Fort Bliss Monitor

Understanding Attention Deficit Hyperactivity Disorder

Lt. Col. Roman Bilynski, MD
WBAMC

Attention deficit hyperactivity disorder is a neurobehavioral disorder of children, adolescents and adults. It affects between 4 percent and 12 percent of school-aged children, with three boys affected for every girl. It affects three major areas of functioning resulting in inattention, hyperactivity and impulsivity. It is important to remember that all children exhibit some symptoms of ADHD from time to time depending on the family, home or peer situation. For ADHD to be confirmed, a set number of problems must occur in at least two settings, i.e. home, school, daycare, social situations and work if applicable. The behaviors must start before age 7 and must cause significant impairment in successful functioning in at least two of these situations. Often the behaviors start in early childhood but are attributed to ‘being a boy,’ ‘being a girl,’ ‘tomboy,’ ‘very outgoing,’ ‘athletic,’ ‘just like his/her ___(fill in with someone’s name), etc. Often the problem is first recognized by people outside the family, most commonly a teacher or childcare provider who brings their concerns to the child’s parents.

ADHD is a biological disorder affecting chemicals (neurotransmitters) in the brain. Inattention appears to result from lower levels of chemical activity in the brains of ADHD kids. ADHD kids do not have enough of these chemicals and that is why stimulants are used to increase the biochemical levels back into the normal range. The lack of these biochemicals prevents them from inhibiting their behaviors.

ADHD appears to run in families, suggesting a genetic component. It is not uncommon for a parent, either mother and/or father, to be diagnosed when the child is brought in for evaluation. There is no clear scientific evidence that it is caused by eating too much sugar or sweets, food additives, allergies or immunizations.

Diagnosing ADHD

ADHD is a clinical diagnosis, based on standard guidelines developed by the American Academy of Pediatrics. It is more difficult to diagnosis under 5 years of age because there are other developmental conditions that can mimic the neurobehavioral manifestations of this disorder. As a child grows into adolescence many of the symptoms seen in childhood appear to remit. A formal diagnosis requires input for several sources in different environments — typically the parents at home, teachers at school and daycare providers. There are no specific medical tests for ADHD despite what you may have heard. Various medical tests involving blood and urine, electroencephalograms (or brain wave tests), brain imaging studies (CT scan, Magnetic Resonance Imagery, Single Photon Emission Computerized Tomography, etc.) will not rule in or rule out a diagnosis of ADHD. A primary care provider, i.e. personal pediatrician or family practitioner, may request a test if there is concern for some other medical disorder.

Symtoms include

Inattention – difficulty paying attention, does not seem to listen, easily distracted from work or play (i.e. a leaf falling outside the classroom window, sounds of other students in the classroom, television in the next room, etc.), makes careless mistakes or has poor attention to detail, does not follow through on tasks or instructions (i.e. has to be supervised every step of the chore or project), has difficulty organizing themselves (such as difficulty remembering their backpack, homework, school assignments), loses things frequently (i.e. homework, lunch, coats or misplaces them and can’t seem to remember where they put them even if they are laying out in the open), forgetful, appears to daydream a lot and avoids activities that require significant mental effort (reading, homework, etc.).

Hyperactivity – has difficulty remaining seated (difficulty sitting through a meal, movie, religious service, etc.), squirms and fidgets, talks excessively, acts as if “driven by a motor,” “on the go,” runs or climbs excessively and has difficulty with quiet play or activity.

Impulsivity — has difficulty awaiting turn or standing in line, cannot wait for things, answers before question is completed, often interrupts others, acts or talks before thinks, and engages in dangerous or foolish activity (running into street without looking, climbing on the roof, jumping out a window).

Associated problems

ADHD is often associated with other neurobehavioral problems. In 25-50 percent of children, adolescents and adults with ADHD there are coexisting mood or anxiety disorders. These include depression, bipolar disorder (also referred to as manic-depressive), generalized and social anxiety disorders. Learning disabilities commonly occur with ADHD and are diagnosed through the child’s school (formal psychoeducational testing).
Oppositional Defiant Disorder is seen in children who tend to lose their temper easily, annoy or bother others on purpose, with defiance and hostility toward authority (parents, teachers, daycare providers, etc.).

