for Clonidine are; tics, severe ADHD, severe aggression, sleep disturbances in ADHD, detoxifying Heroin addicts, menopausal flushing, and sometimes autism. The good thing about this is that it never aggravates tics, and works in very aggressive kids who never sleep. A recent study showed that when added to a stimulant, children with ADHD and ODD or CD had a noticeable improvement in their ODD and CD symptoms, but not their ADHD symptoms with few side effects. It is safe for pre-schoolers and comes in a pill called dixarit that is sweet tasting and looks exactly like smarties. As a result, kids will easily take it. It also comes in a larger size. It is a good choice when tics are present, in autism, preschoolers, and very aggressive kids with ADHD and severe insomnia.

And the bad side of Clonidine?

How to use it

The usual full dose is .1 to .2 mg a day. It is usually given in .1 mg or 05 mg size pills two or three times a day.

Tricyclics

This is a group of medications (desipramine and nortryptiline) which were the first drugs used for depression in adults. One of them, imipramine or tofranil, has been used for years children who bedwet. They work in a slightly different part of the brain. The good thing is that they work very well in children who are also depressed or anxious. They do not wear off over the day. They can be given it at breakfast and bed time. They do not usually worsen tics.

So why aren't they used more?

Approximately 5-10 children have died suddenly while taking one of these drugs, desipramine. This turns out to be a rate of about 8 per million. Children die of unknown causes at a rate of 8 per million. To put this in perspective, the childhood suicide rate is about 8 per million. The risk of dying in an auto accident are about 70 per million. So, although there is a very slight risk, compared to the risks of the disorder, it is very small. In my practice, it would be ten times more likely that someone would die on the way to their appointment with me in a car crash than die of sudden death related to these drugs. There is still a debate as to whether this small increase in deaths is from the medication or something else. It is also unclear as to whether monitoring as below will pick out these super rare cases. It has only happened with desipramine. A much more real risk is over dose. If children or adults take too much of these drugs accidentally or on purpose, they can die. These drugs can cause rhythm problems in the heart, blood pressure problems, and fast pulse, plus constipation and dry mouth and occasionally sweating and dizziness. It is very hard to figure out the dose.

Are they safe?

Yes, they quite safe if they are used correctly. The American Heart Association studied this issue and published their recommendations in August of 1999. They suggest the following.

First I get an EKG. If it is normal, we start the drug at a very small test dose amount. For Desipramine, this is usually 1 mg/kg. The doses for Nortryptiline are half of this. Over the next few weeks I slowly increase the dose to 3-5 mg/kg for desipramine or 2-3 mg/kg for Nortryptilin . At this point we check a blood level and another EKG. It takes a week to get the result back. Based on the results of the blood test, I adjust the dose, and occasionally a person will need another EKG and blood test, but not usually. I check the blood pressure and pulse after a few weeks. The toxicity of these drugs is mostly related to the blood level and the EKG. By following these very conservative guidelines, the drug is very safe and often very effective.. BUT, it is a fair amount of hassle. Obviously if someone is dead set against having their blood drawn, they will never get this.

I heard of somebody who was taking two drugs at the same time. Why would you ever do that?

Attention Deficit Hyperactivity Disorder is sometimes so severe that one drug won't control it. It can be a life threatening disease as it makes accidents much more likely. There are certain cases where it is necessary to use two drugs to control Attention Deficit Hyperactivity Disorder. This requires even more monitoring and even a more careful approach..

The most common combinations are

For ADHD that doesn’t respond to Stimulants alone

Welbutrin plus a Stimulant

For ADHD plus ODD or CD that doesn’t respond to a stimulant alone

Welbutrin plus a Stimulant
Stimulant plus clonidine
Stimulant plus Risperidal

For ADHD plus ODD or CD that is very disabling and doesn’t respond to any two drugs

Welbutrin plus Stimulant plus risperidal

ADHD

by Jim Chandler, MD, FRCPC

Contributing Author for MyOutOfControlTeen.com

Attention Deficit-Hyperactivity Disorder (ADHD) is one of the most common psychiatric disorders of children. Approximately 3-5% of children around the world have this disorder. About 50% have another psychiatric disorder with ADHD. In the past, it has been thought that this was only present in boys. However, we now know that many giRestless Leg Syndrome have it, too. You are probably reading this because a family member, pupil, or friend has the disorder.

· Clinical Description

Criteria for Diagnosis

All four main areas must be present (A. through D.)

A. Signs and Symptoms

Six or more of the following symptoms of inattention must persist for at least 6 months to a degree that is maladaptive and inconsistent with the developmental level.

Inattention

often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
often has difficulty sustaining attention in tasks or play activities
often does not seem to listen when spoken to directly
often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to failure to understand instructions)
often has difficulty organizing tasks and activities
often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
is often easily distracted by extraneous stimuli
is often forgetful in daily activities

Hyperactivity-impulsiveness

Six or more of the following symptoms must persist for at least 6 months to a degree that is maladaptive and inconsistent with the developmental level

often fidgets with hands or feet or squirms in seat
often leaves seat in classroom or in other situations in which remaining seated is expected
often runs about or climbs excessively in situations in which it is inappropriate (in adolescents, this may be limited to subjective feelings of restlessness)
often has difficulty playing or engaging in leisure activities quietly
is often "on the go" or often acts as if "driven by a motor"
often talks excessively
often blurts out answers before questions have been completed
often has difficulty awaiting turn
often interrupts or intrudes on others (e.g., butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.

C. Some impairment from the symptoms is present in two or more settings (e.g., at school and at home)

But half the children I know have those signs!

That is why the last criteria is in here-

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

Some of the signs of ADHD are present in a lot of kids. Others are rarely present unless people have really disabling ADHD. The signs that are usually only present in disabling ADHD are written in Red above.

There are three kinds of ADHD:

Combined type- symptoms and signs of both attention deficit and hyperactivity-impulsiveness.

ADHD without hyperactivity - symptoms and signs of attention deficit only.

ADHD, hyperactive-impulse type - symptoms and signs of hyperactivity-impulsiveness only.

ADHD isn’t just about being impulsive, Hyperactive and Inattentive….

Recent studies have shown that people with ADHD have some other interesting problems. These include:

Clumsiness

Children with ADHD tend to fall down more, tip over more things accidentally, and have worse fine motor skills than other children. While some of this is related to their hyperactivity, a good part of it is not. This is partly the reason that people with ADHD have more accidents, have poorer handwriting, and always seem to be spilling things. This poor coordination predicts a poor outcome as adults. Those children who have marked coordination problems and ADHD are much more likely to have trouble with the law, reading problems, work difficulties and substance abuse problems as adults.

Time perception

To be coordinated and get things done, we need to have a stable internal clock. People with ADHD have much more difficulty figuring out how much time has really passed either in the short term (while trying to coordinate a movement) or in the long term (trying to decide how fast to work to get something done in a certain time frame). This inability to judge time does improve with medication.

Planning things out

· ADHD at each stage of development

The examples below are for the combined type of ADHD. Persons with either the inattentive type or impulsive hyperactive type will only have some of these signs and symptoms.

Infant

It is not uncommon that parents can see signs of ADHD even before children can walk. When compared to other babies they are often more squirmy and are a less able to cuddle. Infants who will go on to develop ADHD often have a more difficult temperament. They are more impatient, easily frustrated, and require more attention than the average baby. They have more colic. On the other hand, many children that will grow up to have ADHD show no abnormalities at this stage. I have never seen or heard of an infant referred for ADHD.

Toddler (1-3)

For many children, the first point at which signs of ADHD become apparent is as a toddler. Here are the findings.

Attention

Toddlers naturally have a short attention span. They usually can entertain themselves for a few minutes and often can work on an activity with their parents for a little bit longer. Toddlers with ADHD can not even sustain their attention that long. What this means is that conversations are interrupted by any distracting sound or sight. Eye contact during conversations is poor. The toddler with ADHD will often automatically develop responses to requests like, "huh?" or "What?". Most toddlers with ADHD will be able to sustain their attention for a few favorite activities - certain videos, wrestling, and playing at a playground. If you are the caregiver for a child like this, you are spending more time than usual in direct one to one contact with the child to keep her occupied and to keep her out of trouble. I have never seen a toddler with ADHD in which the chief concern was attention span. At its most severe end, Children with ADHD can only concentrate on things like running or wrestling. Toys, books and games are played with for a few minutes only and then either ignored or destroyed.

