ADHD Treatment For Children: What Works

Why And When Do We Need To Treat ADHD

ADHD Treatment For Children

Start With Your Primary Care Doctor

If you are concerned that you have ADHD or that your child has it, the first step is to talk to a professional. We recommend that you speak with someone who has experience assessing and treating ADHD and who can do a thorough assessment. These professionals include psychiatrists, psychologists, psychiatric nurses, and social workers.

Diagnosing ADHD

The process of diagnosis is one of exclusion, because many other disorders such as anxiety, depression, or sleep disorder can have similar symptoms.
Psychological testing is not required to make the diagnosis. The AAP (American Academy of Pediatrics), APA (American Psychiatric Association) and AACAP (American Association of Child and Adolescent Psychiatry) guidelines recommend that the healthcare professionals ask the patient, the parents, the teachers or other adults involved in the interactions with the patient about changes in the behavior in at least two areas (for school age children it is at home and at school).

ADHD and Executive Function

By and large ADHD can be conceptualized as a disorder of “executive function.” Individuals with ADHD show a reduced ability to exert and maintain cognitive control of their behavior. Compared to their peers, individuals with ADHD have a lower ability to react to insignificant external or internal stimuli. The MRI studies of individuals with ADHD show thinning of the cortex in the areas associated with working memory and attention. (Molecular Neuropharmacology; Nestle, Hyman 321-323).
ADHD is diagnosed based on the DSM 5(Diagnostic and Statistical Manual of Mental Disorders, 5th edition) diagnosis criteria. Here are the criteria below in shortened form. Please note that they are presented just for your information and not to be used for self-diagnosis. Only trained health care providers can properly diagnose or treat ADHD.

DSM-5 Criteria for ADHD

People with ADHD show a persistent pattern of inattention and/or hyperactivity–impulsivity that interferes with functioning or development in these areas:

1. Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months and they are inappropriate for developmental level:
o Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
o Often has trouble holding attention on tasks or play activities.
o Often does not seem to listen when spoken to directly.
o Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
o Often has trouble organizing tasks and activities.
o Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
o Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
o Is often easily distracted
o Is often forgetful in daily activities.

2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
• Often fidgets with or taps hands or feet, or squirms in seat.
• Often leaves seat in situations when remaining seated is expected.
• Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
• Often unable to play or take part in leisure activities quietly.
• Is often “on the go” acting as if “driven by a motor”.
• Often talks excessively.
• Often blurts out an answer before a question has been completed.
• Often has trouble waiting his/her turn.
• Often interrupts or intrudes on others (e.g., butts into conversations or games)

In addition, the following conditions must be met:
• Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
• Several symptoms are present in two or more setting, (such as at home, school or work; with friends or relatives; in other activities).
• There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
• The symptoms are not better explained by another mental disorder (such as a mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). The symptoms do not happen only during the course of schizophrenia or another psychotic disorder.

Types Of ADHD

Based on the types of symptoms, three kinds (presentations) of ADHD can occur:
Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months
Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months
Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.
Because symptoms can change over time, the presentation may change over time as well.

ADHD in Adults

ADHD often lasts into adulthood. About 65% of individuals diagnosed as children with ADHD will have persistent impairing symptoms by age 25. (Parikh MD, Baker, MD Adult ADHD: Pharmacology in the DSM -5 era, Current psychiatry, Oct 2016)

Changes In The DSM-5

The fifth edition of the DSM was released in May 2013 and replaces the previous version, the text revision of the fourth edition (DSM-IV-TR). There were some changes in the DSM-5 for the diagnosis of ADHD:
• Symptoms can now occur by age 12 rather than by age 6;
• Several symptoms now need to be present in more than one setting rather than just some impairment in more than one setting;
• New descriptions were added to show what symptoms might look like at older ages; and
• For adults and adolescents age 17 or older, only 5 symptoms are needed instead of the 6 needed for younger children.

Obstacles In The Treatment OF ADHD

One of the obstacles I see in my practice to effectively treat ADHD is the fear of addiction to the medication. This is a myth. In fact, a multi-cohort national study sampling of about 40 000 individuals, recently published in the journal of the AACAP in June 2016 showed that starting the treatment for ADHD early and continuing it for more than 6 years was associated with a rate of substance use which was lower than in the general population. Also, individuals who started the treatment later, and taking the medication for less than 2 years had similar rates of substance use with the general population.

Relative immaturity is one of the challenges that ADHD brings with it. It has been shown that children and adolescents with ADHD tend to be less mature than their peers. (JACCAP 2016;55(10):886-895). The female gender is more protected against developing ADHD than the male gender (JAACAP 2016;55(6):504-512), and that also explains the higher prevalence in males than in females.