Children with conduct disorder typically break rules, destroy property willfully or by fire setting, and violate the rights of others by fighting, stealing, lying, conning others, or threatening or using weapons. Children with the latter disorders often need the help of counseling on a regular basis to help deal with these problems.
A small percentage of children with ADHD symptoms may have them secondary to autistic spectrum disorders, like classical autism, Asperger’s disorder and pervasive developmental disorder not otherwise specified – their diagnosis typically requires referral to a specialist in neurodevelopmental disabilities, developmental pediatrics, child neurology and/or child psychiatry.

Treatment options

There is no cure for ADHD, but treatment requires long-term planning and management like with any other chronic medical or psychiatric disorder. Before considering treatment, one must consider what the goals of treatment should be. Typically it includes improving problem behaviors, relationships with peers, teachers, siblings and parents, improving schoolwork and self-esteem and minimizing unsafe behaviors. Goals should be measurable (e.g. grades in school and various rating scales). Treatment can include education about ADHD, behavioral therapy, parent training, teacher training, child and family counseling and medication therapy targeting the problem behaviors.

Behavioral therapy, in many forms, has the long-term goal to change the child’s physical and social environment to help improve his behavior. Set specific goals, provide rewards and consequences and continue to rewards and consequences consistently for a long time to shape a child’s behavior in a positive way.

The best medications for the treatment of ADHD are the stimulants, used alone or in combination with behavioral therapy with marked improvement seen in about 80 percent of children. Medication options include short acting (immediate release), intermediate acting and long acting forms. Treatment frequency varies from 2-3 times per day to once daily for the extended or sustained release forms. Commonly used medications include methylphenidate (Ritalin, Methylin, Ritalin SR, Metadate ER, Methylin ER, Concerta, Metadate CD, Ritalin LA, Focalin), amphetamine (Dexedrine, Dexostat, Adderall, Adderall XR) and pemoline (Cylert). Side effects of the stimulants are typically minimal but may include sleep problems, weight loss or decreased appetite, headaches, irritability, stomach aches, social withdrawal, dry mouth, dizziness, rebound effects (as the medication wears off), motor tics (twitching), increased blood pressure or heart rate.

In early 2003, atomoxetine (Strattera — a new medication) became available for the treatment of ADHD in children, adolescents and adults. It is a new class of medication for the treatment of ADHD – a selective norepinephrine reuptake inhibitor. Because it is not a stimulant (a controlled substance), it can be prescribed with refills. Unlike the stimulants it must be taken every day (not just school days) for 2-3 weeks before effects are seen. Even though it is not a stimulant it has very similar side effects.

Additional information

National Attention Deficit Disorder Awareness Day is Sept. 7. It is the first and was passed by a Senate resolution in July. Sen. Maria Cantwell of Washington said in her introduction of the resolution, “My hope in identifying a National Awareness Day for ADHD is to encourage an honest discussion about ADHD, its impact on children and adults in schools, in the workplace, and in relationships, and encourage sufferers to seek relief.”

In El Paso, the Third Annual ADHD Conference is scheduled for Sept. from 9 a.m. to 3 p.m. at Las Palmas Medical Center. For information and registration, call Lydia Herrera at 834-7751.

There is much more to know to understand and treat ADHD in children, adolescents and adults. It is important to remember that a structured environment and developing the child’s strengths through behavioral therapy, and using medication therapy where and when needed, will help a child transition into adulthood as a productive member of society.

Additional information can be found at www.addinfonetwork.com, www.chadd.org, www.add.org, www.nichcy.org, www.nimh.nih.gov, www.medem.com and www.rbilynsky.yourmd.com. If a child appears to show symptoms of ADHD on a regular basis for more than six months, please discuss this with their pediatrician or family practitioner who can initiate an evaluation by taking a history, performing a physical examination and providing questionnaires for parents, teachers and day care providers to complete to assist in the diagnosis of ADHD or other neurodevelopmental conditions.



www.bliss.army.mil	Published for the Fort Bliss/El Paso, Texas Community	August 19, 2004