Impulsiveness-Hyperactivity

Toddlers are known for their high activity levels. They also spend a lot of time doing things without thinking. Since they are naturally very hyperactive and impulsive, one would assume that it would be impossible to be more hyperactive than the norm. Unfortunately, this is not the case. Children with ADHD at this stage can be incredibly hyperactive. They are often so squirmy they can not really cuddle. They want to be running or in motion at all times. Their lives can consist of climbing, destroying or messing up wherever they are. Often they are too busy to sit still and eat. They can be too hyperactive to sit still to use the toilet. They are constantly breaking things up. If someone winds them up, it can take hours before they are relatively calm. When there is a lot of stimulation, they can be absolutely wild, hitting everyone, screaming uncontrollably, and looking as if they are only distantly related to human beings.

For most children, impulsiveness goes with hyperactivity. Just as the normal hyperactivity of toddlers is magnified in ADHD, normal impulsiveness is also. Toddlers with ADHD jump off of decks, jump out windows, take more than their share of cleaning product overdoses, have more accidental falls, and tend to do other normal impulsive things more frequently. They break toys more often, write on walls more frequently and run into the roads more frequently.

This hyperactivity and impulsiveness can be absolutely exhausting. It means that every minute of the child's day must be supervised or else the child gets hurt or things get wrecked. What is even more exhausting is that toddlers with ADHD often have sleep problems. They can be incredibly difficult to settle, do not sleep soundly through the night, and can be up around 5 a.m. Sometimes a toddler with ADHD will wake up in the middle of the night and be ready to play, go to the playground, or just run around. This leads to a horrible cycle. First there is not enough sleep in the ADHD child or the parent. This leads to a more inattentive, irritable, and hyperactive child. It also leads to a more irritable, frustrated, exhausted, and impatient parent. This usually leads to worse sleep for the ADHD child and so on. When I have had to see toddlers with ADHD it is often because they were very hyperactive and did not sleep.

On the other hand, there are many children who will develop ADHD who do not show signs of it in the toddler age. This is because you have to have pretty severe ADHD to stand out from an age group in which inattentiveness, impulsiveness, and hyperactivity are the norm.

Daily routine

Here is an example of a typical toddler's day with ADHD.

Robert wakes up at 6 a.m. most mornings and his parents don't even know he is awake until about 6:01 when he jumps down the steps and turns the TV on loud enough to hear in the back yard. Robert watches TV for about 2 minutes, since it is not one of his favorite shows, and is trying to undo the latch to the backyard when his mom comes down to begin her day. While she fixes a cup of coffee, he empties out the cupboards of pots and pans, something she doesn't mind. But when she goes to get some cream for her coffee, he manages to throw most of them down the basement stairs at the dog which brings Robert his first Time Out of the day. Mercifully, Robert's brothers are fairly well behaved in the morning until Robert throws one of the backpacks, complete with assignments, in the toilet while mom is making breakfast for one of the brothers. Robert has had breakfast, too. He ate ¼ piece of toast (the rest is somewhere to be found later in the day) ½ cup of milk (he spilled the rest when he had to run and see a power company truck go by) and a whole bowl of cereal, which he ate only under the threat of more Time Out.

After the big kids have gone to school, Robert is like a big dog, aching to go outside. Robert's mom, Yvonne, does not like to go out to the playground at 7:30 am. However, the alternative is worse. If he isn't run down a little, life will be impossible all morning. So Yvonne throws on her coat and chases Robert down the street to the playground. He loves it. He is of course the only child there and climbs up everything, jumps off anything and screams for quite a while. Every few minutes Yvonne has to chase him around or else he gets bored and wants to go home. Eventually Robert is worn down enough to go home. He actually sits long enough for Yvonne to get some housework done and call a friend.

After lunch, which doesn't really exist for Robert, many children lay down. Yvonne would like to. Robert has not had a nap in a year. Yvonne calls her mom and tells her they are coming. Her mom watches Robert in the afternoon so, as Yvonne puts it, " mommy doesn't go out of her mind". After the big kids come home they go and get Robert who has scared Grandma a little by jumping from the landing to the basement without using the stairs. He loved it.

Yvonne is counting the minutes until her husband Matt comes home. So is Matt, but not for the same reason. Matt comes in the door, Robert runs to him and they wrestle for a half hour while Yvonne takes care of the big kids and makes supper. Then Matt takes Robert out for another walk\run to the playground and then it is time for dinner that Robert will sometimes eat as he walks back and forth past the table. After that, it is time for a story and bed.

This is when Matt and Yvonne want to kill Robert. For the next two hours he is calling out, jumping on the bed, kicking the wall, needing to urinate and much more. Eventually, it is 9 p.m. Robert is asleep. Yvonne should go to sleep now but the fact that Robert is asleep gives her a burst of energy. She lies down at 11 p.m. just as Robert awakes for a brief 15 minute trip to the bathroom and a few kicks to the wall.

Preschool (3-5)

Attention

In this stage children usually are still relatively inattentive. However, there are a few new things they are expected to do. They should be able to sit and do some activity on their own for a few minutes. They should be able to do some pre-school work like sitting at a table. They should be able to listen to a story. They should be able to listen a little to other children and a fair amount to their parents. When pre-schoolers have ADHD, they are usually unable to consistently manage these sorts of things. This is the age when a difference usually appears between how attentive the child is to things he is interested in versus those that he is not. A child with ADHD at this age may be able to play cars and trucks on his own without problems but would be unable to concentrate on coloring or being read to. The biggest problem at this stage is that some children are so inattentive to their surroundings that they are falling a lot, spilling more than usual, and have a hard time playing with other children. The pre-schooler with ADHD is ready to change activities every few minutes, but a normal child will want to keep with something for 10-15 minutes at least. If a ADHD child is playing with another child, this need to constantly do something new usually leads to the normal child feeling frustrated. All things considered, the problems of attention in pre-schoolers are fairly mild. I have never seen a child of this age in which attention was a serious issue.

Hyperactivity-Impulsiveness

With every increase in development, the hyperactivity-impulsiveness part of ADHD gets them into bigger and bigger trouble. Pre-schoolers with ADHD are often starting to get into fights. They are running into streets without looking. They are falling out of windows, starting cars, falling out of trees, and getting bit by dogs they have bothered. Pre-school sometimes is a problem in that many "school" oriented programs require too much sitting time. Some ADHD kids at this age will be thrown out of pre-school. ADHD kids at this stage are in a big hurry and sometimes are unable to sit for a meal, to use the toilet, or to speak clearly. Some children with ADHD will become very, very talkative at this point. Their best friends, if they have them, are other very active children. It is usually unsafe behavior plus being thrown out of multiple day care or pre-school programs which brings children with ADHD to my attention at this stage. However, there are many children who will get ADHD who show no sign of the disorder at this stage.

Daily Routine

Sara is 4 and a half. She wakes up at about 6:30 and used to play by herself alone for about a half hour until her mom got up. Ever since she turned all the burners on and put empty pots over them, her mom gets up with her. As her mom comes to the kitchen, Sara starts talking with her. At least that is what Sara thinks. Her mother Lisa would say Sara is talking at her. Sara usually tells her mom three or four things she wants for breakfast, but by the time her mom gets one of those to the table, Sara is out playing in another room. By 8:00 am it looks as if no one has cleaned this place in a week. Sara has taken out all the toys and played with each for a few minutes. Now she is ready to have Lisa entertain her the rest of the day. Sara will beg, demand, cry and do everything she can to get her mother to take her somewhere. It changes every day. If Lisa gives in and takes her there, she is ready to go home in a few moments. When Lisa's boyfriend comes to visit at lunch, he can't talk with Lisa and Sara is talking all the time.

