Dr. M.J. Bazos, MD Patient Handout


About Your Diagnosis

Attention deficit disorder (ADD) in children is often considered in conjunction with other disruptive behavior disorders, including conduct disorder and oppositional defiant disorder. It is only recently that we have begun to pay more attention to ADD in adults. To diagnose ADD, the child must demonstrate either signs of inattention (ADD) or signs of hyperactivity (ADHD). Signs of inattention include:
1. Failing to pay attention to details, or making careless mistakes in schoolwork or other activities.
2. Difficulty sustaining attention in either task or play activities.
3. Not listening when spoken to directly.
4. Not following through all instructions, and failing to finish schoolwork, chores, or duties in the workplace.
5. Difficulty organizing tasks and activities.
6. Avoiding, disliking, or being reluctant to start tasks that require sustained mental effort.
7. Losing things necessary for tasks or activities.
8. Being easily distracted by other stimuli that have nothing to do with the task at hand.
9. Forgetfulness in daily activities. Of course, these behaviors are fairly common, even in normal children. Therefore six or more of these eight criteria must be present for at least 6 months to a degree that is interfering with a child’s daily function and is inappropriate for the child’s anticipated level of development, for the diagnosis of ADD to be made. In addition to or instead of signs of inattention, the child often shows signs of hyperactivity as indicated by:
1. Fidgeting with hands or feet or squirming in the seat.
2. Leaving a seat in the classroom or in other situations in which remaining seated is expected.
3. Running about or climbing excessively in situations in which that is inappropriate.
4. Difficulty playing or engaging in leisure activity quietly.
5. Being on the go or active as if driven by some kind of motor.
6. Talking excessively.
7. Impulsively blurting out answers before questions have even been asked or completed.
8. Difficulty waiting their turn.
9. Interrupting or intruding on others. In addition, for the diagnosis of ADHA to be made six or more of these signs of hyperactivity must persist for 6 months to a degree that is interfering with the child’s development and is inappropriate for the child’s stage of development. ADD accompanied by hyperactivity is defined as ADHD.
Living With Your Diagnosis
ADD is identified as a persistent, severe pattern of inattention or hyperactivity (ADHD)/impulsivity symptoms as compared with the behavior of other children at the same developmental level. The onset of these symptoms must occur before 7 years of age, and the symptoms must be present in more than one setting; for instance, at school and at home. Of course, other conditions such as anxiety disorders might explain these symptoms. Between 2% and 7% of all children have ADD, and it seems that in schoolage children, its prevalence is higher in boys. By adolescence, the prevalence of ADD has narrowed considerably between boys and girls. It seems that ADD does run in families, because children of parents with ADD have an increased risk of developing the disorder, compared with that of children whose parents are unaffected. Some environmental factors also may play a role in the progression of ADD, including growing up in a very chaotic, crowded environment, growing up in a lower socioeconomic status home, and growing up in a family where the entire family unit, especially parents, is not intact. Also, childhood neglect and child abuse may predispose to its development. Often, the early behavior associated with ADD and ADHD is seen in very young children. Some studies suggest that children as young as 1-1/2 years are brought to physicians because parents are concerned that their children move too much during sleep. At about 3 years of age, however, the symptoms described by parents usually include difficulty playing quietly and excessive climbing and running. Usually parents notice the hyperactivity (ADHD) more than the attention problems (ADD, alone), probably because inattention is often not noticed until a child begins school and grades suffer because of it. Although hyperactivity, impulsivity, and attention problems decline through adolescence, in some individuals they persist well into adulthood. In some populations of adolescents, it has been noted that those with ADD and ADHD have a higher incidence of delinquency, truancy, and substance abuse during adolescence. This pattern of antisocial behavior may also continue through adulthood. Often, other family members, neighbors, or teachers encourage the parents to have their child evaluated for ADD and especially ADHD. Many of these ADHD children are typically described as very active or just “normal boys”; however, looking back, many parents point out that their child’s behavior was not normal. In assessing a child for ADHD, other psychiatric and medical conditions that might be causing hyperactivity must be looked for, as well as family events that the child may be reacting to. The most common way of diagnosing this disorder is through the use of rating scales. Usually the rating scales are completed by teachers and parents because often the child does not display the hyperactivity in the psychiatrist’s presence. Although the parents may be more aware of the child’s behavior at home, teachers are often more aware of different problems in attention because of the more structured nature of the classroom. One of the more common scales used to diagnose ADHD is the Conner’s teacher rating scale, which is used for children from 3 to 17 years of age. The Utah rating scale, also commonly used to diagnose ADD and ADHD, describes certain behaviors. The parents or teachers have to determine how often these behaviors occur and rate the frequency of their occurrence as follows: “not at all,” “seldom,” “often,” or “frequent.” A different number of points is given for each category, and the points are then added. If the child’s behavior score falls outside the norms, then the diagnosis of ADHD or ADD is suspected. In addition to the rating scales, interviewing the child with suspected ADHD and the child’s parents is essential. Finally, there is a role for observing the child and commenting on those observations as part of the diagnosis. Therefore the diagnoses of ADD and ADHD are generally made by considering a combination of factors, including the interviews, the rating scales, and observation. Presently, no specific laboratory tests are available that can help in the diagnosis of these disorders.