ADHD Treatment

1. Medications
a. amphetamine preparations come in short acting and long acting formulations that can be combined according to the individual response. They act through increasing the release of norepinephrine and dopamine that are essential for the frontal brain circuits.
b. methyphenidate preparations also come in short and long acting formulations. Together with the amphetamines they are by far the most effective medications for ADHD. They have common side effects such as insomnia, decreased appetite, growth delay. Combining them would increase the likelihood of the side effects.
c. atomoxetine increases the availability of norepinephrine, is not as effective as a stimulant and can be used as an alternative for people who do not tolerate the amphetamines or methylphenidine.
d. alpha-adrenergic agonist, clonidine and guanfacine also have short and long acting formulations, and can be used by themselves or in combination with the stimulants;
e. bupropion, considered a third line of treatment for individuals who do not tolerate the amphetamines or methylphenidate or can be added to them to enhance the response.

2. Neurofeedback
Evidence from well-controlled studies failed to support neurofeedback as an effective treatment for ADHD (Cortese and collab JAACAP 2016;55(6):444-455).

3. Brain Training Games
Brain training games did not gather solid scientific evidence that it works for ADHD, however these programs are early in their development and it is believed that the future will bring new possibilities. At the present time they are being used for cognitive rehabilitation. (Psychiatric Times, June 2014: The Evidence and Application of Brain Training Games: Science or Sales, Larry Brooks).

Myths About The Treatment Of ADHD

(Strawn, MD/Current Psychiatry October 2016)
1. Contrary to the popular belief that treatment with stimulants would worsen anxiety, a meta-analysis of about 3000 patients showed that a stimulant treatment has a low relative risk for anxiety and many patients experience improvement in their anxiety while some of them could experience an increase in anxiety level.
2. A meta-analysis of 22 studies including 2400 patients showed a lack of association between stimulant treatment and a new onset or worsening of tics despite the ‘contraindication’ included in the package insert.
3. Polypharmacy(the simultaneous use of multiple drugs to treat a single ailment or condition) in ADHD is beneficial because it allows synergistic effects of different medications and does not represent a treatment ‘failure’.

Consequences Of Not Treating ADHD

Here is what the research says about the consequence of not treating ADHD.
1. School failure, peer rejection, and subsequent association with a delinquent peer group can increase the likelihood of substance use, especially in the presence of comorbid conduct disorder (Molecular Neuropharmacology, Nestle, Heyman pg 321-323)
2. ADHD in childhood and adolescence predicted homelessness in adulthood, maybe partly for the high degree of comorbidities with conduct, SUD, arrest, and school dropouts. (Garcia Murillo and colab/JAACAP 2016;55(11):931-936
3. The degree of severity of ADHD symptoms in adults is related to not addressing the symptoms during childhood. In other words, treating ADHD during childhood and adolescence minimizes the symptoms persistent into adulthood. (Roy and colab JCAAP 2016;55(11):937-944
4. Adult functioning is worse, when less ADHD symptoms persist from the adolescence period. (Hechtman, MD and collab/JAACAP 2016;55(11):945-952). It is important to identify ADHD symptoms early and intervene in a timely manner to promote better functional outcomes
5. Adults with ADHD have more traffic violations and accidents and a higher rate of incarcerations and convictions
6. A mortality rate almost 2 times higher with great differences in suicide and accidents (Parikh, Baker Current Psychiatry 2016, October)

Further References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Arlington, VA., American Psychiatric Association, 2013.
CDC website: https://www.cdc.gov/ncbddd/adhd/diagnosis.html

Fairy Tales And Kids

The Importance of Fairy Tales and Folk Stories in Fostering An Emotionally Healthy Child

Fairy Tales And Kids

A subject of interest for me is the role of fairytales and folk stories in bringing out and nourishing children’s spirituality.

There are many reasons why I think fairy tales are good for kids development. This article outlines just a few. Fairy Tales do the following:

  • Teach right from wrong
  • Help children deal with emotions
  • Foster imagination
  • Develop cultural literacy introducing them to different cultures
  • Develop critical thinking skills
  • They are fun!

Parents have a great opportunity when their kids are young to help them learn about people, the world, and themselves. Fairy tales provide kids the chance to put themselves in the shoes of the characters, which allow children and begin to develop essential decision-making skills. These are skills that will help children throughout their lives.

 

The Role Of Myths And Fairy Tales

Myths and fairy tales give children the opportunity to figured out how to apply the meaning of the stories in their own lives. The answers that are offered by fairytales are suggestive, not definite (Bruno Bettelheim). Which allows room for interpretation and questioning.

Sometimes children accept and internalize lessons more easily from fairy tales than from their parents. Fairy tales speak a language that is familiar and makes sense to children.  Children tend to think animistically, everything has a soul, and both inanimate and the animate object freely interact. Since there is no clear distinction between the two worlds, kids may believe that death can be reversed, and things and people can come back to life. Fairytales and folkloric tales answers children’s fundamental questions such as: who am I, where do I come from, where am I going, and what is life all about?

