Resource Articles by Dr. Hess

Addressing Practical Solutions to Attention Deficit Hyperactive Disorder

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By Esther B. Hess, Ph.D.

Attention Deficit Hyperactive Disorder (ADHD) is a collection of specific symptoms (E.g., Inattention, distractibility, impulsivity, hyperactivity) beginning early in a person’s life that are unusual as compared to peers and that typically occur whenever the individual is at home or school and causes significant problems. Historically, ADHD has been considered a disorder of childhood. However, it has become quite clear that many children do not ‘grow out of it.’ And ADHD can continue to cause tremendous problems for an individual and their families well into adulthood. This article will attempt to look at some of the questions and frustrations that parents have expressed to me over the years regarding their child’s disorder. In addition, this paper will also examine solutions to some of the challenges commonly associated with ADHD.

The latest and most current terminology for the disorder came at the end of the twentieth century. The name remained descriptive, without implications of a known cause, such as brain-damage. According to the American Psychiatric Association’s Diagnostic and Statistical Manual, a child who shows six or more symptoms of inattention for a duration of six months with an onset before the age of seven meets the criteria for ADHD, inattentive type. A child who shows six or more symptoms of hyperactivity-impulsivity for a duration of six months with an onset before the age of seven meets the criteria for ADHD, hyperactivity-impulsivity type. A child who shows six or more symptoms of inattention and six or more symptoms of hyperactivity-impulsivity for a duration of six months with onset before the age of seven meets the criteria of ADHD, combined type. Symptoms must be present in a persistent form for at least six months and must occur to a degree that is more frequent and more severe than other children at a comparable level of development.

Inattentive symptoms:

1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities.

2. Often has difficulties sustaining attention in tasks or play activities.

3. Often does not seem to listen when spoken directly to.

4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

5. Often has difficulty organizing tasks and activities.

6. Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework).

7. Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools).

8. Often is easily distracted by extraneous stimuli.

9. Often is forgetful in daily activities.

Dear Dr Hess:

I cannot believe I am so frustrated with my son, this early into his school semester. J is almost eleven and because he has ADHD (attention deficit hyperactive disorder), he continues to struggle in class with basics like getting himself and his stuff organized enough to make sure that his homework goes from his desk into his back pack, from his back pack to his desk at home and then once complete, from his desk at home back into the backpack to be presented into the teacher’s in –box in the a.m. What is so hard about that?! We have only been in school 3 weeks and the teacher called to say that she has yet to receive one homework assignment from my son. We need some guidance NOW! Much thanks, Mark in Tarzana, CA.

Dear Mark,

The beginning of the school year often reanimates behaviors that we, as parents, might have hoped would have disappeared over the summer. Executive functioning which is located in the frontal lobe region of the brain is responsible for our ability to organize information and execute directions. ADHD is a neurological disorder and the general consensus is that the symptoms that you describe arise due to the inability of the brain to process appropriately chemicals called neurotransmitters that are responsible for supporting attention, reducing distractibility, irritability and impulsivity.

My first question to you, is how aware is your son’s teacher and the administration regarding his condition? Is he on some type of medication (traditional western psychotropic, homeopathic, etc.)? Have you asked for an Individual Education Plan (IEP) where your son could be assessed and perhaps have some of his academic program modified to best support both his strengths as well as his challenges? When teachers are made aware of a student’s difficulties, typically there is compassion, as well as renewed direction, as the teacher begins to understand what is the best approach for reaching a student, who could be quite bright, but may need specific supports to best channel particular learning styles.

In regards to support, there are a variety of tips that can make a world of difference in assuring that a child knows what is going on in class and consequently feels good about himself and his abilities.

  1. Children and adolescents with ADHD need more parental supervision than their typically developing peers. Have the teacher e-mail you a copy of the homework assignment nightly. That way, you can monitor whether or not there is homework and help assure that the work, will, at the very least, make its way into the backpack for the trip back to school.

  2. Ask the teacher for a second set of text books that you can keep, so that if a text is left behind at school there are back up materials to make sure that your child is caught up with his class.

  3. Because ADHD is a neurological disorder there are often underlying sensory processing disturbances that are contributing to a child’s inability to attend and regulate. You may want to consider occupational therapy techniques that take into consideration how a body organizes when confronted with environmental stressors. These can include having your son chew gum (if school policy allows) and/or drinking from a water bottle with a sports top. The oral actions (the chewing and the sucking) can provide proprioceptive input for the body that helps support attention and calming.

  4. Many children with ADHD get visually overwhelmed and subsequently distracted. Suggest to your teacher that your child sit close to the board and have the staff create a visual schedule which clearly delineates what is going on in the class at any given moment.

  5. If these simple strategies are not providing your child with substantive results, you may want to consider a more coordinated program of support which can include occupational therapy, education support and vision therapy. Your pediatrician or local developmental specialist should be able to provide you with a listing of referrals.

Hyperactive symptoms:

1. Often fidgets with hands or feet or squirms in seat.

2. Often leaves seat in classroom or in other situations in which remaining seated is expected.

3. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness).

