Treating ADHD:
A Child Psychiatrist Answers Questions

What is the first step to take in treating Attention Deficit Hyperactivity Disorder (ADHD)?

First, we must have an accurate diagnosis. It's not always easy to pinpoint clearly a diagnosis of ADHD. There are many reasons people squirm or are inattentive. They may be depressed, psychotic, constipated, or a victim of abuse.

Also, ADHD is often seen in combination with other disorders. Sometimes it's hard to tell what came first-the disorder or the ADHD. Or they may be separate, distinct problems.

If children are hyperactive, inattentive, and impulsive, we don't know if it is because they have ADHD or because they have that plus something else. For example, if a child is anxious, is that an anxiety disorder or something related to ADHD? Children with ADHD also may need treatment for other problems that either develop with the ADHD or separately, in their own right.

Why is it so difficult to know if a child has ADHD?
Part of the problem is we don't have a complete understanding of the brain. We can't look at a x-ray and say, "Yes, you have ADHD."

Teachers, pediatricians, and other professionals often see impulsive, distractible children. It's a challenge to sort out the cause of the problems. Children often show depression and anxiety by inattention and hyperactivity. They have a limited way of expressing their moods, their unhappiness, and their struggles.

Who usually first recognizes ADHD in a child?
Sometimes it is the parents who express concern about a child's behavior and seek treatment. Many referrals come from school officials. The regimen of school can underscore a child's inability to sit still and pay attention.

Schools sometimes work with pediatricians, who may begin the prescription of Ritalin based on school interviews and school testings.

Many of the patients I work with come to me after they've tried a treatment for a while and it hasn't gone well.

Does that mean that pediatricians over-prescribe Ritalin without a careful enough evaluation?
Not necessarily. ADHD is a disorder we're just beginning to understand. It's an expensive disorder because of the disruption and problems it causes.

For simple cases, it may be overkill to go through full evaluations. Using the rating scales, teachers' scales, and pediatrician-prescribed Ritalin is enough.

However, simple cases are the minority. About 25 percent of my patients are straightforward ADHD. The vast majority are intermixed with other problems.

The first step, then, is a full evaluation?
Yes, if you suspect ADHD, you should contact a psychologist for a full evaluation. The tests help determine the diagnosis. After the testing, the psychologist can report the findings to a psychiatrist.

The tests may show clear evidence of ADHD and may point to mood, anxiety, or family problems. I can help my patients with their problems more effectively when we've performed these diagnostic studies.

How do you treat ADHD?
The treatment typically involves combined approaches.

We start with helping parents and the child understand the problem. The family must realize that something is happening in the child's brain, it doesn't work like everyone else's. Parents need to know that their strategies of coping with other children probably will not work with their child who has ADHD.

Can't people just take medication to correct the problem?
Medicine does not cure Attention Deficit. Medications help by treating the symptoms of the disorder, but they won't stop the underlying problem.

If parents say, "Just give him a pill to fix this," I try to help them understand how to manage the problem.

Where do families start in addressing ADHD?
To a large extent, the good diagnostic workup includes a lot of education for parents on what the problem is. They also need to learn specific parenting skills.

Education is important for the child, too. Children need to realize that they have certain deficits that other children don't. They may have to learn strategies and techniques so they can stop and think before they act.

Typically if children are diagnosed at a young age, they are more naive and haven't experienced a lot of negative feedback. They can learn coping skills to avoid some of that negativism.

Older children may have already received a lot of negative feedback. If your parents are always disciplining you, saying "No. Stop that. Get out of there," you're getting a lot of negative feedback throughout the day. Then in school, you can't sit down. You can't focus well. You may be bright, so are doing well academically, but teachers may be constantly reprimanding you. Other children may taunt you. This negativism can hurt your self-esteem. You become more angry and upset.

This is why it's important to make an accurate diagnosis as soon as possible so children avoid the negativism.

What role do medications play?
First, we don't just put children on medication if they seem hyper. By the time families come to me, the parents should be receiving education and help in coping. Children should be getting help-maybe individual therapy.

Medications are the third level of treatment. They're important, but they aren't the complete answer.

As stated before, they aren't curative. Medications won't take the disorder away. In fact, this disorder often persists into adulthood and may last a lifetime.

Parents ask, "Does this mean my child needs to stay on medication forever?" Generally, the answer is no. But typically medication can be helpful during the school year because children have few options open to them-they must attend school.

Adults can choose jobs that suit their styles. Adults with ADHD may opt for a career that allows them movement and flexibility instead of a more sedentary job.

What kinds of medications treat ADHD?
We use both stimulants and antidepressants. The most common stimulant is Ritalin. Others include Dexodrine and Cylert.

Stimulants help children focus better. But because they are stimulants, they also may produce some side effects like loss of appetite, sleep difficulties, irritability, nervousness, or anxiety.