On his way out he takes Sara to the YMCA. They carefully check what Sara is wearing, so that they can look for it in the lost and found. Sara rarely finishes the running, swimming, and other activities without losing a few pieces of clothing. When Lisa goes to get her a few hours later, the other children are sitting quietly watching a video in the corner of the big room. Sara is practicing take-offs. In the late afternoon Sara is able to concentrate on bugging her older sister. Usually Lisa is able to get Sara away and draw a picture with her name for about 10 minutes. While the rest of them eat, Sara runs around, occasionally requiring a time out for tipping over garbage cans and other such things. When bedtime comes, Sara is finally ready to eat, read books, and anything else she can think of. Eventually, at 8:30, Sara is asleep.

Toddler and Preschooler ADHD can destroy families and children

Recent studies have shown that this group has very serious deficits. They are very aggressive and have very poor social skills. They are associated with severe family stress (three times normal). They disobey twice as much as normal children. They behave inappropriately five times as much. Not surprisingly, parents felt that the stress in their lives was three times what you would see in a family without a preschool ADHD child. What does this mean? Preschool ADHD leads to mom's (and occasionally dad's) becoming mentally ill. It can lead to marriage break ups. It can lead to other siblings becoming quite dysfunctional.

ADHD in other Stages

Early Elementary

Attention

To successfully complete grades primary through two requires a huge step in a child's ability to sustain attention. More importantly, the child must be able to sustain his attention on things which he or she is not really interested in. Outside of school there is an increase in the attentional demands, but not as much as in school. You need to be able to attend to other children's interests, emotions, and abilities to maintain friendships.

The biggest problems are at school. Children with ADHD will be able to start nearly any task and often be relatively enthusiastic about it. However, their attention drifts away and the work is not completed. Some will hurry in every aspect of their work and it will be messy. Others will never actually get the crayon or pencil to the paper. They are too distracted by everything that is going on in a classroom and by their own thoughts. If you think about it, if you have a hard time with extra stimulation and distractions, there is no worse place than a busy classroom. Usually children with ADHD will occasionally amaze their teachers because the task at hand is something they are very interested in for one reason or another, or it is one of their better days. A page of mathematics that the child could not do at all a week ago comes back 90% correct. The next day they can hardly recall any of it. This uneven performance begins at this stage and starts to drive teachers and parents crazy. They know that their child is smart, but she only shows it rarely.

Besides these problems, organizational skills start to be noticeably lacking. What is supposed to go home doesn't. What is supposed to go back to school never gets there. Since work is frequently not finished at school, it has to make that trek home, and that is often a difficult one. Children lose backpacks, get distracted on the way to school and on the way home.

Some children will be lucky and have these signs but be so intelligent that they can still successfully complete these grades without ever organizing themselves and really working. Others will have teachers who do not require a lot of organization or who will mark a child based on their best effort rather than an average over time. Many parents will be told their child is lazy, uninterested, and not trying. There is difference. In ADHD children can not pay attention. In lazy children, they will not.

Impulsiveness-Hyperactivity

By the time a child is in second grade, he spends as much time sitting at his desk as the average adult. While the attentional demands make a big increase, the demands to sit still increase even more. This is what usually sinks children at this stage. Children are expected to work carefully in groups and then shift to another activity with only a few breaks in the day. They are expected to listen to the teacher, take turns, and immediately calm down after a break. Children with ADHD often can not do this at this stage. They can not sit still or even sit. They are up walking around the room before they even realize it. They climb over furniture and they bug other kids. Others are just constantly talking and interrupting. Waiting in line and playing with others can be a real problem. Some kids are so wound up that they just run around by themselves. Others do many, many dumb things that get them in trouble. This is often because they are not watching the teachers to make sure no one is looking. Most children will wait until they are not being watched before they do something wrong. Children with ADHD will impulsively throw the stone even when the supervisor is looking right at them. As a result, they are caught 90% of the time, while a less impulsive child will be only caught perhaps 25% of the time. This combination of doing more impulsive activities and getting caught for more of them often leads to the child being labeled as a troublemaker. The worst thing that can happen is to have recess restricted as a result of this trouble. Then the child has even less of a chance to blow off her steam. If a child is quite hyperactive at school, the parents usually hear about it from the school all week long.

At home it can be just as much of a problem. Here it is often a safety issue. Bikes are going off big jumps, children are never looking before they do anything. Children with ADHD have more accidental poisonings, more fractures, and more lacerations needing sutures. Many can best be described as an accident waiting to happen. Often by this time the child will have found a few activities which can sustain her attention. Video games, computers, and legos are often in this category. Many children are mostly outdoors if they can be.

Homework begins at this stage on an occasional basis for most kids but on an almost daily basis for ADHD children. They don't finish the work at school so it is sent home to be done. So the parent must change the environment and supply what the child does not have. The parent usually must sit down in a quiet dull spot and go through the work at the child's side. The parent will have to bring the child's attention back to work many, many times. What could take a normal child 5 minutes takes an hour. It usually drives parents around the bend.

To have ADHD, you must show either attention problems or impulsiveness-hyperactivity by age 7. Some children will show both and come to clinical attention. Some will be able to get by even though these problems are present and not require clinical attention. These are usually the children with primarily attention problems and little or no hyperactivity. It is unfortunate that the children with only attentional problems are rarely thought to be anything more than lazy, eccentric, or immature.

Daily Routine

Stefan gets up at 6:00 in the morning. The bus doesn't come until almost 7:45. He still misses it at least once a week. His mother Becky has to make sure he does everything. If Becky just asked Stefan to get dressed, it would be noon before it was done. So she nags him about that. At breakfast he plays with his food. So Becky is pushing him to hurry there, too. To get washed up is another battle. She feels like she is pushing a big rock uphill all morning and the rock is Stefan. Then she has to help Stefan find boots, gloves, coats, backpack, homework, and all the other things that she thought were all set out when they went to bed. As Stefan runs to the bus, she watches to see that he gets on, says a quick prayer of thanks, and sits down.

On the bus Stefan gets to sit right behind the driver as that seems to keep him out of trouble. That way the driver can make sure that when Stefan gets off he doesn't trip into a puddle, knock someone over, or get into other trouble. She hands Stefan off to the teacher, Mr. Rose. Stefan is lucky, he gets to sit in the front row right next to Mr. Rose at the first table. All the children sit down after "Oh, Canada" and so does Stefan. Mr. Rose tells them to take out some work and automatically adds," Stefan, come back to your seat and take out your blue scribbler. " Without even looking, Mr. Rose knows that Stefan is already up. Later they are to sit in a circle while he reads to them. Stefan listens to as he walks around the back of the circle. Stefan says he listens best when he is walking. When they do the worksheets, Mr. Rose makes a familiar pattern. He helps a child with a problem, then circles around to try to get Stefan to get back to work, then out to help another child then back to get Stefan on task. If the other children need only minimal help, Mr. Rose can help Stefan get half of the worksheet done. Left to his own, the sheets are usually empty or full of wrong answers. When it is science time, Stefan shines. He knows all the answers. He tells Mr. Rose all the answers even when Mr. Rose is not asking any questions. At recess, Stefan is out like a bullet and captured by a playground supervisor who makes sure that Stefan is involved in something which will not get him in trouble and use up the most energy. Races are the usual choice for the short recess and field hockey or soccer for the long recess after lunch.

At 1:00 p.m. the phone rings and Becky swallows, praying that it will not be Mr. Rose saying Stefan is in trouble. Her prayers are answered! For the first time this week, neither the principal or the teacher calls! Becky almost kisses Stefan when he comes home except for the fact that he watches him pick up a big stick and just barely misses hitting the neighbor girl. He wasn't looking at anything, just swinging it. Stefan comes home, eats like a horse (he is too excited to eat at school) and he is back outside for an hour or so until his father comes home. Stefan is building a fort in the woods behind the house, but you can't really tell, as he is still just planning it and hauling old things around.

When his father comes home, it is time for homework. Becky tried to do homework with Stefan, but she screamed so loud once at Stefan that the neighbors came over to see what the problem was. And the problem? How do you spell "boat". Stefan had spelled it ten times. But that was before a bird ran into the window. Now he can't remember. So, Joel helps with the homework upstairs. An hour later, they both come out, homework often done, sometimes not. Joel looks like he has just had a rough work out. So does Stefan. From that point on, things go fairly smoothly. A little hitting, a few broken toys, and a lot of lego later, it is time for bed. Stefan usually goes to bed pretty well now.

