Attention Deficit Hyperactivity Disorder ADHD

Ten years ago I had never even heard of ADHD. Today it is not uncommon to have at least one child diagnosed with ADHD in every class. There are ten qualified teachers in our organisation from around the globe yet we are all in the continual process of researching and learning about ADHD, the most common behavioural disorder in childhood. As teachers we are concerned with the best way to teach, motivate and help children with ADHD. It is important that common myths are dispelled and factual information is acquired so informed choices can be made.

If you suspect your child has symptoms of ADHD Mr. Michael Wood, Educational Psychologist for the English Schools Foundation advises, “A good starting place for parents is the school.” The special needs department can help the parent establish whether ADHD is suspected and then formulate a plan.

Every published medical report I have read and health care practitioner I have spoken to give the same consistent advice. It is imperative a thorough comprehensive evaluation and proper assessment is done by a qualified health care professional knowledgeable in ADHD.

Dr. Peter Jaksa, a psychologist explains in a nutshell, “ADHD is a diagnosable, treatable, biologically based disorder.” (1)

Parents should note it has nothing whatsoever to do with bad parenting.

“There is a great deal of evidence that ADHD runs in families, which is suggestive of generic factors.” (2)

“Most experts recommend a multimodal treatment approach for ADHD.”(3)

“Clinical experience has shown that the most effective treatment for ADHD is a combination of medication (when necessary), therapy or counselling to learn coping skills and adaptive behaviours, and ADHD coaching for adults.” (4)

Five steps in the management of a child with ADHD according to MSN WebMD are:-

1. diagnosis
2. appropriate treatment
3. vigilant monitoring
4. communication between physicians, caretakers and schools
5. an ongoing exchange of information. (5)

It is also important to get informed. Two definitive websites recommended by Mr. Wood are- www.add.org and www.chadd.org. Both sites are very informative and should leave parents, teachers and caretakers well informed on practically every aspect of ADHD.

We asked Dr. Tim Trodd to write an article on ADHD. Dr. Trodd was recommended to us as a GP with an interest in ADHD who has helped parents in Hong Kong with ADHD children.

Dr. Tim Trodd reports, “Attention Deficit Hyperactivity Disorder (ADHD) is the most commonly diagnosed behavioural disorder in childhood, in some communities 10% of children are diagnosed with ADHD and there are 8 million children in the USA taking medication for ADHD. Boys are seven times more likely to be affected than girls and more prone to being hyperactive as well as inattentive. Although ADHD is usually diagnosed in childhood about 60% of these children will go on to have behavioural problems as adults.

ADHD is a syndrome characterised by agitated behaviour and an inability to focus on tasks. There are separate sets of criteria for inattention and hyperactivity-impulsivity. In order for the diagnosis to be made the symptoms must have been present for at least 6 months to a degree that is inappropriate and inconsistent with the child’s level of development. The diagnosis is made by a trained professional who assesses the child’s symptoms according to a set of criteria. There are several tools used to aid in the diagnosis, the Connor’s Abbreviated Rating Scale is shown below, a total of more than 15 is suggestive of ADD/ADHD:

ADHD often causes poor academic performance. It can occur in all intelligence groups but is harder to recognise in children with low or high intelligence. Although school is often the focus of problems in these children they often have difficulties making friends and their behaviour puts stress on the family. The older children often have problems with law breaking and drugs. For the parents the following list of problem behaviours may be more useful for assessment of problems as they are targeted towards the home environment:

• Active manipulations: Noncompliance, oppositionalism, temper tantrums
• Verbal manipulations: Poor-me statements, negative statements, nagging, interrupting, non-existant physical complaints
• Inattention Behaviours: Not paying attention, helplessness and dependency, dawdling, poor reading skills, poor school performance
• Other common misbehaviours: Tattling, fighting with siblings, aggression, lying

ADHD very often co-exists with other conditions. These include co-ordination problems, speech delay, dyslexia, Asperger’s Syndrome, tics and oppositional defiant disorder.

Before any treatment the child should have a full psychological assessment. A treatment plan can then be constructed which should always be multi-modal with input from a psychologist, teachers, a doctor and possibly others such as occupational therapists.

Many children receive drug treatment for their ADHD. Drug treatment must be carefully monitored by a doctor who is familiar with the use of these medicines. The two groups of drugs most often used are stimulants (amphetamines) and anti-depressants, with some children taking both. The most commonly used drug in Hong Kong is Ritalin, which is a stimulant. About 70% of sufferers will respond well to Ritalin and a useful alternative drug can be found in a further 20%.