From the adult’s point of view, the explanations given by the fairy tales are not realistic and in a rushed analysis, could be presented as ‘false,’ to a child’s mind that lacks certain abstract thinking. These realistic explanations are difficult to comprehend. Parents can serve as guides through the fairy tale world, helping their children to understand the underlying concepts in terms they can understand.

fairy tale castle

The story of Snow White and the Seven Dwarfs is a great fairy tale that has many lessons. Among the lessons are the following:

  • Be cautious with strangers
  • It’s great to have friends
  • Never give up hope
  • Bad deeds rarely go unpunished
  • Watch what you eat
  • Insecurities do not justify a mean attitude
  • Real beauty comes from within

Fairy tales are a great way to spend quality time with your kids, and help them learn about life.  It is important that kids be exposed to fairy tales at the right stage of their development. Fairy tales are ideal bedtime stories, especially for 3 to 10-year-olds. Here are some websites that I like for book suggestions of various ages:

http://fairydustteaching.com/2010/11/age-appropriate-fairy-tales/

http://www.waldorflibrary.org/articles/977-choosing-fairy-tales-for-different-ages

https://parenting.blogs.nytimes.com/2009/01/12/are-fairytales-to-scary-for-children/?_r=0

 

To learn more about Psychiatry for Children, contact Daniela White, M.D. Psychiatrist for Children Houston at 713-426-3100.

 

 

How Do We Talk to Our Kids About Violence?

It is important to talk to kids about violence to help them understand what happened and how to cope  with the emotions that this brings up. Here is some information on how to talk to kids about violence.

http://www.holmesworldmedia.com/wp-content/uploads/2013/10/How-Do-We-Talk-to-Our-Kids-About-Violence-Elizabeth-Street1.pdf

Daniela M. White MD Psychiatrist

Daniela M. White – MD

Dr. Daniela White received her training in general psychiatry at Baylor College of Medicine, followed by a fellowship in Child and Adolescent Psychiatry.

Her private practice, started in 2002, is currently outpatient-based, and provides the appropriate care based on modern psycho pharmacology in a relaxed and welcoming environment.

Her integrative psychiatry model is a very holistic model of treatment that looks at health and mental health markers to thoroughly assess what is going on.

Dr. White and her staff strive to make patients feel comfortable from the moment they step into the office and try to initiate care as quickly as possible. Phone calls are returned promptly and the coordination of care is maintained with the other care providers involved in the patient’s treatment.

If you like to make an appointment with Dr White, schedule your first session by calling us at 713.426.3100.

 

Interview on KHOU

Should You Allow Children To Watch News Coverage On The Aftermath Of Tragic vents?

In most cases of young children, probably not, older kids with supervision as this video explains.

Video on whether to allow children to watch news coverage on the aftermath of tragic events.

Dr Daniela White interviewed by Television Station KHOU.

If you like this article on allowing children to watch TV after tragic events, or have questions, schedule your first session by calling us at 713-426-3100.

 

How Much Media Coverage of the Tragedies is Too Much

When a tragedy strikes, like the recent one in Aurora, Colorado, adults and children alike are faced with a lot of questions. Media coverage of the traumatic events helps communities to come together in showing support for people who lost dear ones in tragedies.

However, another question arises for the mental health professionals, psychiatrists, psychologists and counselors. What is the impact of watching traumatic images on children and adolescents who are not necessarily the direct victims of the tragedies? Is this indirect exposure to the trauma having an impact on the psychological development of children and adolescent watching the news at home, in a remote location from the tragedy?

In general, the research shows a positive correlation between exposure to media coverage of tragedies and symptoms of post-traumatic stress disorder (PTSD) in children. Children who witness violence, directly or indirectly, may experience a disruption of the normal developmental trajectory of childhood, depending on the different age groups. Repeated television coverage of the disaster may perpetuate panic, fear, despair and a potential re-experience of trauma with each viewing.

What do experts recommend in order to minimize the negative effects of media coverage?

  1. Monitor the amount the child watches new shows
  2. Watch the news with the kids
  3. Allow appropriate amount of time to discuss feelings or questions elicited by the show
  4. Ask the child what he/she has heard and what questions does he/she may have
  5. Provide reassurance regarding his or her own safety, emphasizing that the adults in his/her life are going to keep him/her safe
  6. Look for signs that the news may have triggered fears or anxieties such as sleeplessness, fears, bedwetting, crying, or talking about being afraid.
  7. If there are serious concern, the parent should contact a child and adolescent psychiatrist for a consultation and assistance.

If you like this article on How Much Media Coverage of the Tragedies is Too Much, or have questions, schedule your first session by calling us at 713-426-3100.