Later Elementary School

Attention

There is a fairly big gap in Canada between second and third grade. Work begins in earnest in third grade. There is more work in class and more homework. The work is often the type that requires multiple steps and planning. This includes things like book reports and other projects. Outside of school, most children are spending an hour or so on an activity and often there will be almost as much organization required for play as at school.

It is the organizational demands that tend to sink children at this stage. Children with ADHD often have great ideas and either don't get started or quit part way through. Left to their own, everything is late. However, they will still mystify their teachers and family by occasionally doing brilliant work on something that they are especially interested in. At this point the amount of work is great enough that most parents can not help the child to keep up unless they spend over an hour a day in homework. This is usually just as frustrating to all parties as when they were younger. It is at this stage that children with ADHD without hyperactivity will start to come to clinical attention. Those are the lucky ones. Since they are often quiet, and not a behavior problem, some of these kids will just drift through these years using only a fraction of their capabilities. Most are thought to be lazy or uninterested.

Impulsiveness-Hyperactivity

Most children with ADHD will settle down a little by this stage. Most can sit in a chair, but are quite squirmy. They are less likely to walk around and more likely to talk out of turn, bug other kids, or become class clowns. Outside of class they still have a hard time staying still and spend a lot of time doing things outside. The big problem is impulsiveness. If you have ADHD, the older you get, the more trouble impulsiveness can get you into. Shoplifting muffins, taking apart vacuum cleaners, starting fires, getting into fights, nearly drowning, nearly getting killed on their bikes, climbing on roofs, and saying very stupid things to people in authority are some typical ones. Evil children will also do these things, but are less likely to get caught. They are "pre-meditated" crimes. ADHD kids do these things for no real reason and are almost always caught. I see many extremely impulsive children at this stage because their parents can see where things are headed and they don't want their child to go down that road. Very impulsive and hyperactive kids at this stage are often labeled as criminals of the future because they are doing dumb things and getting caught. But anyone who spends a lot of time with the child will realize that this is not an evil and cruel person.

Daily Routine

Megan is now in grade 5. Life is a lot different this year than last year. At the end of the year, there was a big meeting at school regarding Megan. Some wanted her suspended, others wanted her held back. In the end, it was agreed to graduate her into grade 5 but there would be zero tolerance of any misbehavior and if she was behind after two months, back to grade 4 she would go. In grade 4 Megan was always late, missing things, forgetting everything and was months behind in everything. Amazingly, she was too busy to do this work. No one ever did figure out what Megan was so busy doing. She spent most of her time daydreaming, screwing around, and saying things to her teacher and principal that got her lots of punishment. Hitting anyone who teased her didn't help. So when grade 5 started, Megan's Dad decided that they should run Megan's life like boot camp. There was a schedule for everything. There were lists to be checked off in the morning to make sure everything was organized for Megan. All projects and homework were written on a big chart. Megan helped the janitors at recess. She went to resource for as much time as possible to get more one on one help. In the early evening, Megan's parent's took turns helping Megan with her work by taking her through each step of each task. Megan did her tests in a room by herself to cut down on distraction. At home, Megan was watched all the time and was in Girl guides, 4-H, church groups, Karate, and swimming. She went out with her Uncle and snared rabbits on the weekends.

After the Christmas report cards, Megan's parent's were ecstatic. Megan was actually passing. Or was it Megan's parents who were passing? It became obvious who was passing when Megan's mom had the flu for most of January and could hardly help around the house, much less work with Megan. Everything started to crumble again - Megan was in trouble. She was behind and the teacher's were calling for a parent conference. Luckily, Megan's aunt was laid off and helped out. Aunt Julie was about to give up herself but luckily Megan's mom was able to get back on her feet in time.

The most amazing thing is that even though Megan's life was extremely regimented and structured, she didn't seem to mind. In fact she thrived. While her parents were proud of her, they were counting the days left of school. When school ended and there was no more homework, it was hard to tell who was happier, Megan or her parents. What kept them going? Sadly, it was Megan's grandmother. She always said Megan was the laziest child she had ever seen. Not a week went by when she did not predict that nothing good would come of Megan. Along with these unhelpful predictions, she also had some suggestions. The most frequent was that they were spoiling that child and actually had caused Megan's problems. Who can argue with a grandmother? They intend to prove she is wrong.

Junior and Senior High School

When ADHD persists into this age range, a whole new set of problems emerges. As a result of these, ADHD in teenagers can be devastating. Why? Often the answer has to do with Executive Functioning.

Attention in teenagers

At this point, the attentional demands on adolescents are the greatest. This is because they have little choice over the courses they take and yet have to do very adult things. The distractions between classes are immense. The adolescent with ADHD at this stage is part of the group who didn't outgrow it at puberty (see Prognosis section). For the most part, they start failing in a big way. Often their attention span is still that of a fourth grader or less, but the demands for sustained attention to boring things is very great. So, they don't do any work. Or they just fail because they are not trying. Or they become the clown to keep from working. At this point, even the most dedicated parents can not keep a child going (see above example of Megan). There is too much work. At this point it is sink or swim, and most start to sink. Many will drop out, skip classes, get in trouble, or only do a few things that actually interest them. It is common to see a child who has failed three times in Junior High be able to teach other kids how to do something which they have not learned themselves. At this point, the schools have basically written off the child as trouble or not able to do academic work. I will see kids in this age group for the first time when the parents have found that they could not do what they did in grade school (see Megan example above) and are seeing their child fail.

Impulsiveness-Hyperactivity

Children are usually fidgeting and restless at this age with ADHD, but unless you spend a fair amount of time with them, they don't seem that hyperactive. However, there is usually a clear preference for activities that don't involve sitting quietly. It is the impulsiveness that is sinking them. At this point, children are suspended for skipping school, disrespectful remarks, fighting and other stupid mistakes. The most impulsive will be involved with drugs, alcohol, smoking, and minor vandalism. Others will do something really stupid like crash a car and be paralyzed, hit a RCMP officer, or accidentally shoot a gun and kill someone. These are all examples I have seen. There are a lot of adolescents with ADHD who are only minimally impulsive and hyperactive, and they are less likely to get in quite so much trouble. They are more likely to just be frustrated, depressed, and drink. By late adolescence, severe ADHD is a horrible problem and can be life threatening.

Daily Routine

The horn honks and Shawn's mother calls to tell him Tara is here. Amazingly, Shawn appears dressed and his mother hands him his books as he goes out the door. As they drive away, she still can not believe how lucky they all were to have Tara appear. Tara and Shawn are both 17. If only Tara's parents had moved here two years ago! Before she can reminisce about the past, the car is back. Shawn races into the house, "I forgot my medicine!" She hands him the pills and out he races. She knows it wasn't Shawn who remembered the medicine, it was Tara. By the time Shawn was in 10th grade, he was frustrating everyone, even himself. He had great ideas, but couldn't follow through with them. It seemed they were always nagging him about work and homework, even though they had promised that once he was 15 they would not watch him every minute. Shawn dropped out of school at age 16 and helped his uncles when there was work in the woods or on the boats. The rest of the time was full of great plans and half-finished projects. Like going to community college (she still has the half filled out application) or starting his own graphic arts company (he lost interest after he designed the logo). Luckily Tara appeared that summer. They would be both going into grade 11, but it would be his second time. So now life was better. Shawn was doing great in school and everyone admires his art work. Tara adores him. She gave up wondering how much was this because of the medicine and how much is it Tara. Of course maybe, just maybe, after all these years of battling this ADHD he is growing out of it.

Attention Deficit Disorder in Adults

While some adults with ADHD will outgrow it, about 30% will continue to have it. the lucky ones are like Shawn and find a combination of the right partner, the right job, and sometimes the right medicine. The unlucky ones go on to have failed relationships, troubles with the law, drug and alcohol abuse, and occupational failure. All the adults I have ever seen with ADHD have come for help because their children had been diagnosed and successfully treated for ADHD. Either the adult with ADHD or their partners and friends suggested they check out treatment, too.

· Subtypes of ADHD

So far I have described children and adolescents who have both the inattentive symptoms and the hyperactive-impulsive symptoms. However there are some children who have only problems with hyperactivity and impulsiveness and other who have no hyperactivity or impulsiveness at all.

