Medication is mainstay in ADHD treatment
Sunday, Dec. 9
Photo by Brand X Pictures
By Dr. Michael Amster
Special to the Times-Democrat
“He has a motor that just won’t shut off….”
“She is a bright child, but always forgets her homework, and is failing two classes….”
“His classmates won’t sit with him, and keep calling him a ‘spaz’....”
I have heard variations of these over the years countless times in the office, and from family friends.
Sometimes hyperactivity and distractibility can be family traits, with the child following in the footsteps of one of the parents.
For those who are carrying issues further, however, they may have ADHD, or Attention Deficit and Hyperactivity Disorder.
Typically ADHD is characterized by the classic high motor, impulsivity, lack of focus, and emotionality.
While the exact mechanism of how ADHD occurs is in debate, the impact ADHD can have on a child can be all-encompassing.
Over the years, different neurologic and psychiatric experts have discussed different mechanisms of how ADHD affects the brain, and how thought processes and attention are altered.
Normally, the receptor cell, the one taking in stimulation from the outside (ear, eye, etc.) tries to signal cells deeper in the brain to pay attention and make decisions based on that input. The signal is strong, and the cells in the brain are easily activated.
Memories are made, and proper attention is applied. Secondary brain functions, such as those for impulse control and higher thought processes, are fully engaged and also enjoy good signal strength, modifying the signal from the sensory cells.
In children with ADHD, the initial signal is weak, like getting a less than adequate signal on your TV.
Since your TV doesn’t know what signal is most important, it will respond only to the one that is strongest at that moment. Thus signals from other locales or stations will break in on the original signal.
In the case of ADHD, other brain areas also bombard the deeper brain cells with static and extraneous information. Since that cell doesn’t know which signal is most important, it goes with whatever catches its attention, and the original thought or desire is gone.
Furthermore, those secondary areas like impulse control that have continuous input in the background have much less influence due to their weak signal, and often cannot alter actions highly desired by the child, like blurting out answers or hitting the child next to him or her.
The affects of ADHD can be tremendous and devastating.
Imagine trying to learn where you were only able to receive and process a third of material presented to you.
Furthermore, when you went home to try to learn it later, you could only pay attention for a few minutes before wandering off to engage in other activities.
Children have trouble processing the information given to them in class and from what they read, and fall notably behind. Their inability to make new or long-term memory of the information compounds the problem.
As they fall farther behind, they have further difficulty trying to understand new information being presented.
Parents often think their children are just being lazy, or irresponsible, and more discipline and stricter rules will help. While more structure does help, the simple fact is the children just can’t help it.
With intense effort, they can sometimes alter the situation for brief periods, but the issues always return.
In preschool and kindergarten, children are often unaware that they are different, but within a short period of time, they realize that other children are able to accomplish things they cannot, know things they don’t, and receive much more positive feedback from teachers and peers.
Frustration sets in, and self-esteem plummets. Many children with ADHD start to have emotional difficulty, and acting-out behavior can take on different forms.
Children with ADHD may have extensive social issues and difficulty making friends. Much of this difficulty comes from the expected consequence of impulsive behavior and continuous activity, that other children do not want to be around them.
Because they act differently, they can be ostracized, teased or even bullied.
Children with ADHD may lack awareness of social cues, and often say or do inappropriate things. They may not recognize the social needs of others, and lack the ability to have a normal friendship.
They recognize that they are not liked, but do not understand why. This leads to self-hatred and often more acting-out behaviors.
Many children with ADHD have cognitive issues, as well, meaning issues with thought processes and learning.
Even if they are able to learn information correctly, they do not understand what they have learned, and lack the ability to put it into proper context.
Working through more complex problems and topics is difficult, and makes taking tests nearly impossible.
Executive functioning, the area of thought that deals with planning, judgment and organizational skills, is often dysfunctional.
As a result, children with ADHD may not know their behaviors are not in their best interest, like blurting out answers in class.
Because they cannot organize themselves, they lose homework assignments, forget what they were doing, miss directions, and much more.
Inability to plan and organize their lives can lead to significant disability, and causes notable stress at home and at school.
Sleep is hard, as many children have thoughts racing in their heads. They find it difficult to “quiet” things to allow them to follow one thought as they go to sleep.
The hyperactivity component of ADHD is most often seen in boys, making identification much easier.
A child who is actively destroying a classroom is easy to spot. Girls more often take on the distractibility aspect, and look more like a “daydreamer.”
Since they don’t disturb those around them, a longer period of time can go by before anybody realizes there might be an issue.
There is often resistance to diagnosing a child with ADHD. Parents remember the stigma of schoolmates having to go to the school nurse at lunch to get their medication, and being labeled as different.
They feel the medications, many of which are neuro-stimulants, are dangerous and need to be avoided.
But most of all, most parents are just simply in denial.
Diagnosing a child with ADHD means their child is “different,” and that will always be. The truth is that their child is already different, and most of the time is suffering as a result of that.
Much of the evaluation process we go through not only illustrates what the diagnosis is, but helps the parents realize that treatment will be of great benefit.
Evaluation entails discussion with the parents and teachers, rating scales, and discussion with the child. No two children are alike, and there is really no one test that says “your child has ADHD.”
Different rating scales, such as the Vanderbilt or Conner’s Ratings, may give clues that ADHD may be the issue, but are not diagnostic. They are only one tool we consider.
Only by looking at the information from all sources as a whole, as well as school testing, grades, and direct observation of the child, do we come to a diagnosis.
Many times ADHD is only one of the issues. Almost half of children with ADHD have another psychiatric diagnosis, such as a learning disability, mild autism, depression, or adjustment disorder.
Sometimes we aren’t able to appropriately evaluate for these until after the ADHD has been treated and the other issues stand out more prominently.
The mainstay of treatment is medication. Nearly all the medications used fall under the stimulant category (Ritalin, Concerta, Adderall, Focalin), similar in chemistry to amphetamines.
While it may seem counterintuitive to give an amphetamine to a child who is already hyperactive, I refer back to the TV example.
The stimulant medication boosts the signal of the cells trying to talk to eac h other, allowing for the proper interaction of thought.
Ideally, proper focus occurs, memory is stored in both short term and long term, and other secondary brain areas are able to function correctly.
Thus organization and executive processing are improved, social awareness improves, and eventually self-esteem improves.
There are some classes of medication that are non-stimulant, such as atomoxetine (Strattera), which enhance the body’s natural amphetamine in the brain, essentially causing the same effect.
Guanfacine (Intuniv, Kapvay), a blood pressure medication used at low dosage, acts indirectly on several areas, including attention and impulsivity.
There are issues and considerations with the use of medications. Appetite can be affected, and we monitor for weight loss.
Sometimes headache and stomach ache can occur. Most importantly, issues do not magically go away once medication has started.
Often we will enlist social group-training to teach the children proper social skills, and organizational training to help them learn to plan and organize.
Because these skills were turned off for so long, for most, the skills need to be relearned, and there can be inherent problems.
Learning disabilities are able to be identified and properly dealt with, as well as emotional disabilities.
It is important to remember that the medication is not a cure, but a supplement of a factor the body is without.
When the child comes off the medication, the problem will still be there.
Recommendations change through the years, but we generally avoid “drug holidays” or taking them off medications over weekends and holidays for that very reason. Learning and processing are ongoing on weekends, too.
Attention Deficit and Hyperactivity Disorder can be an all-encompassing issue, causing distress for the child, parents and teachers.
With recognition, help, and medication, we can help them not only live up to their potential, but enjoy life, as well.
Amster practices at Warrenton Pediatrics in Warrenton. Call (540) 349-3225.
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