<map name="boxmap-b4"> <area shape="rect" coords="0, 589, 120, 600" href="http://rcm.amazon.com/e/cm/privacy-policy.html?o=1" > <area coords="0,0,10000,10000" href="http://www.amazon.com/exec/obidos/redirect?tag=&creative=92501&camp=8117&link_code=dl1&path=subst/misc/amazon-cobrand-cc/v3/marketing-from-associates-step1.html/ref%3Db1_assoc_29" > </map>	Understanding Attention Deficit Hyperactivity Disorder Lt. Col. Roman Bilynski, MD WBAMC Attention deficit hyperactivity disorder is a neurobehavioral disorder of children, adolescents and adults. It affects between 4 percent and 12 percent of school-aged children, with three boys affected for every girl. It affects three major areas of functioning resulting in inattention, hyperactivity and impulsivity. It is important to remember that all children exhibit some symptoms of ADHD from time to time depending on the family, home or peer situation. For ADHD to be confirmed, a set number of problems must occur in at least two settings, i.e. home, school, daycare, social situations and work if applicable. The behaviors must start before age 7 and must cause significant impairment in successful functioning in at least two of these situations. Often the behaviors start in early childhood but are attributed to ‘being a boy,’ ‘being a girl,’ ‘tomboy,’ ‘very outgoing,’ ‘athletic,’ ‘just like his/her ___(fill in with someone’s name), etc. Often the problem is first recognized by people outside the family, most commonly a teacher or childcare provider who brings their concerns to the child’s parents. ADHD is a biological disorder affecting chemicals (neurotransmitters) in the brain. Inattention appears to result from lower levels of chemical activity in the brains of ADHD kids. ADHD kids do not have enough of these chemicals and that is why stimulants are used to increase the biochemical levels back into the normal range. The lack of these biochemicals prevents them from inhibiting their behaviors. ADHD appears to run in families, suggesting a genetic component. It is not uncommon for a parent, either mother and/or father, to be diagnosed when the child is brought in for evaluation. There is no clear scientific evidence that it is caused by eating too much sugar or sweets, food additives, allergies or immunizations. Diagnosing ADHD ADHD is a clinical diagnosis, based on standard guidelines developed by the American Academy of Pediatrics. It is more difficult to diagnosis under 5 years of age because there are other developmental conditions that can mimic the neurobehavioral manifestations of this disorder. As a child grows into adolescence many of the symptoms seen in childhood appear to remit. A formal diagnosis requires input for several sources in different environments — typically the parents at home, teachers at school and daycare providers. There are no specific medical tests for ADHD despite what you may have heard. Various medical tests involving blood and urine, electroencephalograms (or brain wave tests), brain imaging studies (CT scan, Magnetic Resonance Imagery, Single Photon Emission Computerized Tomography, etc.) will not rule in or rule out a diagnosis of ADHD. A primary care provider, i.e. personal pediatrician or family practitioner, may request a test if there is concern for some other medical disorder. Symtoms include Inattention – difficulty paying attention, does not seem to listen, easily distracted from work or play (i.e. a leaf falling outside the classroom window, sounds of other students in the classroom, television in the next room, etc.), makes careless mistakes or has poor attention to detail, does not follow through on tasks or instructions (i.e. has to be supervised every step of the chore or project), has difficulty organizing themselves (such as difficulty remembering their backpack, homework, school assignments), loses things frequently (i.e. homework, lunch, coats or misplaces them and can’t seem to remember where they put them even if they are laying out in the open), forgetful, appears to daydream a lot and avoids activities that require significant mental effort (reading, homework, etc.). Hyperactivity – has difficulty remaining seated (difficulty sitting through a meal, movie, religious service, etc.), squirms and fidgets, talks excessively, acts as if “driven by a motor,” “on the go,” runs or climbs excessively and has difficulty with quiet play or activity. Impulsivity — has difficulty awaiting turn or standing in line, cannot wait for things, answers before question is completed, often interrupts others, acts or talks before thinks, and engages in dangerous or foolish activity (running into street without looking, climbing on the roof, jumping out a window). Associated problems ADHD is often associated with other neurobehavioral problems. In 25-50 percent of children, adolescents and adults with ADHD there are coexisting mood or anxiety disorders. These include depression, bipolar disorder (also referred to as manic-depressive), generalized and social anxiety disorders. Learning disabilities