4. Often has difficulty playing or engaging in leisure activities quietly.

5. Often is ‘on the go’ or often acts as if ‘driven by a motor’.

6. Often talks excessively.

Impulsive symptoms:

1. Often blurts out answers before questions have been completed.

2. Often has difficulty waiting for a turn.

3. Often interrupts or intrudes on others (e.g., butts into conversations or games).

According to recent statistics from the United States Centers for Disease Control and Prevention, 7.8% of children (11% boys, 4.4% girls) aged four to seventeen years have been diagnosed with ADHD at some time in their lives. The most common form of ADHD is the combined type, followed by inattentive. The least common form of ADHD is the predominately hyperactive-impulsive type, in which children are on the go, impulsive, talkative and behaviorally disruptive but able to focus, listen and follow directions equally well as peers their age.

The diagnosis of ADHD is made through a careful ‘clinical history.’ This refers to a doctor or other clinical expert in childhood disorders (developmental psychologist, neurologist, child psychiatrist, for example) taking a verbal history from parents/guardians, from children themselves and at times from other persons involved in a child’s life such as a teacher or coach. There are four key points that need to be assessed before reaching the diagnosis of ADHD. They include; (1) each ADHD symptom must occur to a degree that is unusual for a child his/her age. Children with ADHD stand apart from their peers by how often these symptoms happen as compared with their peers. (2) ADHD symptoms must occur in more than one setting. In other words the child with ADHD symptoms has symptoms at home, in school and other settings such as sports activities. (3) ADHD symptoms must be present before the age of seven. (4) ADHD symptoms should not be explained by another condition. To come to this conclusion, the assessing clinician will consider other factors that may explain a child’s aberrant behavior. Biological, psychological and social factors are considered and then ruled out as major contributors to a child’s current demonstration of behaviors.

The model for psychiatric treatment for ADHD is an integrated model, combining biological treatment, psychological treatment and social treatment. For ADHD biological treatment principally involves medication. Psychological treatment may involve a developmentally sensitive model like DIR/Floor Time that combine treatment for the child and/or family addressing self esteem issues, social and family conflict while taking into consideration the child’s developmental capacities and neurological challenges to optimum development. Social treatments can include social skills groups for the child that increases social connection and social awareness.

Stimulant medications have been shown to be the most effective medication treatment for ADHD. Stimulants are effective in improving ADHD symptoms in the majority of children who take them (approximately 75%). Typically the brain communicates messages by stimulating chemical s called neurotransmitters that have been released by neurons in the creation of brain maps. In Individuals impacted by ADHD, there appears to be less neurotransmitter available in the areas of the brain most associated with attention, calming and focusing. Stimulant mediations appear to work by increasing the neurotransmitter (dopamine, norepinephrine) message from one neuron to the other.

Dear Dr. Hess,

My daughter is seven years old and was recently diagnosed with pretty severe ADHD (Attention Deficit Disorder-Hyperactive Type). Her pediatrician put her on stimulant medication for inattention, distractibility and to try and help her with organizational skills. The problem is that although the medication seems to be working in terms of helping her concentrate better at school, it’s really affecting her appetite and her sleep cycle. She was a skinny kid to begin with but now she is never hungry and I often catch her roaming the halls in our home late into the night. My question is that since we are now officially into summer, do you think it would be ok for me to give her a ‘medication vacation’, so that her body has a chance to grow and get back to normal? Elana F., Laguna Hills, CA

Dear Elana,

Attention deficit is probably one of the most well researched areas of childhood concerns. And while there is still much to be learned about this disorder, the general consensus is that the symptoms that you describe in your daughter; the hyperactivity/irritability, impulsivity and distractibility seem to stem from the brain’s inability to process appropriately those natural chemicals (neurotransmitters) that aide in calming, focusing and attending (Zametkin, et al. 1990). While I identify myself as an advocate for children and not an advocate for medication, sometimes the behaviors of children interfere with their functioning to such a degree, that medication may be warranted to help get a child back on track. While stimulant medication has proven very effective in remediating those symptoms most closely associated with attentional issues, all western psychotropic agents have side effects. These side effects often can include the anorexia and sleep disturbances that you are observing in your child. Because of the concerns associated with these side effects, it is not uncommon to put a child on a ‘medication vacation’ for example over summer vacation when the demand to attend and focus is not as critical. Because stimulant medication has the advantage of staying in the system for a relatively short amount of time (in general a shelf life of approximately 10 hours), it is possible to allow the body a period of time where it can readjust. Often children do put on weight and sleep better during these breaks. My first suggestion before your proceed is to share your concerns directly with your child’s pediatrician. You may also want to seek out the expertise of a psychotropic specialists (such as a child psychiatrist or developmental pediatrician) who can also discuss a variety of medicinal options including homeopathic and biofeedback, which may provide support with less invasive side effects.

Awareness and understanding of ADHD and strategies help both parent and child deal with the challenges of this disorder. Knowledge can lead to reasonable and realistic expectations of the part of all parties involved and this can lead naturally into improved communication that is necessary for all individuals to succeed in life.

References

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4thedition, text revised. Washington DC: American Psychiatric Association.

Hammerness, Paul (2009). ADHD: Biographies of Disease. Westport, Conn: Greenwood Press.

Reif, Sandra (2008). The ADD/ADHD Checklist: A Practical Reference for Parents and Teachers. San Francisco: Wiley Imprint, 2nd edition.

Zammetkin, A.J. and J.L. Rapoport (1991). Neurobiology of attention deficit disorder with hyperactivity: Where have we come in 50 years? J. Am. Child Adolesc. Psychiatry 26: 676-86