The most effective treatment of ADD and ADHD is a combination of psychosocial and drug therapy. The drugs most commonly used are the so-called psychostimulants, which seem to have an opposite effect on children with this disorder. Instead of overstimulating these children, these drugs help them feel calmer, more relaxed, more focused, and less scattered in their thinking. Drugs used to treat this condition include methylphenidate (Ritalin), dextroamphetamine, and pemoline (Cylert). Ritalin is the most commonly prescribed drug in this country for treating ADD and ADHD and accounts for more than 90% of all stimulant use in the United States. Because of their tendency to improve attention, the stimulants used in children with ADD and ADHD often lead to an improvement in their school
function. Ritalin is often used because it is less likely to cause side effects than some of the other drugs. Ritalin can cause insomnia and appetite suppression, and so the drug is usually given in the morning. The typical dose is 5 mg to start, and is increased by 5 mg until the desired effect is achieved. If the drug is given three times a day, the last dose of the day is usually one half the morning or noon dose. The recommended maximum dose is 60 mg, although in some cases, higher doses have been used successfully. If dextroamphetamine is to be used, it should only be used after failure of a trial of Ritalin. Dextroamphetamine is more potent, so the dose is lower than that which would be used for Ritalin to treat ADHD. Antidepressants have also been used, especially imipramine and desipramine. They do, of course, have side effects that include rapid heart rate, a drop in blood pressure when standing, and some blurry vision. Generally these problems are not sufficient to discontinue the medication if it is working. It is important to point out that there have been rare reports of sudden death in infants who were taking desipramine. The serotonin drugs, such as Prozac, are currently under investigation for the treatment of this disorder, and a drug used to treat high blood pressure, clonidine, has also been used successfully. However, the hallmark of treatment with medication for ADHD remains the psychostimulants and preferably Ritalin. In adults with ADHD and ADD (formerly known as residual ADD), there is often a history of failed relationships, problems at work and frequently changing jobs, many activities started but never completed, and occasionally alcohol and drug abuse. Many of these patients as adults have been in different psychiatric facilities where they may have been misdiagnosed as having either anxiety disorders or manic depressive disorder. The use of psychostimulants in this population is often very effective in helping patients return to functioning fairly normally. One major concern is the use of psychostimulants in populations that have had a history of substance abuse, particularly stimulant abuse involving cocaine, PCP, or the amphetamines. Ritalin and dextroamphetamine should not be used in this population. Instead, those individuals with substance abuse and ADHD or ADD should be treated primarily with the more stimulating antidepressants such as desipramine, imipramine, and fluoxetine (Prozac). Some reports indicate that patients with ADD and a history of drug abuse have been treated successfully with Cylert, which may have a less addictive potential than dextroamphetamine and Ritalin. Having a child with ADD or ADHD can be extremely distressing for parents, often stretching their patience to the limit. These children can be extremely irritable and aggressive, and parents have to keep a close watch on them. Therefore, support for the parents is essential. In adults, the ADD may coexist with depression, and some studies have reported successful treatment of major depression in ADD with a combination of Ritalin and either imipramine or Prozac. Some studies have shown that growth retardation can occur with dextroamphetamine and other agents besides Ritalin, but this has not been well documented. Of course, the traditional side effects of antidepressant drugs such as desipramine include dry mouth and blurry vision, and Prozac can cause nausea, upset stomach, and, in adults, sexual dysfunction. In higher dosages, the psychostimulants can increase the occurrence of cardiac arrhythmias and potentially cause seizures. Although it is important to remember that not all active children have ADHD, parents should not hesitate to have their children evaluated if their behavior seems to be different in terms of their level of activity, compared with the activity level of siblings or neighbors’ children. The use of the medications mentioned above can give a child a sense of accomplishment and increase self-esteem that is often lacking in individuals who have this disorder.
The DOs
If irritability is a problem, adults with ADD should consider support groups for anger control. Patients with ADD should engage in a regular exercise program and try to maintain some structure and routine in their lives.
The DON’Ts
Individuals with ADD should not attempt to selfmedicate hyperactivity with drugs or alcohol, or use excessive amounts of caffeine or sugar. They should
prioritize activities and not begin several tasks at one time. Also, doses of Ritalin or amphetamine should only be increased by a physician. These drugs do have addictive potential.
When to Call Your Doctor
You should call your doctor if you notice any side effects of medication, including muscle twitching, nausea, rapid heartbeat, or confusion. Depression, aggressive behavior and/or psychosis should also be reported. You should also contact your physician if you feel the need for a mental health referral or a support group to help you deal with your child’s condition.
ADD Archive: http://www.seas.upenn.edu/~mengwong/add
ADD Checklist: http://www-leland.stanford.edu/group/dss/disability/add/adult.checklist.htm
Children and Adults with ADD: http://turnpike.net/metro/B/bernstp/ chadd544.htm
Facts About Ritalin: http://services.bunyip.com:2331/medica/c/pharmacy/ritalin.htm/