ATTENTION DEFICIT DISORDERS
INFORMATION AND GUIDELINES
Understandably, one of the first questions
parents ask when they learn their
child has an attention disorder is “Why?
What went wrong?” Health professionals stress that since no one knows what
causes ADHD, it doesn’t help parents to look backward to search for
possible reasons. There are too many possibilities to pin down the cause with
certainty. It is far more important for the family to move forward in finding
ways to get the right
help.Scientists, however, do need to study causes in an effort
to identify better ways to treat, and perhaps some day, prevent ADHD.
They are finding more and more evidence that ADHD does not stem from home
environment, but from
When you think about it, there is no clear relationship
between home life and ADHD. Not
all children from unstable or dysfunctional homes have ADHD.
And not all children with ADHD come from dysfunctional families.
Knowing this can remove a huge burden of
guilt from parents who might blame
themselves for their child’s behavior.
Over the last decades, scientists have come up with
about what causes ADHD.
Some of these theories have led to dead ends, some to exciting new avenues of investigation. One disappointing
theory was that all
attention disorders and learning disabilities were caused
by minor head
injuries or undetectable damage to the brain, perhaps
from early infection or complications at birth. Based on this theory, for many
years both disorders were
called “minimal brain damage” or “minimal brain dysfunction.” Although certain types of head injury can explain some
cases of attention disorder, the theory was rejected because it
could explain only a very small number of cases. Not everyone with ADHD or LD
has a history of
head trauma or birth complications. Another theory was
that refined sugar and food additives make children hyperactive and inattentive.
As a result, parents were encouraged to stop serving children foods
containing artificial flavorings, preservatives, and sugars. However, this theory, too, came under question. In
1982, the National Institutes of Health (NIH), the Federal agency responsible for biomedical research, held a major
scientific conference to discuss the issue.
After studying the data, the scientists concluded that the restricted diet only seemed to help
about 5 percent of
children with ADHD, mostly either young children or
children with food
Is Not Usually Caused by:
In recent years, as new tools and
techniques for studying the brain have been developed, scientists have been able to test more
theories about what causes ADHD. Using one such technique, NIMH scientists
demonstrated a link
between a person’s ability to pay continued attention
and the level of activity
in the brain.
Adult subjects were asked to learn a list of words.
As they did,
scientists used a PET (positron emission tomography)
scanner to observe the
brain at work. The
researchers measured the level of glucose used by the areas of the brain that inhibit impulses and control
attention. Glucose is
the brain’s main source of energy, so measuring how
much is used is a good indicator
of the brain’s activity level.
The investigators found important differences between
people who have ADHD and those who don’t.
In people with ADHD, the brain areas that control attention used less glucose, indicating that they were
less active. It appears from this research that a lower level of activity
in some parts of
brain may cause inattention.
Brain scan images produced by positron emission
tomography (PET) show differences between an adult with Attention Deficit
Hyperactivity Disorder and an adult free of the disease.). The next step will be
to research WHY there is less activity in these areas of the brain.
Scientists at NIMH hope to compare the use of glucose and the activity level in mild
and severe cases of
will also try to discover why some medications used to treat ADHD work better than others, and if the more effective
medications increase activity
in certain parts of the brain.
Researchers are also searching for other differences
between those who have and do not have ADHD.
Research on how the brain normally develops in the fetus offers some clues about what may disrupt the
process. Throughout pregnancy and continuing into the first year of life, the
brain is constantly developing. It
begins its growth from a few all-purpose cells and evolves into a complex organ made of billions of specialized,
interconnected nerve cells. By
studying brain development in animals and humans, scientists are gaining a better understanding of how the brain works
when the nerve cells are
connected correctly and incorrectly.
Scientists at NIMH and other research institutions are
tracking clues to determine what might prevent nerve cells from forming
the proper connections. Some
of the factors they are studying include drug use during pregnancy, toxins, and genetics. Research shows that a
mother’s use of cigarettes, alcohol, or other drugs during pregnancy may
have damaging effects on the unborn child. These substances may be
dangerous to the fetus’s developing brain. It
appears that alcohol and the nicotine in cigarettes may distort
developing nerve cells.
For example, heavy alcohol use during pregnancy as been
linked to fetal alcohol syndrome (FAS), a condition that can lead to low
birth weight, intellectual impairment, and certain physical defects.
Many children born with FAS show much the same hyperactivity, inattention,
and impulsivity as children with ADHD. Drugs such as cocaine—including the
smokable form known as crack—seem to affect the normal development of brain
receptors. These brain cell parts help to transmit incoming signals from
our skin, eyes, and ears,
and help control our responses to the environment. Current research suggests that drug abuse
may harm these receptors. Some scientists believe that such damage
may lead to ADHD. Toxins in the environment may also disrupt brain development or brain
processes, which may lead to ADHD. Lead
is one such possible toxin. It
is found in dust, soil,
and flaking paint in areas where leaded gasoline and
paint were once used. It is also present in some water pipes. Some animal studies suggest that children exposed to lead may develop symptoms associated
with ADHD, but only a
few cases have actually been found.
Other research shows that attention disorders tend to run
in families, so there are likely to be genetic influences.
