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 biological causes. 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 possible theories 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 allergies. ADHD Is Not Usually Caused by:  

  • too much TV
  • food allergies  
  • excess sugar  
  • poor home life  
  • poor schools  

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 the 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 ADHD.  They 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.

IDEAS FOR HOME INTERVENTIONS FOR ADD KIDS

Here are some suggestions to help ADD children in the home setting:  

  1. 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. Explain any changes ahead of time so they will be expected.
  2. 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 child behaves, he should earn rewards or privileges.
  3. Give instructions as simply and clearly as possible. Ask the child 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.
  4. Provide him with his own special quiet spot without distractions, in which to do homework or quiet activities. Face the desk towards a blank wall, avoid clutter and avoid bright or distracting patterns in decor. Remember, the child may have difficulty filtering out unnecessary stimulation.
  5. 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.
  6. 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 that 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.
  7. Repeated messages, directions, requests, etc. (“nagging”) are inefficient 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!
  8. 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.
  9. 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.
  10. Help your child find avenues of self-expression that will help him 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 want to have happen as a result of this behavior?” and help him find other ways to gain it.
  11. Use a timer with small chores in order to help give your child a sense of the passing of time.
  12. 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.
  13. 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!
  14. Above all else, the ADD child needs compassionate understanding. 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 his 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 understanding, much can be done to help the ADD child and he can be as happy and successful as other children.

TREATMENT

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. Stimulants, 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 home privileges.

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.

SHORT ACTING RITALIN

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

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 spansule.

The half life of dexedrine (tablet) is approximately 10 hours, significantly longer than Short Acting Ritalin.

CYLERT (PEMOLINE)

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

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. .

MEDICATION 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.

In order 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.

School 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.

School personnel should encourage the student's parents to notify the doctor of any unusual effects or behaviors noted while the child is on medication.