We hear ourselves use the term "ADD" when we are having a "wifty" day and just can't seem to think straight. When our kids or spouses forget something important or acts "goofy", we throw around the ol' ADD lingo. Well, you're lucky if this kind of thing happens to you/yours only once in a while. You know the feeling, don't you? It happens when you are stressed, haven't slept or eaten well or are overwhelmed. In these situations, you take a break, eat a balanced meal, get hydrated and get some zzzz's and you are good to go. So, what is ADD or ADHD? What really goes on in there that causes so much trouble in our lives?
First, let's figure out exactly what we are talking about. The disorder has undergone quite a few name changes before we settled on the most recent one. It is officially called Attention-Deficit/Hyperactivity Disorder and has three main types and they are characterized as being "in partial remission" and the symptoms are described as mild, moderate or severe.
1. Predominantly Inattentive Presentation. This means that...
- You have organizational problems including keeping materials straight and keeping your workplace orderly. ("Now, where did I put that W-9? I just had it here a minute ago?")
- You don't focus on details (It's the War of 1812, not 1813. Your anniversary is 8-15, not 8-17...oops!)
- You can't sustain attention during tasks, especially the ones that are tedious and do not interest you. You "bail out" mentally. You stick mainly to the "preferred" tasks.
- You don't seem to "hear" even when someone is speaking directly to you. You walk away and realize that you are not "sure" what your supervisor or spouse said.
- You do not follow through on instructions or finish "anything". You can start the task, but finishing it is another thing. Think about that yard-long "honey do" list.
- You avoid tasks that require sustained attention (like reading this post). You wonder why only half of the recipe was written down when you go to prepare it!
- You lose necessary materials to get the job done. Some of the favorite things we like to lose are keys, glasses, cell phones, hats, umbrellas, anything that you might lay down somewhere.
- You are easily distracted by the butterfly that just fluttered past the window...external events or even internal thoughts hijack your attention span.
- Your are forgetful. You don't pay the bills even when you have the money; you miss appointments, forget to pick the kids up from soccer practice and on and on and on. More than once, I've heard from parents that they got a divorce because he did not pay the car insurance, phone and electric bills and because she didn't prepare meals, do the shopping, laundry, clean house or get the kids to and from school on time and teachers complain that your children's homework isn't done and no one shows up for parent conferences.
2. Predominantly Hyperactive/Impulsive Presentation. This means that...
- You feel restless (adolescents/adults) or run about or climb in situations where it is inappropriate (children).
- You fidget with your hands or feet or squirm in your seat. Anything within your grasp is "game" to use as a fidget even if it doesn't belong to you.
- You get out of your chair and walk around when it is not appropriate..awkward!
- You are the loud one in the group even in recreational activities. You don't seem to "get" the feedback that your voice is BOOMING!
- You are "on the go" and have difficulty sitting still for a while such as in a meeting or in a restaurant. Others may feel that they have trouble keeping up with you.
- You talk excessively. The term "oral diarrhea" is frequently used in my office (by parents) although I have borrowed the phrase (I don't remember from whom..) OTM-OTM...On the mind, out the mouth...uh huh, yeah, you know what I mean. Hello? Where's the gatekeeper??
- You just cannot, cannot, cannot wait your turn.. you just can't. You might have that "entitled" feeling or you may just be coming out of your skin, but you can't wait your turn. You have to be first or next.
- You are likely to blurt out answers before the question has been completely presented. No, life is not a game of Jeopardy where you try to beat everyone else to the buzzer.
- You interrupt others or intrude on others' conversations and yes, your relatives are not exempt from this...they can be ADHD, too. It has a strong genetic component. Oh no!
3. Combined Presentation. That means you have significant behaviors related to both inattention and hyperactivity/impulsivity. It's a serious life challenge.
Second, this disorder is not just about being inattentive or being hyperactive/impulsive. It is associated with a number of very serious "life" problems. Here's what I've seen. A bit of a warning here. This is ugly and a lot more dangerous than you ever thought.
Those with ADHD, especially those who go untreated in childhood are at greater risk for:
1. Academic problems because:
- You have sufficient knowledge, but have "production" failures. You don't turn in the work or complete the assignments.
- You lose the paperwork or the disk or the flash drive or memory stick that is necessary to complete the assignment.
- You forgot that you had to go to the library to get the book. What time does it close?