Children who have ADHD usually have at least one close relative who also has ADHD.
And at least one-third of all fathers who had ADHD in their youth bear children
who have ADHD. Even more
convincing: the majority of
identical twins share the trait. At the National Institutes of Health,
researchers are also on the trail of a gene that may be involved in transmitting ADHD in a
small number of families
with a genetic thyroid disorder.
FOR HOME INTERVENTIONS FOR
are some suggestions to help ADD children in the home setting:
Set up specific time periods for waking, bedtime, chores, homework,
playtime, TV, dinner, etc. Changes in schedule are disturbing
to ADD children, so be as consistent as possible.
any changes ahead of time so they will be expected.
- Set up clear and concise rules for the family, including the ADD
child. Rules, as well as consequences for breaking them, and
rewards for appropriate behavior can be written down and posted
in a prominent place. Consistency is the rule here - if a
rule is broken, consequences should follow every time. If the
behaves, he should earn rewards or privileges.
- Give instructions as simply and clearly as possible. Ask the
to repeat them back to you, and praise him if he does so correctly.
Do not give more than one or two instructions at a time. If a task is difficult or complex, break it into smaller parts
and give one or two parts at a time.
- Provide him with his own special quiet spot without distractions,
in which to do homework or quiet activities.
the desk towards a blank wall, avoid clutter and avoid bright
or distracting patterns in decor. Remember, the child
have difficulty filtering out unnecessary stimulation.
- Try to keep the child’s stimulation level as low as
possible. Have him play
with one child at a time, involve him in one activity
at a time, remove needless background noise such as radio
or TV, have him put unused toys, games, etc. out of sight.
- Keep a diary of foods eaten and the effects, if any, on the child’s
behavior. Although rare, sometimes allergies can produce
reactions similar to hyperactivity. Be aware that the effects
of eating a certain food may not show up until later
day or the next day. Some common food products may be chocolate,
tomato products, wheat, sugar, milk products and peanuts.
Note any strong reactions (such as headaches) to fumes from
perfumes, inks, detergents or cleaning products.
- Repeated messages, directions, requests, etc. (“nagging”) are
disciplinary techniques and create a variety of unpleasant
side effects, including oppositional behavior and increased
“tuning out” of the parents. To stop this ineffective process,
try the following: Say what you need to say, but say it
once - briefly - firmly - completely - calmly. Follow through with a logical consequence or
restructuring approach. ACT
- DON’T YAK!
- Provide supervision by being physically near the child, if he is
trying to stay on track while doing a task. Don’t hover over him,
but be available to set him back in the right direction if needed.
- Allow your child choices within the limits you have set. (“Do you
want to clear the table or would you rather sweep the floor now?”) This will help him develop
initiative and self-control.
- Help your child find avenues of self-expression that will help
tell others what he wants and needs in an acceptable, useful
manner. Children sometimes use misbehavior to communicate.
Teach (by modeling or demonstrating) appropriate verbal
communication skills. Ask yourself, “What does my child
to have happen as a result of this behavior?” and help him
find other ways to gain it.
- Use a timer with small chores in order to help give your child a
sense of the passing of time.
- The ADHD child’s behavior can often be irritating. However, should
you become excessively angry your effectiveness with your
child will be greatly reduced. Anger is normal, but it can
and should be controlled while disciplining your child. Strive
to keep your voice quiet and your manner calm.
- Separate the behavior you do not like from your overall assessment
of your child, as in “I don’t like it when you track
mud in the house” rather than “How did you get to be such
a dirty child?” Bad behavior does not equal a bad child!
- Above all else, the ADD child needs compassionate
His parents, siblings and teachers should not pity
or overindulge this child, nor should they tease him or make
him feel guilty. He did not choose to have ADD, nor did
parents or anyone else cause it. Although he may need extra
help in adapting to the demands of school and home life, he
wants to fit in and would usually choose to not be in trouble
or have others be angry with him. With patience and
much can be done to help the ADD child and he can
be as happy and successful as other children.
ADHD is sometimes treated with medications (stimulants, antidepressants,
and others). Each of the medicines acts in a different way to modify
levels of brain chemicals and improve ADHD behaviors.
including small amounts of amphetamines and methylphenidate (Ritalin),
have been used and tested the most and are probably the safest and most
effective of the ADHD drugs. Medical research has shown that stimulants
work well in improving attention and reducing impulsive behavior and
hyperactivity. Stimulants also seem to improve academic performance of
children with ADHD - they get better grades, with math sometimes
improving more than reading.
Antidepressants are good second-choice drugs; studies
have shown that they also help children with ADHD. Other drugs used to
treat ADHD are usually chosen when stimulants and antidepressants either
don't work or are causing unpleasant side effects. Treatments like
following special diets or taking megadoses of vitamins have not proven
themselves, but some are still being studied.
Because no single ADHD drug always works for every
child, doctors depend on parents' and teachers' input in prescribing
medicine for ADHD. Sometimes more than one drug must be tried before a
child's behavior improves, and side effects always need to be evaluated.