commonly occur with ADHD and are diagnosed through the child’s school (formal psychoeducational testing). Oppositional Defiant Disorder is seen in children who tend to lose their temper easily, annoy or bother others on purpose, with defiance and hostility toward authority (parents, teachers, daycare providers, etc.). Children with conduct disorder typically break rules, destroy property willfully or by fire setting, and violate the rights of others by fighting, stealing, lying, conning others, or threatening or using weapons. Children with the latter disorders often need the help of counseling on a regular basis to help deal with these problems. A small percentage of children with ADHD symptoms may have them secondary to autistic spectrum disorders, like classical autism, Asperger’s disorder and pervasive developmental disorder not otherwise specified – their diagnosis typically requires referral to a specialist in neurodevelopmental disabilities, developmental pediatrics, child neurology and/or child psychiatry. Treatment options There is no cure for ADHD, but treatment requires long-term planning and management like with any other chronic medical or psychiatric disorder. Before considering treatment, one must consider what the goals of treatment should be. Typically it includes improving problem behaviors, relationships with peers, teachers, siblings and parents, improving schoolwork and self-esteem and minimizing unsafe behaviors. Goals should be measurable (e.g. grades in school and various rating scales). Treatment can include education about ADHD, behavioral therapy, parent training, teacher training, child and family counseling and medication therapy targeting the problem behaviors. Behavioral therapy, in many forms, has the long-term goal to change the child’s physical and social environment to help improve his behavior. Set specific goals, provide rewards and consequences and continue to rewards and consequences consistently for a long time to shape a child’s behavior in a positive way. The best medications for the treatment of ADHD are the stimulants, used alone or in combination with behavioral therapy with marked improvement seen in about 80 percent of children. Medication options include short acting (immediate release), intermediate acting and long acting forms. Treatment frequency varies from 2-3 times per day to once daily for the extended or sustained release forms. Commonly used medications include methylphenidate (Ritalin, Methylin, Ritalin SR, Metadate ER, Methylin ER, Concerta, Metadate CD, Ritalin LA, Focalin), amphetamine (Dexedrine, Dexostat, Adderall, Adderall XR) and pemoline (Cylert). Side effects of the stimulants are typically minimal but may include sleep problems, weight loss or decreased appetite, headaches, irritability, stomach aches, social withdrawal, dry mouth, dizziness, rebound effects (as the medication wears off), motor tics (twitching), increased blood pressure or heart rate. In early 2003, atomoxetine (Strattera — a new medication) became available for the treatment of ADHD in children, adolescents and adults. It is a new class of medication for the treatment of ADHD – a selective norepinephrine reuptake inhibitor. Because it is not a stimulant (a controlled substance), it can be prescribed with refills. Unlike the stimulants it must be taken every day (not just school days) for 2-3 weeks before effects are seen. Even though it is not a stimulant it has very similar side effects. Additional information National Attention Deficit Disorder Awareness Day is Sept. 7. It is the first and was passed by a Senate resolution in July. Sen. Maria Cantwell of Washington said in her introduction of the resolution, “My hope in identifying a National Awareness Day for ADHD is to encourage an honest discussion about ADHD, its impact on children and adults in schools, in the workplace, and in relationships, and encourage sufferers to seek relief.” In El Paso, the Third Annual ADHD Conference is scheduled for Sept. from 9 a.m. to 3 p.m. at Las Palmas Medical Center. For information and registration, call Lydia Herrera at 834-7751. There is much more to know to understand and treat ADHD in children, adolescents and adults. It is important to remember that a structured environment and developing the child’s strengths through behavioral therapy, and using medication therapy where and when needed, will help a child transition into adulthood as a productive member of society. Additional information can be found at www.addinfonetwork.com, www.chadd.org, www.add.org, www.nichcy.org, www.nimh.nih.gov, www.medem.com and www.rbilynsky.yourmd.com. If a child appears to show symptoms of ADHD on a regular basis for more than six months, please discuss this with their pediatrician or family practitioner who can initiate an evaluation by taking a history, performing a physical examination and providing questionnaires for parents, teachers and day care providers to complete to assist in the diagnosis of ADHD or other neurodevelopmental conditions.