Friday, April 12, 2013

Conquering ADHD Part II: Diagnosis

In my practice I first conduct a thorough evaluation in order to ascertain the diagnosis of ADHD by interviewing the parent(s) or caretaker, meeting with the child and talking to the other people who are involved in the child’s life such as teachers, nannies, coaches etc. I give out rating scales such as the Conner’s ADHD rating scales (2) for parents and teachers and the Child Behavior Checklist (3) to get input from other sources. In order to properly diagnose ADHD, the symptoms have to be often present in multiple areas of the child’s life. Many times children with ADHD can show different types of focusing capacities e.g. video games versus reading books. This is because the neurological pathways are different for different activities. Having a specific captivated interest in something might lessen the appearance of symptoms for short periods of time because of the child’s ability to use interest to focus. This might give a false notion that my child does not have ADHD if he can play video games all day. 

In order to make the official psychiatric diagnosis the symptoms must meet at least 12 of the 18 DSM IV criteria. (4) It is important that these symptoms persist for at least 6 months, cause significant interference in the child’s performance and daily functioning and usually begins before the age of seven. The symptoms are divided into three groups as follows:

          Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
          Often has difficulty sustaining attention in tasks or play activities.
          Often does not seem to listen when spoken to directly.
          Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions.)
          Often has difficulty organizing tasks and activities.
          Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework).
          Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools.)
          Is often easily distracted by extraneous stimuli.
          Is often forgetful in daily activities.
          Often fidgets with hands or feet or squirms in seat.
          Often leaves seat in classroom or in other situations in which remaining seated is expected.
          Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness).
          Often has difficulty playing or engaging in leisure activities quietly.
          Is often "on the go" or often acts as if "driven by a motor."
          Often talks excessively.
          Often blurts out answers before questions have been completed.
          Often has difficulty awaiting turn.
          Often interrupts or intrudes on others (e.g., butts into conversations or games.)

Once the diagnosis is confirmed and parents educated about ADHD and the types of ADHD i.e. Hyperactive and Impulsive type or Inattentive type or combined type, then I go over the treatment options. ADHD has many different symptoms and not every child has all of them. For many parents it can be very difficult to emotionally understand and accept that their child has ADHD and the idea that medications have to be used for long periods of time. As a parent myself I understand how difficult this can be and hence I often tell and describe to them in simple terms what “their child’s ADHD” is and why it important for it to be treated. I explain that it is not often the child’s fault for having ADHD and it can really impact their day to day functioning as these children have to put in more energy and work just to do things compared to those without ADHD who take it for granted. It often becomes extremely frustrating and can cause a low self-esteem and other problems in the long run. I also tell them that there have been many times that children are very easily prescribed medications for ADHD for behavioral issues that may not stem from ADHD causing a bad rap towards the use of medications for someone who can truly benefit from it. So when I prescribe medication I am sure that your child will benefit from it otherwise I would not recommend it.

Unfortunately, Nature does not offer alternative skills to offset the negative impact of this innate condition. However, a child with ADHD has to compete with other children who do not suffer from this ailment. Ultimately it is up to the adult caregivers to take extra measures to help these kids hone in on their talents and develop them into powerful tools of survival in the face of adversity. It is therefore up to the parent to recognize this fact very early on and take appropriate actions. By the fact that many parents seek my help is an indication of the first step to improve the chances of a bright future for these children.

The way one chooses the treatment options and the duration of its implementation depends on the individual child and how mild to severe the ADHD is and if there are other comorbid conditions like mood disorders such as learning disorders, oppositional defiant disorder, bipolar disorder and depression, anxiety issues and PTSD, psychosis, autism and other social skill issues. In this article I will be discussing more straight forward single diagnosis ADHD issues.

I sometimes recommend psychological and neuro-psychological testing be done to see if the child has any learning disorders in addition to the ADHD. This is very important so that other causes of poor performance can be addressed by modifying the school curriculum for the child.  This can help decrease the overall frustration that these children face hence they can spend more energy in trying to work with their ADHD. In this way the child can get specific interventions for whichever learning disorder they have.

It is also important to make sure that there are no medical conditions such as loss of hearing and thyroid problems such as hyperthyroidism that is causing a picture of hyperactivity and inattention. In rare circumstances there are genetic disorders like Fragile X syndrome where children have significant ADHD symptoms. A thorough checkup with the pediatrician is needed during the evaluation.

Preetham Grandhi M.D

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