Side effects to Ritalin are common and include poor appetite and growth, restlessness, tics, headache, poor sleep and mental dullness. It is important to note that Ritalin does not cure ADHD, the effect only lasts for a few hours after each dose and then wears off. Most children concentrate better after Ritalin whether they suffer from ADHD or not, therefore improved concentration after Ritalin does not indicate a diagnosis of ADHD. According to the manufacturers “The long-term safety and efficacy profiles of Ritalin are not known“, this is because no safety trials longer than 3 months have been undertaken. The advantage of drug treatment is that improvements are seen immediately and that, compared to dietary manipulation and behavioural techniques, medicines are much easier to administer for both parents and child.

There is some evidence that dietary manipulation can be of benefit in ADHD. A study at The Great Ormond Street Children’s Hospital in London demonstrated that 80% of children improve on restricted diets. Many parents notice that their child’s behaviour worsens after certain foods containing refined sugar and food colourings. Food intolerances are more common in children who have eczema, asthma, recurrent ear infections, headaches, fatigue and recurrent stomach pains. Children with Aspergers syndrome and High Functioning Autism are often intolerant of wheat and cow’s milk. The Feingold Diet has many supporters and focuses on the avoidance of food additives.

Nutritional deficienceis often occur with ADHD. The most common deficient elements are magnesium and zinc. Children with magnesium deficiency are often hyperactive and have muscle weakness (hypotonia). Children with Zinc deficiency often have poor sense of taste (and therefore a restricted apetite), thin hair, susceptability to infection, poor growth and white spots in their fingernails (these are due to zinc deficiency rather than calcium problems).

The zinc taste test can simply demonstrate zing deficiency. A teaspoon of zinc sulphate is held in the mouth for 5 seconds and then swallowed. This tastes foul to those with good zinc levels whilst those with low zinc levels taste nothing. Iron deficiency has been shown to cause developmental delay but, in my experience,
it is not very common in Hong Kong

There are often essential fatty acid imbalances in those with ADHD. The omega 3 and 6 group are particularly important in part because the dietary intake of these important fats has decreased over the years. One of the benefits of breast feeding is that the infant receives essential fats that are lacking in formula. However if the breast feeding mother is deficient in these fatty acids her breast milk will also be deficient. The essential fatty acid content of Australian breast milk has fallen 30% in 14 years. Signs of essential fatty acid deficiency include dyspraxia (clumsiness), excessive thirst, bed-wetting and bumpy skin on the backs of the upper arms and/or face (doctors call this hyperpilaris keratosum). Supplements of evening primrose oil, flax seed oil and fish oil are often used to treat fatty acid deficiency. The old fashioned supplement of a teaspoon of cod liver oil helps supply DHA, an important fat for mental functioning, and Vitamin A that helps fight infections.

Heavy metal toxicity is very well described as causing behavioural problems. A recent study from Devon, England published in the Archives of Diseases of Childhood found high lead levels in children with behavioural and/or developmental problems. In the article they state that “Lead, a known and more importantly, a treatable neurotoxin, would further contribute to the impairment suffered by these children. We argue that this group of children should be screened for lead“.

Lead and Mercury are probably the most common toxins contributing to behavioural problems in Hong Kong. Testing for heavy metals is controversial. The study mentioned above used blood testing, others have used hair testing. Both tests have advantages and disadvantages. Another way of testing is to collect urine from the child after they have taken a medicine that removes metals.

Behavioural techniques may be very helpful and should be tried in all cases. Behavioural techniques involve rewarding good behaviours and negatively reinforcing target behaviours. Most techniques also involve teaching the child attention and memory as these improve with practice. Helping the child remember and prompting may actually make behaviours worse as the need to remember and pay attention is delegated. A useful book is “Ritalin Is Not The Answer” which, despite the contentious title, contains an excellent and well thought out behaviour program. Most children will be given behavioural advice by the psychologist who makes the diagnosis.

This article is a brief overview of ADHD, the most common behavioural disorder in childhood. In general it is best to seek professional advice sooner rather than later.” (6)

Finally one quote from Dr. Edward M. Hallowell MD, a pioneer in ADHD treatment, made me laugh. When writing an article on ADHD entitled, “What’s it like to have ADHD?” he begins, “First of all I resent the term. As far as I’m concerned most people have Attention Surplus Disorder. I mean, life being what it is, who can pay attention to anything for very long? Is it really a sign of mental health to be able to balance your checkbook, sit still in your chair and never speak out of turn? As far as I can see, many people who don’t have ADD are charter members of the Congenitally boring.” (6)

As exasperating as it is coping with an ADHD child, it can be very rewarding too. After all wouldn’t life be boring if we were all the same. “The key in managing ADHD is to identify and preserve the positive attributes, like creativity, energy, and intuition while also containing the down side.” (7)

Bibliography

1 www.add.org What is ADHD Dr. Peter Jaksa
2 www.add.org Dr. Peter Jaksa
3 www.chadd.org About ADHD
4 www.add.org What is ADHD
5 msn WebMD
6 Dr. Tim Trodd
7 www.add.org Dr. E.M. Hallowell