Another problem is that stimulants work for everyone, so we can't use them to aid in diagnosis. Even people whose brains are working normally will find their focus improved. That's why it's so important to have an accurate diagnosis of ADHD. We want to insure there is a significant dysfunction that warrants taking the risks that medications present.

Ritalin is widely used and is relatively safe. It is effective for 60-70 percent of children, has few side effects, and you can see results within a half hour. Ritalin works well for focusing and improving attention.

The shortfall is that the dose only lasts three to four hours, so patients have to take it several times during the day. As it wears off, a child may experience "rebound" and have some difficulties.

Another option is Cylert. A major difference is that Cylert may take two to four weeks to show its benefits. However, it is a once-a-day dose, so it lasts 24-hours without wearing off. This is a benefit for children and adolescents who don't want to be stigmatized by having to take medication during the day at school.

What about antidepressants?
Like Cylert, antidepressants offer day-long coverage. Although they may be effective in simple ADHD cases, they are also particularly helpful in cases where mood disturbances complicate the ADHD used in combination with stimulants. Sometimes if children experience side effects like irritability and sleep problems on Ritalin, they also may take an antidepressant to offset those side effects.

How can parents get involved in determining medication?
Together, we weigh the risk/benefit ratio. We talk about the risk of the medication and the risk of not treating the problem. Then we look at the potential benefits of the medication.

I work with parents to educate them about the choices of medication. ADHD can be quite disruptive and devastating. Parents who are afraid of medication must understand that something is not working in their child's brain. To ask their child to control his/her behavior without medication is like asking diabetics who need insulin to just watch their diet and exercise.

Coping skills and techniques are helpful parts of the treatment-and so is medication.

Once a child is diagnosed with ADHD, what kind of time commitment does treatment require of a family?
Each case is individual. However, families can usually expect three months of more intensive involvement. Counseling and education could take place every week or every other week. That also is usually enough time to investigate and stabilize medication.

As a psychiatrist, I would prescribe medication and see the child and family back in two weeks. In that time, we may have talked on the phone and made some adjustments. If-at the two-week appointment-we're making progress and all is going well, I may not see the child for six weeks or even a couple of months. It depends on how much educating the parents need and how reliable they are in following up with the medications.

Typically during those three months, the child and family will work with a psychologist or social worker to provide therapy. Some of this might be individual, couple, or family therapy. Facilities-like Pine Rest-that offer the variety of therapies from these professionals are most helpful. The psychiatrist, psychologist, and social worker can consult together as a team to best serve the family's needs. We can talk with each other about the concerns we might have and intensify treatment, if necessary.

What is the parents' role?
In some ways, they become part of the team. Parents need to learn about the medications. They must know the risks, benefits, and the alternatives. The more informed they are, the better able they are to come into the doctor's office and tell us what is and isn't working for their child.

Parents also can become an advocate for their child at school. There are a variety of steps the school can take to modify the environment and improve structure to help children with ADHD remain focused. Also, by understanding their child's difficulties, parents can help their child in coping with the daily challenges he or she faces.

Controversial Treatments for ADHD*

EEG Biofeedback
Proponents of this approach think that children with ADHD can be trained to increase the types of brain activity associated with sustained attention, while decreasing activity related to daydreaming. Brainwave information is fed into a computer and then goes to a special display that provides feedback to the child. EEG biofeedback training is often combined with a tutoring program. Treatment takes 40-80 sessions. Insurance companies often refuse to pay for this method due to the lack of scientific evidence that it actually works.

The theory that the brainwaves of ADHD children are different from children without ADHD is supported for some kinds of ADHD. Two or three early studies have positive results, although these also had serious scientific flaws. Little, if any, research has been published in the last 20 years that supports the use of this method. Thus the application of biofeedback technology in the treatment of ADHD is unproven, and parents are urged to use caution. It is an expensive approach whose effectiveness has not been demonstrated. EEG biofeedback should be considered "experimental" due to this lack of published scientific evidence.

Special Diets
Over the years, people have claimed that special diets or supplements are effective as a treatment for ADHD. Methods like the Feingold Diet, Candida Yeast Diet, and the use of megavitamin supplements have been described as improving learning and attention problems.

Scientific studies of the Feingold Diet and megavitamin therapy fail to support these methods. With Candida Yeast, there is no scientific evidence, and the theory behind the treatment is inconsistent with what science knows about ADHD. These methods should not be used to treat ADHD.

Optometric Vision Training
A sub-group of optometrists think that reading disorders are caused by visual problems such as faulty eye movements and trouble with the eyes focusing together. Vision treatment includes a combination of eye exercises. Some supporters of this method also report that they can successfully treat ADHD.

After viewing the evidence, many professional groups are highly critical of this approach. The method is unrelated to current scientific theory on ADHD. It is not a scientifically-supported treatment.

* Paraphrased from an article by Sam Goldstein, Ph.D., and Barbara Ingersoll, Ph.D., published in the 1992 fall/winter edition of the CHADDER, a newsletter from the national support group, CH.A.D.D.