Hyperactive-impulsive subtype

These are children who are able to perform academically quite well, as long as someone is keeping them busy. They are children who can stand at their desk and walk all around it while still doing their work or reading. Often these children will be in fights, engage in risky behaviors, yet be able to do their work without too much difficulty. Although they might not get a failing grade for bus riding, often they are above average in school work. Little is known of this group. In my practice, only about 5% of children with ADHD have this picture.

Example: Brett

Brett is 9 and in fourth grade. He is young for his class and rather small. Until Brett gets to the bus stop. you don't notice any real problems. He gets ready for school okay, eats quickly, kicks the soccer ball very close to the table which the cereal and milk are on, and is out the door. Last month, before his mom even noticed he was out there, there was trouble with either purposeful teasing or Brett just playing too rough for everyone else. Now Brett's mom comes out with him. She comes out to the bus stop with Brett and then enlists Brett and the other kids in picking up trash along the road while they wait for the bus. In this way, Brett stays busy, runs off some energy, and stays out of trouble. On the bus, brett stays in the front seat. He knows that going out for recess and staying up until 8:30 are determined by his school bus performance on the way to school. Some days, if Brett is particularly wound up, his teacher calls his mom and she comes and gets him, because the teacher can see that there is no way Brett can handle a bus ride. At school Brett is kept busy every second. The teacher is watching him constantly and if he gets done early (which is often the case) she puts him to work taking care of the animals in the back of the classroom or doing something on the computer. She figures she spends as much time with Brett as all the other children combined. At lunch time, it turns out that the monitor always happens to sit next to him. When he is done and on the way out for recess, they always try to get a game of floor hockey going to keep him busy. Occasionally, on rainy days, they have him go lug things around with the janitor over recess. Once he is at home, he is mostly outside. Brett's mom's greatest fear is a snow day- no activities and no way to get out!

ADHD without hyperactivity subtype

Children with ADHD without hyperactivity are different in many ways from ADHD kids. First of all, they often have lower energy than normal. Often they are less assertive than normal. As a result, they are usually quite popular in elementary school compared to ADHD kids. They are much more likely to have learning disorders (especially Math) than ADHD kids. They are much less likely to have ODD or conduct disorders. There is no difference between ADHD and ADHD-D children in the frequency of other co-morbid conditions. ADHD-D children and adolescents do not get identified early in school, which is a shame. They are more likely to quietly daydream and never accomplish much. As a result, in a busy classroom, the child is not the "squeaky wheel". These children have a tendency to just drift through school. Nevertheless, it can be a very horrible illness. About 15% of ADHD children have this type.

Example Jeanettte

Jeanette is 11. When she was a preschooler, all of her mom's friends commented on what a wonderful child she was. Content to play with just about anything, a good sleeper, and an easy going attitude about life. As Jeanette went through school, these points were heard less and less. The fact that she was way behind in math, never seemed to apply her self, and had bad coordination were what people noticed. Jeanette still passed every year, but never with any effort on her part. At home she played with friends or just sat around and drew or watched TV. The families biggest problem was getting her to do anything. Jeanette's clothes, books, pencils, and boots just seemed to disappear into thin air. When her parents took things away because she didn't bring home her homework, she didn't care. When 5th grade came, so did book reports and projects with deadlines. Jeanette seemed to be ignorant of all this. Most kids liked Jeanette. Finally, at a teacher parent conference, the teacher showed the mom some of Jeanette's work on drawing cross sections of a house. It was incredibly good. The teacher almost wondered if the mom had done it. The teacher also confessed to the mother that up until that point she had privately thought that Jeanette was just not very bright. Now she realized there was something else wrong, and was suggesting Jeanette get checked out to see what was the matter.

The treatment of ADHD without hyperactivity is just the same as ADHD. However, some of the behavioral interventions are not the same, since impulsiveness is not an issue.

More About ADHD

· Causes of ADHD

The two types of causes are genetic and environmental.

Genetic

About 90% of ADHD is genetic. Studies of adults with ADHD have found that about 50% of their children will also have ADHD. It is certainly possible that ADHD that disappears at puberty will be less inherited than this, but there are no data on that issue. Some researchers have found that if a mother has ADHD, it is much more likely to be passed on than if the father has it. The other problem is that more often than by chance two people with ADHD will marry each other. From basic genetics, one would then estimate that 75% of the children would have ADHD. Another common problem is that people with ADHD marry people who have learning disabilities, which are also strongly inherited.

So what exactly is being inherited that causes ADHD?

The answer isn't totally clear yet, but researchers are a lot closer to knowing than they were five years ago. A chemical called Dopamine is involved in ADHD. Researchers think that changes in the genes that make the chemicals that transport Dopamine and bind it in the brain may be what is inherited.

Alcoholism in parents is also associated with an increased risk of ADHD. If a parent has alcoholism, their child is about twice ask likely to have ADHD. If both parents have alcoholism, the risk is three times as high. It is unclear whether this is from being related to an alcoholic parent or from living with them.

Environment

As far as ADHD goes, the most important part of the environment is that in the womb and the birth. About 15% of ADHD cases are related to birth trauma or problems with the pregnancy. Women who smoke during pregnancy are more likely to have a child with ADHD. ADHD is more common in most genetic syndromes and is also common in cases of mental retardation. Severe head trauma can produce ADHD, too. About one out of five children with head trauma will develop ADHD. A common question I am asked is if you can "make" a child have ADHD from things like abuse? No one is sure, but probably not. What is certain is that you can worsen ADHD by family chaos, deaths or separation of parents, poverty, abuse and neglect. Food colorings and additives may also worsen ADHD in some cases (see dietary treatment section).

Brain findings

Over the last few years, researchers have looked at the brain in people with ADHD and have found some clear abnormalities. MRI scanners take a very detailed picture of the brain in cross section. They show that parts of the base of the brain associated with attention are smaller on the right in people with ADHD. The part of the brain that connects the left and right front of the brain has also been found to be smaller in a couple of studies using MRI. When researchers look at how much work different parts of the brain are doing, they have found decreased activity in the front parts of the brain in ADHD. On the other hand, no change is found off and on Ritalin in brain activity with these tools, even though the children are better on the drug. All of these studies suggest that the parts of the brain which we know are involved in planning, attention, and controlling motor activity show some minor abnormalities. They can not be used to test for ADHD, but they certainly confirm its biological basis.

· Co-morbidity in ADHD

When diseases tend to occur together more often than chance would predict, it is called comorbidity. A familiar example is Diabetes and high blood pressure. Identifying comorbid conditions when ADHD is present has led to better treatments and great advances in child psychiatry. When a child is assessed for ADHD, it is absolutely essential to see if any of the other common comorbid disorders are present. The presence of these comorbid problems predicts which treatments will work and what the long-term prognosis is. About 50% of children have ADHD plus some other disorder. Here is a brief description of the common disorders comorbid with ADHD. Virtually all the child hood psychiatric disorders are more common in ADHD. GiRestless Leg Syndrome tend to have more comorbid disorders than boys.

Conduct disorder

This is an inherited disorder characterized by cruelty, violence, and disregard for the rights of others. When it is present with ADHD, it is a bad sign. Approximately 25% of ADHD children also have this. Children and adolescents with ADHD without hyperactivity do not have an increase in Conduct disorder. A third of ADHD children who also have conduct disorder will have committed multiple crimes by the time their teenage years are over compared to 3-4% of children who have only ADHD. Children with ADHD and Conduct disorder have a higher rate of becoming criminals as adults, too.

Oppositional Defiant Disorder

This is a disorder characterized by aggression, bad temper tantrums, and a desire to irritate and oppose others. About 80% of children with this also have ADHD. Children and adolescents with ADHD without hyperactivity do not have an increase in Oppositional Defiant disorder.

Tic disorders

Sudden movements of the body or sudden sounds which are not voluntary are characteristic of Tourette's and related problems. ADHD and tics often go together. Tics can certainly change the treatment of ADHD.

Anxiety Disorders

Anxiety disorders are not uncommon in children, but ADHD children are twice as likely to have them. One-third of ADHD children have anxiety disorders. They predict school failure and strongly influence the treatment of ADHD. Children with ADHD and anxiety are less hyperactive and impulsive than children with ADHD only. On the other hand, children with AHDD plus anxiety have more difficulty with difficult work and get "bogged down" more frequently.