- You did not plan enough time to get the assignment done. Edward Hallowell, M.D., a famous ADHD-er and dyslexic, is known to say that "people with ADHD start getting ready when they are already late".
- You work more slowly than is expected. Those with ADHD are vulnerable to slow processing speed. We're not sure why this is the case, but speed of processing appears to be "hard-wired" and is not substantially improved with medical management of ADHD. The pace of educational instruction waits for no man...or 2nd grader.
- You give up on being successful in school and attendance becomes a problem. Why put your hand on the hot burner? Get away! Get away!
You end up just knowing that you are stupid because your grades are poor. After all, aren't grades absolute proof of intelligence? The reality is that the problem is with "production" and is not related to intelligence.
The school failure part is dangerous because it leads to a number of other "unintended consequences" such as limitations to potential peer groups. Kids have a tendency to "trickle" down to the peer group who will accept them which is most likely other kids with ADHD or behavioral problems that lead them to divorce themselves from school. Misery loves company, but it also sets up your child for behaviors problems as these kids reinforce one another's antics.
A poor school performance has the potential to limit future aspirations. "If I can't do well in school, what kind of job can I get?" These kids sit right there in front of me in my office and tell me, convincingly, that they will NEVER be able to go to college even though I have just shown them the evidence that they are smart and have actually learned a lot. The scars of failure run deep and they've long since stopped believing anybody who is "cheering them on". They haven't experienced genuine success (defined as the success they know they have actually earned) and they are afraid to believe it is even possible.
2. Social problems because:
- You say the wrong things at the wrong time and hurt people's feelings because you just don't "survey the social landscape" and plan and organize an acceptable response. It's that "friend" who tells you that you can have another baby after a miscarriage or that it's a blessing that your father died because he was suffering. It's OTM-OTM all over again. Do they even HEAR themselves?
- You are socially underdeveloped because you missed out on those critical stages where you "should" have learned basic social skills, but because your brain was "disengaged", you missed out on early training. Or, you were shunned (neglected or rejected) by your peer group and never had all those chances to practice your social skills. You may have withdrawn or acted out as a result.
- You don't "read" other people as accurately as you need to and your responses are "off base". You don't pick up on the clues as to whether or not you should enter a group. You may not realize that others are looking at you strangely or stop talking as you approach.
- Your social timing is "off". At times, when I give talks about this concept, I have the audience stand up and sing "Take Me Out to the Ballgame", the singing of which usually involves some subtle swaying back and forth. Oh boy! It is so very, very easy to see who is "off" and even if it is just a "tick", it is very obvious. Even subtle timing differences can impact the social exchange.
- You don't process verbal information quickly and cannot make decisions quickly. As a result, you might be seen as "strange". If you take too long (and this is especially true with kids), your "communication partner" is going to wonder "What is wrong with you?" If you can't make a decision what to order for lunch in a reasonable amount of time, you won't be invited again. You're out of step with others. The rejection/neglect dynamic is extremely painful and damaging to the spirit.
- You don't show up when you are supposed to and you are just "too much work". Richard Lavoie wrote a wonderful book called, "It's So Much Work to be Your Friend" about the social dynamics of the learning disabled child. Loved it. Very helpful.
- If you are an ADHD kid, you don't follow the rules, are a poor sport, get angry and stomp off, get out of control and on and on. You get the reputation for being a pain in the neck and are not invited to sleepovers or birthday parties because you will be the one to ruin it. Again, you lose out on chances to practice your social skills AND you feel bad about yourself and have no idea how to "fix it". Sad.
- You don't keep your agreements. You don't do your part of the group project or you don't show up when you said you would be there. Mostly this kind of thing happens because of memory problems and time management deficits. You promise someone you'll help them and forget about it and then commit to someone else. Ouch. You get a reputation as being unreliable, undependable and uncaring. You may also be seen as flaky, selfish or manipulative.
3. Quality of life problems because:
People with ADHD, and especially those who are not treated, are vulnerable to a paralyzing constellation of "life problems" that are expensive, inconvenient, painful and possibly fatal.
- Have multiple jobs of short duration (late to work, don't finish your assignments..."You're fired!"
- Get into trouble with the cops by behaving dangerously by speeding, etc., and not complying with police requests.
- Financial problems due to failure to maintain a job and/or reckless spending.