Medicines are also available in longer acting forms, which may allow
your child to go through a school day without a lunch time dose of
medicine from the school nurse. And no matter what medication your
doctor prescribes, even successful treatment needs to be re-evaluated
each year, especially if there is any reason to suspect that the
medicine is no longer needed or the dosage can be reduced.
Even if your child is already taking medicine for
ADHD, there is still more that can be done. You and your child's
teachers can use special
techniques, called behavior modification, to help him recognize and
change his own behaviors. This can mean a reward system or point system
to "catch him being good." Good behavior would either earn him
a small prize or give him "points" toward special school or
Most children with ADHD do best when medication and
behavior modification are used together. They also have a special need
for good relationships with children their own age - so having friends
is a big help.
STIMULANTS MEDICATIONS FOR ADHD
Stimulant medications may be effective in 70-75% of
patients diagnosed appropriately with ADHD. Cylert appears to be less potent in its activity, and often takes
several weeks to start working. It is probably best reserved for younger
children who need a chewable medication, or for situations where the
patient has had an "overreaction" to other stimulants.
Although not common, children will sometimes appear to be withdrawn,
depressed and tearful if the dosage of stimulants is too high. It is
best to start with a low dosage and gradually increase it as needed. Too
high a dose of stimulant medications has lead to hallucinations and
paranoid thinking in a small number of cases.
The short acting form generally starts working about a half hour
after it is given, peaks at 2 hours and is gone at 4 hours. It has a
half life (the time required for one half of the available material to
be removed from the body) of 2-3 hours. It must be taken several times
daily to maintain effectiveness.
It comes in 5 mg, 10 mg, and 20 mg tablets. The
tablets tend to be bitter, and are best swallowed whole.
Common side effects are headache or stomach ache,
usually minimized by taking the medication after having food.
SUSTAINED RELEASE RITALIN
The long acting form ( Ritalin SR) comes only in a 20
mg tablet. It is designed to slowly release its contents from a series
of "microchannels", and the tablet can not be cut. This dosage
form is quite variable, working well for some people but poorly for
others. It may be worth trying if a child on Ritalin is very resistant
to taking medication at school. It tends to start acting more slowly
than regular Ritalin, often taking 1.5 hours to start working. For this
reason, it is often given with a small dose of regular Ritalin in the
morning to provide initial coverage. Ritalin SR peaks at approximately
4.5 hours from the time it is administered.
It is not uncommon to have parents report a
"rebound hyperactivity" in the late afternoon as the long
acting Ritalin wears off.
Dexedrine ( or Dextroamphetamine ) is a stimulant used
in the treatment of ADHD. It comes in both long and short acting forms.
The short acting tablet comes in 5 mg dosages, and reaches a peak level
two hours after administration. The longer acting spansule is available
in 5 mg, 10 mg, and 15 mg sizes and reaches a peak blood level eight to
10 hours after administration. This permits once daily dosing with the
The half life of dexedrine (tablet) is approximately
10 hours, significantly longer than Short Acting Ritalin.
Pemoline is similar to the other stimulants in its
side effects, tending to cause insomnia and decreased appetite.
It reaches a peak two to fours hours after it is
taken, and has a half life of 12 hours. This relatively long half life
means that it can be taken once daily.
Pemoline is metabolized by the liver, and has been
associated with some cases of liver inflammation. Liver function should
be tested prior to starting this medication and done periodically during
the course of therapy to monitor for inflammation of the liver.
Pemoline is the only stimulant which comes in a
chewable form, making it useful for small children who can not otherwise
take a bitter tasting stimulant.
Cylert comes in 18.75, 37.5 and 75 mg tablets and in a
chewable tablet in 37.5 mg.
Adderall (mixed salts of a single-entity amphetamine
product) typically improves attention span, increases the ability to
follow directions and decreases distractibility among children ages
three and older. Adderall may also decrease impulsivity, stubbornness
and aggression. Adderall is convenient for patients, parents and
caregivers because it is effective for most patients when taken once or
twice a day. Since it is a different mixture of amphetamine isomers,
Adderall may help some individuals when other medications (such as
Ritalin) have not proven effective.
The effects of Adderall can be felt after a few doses
or even after the first dose. Often it takes additional time to achieve
the full effect. This may require changes in dosing. Most people can
achieve maximum benefit in 3 to 4 weeks.
Are there any Drug Interactions?: Taking more
than one medication at a time may cause a negative or harmful reaction.
However, never discontinue the use of any medication unless permission
is given by your doctor. Be sure to tell your doctor if you are taking
any other medications, including over-the-counter medications like
aspirin, herbal remedies, and vitamins. .
MONITORING IN SCHOOL
It may be
beneficial to display the medication schedule on the student's desk.
The student can
then check off or otherwise indicate
when the medication has been received. This helps the
student develop self-responsibility for medication management.
to increase communication between the school and home
regarding the student's
medication, it may be helpful to send a
notebook between home and school. Administration
of medication and any significant effects can be noted.
personnel should monitor the student's behavior and academic performance
while on the medication. This
information may be shared with parents or physician upon request.
personnel should encourage the student's parents to notify the doctor of
effects or behaviors noted while the child is on medication.