Depression

Varying degrees of depression are present in many children with ADHD, especially after about age 10. This changes the treatment and predicts a worse outcome. About 40% of children with ADHD have marked depression. Often a child with ADHD will have relatives with depression. In some families, some relatives will have ADHD and others depression. Children with ADHD and depression are not more likely to commit suicide.

Learning Disabilities

Many children with these have ADHD. It makes life even more frustrating and difficult. About one third of ADHD children have learning disabilities. Children with ADHD without hyperactivity have more learning disabilities. If a child with just learning disabilities is given stimulant medication for ADHD, it will not improve their learning. However, if a child with ADHD and learning disabilities (especially a reading problem) is given stimulant medication, their reading improves markedly.

Mania

Mania is quite rare in children. It is the opposite of depression. About 90% of manic children have ADHD. This is a very, very severe problem when it occurs.

Autism and related disorders

ADHD is present in about a quarter of this group, about five times what you would expect.

Enuresis and Encopresis

Not being in control of your feces or urine is much more common in ADHD than in children without ADHD. Having ADHD can make it harder to control these problems. On the other hand, many times the treatment of ADHD will improve these problems also. About 30% of children with ADHD have enuresis.

Developmental Coordination Disorder

Being exceptionally clumsy and poorly coordinated is much more common in ADHD children. This combination can lead to very poor self-esteem, especially in boys.

Speech-Language Disorder

This is one of the most well documented connections. ADHD is much more common in this group. ADHD can make speech therapy much more difficult.

Epilepsy

About 20-30% of children with epilepsy also have Attention Deficit Hyperactivity Disorder. In a recent study, 70% responded positively to medications for Attention Deficit Hyperactivity Disorder. The medications for Attention Deficit Hyperactivity Disorder are safe with most seizure medications.

Auditory Processing disorder

These persons hear all right, but they have a hard time filtering out sounds that are not important. About 50% also have ADHD or one of the sub-types of ADHD.

Substance abuse

If you go to drug and alcohol programs for teenagers, you will find many more cases of ADHD than you would expect. However, the good news is that this is not due to ADHD, but due to Conduct Disorders. That is, ADHD alone is not associated with an increased risk of substance abuse, outside of cigarettes. Conduct disorder is associated with a marked increase in substance abuse. So if your child has conduct disorder and ADHD, there is a great risk of substance abuse. But if the child just has ADHD, he or she is not at a higher risk for drug abuse as a teenager. There is some evidence to suggest that if a person still has ADHD as an adult, even without conduct disorder, they will be at a greater risk for alcoholism.

Comorbidity doesn't always mean just two disorders. I frequently see two or three different disorders besides ADHD in one child.

· Making the Diagnosis of ADHD

In medicine, there are three methods that are used to diagnosis diseases. These are the history (what the patient and his family tells you), the examination of the patient, and lab tests. Each has a role in ADHD diagnosis. The job in diagnosis is to find signs of the disorder you are looking for and make sure it is not something else.

History

A lot of the diagnosis is based on the story a family, school, and child tells me. I have to find out about all sorts of other medical problems and all these comorbid conditions. If a child has three or four psychiatric disorders, this can take a good hour. The most common mistake in the history in evaluating ADHD children is to forget about asking about comorbid conditions.

Examination

When you do an exam for ADHD, you are looking for a few neurologic problems, but mostly you are observing for signs of the many different psychiatric disorders, including ADHD. Checking for signs of ADHD and the many other comorbid conditions doesn't usually mean a general physical. It means watching how they relate to others, play, read, write, interact with me, and many other things. You can diagnose ADHD without an exam, but you will often be wrong, especially about comorbid problems.

Lab and X-ray

There are a few other disorders that sometimes can look like ADHD. One is Sleep apnea. In this problem children are often snoring and they stop breathing in their sleep for a few seconds. This interrupts their sleep and can cause hyperactivity, inattentiveness, and other behavior problems. It is important not to miss this. It is not that rare. About 1-2 % of children have this, but up 18% of children who are having major problems in school have it. Some children can be markedly improved when this is treated. The treatment often involves surgery.

Substance abuse can cause many signs of Attention Deficit Hyperactivity Disorder. The most likely is Pot or Cannabis. In fact 14% of teenagers who go to their family doctors test positive on a urine drug screen for street drugs. It is almost always Pot that is found in the urine. In children with school problems, Some kinds of epilepsy and certain disorders of the brain and metabolism can appear like ADHD. Overall these are very rare. If children are going downhill neurologically and psychiatrically, or if nothing seems to fit, then I get much more aggressive about doing special tests. Hearing tests are different. All children who are thought to have ADHD should have their hearing tested.

In the vast majority of children, the diagnosis is clear from the history and examination without special tests.

Common Mistakes in Diagnosis

Sleep Disorders

If you look at children with ADHD, almost half of them have trouble sleeping. In most cases, this is because of a combination of their ADHD, ODD, and the environment. However, there are other cases when a sleep disorder is actually causing ADHD.

· Not enough sleep

Many children with ADHD or ODD do not get enough sleep. Overall, a child needs 9-11 hours of sleep a day. There are a number of things to check out to make sure common causes of insomnia aren’t missed.

Things the child is doing or taking that make him aroused

· Medications- especially meds for ADHD, but also some asthma medications

· Caffeine- no children with sleep problems should take the following after about 4:00 pm: coffee, tea, pop, chocolate

· Video- Video arouses people, no matter how dull it may seem at the time. Kids should not be playing video games, using computers, or watching TV less than an hour before bedtime

Environment

· The bedroom should be for sleeping and other dull activities. There should not be TVs, computers, or video games in the child’s room. The child should not be using the bed for a place to study, relax, talk with friends, play games, or anything else.

· The bedroom should be the right temperature and quiet.

· Bedtimes should be regular and relatively inflexible. Even on the weekends, it shouldn’t vary by more than 90 minutes. The same applies to wake-up time.

· parents need to follow the same approach to sleep hygiene.

Sleep Apnea

When a person goes to sleep, he or she is supposed to breathe deeply and with little effort. If there is an obstruction so that the person can not breathe well, then they will not get enough sleep and awaken. In sleep apnea, a variety of factors are leading to obstructed airways during sleep so that everytime a person falls deeply asleep, their breathing is worse, and they awaken. Since they do not get deep unbroken sleep, they get psychiatric problems. They have trouble learning, are inattentive, irritable, and more difficult overall. In adults, they are usually tired out, but in children, it results in hyperactivity. About 2% of children have sleep apnea. Those at greatest risk are children who have the following features:

Obesity
Family History of sleep apnea
Premature birth
Gasping, labored breathing during sleep, lound snoring
Wheezing in the day
Sinus problems and mouth breathers
People who are African-american in race
Certain genetic syndromes
Enlarged tonsils and adenoids

The reason this is important, is that the usual treatment for obstructive sleep apnea in Children is having your tonsils and/or adenoids removed. This results in 80-90% of the children improving.

Diagnosing Sleep Apnea

If the clinical picture looks right, the best test is to do a full sleep study. This involves going to a sleep centre and having an all night recording of sleep while you have many things attached to you. This includes electrodes to monitor your brain waves, tubes to monitor your breathing, a finger mitten to monitory the oxygen in your blood, and another few wires to monitor your movement. Unfortunately, many children with psychiatric problems can not actually sleep with all this on. Secondly, there are very few centres for this and the backlog is quite long, as you can only do the test at night.

The second choice is a home sleep study. This includes quite a few less items. You have a finger mitten to monitor oxygen in the blood, movement monitors, and a tube to measure airflow in and out of the mouth. Most kids can sleep with this on. If this is consistent with sleep apnea, it is not necessary to do a full sleep study. The next step is to do go to a ENT surgeon to see if surgery is reasonable.

The third choice is oximetry. That is a finger mitten only. In difficult kids who are non-compliant, it is better than nothing. It if is very abnormal, it would make me want to pursue a home sleep study, if possible.

And what if the surgery doesn’t work?

Sometimes people have sleep apnea and ADHD. Other times the diagnosis wasn’t carefully checked out before surgery.