- Excessive ER visits due to high-risk behavior or substance abuse.
- Multiple traffic accidents due to failure to pay attention, use sound judgment or having low frustration tolerance for others on the road and not leaving in time to reach the destination.
- Multiple relationships of short duration. They might be fun and exciting for a while, but they'll wear people out with their inconsistency and "drama" and they will move on.
- They don't develop a support group because they don't reciprocate. People cannot rely on them, so they can't rely on others.
- Depression and anxiety develop due to the architecture of the ADHD brain that leads to reduced dopamine (the satisfaction/motivation neurotransmitter) and serotonin (the naturally occurring "antidepressant"). They are also vulnerable because life is just more challenging as they are "blindsided" again and again by failure and difficult situations that they never same coming or could not control.
- Increased risk of suicide attempts.
- Increased risk of substance abuse which is likely resultant from attempts to self-medicate and/or cope with feelings of failure, stress and dissatisfaction.
- Low frustration tolerance causing work, academic and social problems.
- Emotional instability due to a failure to regulate emotions and develop effective coping skill.s
- Chronic irritability which makes them just oh so pleasant to be around. Subsequently, they don't have a chance to establish or maintain a social support group.
- I've seen more than one kid flunk out of college because Mom and Dad were not around to organize their lives. Being asked to leave a college is a life-altering event and oftentimes, is way too public ("I saw Sam the other day. Why is he home from college?"). Professors hand out a syllabus and they don't follow students around and coax them to get the work done. Mom is not there yelling at them to stop playing World of Warcraft. Kids have to meet their own basic needs. Without someone to account to, they drink, socialize and play video games to the point of gluttony and realize waayyyy too late that they cannot recover in time. Because most of them are over 18, "notices" home do not happen. Mom and Dad know nothing until Sam shows up with his bags packed and gives them a "minimize, marginalize and deny" song and dance.
- Conflict-driven behavior is particularly dangerous. These are folks who have to get into a fight in order to "think clearly". I have parents who come in and say, "What is THIS?" He starts a fight just before homework and once it's over, he gets right to work! It's exhausting and we dread this.". Getting into a fight causes significant physiological responses that begin with dumping adrenaline which increases heart rate and "turns" on the brain. Ta da! Big problems are in store if you develop the "adrenaline junkie" syndrome whereby you need the "fear factor" to get going. You really don't want to train the brain to dump adrenaline that easily. You get good at what you practice and if you practice triggering the adrenaline, it is easier to set it off with less and less stimulation. Eventually, you "go off" with every little frustration.
People with ADHD have a wide assortment of "miscellaneous" challenges that increase the misery index. There are:
1. Sleep Disorders: ADHD is a regulatory disorder which means that there is difficulty with the "gas" and the "brake". Those with ADHD find it difficult to transition to sleep and then, transition to wakefulness. And, if you don't get enough sleep, there goes your ability to pay attention and to use language skills, both of which are necessary for life in general, but is especially critical for academics. If you don't get enough sleep, no amount of medication is going to make up for it. Medication does not work if your neurology is undermined by sleep deprivation.
2. Poor diet: It takes planning and preparation to purchase the ingredients and prepare a salad. It's just easier to drive through Mickey Ds or El Pollo Loco 6-10 times a week. Next time you go grocery shopping, observe the steps it takes to prepare to shop, to shop for and put away the items. Then, you have to remember that you have the ingredients to make a meal! Executive functioning deficits undermine intention.
3. Executive functioning deficits: What in the world is THIS? Executive functioning "brain dynamics" occur in the prefrontal cortex (the area behind the forehead) and it is also the area that is significantly impacted by ADHD. Executive functioning skills include:
- Planning and organizing
- Starting tasks (initiation)
- Inhibiting inappropriate (dangerous or socially costly) behaviors
- Monitoring yourself as you move throughout the day or through a task. It's the quality control process. "How am I presenting myself in this situation?", "Hmmm, is this the right approach for this project?"
- Emotional control. Are you over-reacting or under-reacting to a situation?
- Using working memory. Do you retain information in your mind while you work with it?
