ADHD Family Solutions: A Doctor Q & A
To help you and your child get the school year off to a strong start, HealthCentral lined up a team of ADHD experts to answer your questions. Here are responses during a recent live discussion with Dr. Mark Bertin, a board-certified developmental behavioral pediatrician and Assistant Professor of Pediatrics at New York Medical College.
ADHD is a developmental condition defined primarily by delays in certain skills related to self-management. The latest way ADHD is defined includes both the hyperactivity/impulsive type and the inattentive type, which used to be called ADD. Practically speaking, it has outgrown its name. ADHD isn't really a disorder of attention or hyperactivity alone. Those concerns occur as part of "executive function."
Executive function includes all the skills we use to manage and coordinate our thoughts and activities and those skills are what ADHD impacts. So attention, impulsiveness and all the rest are often a large part of it, but so are issues with organization, emotion and lots more. ADHD isn't really an attention disorder, it is one of executive function. That explains issues with time management, emotional reactivity, poor handwriting and narrative writing.
Sure, If you recognize that 'attention shifting' is a challenge in ADHD, you can change how you approach a child to get things done. One small step to getting them to shift attention and listen is making sure you have their attention fully before stating your request. From there, it is often parent and teacher based routines that increase compliance, which over time leads to more independence.
It isn't likely, but it does happen. The diagnosis of ADHD often includes messiness, forgetfulness, and disorganization. It can also be very challenging to have OCD symptoms and also have the challenges created by ADHD present too. And as a broader point, what is common is that most people with ADHD have other conditions, ranging from anxiety / OCD to learning disorders, tagging along with it.
Diagnosis is based on observation and getting to know an individual and family well. Even though we know ADHD neurology well, we don't yet have conclusive tests. Instead, we try to prove that certain behaviors are happening, and that there is a long-term pattern of ADHD symptoms, and these symptoms are not better explained by something else and are significant enough to cause ongoing impairment.
I think we can all agree that whenever we can NOT prescribe for any medical disorder, that's the best solution. So it makes sense that many parents are reluctant to try medication. The confusing part for parents is that so much of what is taken for granted about medication for ADHD isn't true. My goal typically is just for parents to have objective information, whether they choose for or against.
Medications for ADHD have been shown to benefit many kids, and when used appropriately there should NOT be any ongoing side effects and since these medications do not have long term effects, if you stop them you return to baseline. Medication rarely if ever manage ADHD all on their own, and there is generally room to start with other interventions.
Accommodations typically start with classroom modifcations like preferential seating and reward-based behavioral plans, but also need to include organizatoinal help and reminders. This applies all the way through high school - a forgetful 10th grader with ADHD shouldn't be punished over and over for not handing things in, that's his (or her) ADHD.
Lifestyle options are big ADHD topic. There is research suggesting, for example, that exercise helps many. Regarding diet, though, research is more open. It is possible there is some benefit from omega 3's. And some research stating that children may have their symptoms exacerbated (but not caused) by food dyes. Although neon foods aren't generally so healthy to start.
This would be best answered from knowing more specifics and talking directly with the college student involved. But in general if there is clearly medication diversion going on, not prescribing that medication may be the answer. There are non-stimulant ADHD medication options, so switching medication may be the best front-line approach.
You can start by looking at executive function as affecting attention; behavior management; information management (like coordinating thoughts for writing); emotional management; sustained effort, and organization and planning (from Tom Brown's model.)
So one way to organize classroom planning through the whole process, is to look at each aspect of development. So a well structured, consistent classroom that minimizes distractions helps as does direct support around organization, breaking up projects, remdiners to hand in stuff, right up until a child proves themselves independent.
So like at school, a start is creating a homework environment that is free of distraction. And then there is the behavioral, motivational part - adding rewards to the mix. Many children also focus better when they know there are scheduled breaks, so using a timer for a set period of time on and then one off is useful. If these efforts don't work, it's time to consider other options - like medication.
There is definitely a sense that overly intense academic demands lead to misdiagnosis of ADHD, particularly in younger kids. There is even one study showing that younger kids in KG may get overly diagnosed. A good resource for that is Dr. Hinshaw's The ADHD Explosion.
Many things influence ADHD, and seeing all the different possibilities goes a long way towards best managing it. Exercise is one thing that may improve both ADHD symptoms and mood. And yet, having ADHD often makes it harder for kids to enjoy sports, and harder to sustain an exercise routine. So like much of ADHD, creating a healthy routine from the start, until it becomes habit, matters.