Restless Leg Syndrome and ADHD

This is a disorder where people have a hard time keeping their legs still. If they don’t keep moving their legs, they get unusual sensations in their legs. Sometimes it is pain, sometimes, aches, and other times it is some sort of vague discomfort. This goes away if they start moving. It is usually worse in the night. Often it is accompanied by Periodic Leg Movement Disorder, in which people’s legs make sudden movements in the night to such a degree that they wake themselves up.

So what does this have to do with ADHD?

If a person can not keep still because of Restless Leg Syndrome, it can look just like the hyperactivity of ADHD. Likewise, people who have both ADHD and Restless Leg Syndrome have a hard time getting to sleep. Many of them are sleep deprived because they can not get to sleep because of the restless legs and then they are awakened by periodic leg movements. This can result in bad tempered children who can not pay attention, common signs of ADHD.

What causes Restless Leg Syndrome and Periodic Leg Movement Disorder?

There are two common causes: low iron and genetics. It is very strongly inherited, especially if it appears in children. Almost always a child with these disorders will have a parent with them. Overall, they become worse, not better, with age. However, often times they will come and go in intensity over time.

ADHD and Restless Leg Syndrome run together

About 44% of children with ADHD also have signs of Restless Leg Syndrome. On the other hand, 26% of children with Restless Leg Syndrome have signs of ADHD.

Signs that this may be Restless Leg Syndrome and Periodic Leg Movement Disorder and not just ADHD

Children can not sit still because it hurts to sit still.

Worse restlessness in the evening

The restlessness primarily involves the legs, not the arms and the rest of the body

Watching the child in the hours of 3am until 5am shows sudden movements

Parents with the same problem

How is it diagnosed? According to International Restless Legs Syndrome

Study Group, the first thing is to make sure the person has the four main signs:

An urge to move the legs, usually accompanied or caused by uncomfortable or unpleasant sensations in the legs (Sometimes the urge to move is present without the uncomfortable sensations and sometimes the arms or other body parts are involved in addition to the legs.)
The urge to move or unpleasant sensations begin or worsen during periods of rest or inactivity such as lying or sitting.
The urge to move or unpleasant sensations are partially or totally relieved by movement, such as walking or stretching, at least as long as the activity continues.
The urge to move or unpleasant sensations are worse in the evening or night than during the day or only occur in the evening or night.(When the symptoms are very severe, the worsening at night may not be noticeable, but must have been previously present.)
In children, there also should be a parent with the same problem, major problems with sleep and Periodic Leg Movements

How common is this?

It depends on your age. In those over age 65, it has been estimated that almost 25% of people may have it. In young adults, the prevalence is 5-15% Everyone who is suspected of having this disorder also should have their Ferritin level in their blood checked, too.

What can be done?

Like most things in medicine, there are medical and non-medical treatments.

Non-Medical Treatments

Eliminate caffiene after 3pm
Moderate exercise every day
Stretching excercises before bed
Stop smoking, do not drink alchohol

Medical treatments

Eliminate drugs which might be causing the problem.

Commonly used psychiatric drugs to try and avoid:

(fluoxetine), Paxil (Paroxetine), Zoloft (Sertraline), Celexa (Citalopram), Luvox (Fluvoxamine), Risperdal (Risperidone),

Non-psychiatric drugs to avoid:

cold medications, nausea medications

None of the ADHD medications which are stimulants or antidepressants such as Ritalin, Dexedrine, Concerta, Adderall, Strattera, Desipramine consistently make RESTLESS LEG SYNDROME worse or better.

Quite safe psychiatric medications which may even help:

Welbutrin

Medications for Restless Leg Syndrome

Permax (Pergolide)

This is a medication used for Parkinsons and Restless Leg Syndrome. It has also been used in children who have Tourette’s. It is quite well tolerated. It comes in a .05 mg size pill and the dose would be given an hour or so before sleep. There are no trials of its use in children

Mirapex (Pramipexole)

This is also used for Parkinsons and Restless Leg Syndrome in adults. The usual dose is one one half of a .25 mg tablet before bed. There are some case reports of this successfully being used in children.

Requip (Ropinirole)

This is the first approved drug for Restless Leg Syndrome. It has mostly been used for Parkinsons. The dose is usually started at one-half of a .25 mg pill. There is one case report of the use of this drug in a child with ADHD and RESTLESS LEG SYNDROME. Both sets of symptoms improved.

Side effects-

Nausea –

this is usually mild if the dose is slowly increased

Augumentation-

What this means is that rather than having the symptoms primarily in the evening, they start happening in the day. As a result you sometimes have to give more earlier in the evening.

Long term side effects –

so far in children, there do not seem to be any. The longest any child has taken these medications in the medical literature is 3 years.

If my child has ADHD and RESTLESS LEG SYNDROME, will RESTLESS LEG SYNDROME medication make his ADHD go away?

There are only a few articles written on this. There are cases where adding medications for RESTLESS LEG SYNDROME has made a huge difference in a child’s ADHD symptoms and ODD symptoms. Other times it has led to a lower dose of ADHD medication. Often times people ending up taking medications for RESTLESS LEG SYNDROME and ADHD at the same time.

Other Mistakes in Diagnosis

Severity

If you look at the list of symptoms for ADHD, you will probably find that at one time or another you have had all of them. One of the common problems with checklists of symptoms is that for ADHD symptoms to count, they must be severe enough to be disabling either at home, at school, or with friends.

Duration

Even if you have all the signs of ADHD and it is disabling, if it came on for the first time at age 15, it isn't ADHD. It is something else. When this is the history, it is key to look more carefully at what else might be going on. Drugs? Abuse? Mood disorder? Head injury? Epilepsy? These needed to be checked out.

Diagnosing ADD without hyperactivity

There are not too many things in pediatrics which cause hyperactivity and impulsiveness which starts before age seven and never goes away. That makes diagnosing ADHD relatively easy. The same does not hold true with ADHD without hyperactivity. Being disorganized, inattentive, distracted, and forgetful can be caused by a number of other brain disorders that are in the family of learning disorders and language disorders. It is easy to understand these problems if you understand how something that we see or hear gets into our mind. For example, When a teacher tells a child something, a number of things must happen for it to "register".

To truly understand something a teacher says-

The child must be able to hear the sounds the teacher makes.

Hearing loss from ear infections and fluid behind the ear drum are two common causes of problems at this level. If this is the problem, children have as much trouble hearing good news as homework assignments.

Example Terry can't hear

Terry's teacher called to tell his mother that Terry was falling further and further behind because he was ignoring what she said and not listening. The teachers suspected ADD and wanted the child tested for this. The mom started watching Terry at home. She started softly talking about getting him a new bike, something he had been asking for daily all spring. Terry did not hear. She mentioned it to her husband not so softly, yet still Terry did not hear. So, She had his ears tested and sure enough, he had a lot of fluid behind his ears. Tubes cleared up this case of not listening!

All children who are not listening should be checked to make sure they are hearing.

The child must focus her attention on the teacher's voice.

ADD or ADHD is the cause of problems at this level. A child with ADD can hear what he is interested in and totally ignore a boring teacher, even if the teacher is plenty loud.

Example Erin hears what she shouldn't

Errin doesn't appear to hear anything in school that she should. However she hears everything she shouldn't. One day she came home and told her mother about how her teacher was going to get divorced. She had heard the teachers talking in the hall while the students were supposed to be working. On the other hand, she never heard instructions. This kind of selective hearing of what is interesting is classic for ADD-D and ADHD.

The child must "tune out" other sounds such as other children talking, trucks going by, and the like

Central Auditory Processing disorder is the usual culprit if this is the problem. Children with this problem do basically normal work if there are no distracting sounds. Children with ADHD and ADD are distracted by sounds, but also their own thoughts, sights, and what is touching them.

Example Rob is a genius at home

Rob gets almost nothing done at school. He is off task, gets frustrated, and can't appear to follow directions. So he takes most of the work home. His mother has learned what to do. She turns off the TV and radio and shoos the other kids out of the house. Then she turns the telephone down and puts Rob in his room at his desk. It is dead quiet. He finishes his work within an hour and rarely makes a mistake. The teacher can't believe the difference between his homework and schoolwork. If a child's problems seem to lessen dramatically when he works in a dead quiet spot, he should be checked for an auditory processing problem.