- Metacognition (this is a biggie!). Metacognition is the "thinking about thinking" dynamic. "Let's see, I need to get the bread out of the pantry, get the cheese out of the fridge, and oh, don't forget the mustard. Where's the plate?...Oh wait, let me get this one and I'll need a knife and what else? Hmmm...pickles might be good, dill or sweet? And, I need something to drink." You think I'm kidding here? Watch yourself the next time you do something. Eavesdrop on your mind and hear what is being processed while you work through some "mindless" (basic) task. There's no such thing as "mindless". Even when you are not paying direct attention, your mind continues to work on "stuff". This is the reason why you van come up with information without even thinking of it even though you could not recall it a few minutes earlier. WOW!
- Shifting gears from one task to another (Mothers are GREAT at this because we rarely get the chance to finish anything before somebody needs something from us!). Cognitive shifting and behavioral shifting are critical to daily success.
4. The Continuum of Catastrophe: ADHD does NOT end with childhood. Best estimates are that 60%, yes, 60% of children with ADHD go on to have treatable levels of symptoms as adults. You won't grow out of it, but if you had hyperactive/impulsive symptoms as a kid, you are likely to not demonstrate those behaviors as an adult, but the inattentive stuff persists. As your neurology matures and you are socialized, the hyperactivity is reduced. Aaahhh, at least a little break.
For an alarming number of kids, especially boys, ADHD "morphs" into Oppositional Defiant Disorder (ODD) in late childhood and early adolescence (ages 8 to 12). Along with the "make me" mentality, ODD is characterized by:
- Being touchy and easily annoyed
- Angry and resentful
- Argues excessively
- Deliberately annoys others
- Rarely (if ever) takes responsibility for their own actions
- Defies or refuses to comply with requests and violates he rules
- Especially spiteful or vindictive
Considering the nature of adolescence, how can you tell this isn't just typical teenage behavior? Because it exceeds the level associated with the teen years in terms of frequency, intensity and duration. It's just more severe. When/If your kids hit this stage, you need to get really serious, really fast because once they have power, it's tough to get it back. Look at our government! Go ahead, try to wrestle that massive power away from those "teenagers". If your child is ODD, get intense parenting support to help your child to rejoin the family.
On multiple occasions, my clients have been sent to residential treatment in an attempt to re-socialize them so that their behavior does not land them in jail because of Conduct Disorder, which, generally, is a pattern of violating the basic rights of others. Specific behaviors include:
- Using weapons to scare or intimidate others
- Being physically cruel to animals and people
- Stealing with/without confronting the victim
- Forcing others into sexual acts
- Fire setting (of the arson variety)
- Destruction of others' property
- Lying to get goods or favors
- Running away from home
- Being truant from school
- Staying out all night without parental permission
I've spent enough time in juvenile court with clients to know that judges do not give a damn about the "why" the kid committed the crime. They seem to view the "reasons" as "excuses", so don't even go there if you are in front of a judge. They know what we may not be willing to face which is that the problems are not going to stop here...they are going to get much, much worse and there is going to be a much longer list of victims and a lot more destruction...of everything. Judges just want someone (usually me) to assure them that this kid is not going to be back in their court (they won't be back in juvenile court, but likely, adult court). My "code" to the judge is to reassure them that they will not be back if they let me "get them to the sidewalk". This means that parents have arranged for their out of control teen to be taken to residential treatment. It is a heartbreaking process for these brave parents. But, it's a whole lot easier to take than a call from the coroner.
I recall a statistic from long ago indicating that untreated ADHD girls have their first pregnancy around age 20 while treated ADHD and non-ADHD girls have their first pregnancy around age 27. The amount of education, work experience, earned income and social development that can take place in those 7 years can change the path of an entire lifetime.
How will ADHD be diagnosed so that I know this is really what it is and not "something" else?
The most common practice in diagnosing ADHD is a "psychosocial" approach. I take a complete (35-page) developmental history and collect data from collaterals (that's Mom, Dad and teachers) as well as from my client. I conduct "blind" classroom observations (the kid does not know me). Or, you can pay for a SPECT scan (single photon emission chromatography) from one of Dr. Daniel Amen's clinics if you've got the cash. The SPECT scan is a "functional blood profusion" study that looks at the brain's blood flow patterns. If blood isn't flowing to your brain competently, "stuff" isn't gonna work!
What am I looking for when I conduct an ADHD assessment? I am looking for functional impairments and I am trying to determine if there is another, more plausible reason for the symptoms I am seeing (the "rule outs"). I listed the diagnostic criteria at the beginning of the post. It is also important to know that you have to demonstrate these behaviors in at least two settings. You can't be ADHD at school and not at home. However, there are factors in any setting which can calm ADHD or cause it to "flame on".
I just love it when I make the diagnosis of Attention-Deficit/Hyperactivity Disorder and one or both parents will say, "Well, gee, aren't we all a little ADHD?" Yes, of course! When we haven't slept well, have eaten poorly or are under stress, two cognitive skills "go" first...attention and language. In periods of stress, have you heard yourself say, "I just can't think straight". BINGO! Imagine living life like that every single day. Not all kids exhibit the same levels of ADHD across all situations which, at times, "dupes" parents into thinking they may not "have it". "Some days, he can do his homework without any problems." It is frequently said that the only consistency about ADHD is its inconsistency.
Just about any "diagnosis" that I can think of has to qualify as a "functional impairment" or it's not considered to be a diagnosable disorder. When laws are written regarding disabilities, the term "functional impairment" appears as a qualifier. It has to be a serious problem to qualify for funds or services.
Well, what is a functional impairment? The best way to describe this is to relate it to something we are all likely to have experienced. If you have a runny nose, headache or scratchy throat, you are still in the game. But, when the fever hits 104, muscle aches wrack your body, your throat is on fire, your head is about to explode, your nose is filled with cement and nothing stays in your gut, you've got the flu (a diagnosis) and you are done, baby, stick a fork in you 'cause the only place you're going is to the bathroom and then right back to bed. Functional impairment...your functioning is indeed, impaired!
The data I collect regarding my clients HAS to convince me that it is, indeed, ADHD and not anything else. I've had youngsters referred to me for potential ADHD when their symptoms were more consistent with:
- Post-traumatic stress disorder
- Sleep deprivation
- Thyroid conditions
- Child neglect
- Intellectual impairment (retardation)
- Substance Abuse
- Bipolar disorder
There are many disorders which are "understood" to have ADHD symptoms as part of the disorder. These include fetal alcohol spectrum disorder and autism. Just because they are an expected part of a disorder does NOT mean that you just let it go. You treat the disorder so that you can take advantage of any genetic endowments (strengths). There are at least 17 other diagnosable disorders whose symptoms overlap with ADHD. Make sure you know what symptoms and disorders you are intentionally treating!!!
The reason that the data has to convince me that the problem is truly ADHD is because medical management is the most effective way to treat this disorder. I suspect that many of you do not want to hear me say this, but research indicates that it is the most effective approach and it certainly is the case in my practice and in my work with kids. Unfortunately, many of my parents have spent tens of thousands of dollars on non-medication interventions that lasted for a short while and then failed. I am not advocating that you just give you kid a pill and be done with it. Far from it. In order to have optimal results, you need to consider the following (these are also recommended if your child, for medical reasons, cannot take medication):
- Diet: Those with ADHD crave carbs. Sweets and fats are the preferred foods. Interestingly, these are the same nutrients that are craved when people are under stress. Hmmmm... You need to give that body protein and considering that the adolescent body uses 90% of its caloric intake to run the thing and only 10% to build it, you need strategies to give your body what it needs. I read a great book called The ADD Nutrition Solution by Marcia Zimmerman and the one chapter that really taught me a lot is called "How Food Affects the Brain". Get the book for that chapter alone. Forget about categorizing food. The ADHD breakfast might, in fact, be leftover meatloaf and mashies or a bean and cheese burrito. No cereal!!! Yes, stimulant medication can reduce appetite so work with the timing of the meds to reduce the impact. Make the most of the foods that are eaten.
- Exercise: Cardio is the key. Swimming is a narcotic to the ADHD body. The total immersion and sensation of the water is just what the brain craves. Team sports may or may not be right choice for your child. Consider all of the obvious options and then go online to explore less traditional activities such as rock wall climbing, snorkeling or fencing. Take into account your child's motor and social skills before enrolling them in a team. After a certain age, teams are focused on winning and not on skill development, so if your child isn't ready to handle the pressure, look elsewhere.