The subject matter must be at a level which the child can understand.

Even if you can hear, pay attention, and tune out other sounds, it will get you nowhere if you can not understand the meaning. For example, if you are reading at a 2nd grade level and the class is reading at a 6th grade level, you will not be able to follow what is going on no matter how attentive you are. Some Learning Disabilities, language disorders, and mental retardation can cause this. The level of difficulty is just too far "over their head"

Example Jeff and reading

Jeff does well at reading but he hates to read and always has. Now he is in 6th grade. He gets some resource help, but he is still mostly in regular class. He reads slowly at a second grade level but is above average intelligence. He can already do some algebra. His teacher wonders if he has ADD. Whenever they are reading he is just looking out the window or screwing around. Why? because he can't follow what they are doing. Once he listened to the same book on an audiotape, his attention span was fine. All children with listening problems need to be checked for learning disorders.

Sometimes, the child must remember what was said by the teacher the next day or later.

A learning disability in memory can cause this difficulty. The child knows and understands it today, but never heard of it tomorrow unless it is repeated over and over.

Example What is going on with Martin?

Martin is 8. His first grade teacher thought he was brilliant. He worked hard, learned to read, and was able to do simple math and counting. His second grade teacher wondered. Martin read fine, but didn't remember the next day. His spelling never seemed to improve. He had a horrible time learning his math facts. Martin started to get frustrated with school and started misbehaving. He was tested and found to have a normal IQ. Unfortunately, there was not time that day to do memory testing. By third grade, his mom and dad had figured it out. Martin couldn't remember things. However, if they worked and worked every day, he was able to get by. Finally his memory was tested and found to be at the 6 year old level for visual and auditory memory. Martin is learning a lot about note taking in resource class. He is also learning to use a computer to overcome his memory. Memory problems in children are uncommon, yet can fool you if you don't check for them.

To make matters even more difficult, all of the problems above could exist along with ADD-D. For example, a child might have a learning disorder in reading and ADD-D

The bottom line is, if a child appears to have ADD-D, each of these other possibilities has to be ruled out first. Sometimes, that is easy, sometimes, it is very difficult.

· Prognosis of ADHD (What does the future hold?)

As children with ADHD grow older, one of three things will happen.

The symptoms will go away. About 15-20 % of children with ADHD will grow out of it sometime in childhood or early adolescence. If a child has had this disorder for a long time, then he or she is less likely to grow out of it. For example, if a child is diagnosed with this disorder between ages 2-4, then they have about a 50% chance of outgrowing it. By the time they are age 5 at diagnosis, only about 25% will ever out grow it. Family problems are associated with pre-school children not outgrowing this disorder.
The symptoms will partially go away. Some children will show mild signs of it throughout their life but get by without too much trouble.
The symptoms will stay the same or worsen. About a third will have the full syndrome their entire life. It is more likely that ADHD will continue into adulthood if there is a strong family history of ADHD, a dysfunctional home, or comorbid psychiatric disorders. If two or three of these factors are present, it is almost certain that the child will have ADHD as an adult.

The Bad news of untreated ADHD – one of the worse psychiatric disorders

As children with ADHD get older, comorbid disorders become more frequent. If you watch children with ADHD for four years, they have about 20 % more likelihood of having a comorbid disorder. About 60% will end up using some psychiatric medication at one time or another. About 45% will have been in a resource class. About 40% will have repeated a grade.

Cigarette smoking is likely in children with ADHD. About 20% of 10 yr. olds with ADHD will be smoking four years later, twice as much as normal children.

Children with ADHD have more accidents. Children with ADHD are more likely to have lacerations requiring sutures. They are more likely to break bones. They are much more likely to have severe head trauma. That is, if you look at children who have severe head trauma, ADHD is four times as common as one would expect in a group of children.

Substance abuse is likely in children with ADHD. About 50% of children with untreated ADHD will go on to have a substance abuse problem as adults. These rates are much lower if they stay on medication.

Adolescents with ADHD are four times more likely to have sexually transmitted diseases than those without ADHD. They have many more children, but in follow up only 54% actually have custody of their biologic children.

Adolescents with ADHD have more accidents in vehicles. They have three times as many serious injuries from accidents and four times as many motor vehicle accidents. They lose their licenses more often, have more crashes, and more speeding tickets. These rates are the same as normals if they take their medication.

People with ADHD don’t do well in school without treatment. They are three times more likely to be held back a grade, three times more likely to be suspended, and are much more likely to drop out (about a third drop out).

A bad outcome is more likely in children who come to clinical attention before school age, those with two or more comorbid conditions, those who are abused or come from chaotic families, and those who receive no treatment. What do I mean by bad outcome? Poverty, suicide, psychiatric disability, no stable partner, alcoholism, prison, and unemployment. ADHD is six times more common in suicide victims than in the general population.

ADHD is a very serious condition. Some children will grow out of it and have few problems. Many will not. It is in these children that treatment is essential. My view is that ADHD should be treated aggressively. Children should be treated early. A number of different interventions should be tried. Parents should learn all they can about this condition and demand the best possible treatment for their children.

The prognosis can be very bleak, but that doesn't mean that it is hopeless. I have seen children and adolescents with multiple co-morbid conditions and other bad prognostic features do well with treatment that involves a little bit of everything. Unfortunately, I have also seen many children who seemed immune to any intervention.

And the Good News?

ADHD is probably the most treatable disorder in all of neurology and psychiatry! Read on for the details!

ODD-ADHD.com

Children With Oppositional Defiant Disorder from AACAP

ADHD Treatment

Natural Treatments

What does this mean?

That sounds great! Is there any problem?

Giving fish oils scientifically

Should everyone receive fish oils before they are tried on medication?

Will fish oil help medications work better?

Are there any side effects?

Are there long term side effects?

Standard Medications for ADHD

What exactly do the drugs for ADHD do?

Why would anyone want to give drugs that affect the brain to children?

If the drug works, how will my child be different?

What if it doesn't work?

I have heard that these drugs can do a lot of bad things. Is this true?

What exactly are the side effects?

Are they that dangerous??

How can that be?

What do you mean by Start Low?

What do you mean, Go slow?

What do you mean, Monitor?

How often do I have to see you?

How long do you have to take it for?

So what drugs do you use –How to decide?

How fast does it work?

Number of dosages per day

Can the child swallow Pills?

Cost

Strattera $130.00

Altertec $130.00

Adderall XR $105-115 (all doses are the same price)

Concerta $70-110, depending on the dose

Welbutrin $30-50

Dexedrine Spansules, Ritalin SR $30-50, depending on the dose

Short acting Ritalin and Dexedrine $20-50, depending on the dose

Stimulants

Special Populations

Preschool

Teenagers

Questions about abusing stimulants

How often are ADHD medications abused?

Which drugs get abused?

Which persons abuse them?

In summary –

If my child uses Ritalin or Dexedrine now, will he be more likely to use street drugs and alcohol later?

My son has ADHD but also abuses drugs if he can get a hold of them. Are stimulants safe?

Specific Stimulants

Short acting Stimulants

Ritalin tablets (methylphenidate)

Dexedrine

Long Acting Stimulants

Dexedrine Spansules (long acting Dexedrine)

Concerta (long acting Methylphenidate)

Biphentin (another long acting Methylphenidate)

Adderall XR

Long acting stimulants and sleeping in

Ritalin SR - medium acting methylphenidate

So exactly how do you give these drugs?

Side Effects of Stimulants and their management

Sleep

Medical Treatments for stimulant induced insomnia in ADHD

Appetite

Rebound

Unwanted psychiatric signs and symptoms

Other mild side effects

Serious Side effects- Sudden Death, Stroke, Heart Attacks

Side effects and the school

Non-Stimulant Drugs

Strattera (Atomoxetine)

Bupropion (Welbutrin)

Modafinil (Provigil)

Third line Drugs

Clonidine (Catapress, Dixarit)

Tricyclics

I heard of somebody who was taking two drugs at the same time. Why would you ever do that?

ADHD

by Jim Chandler, MD, FRCPC

· Clinical Description