- Learning Disabilities: Treatment for ADHD does not "cure" or remediate learning disabilities (although I've seen kids' handwriting improve!). If your child has ADHD, there's a chance that processing disorders such as slow speed, executive functioning deficits and memory deficits are lurking somewhere. Treating the ADHD gives them a chance to benefit from remediation and from their educational and social opportunities. Getting an evaluation through school or a private practitioner will give you more information to determine the plan to improve school performance. At the very least, a Section 504 Plan to provide accommodations (even in college) will help your child perform to their potential.
IMPORTANT NOTE: At times, kids have missed out on a great deal of instruction because they were so disengaged that they did not meaningfully participate in their education. They did not learn and so, their achievement (reading, writing and math) deficits are more related to a loss of opportunity than to being "true" disabilities. If they have intensely compromised processing disorders related to speed, memory, visual-motor skills, executive functioning or language processing, they are likely to be diagnosable as learning disabled.
Your child may benefit from "educational technology" such as software and electronic devices that provide them with what I call "external neurology". If they don't have their own competent, internal neurology, they have to supplement it. A grocery list or a piece of paper with directions on it qualifies as "external neurology" in my definition and it really can be as simple as that. Explore the internet for instructional software programs. The companies make them very easy for "non-techies" to use (like Mom and Dad!). In my experience, the iPad 2 has amazing apps that help to organize the "unorganizable". Your child may also benefit from a "pack-up" opportunity at the end of the day whereby they are helped by an adult to get all of the materials they need for homework. Priceless.
- Parenting Support: Get yourself a strong ADD coach (someone with at least a Master's degree and a professional license who specializes in ADHD treatment) if you feel in over your head. I subscribe to a great magazine called ADDitude and they have an amazing website. If you must subscribe to get it online, it's oh so worth it. But, a real, live human is someone you can bounce ideas off of and who can teach you specialized ways to support the unique needs of your child. Stay in touch with them as your child moves through the various developmental stages to keep the issues manageable. Once you let them (the issues) get out of hand, they are like Ursula the Sea Witch in the Little Mermaid. The become ugly, monstrous, really, really mean. No need to say it, but I will...they get expensive. The pain of it all, however, has no price tag.
Because I support a medication approach, I'll no doubt get some nasty notes accusing me of being in bed with Big Pharma...don't bother. I'm not. I am grateful, however, for the many medication options to help my clients' brains get going (kids and adults alike). The kids and parents (when I diagnose kids, sometimes the light bulb comes on for both one or both parents!). The way they turn their lives around is inspiring. They are courageous for wanting a better life and doing what it takes to get it.
This leads me to this next idea of "Why do we have such trouble with the concept of medication?"
Is it the whole Stepford Wives stereotype? Do we really think we are medicating kids to make them conform? Not in my office...We don't seem to have trouble with our kids taking insulin, thyroid medication or using eye glasses. These medications and devices help us to "stay with the pack", stay safe and allow us to be successful by helping our brains to work to their potential. Is it just the idea of psychiatric medications that make us squirm?
If you think that diabetes or thyroid conditions don't impact behavior, just do a Google search and learn about their associated behaviors. Yet, we have no compunction about treating these disorders. Police officers now have a very specific protocol to determine if a person is actually drunk from alcohol or is experiencing diabetic ketoacidosis. Unfortunately, "suspected drunk", but actually diabetic persons have been thrown into "drunk tanks" only to be discovered later, dead from a diabetic crisis. Undiagnosed thyroid conditions lead to fatigue, irritability, loss of concentration and weight gain or loss. Even eye glasses have "side effects" of being yet one more thing for a social predator to tease your child about. They can break during recess and hurt your child. There's risk in every decision. The risk-return algorithm needs to be created and you go with the best decision you can make based on the facts that you have at the time so that there are no regrets. Life waits for none of us and "shoulda, coulda, woulda" isn't going to ease your pain when your child suffers the consequences of untreated disorders of any kind.
Parents say to me, "There's this kid in Sam's class and he's skinny and pale and just a zombie and he's on ADHD medication." Of course, there could be a lot of reasons why this kid looks like this including that he may be on antipsychotics and not ADHD medications and parents aren't telling the truth. They suspect that if you knew the truth, you would be afraid and so would your kid. I only know that none of my clients look like this because the diagnosis was competently achieved and they are under competent medical care to manage whatever symptoms I have quantified and qualified. Don't let fear overwhelm you. Get informed and make decisions in your own child's best interest. BTW, if a kid looks like a zombie, I would suspect something has gone awry in either the diagnostic process or the medical management.
For the "straightforward" ADHD, I am OK with an intensely ADHD-experienced pediatrician managing the medication, but most of the time, my clients have more complicated symptom profiles. I refer my clients to a board-certified child and adolescent psychiatrist who has trained for many, many years only for psychiatry and neurology. This is the professional who works day in and day out with the various ways that ADHD can present and understands the adjunct problems that occur along the various developmental stages. With a psychiatrist on board, I see kids having fewer trials of different medications and more often than not, the most effective medication is the one that is prescribed the first time.
So, what's the deal about these "side effects" I hear about? There can be appetite issues which are minimized through supplements such as Special K drinks or protein bars, etc. Stimulants reduce appetite which is one of the reasons why those who use illegal stimulants are often "scrawny". As for your child coping with the demands of school and a fluctuating level of hunger, nutrition breaks are where they can get a fill-up. Students in elementary school are likely to have more flexibility in being able to leave class and trot up to the nurse's office and have a snack.
Sleep can be a problem if the stimulant medication is taken later in the day. This is an issue to be addressed with the medicating physician who can adjust the dosage and work out a different schedule. Sleep is already a problem for many kids (adults, too) with ADHD and adequate sleep is critical to a person's global well-being, so ask the doctor. Speak up!!
Tic disorders are not as much of an issue as previously seen since the newer generations of medications include effective non-stimulants which do not trigger a person's predisposition to tic disorders. As well, the newer medications offer a smoother delivery without the multiple dosages and abrupt "ups" and "downs" during the day.
There can be the emergence of anger or aggression, but if you report it immediately to the medicating doctor, the information is clinically significant to them and tells them which parts of the brain are being impacted and a different medication will be prescribed or the dosage will be changed.
In terms of height, the research is inconclusive, but one study that I recently read indicated that a child might be one-half inch shorter as an adult as the result of taking medication. Really? How do they know EXACTLY how tall someone is going to be? I'll sacrifice a half-inch for the added brain volume that a child can gain if they are medically treated during elementary school.
OK, now that I know all of this...where did this stuff come from? Your guess is as good as the scientists'. No one knows for sure, we only know about the "associated" features. I mentioned previously that the architecture of the ADHD brain is different. There is increased slow wave activity ("trash" waves that don't do much for you and are associated with passive activity such as watching television...Ha!). Studies based on MRI scans indicate that ADHD brains are smaller (less volume) than the "neurotypical" brain. There might also be a delay in the maturation of the brain. Since the brain matures from back to front, the last area of the brain to mature is the prefrontal cortex (the area behind the forehead) which matures anywhere from age 25 to 35 with females maturing earlier than males (another case for us being goddesses). I think this is a "manufacturing defect"! It just might be the case that society has outpaced Mother Nature's ability to evolve us to meet the demands of the world. When we were an agrarian society (farming), ADHD was around, it just wasn't noticed because we weren't confined to the indoors or to desks. It's this detail-oriented, verbally-dependent, fast-pace that has made the disorder so obvious. Some have promoted the hunter versus farmer brain types. Others have posited that neurotransmitters and serum glucose deficits (brain's absorption of the blood sugar) are responsible.
We know that there is a genetic component. A familial history of alcohol or substance abuse is associated with ADHD and of course, as mentioned, brain insult, whether it be viral or trauma, can leave, in its wake, ADHD.
I have suspected that those women who are under chronic and serious levels of stress during pregnancy might be dumping adrenalin and cortisol (stress hormone) into the developing fetus and changing the wiring which results in an ADHD brain. Perhaps this is partly responsible for the "uptick" in ADHD cases.
If you go through a windshield, slide into the curb off your speeding motorcycle, roll your call because you were speeding and did not judge the turn competently, contracted a nasty viral syndrome, had a serious reaction to medication, had repeated concussions or had a very difficult time being born, you may exhibit ADHD and executive functioning deficits. Protect your brain! Wear the seatbelt. Wear the helmet. Drive at a reasonable. Don't get drunk, out of control and in a fight or fall down. You are unlikely to know the person with whom you get into a fight. You don't know what they will hit you with or where they will hit you. You might win the fight, but end up with serious brain damage. Big deal. No gold medal there. You kill those neurons (brain cells) and they are not likely to come back. No "heading" the soccer ball unless you are a professional player and even then, avoid it because most of the time that ball is whacking right into the forehead where one of the most important parts of your brain lives...ugh.
Look at the recent suicide and violent deaths of NFL players who suffered from Chronic Traumatic Encephalopathy. They rocked their brains within their skulls so many times while making a living that depression set in and they could not get around it, up over it or through it. You cannot damage a brain that much and expect both the structure (the physical brain) and the neurotransmitters (the fluids) to rebound. I think of the brain like a car. There's the actual physical structure that we all "ooh and ahhh" over and then, there are the working parts. You can have a Bugatti Veyron, but if you have no gas, oil, transmission fluid, brake fluid or there is no fluid in one of its 10 radiators, you ain't going anywhere.
Everybody I know has a kid with ADHD. Isn't it overdiagnosed? No, in fact, it is likely underdiagnosed because of the prejudice toward medication. About 5% of kids and nearly 3% of adults have been diagnosed with ADHD in most cultures. That's a very conservative estimate because of the role that culture plays in "confessing" to symptoms and to the societal factors I discussed previously.
Will I/they have to take medication forever? Who knows? The individual person's neurology and life experiences (success v. failure, job and family demands) will determine their medication "destiny". If a child is medicated early enough in life to be successful in learning and social situations, they may develop sufficient coping skills that will allow them to stop taking medication. For others, it is a life-long need. Edward Hallowell, M.D. and John Ratey, M.D. wrote Driven to Distraction, the book that taught us that adults can actually have ADHD and that it is not a "leftover" from childhood. It continues through the lifespan. We previously thought that it was "adult residual ADHD", but it is the "real deal". We see children with the Combined Type of ADHD "outgrow" their "busy"-ness as a result of brain maturation and being socialized, but the Inattentive component can linger throughout life.
I'm an adult. Can I be diagnosed now? The short answer is "yes", have at it. Although the DSM-5 diagnostic criteria indicates that "several symptoms be present before the age of 12 years", adults' ability to recall ADHD-related behaviors from childhood is sketchy at best and is unreliable and for those with primarily Inattentive symptoms, there may be no recollection of difficulties. On at least 10 occasions in my practice, I've diagnosed adults with ADHD who were high achievers throughout school, had no behavioral or social challenges EVER, but who, in college and adulthood, felt chronically overwhelmed and were growing more and more irritable. Several had started drinking more heavily than usual and drinking was actually uncharacteristic of some of them. The ADHD diagnosis was undeniable and medication was the answer along with self- and family education. They went along with their lives feeling more competent, confident and calm (my 3 Cs). As can be the case, they were temporarily more anxious because they began to notice all of the challenges they had previously ignored and which blindsided them frequently. They got the support they needed, learned coping skills and adapted to their "new brain".
What can I do to help myself now? If you are an adult, don't have a diagnosis yet and are untreated, you can help yourself by learning about the disorder, observing yourself and determining the ways it impacts you (which might be a challenge due to a general lack of self-awareness), ask those you trust about your ADHD-related behaviors and ask for any suggestions they may have to help you. Be open, not defensive. If you trust them, have confidence that they want to help you and they may actually be thrilled that you are developing the desire to have a better life. Do a gut check on your drinking and substance use habits, punctuality, the "to do" list, your general health (diet, sleep), your work habits and performance and your social performance. If you tackle everything at once, just go ahead a put a big FAIL sign on your chest. Prioritize the behaviors and choose the ones that most impact your life and tackle one at a time. One at a time. Practice it to the point of mastery and then, move onto the next one. Join CHADD (Children with Attention Deficit Disorder) and access their adult services. They have local adult support groups. Fast track your self-education by harvesting information from the speakers, leaders and participants.
What can I do to help my child now? The same advice goes for you, Mom and Dad. Learn all you can about how ADHD impacts your child at their current phase of development and educational demands. Learn about diet and exercise for the ADHD child. Make certain they are getting the sleep they need for their age. Don't engage them in too many activities outside of school. Talk with the school about support services for them. Get an educational therapist to help them (aetonline.org). Learn effective parenting strategies that reduce conflict and anxiety and increase the chances that they guide themselves instead of you prompting them endlessly. Every year, think about "what" you want your child to "look like" in 5 years and head toward that horizon.
We can do better...knowledge-based judgment is everything...