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Teens with ADHD and Driving

It goes with the territory. All adolescents are at some increased risk of distracted driving. Those with ADHD are especially vulnerable. This fact was reinforced by a study published in the JAMA Pediatrics recently. “ADHD appears to impact specific driving behaviors,” according of Cincinnati Children’s Hospital researcher, Megan Narad, one of the authors of this study. “Both maintaining a consistent speed and central, consistent lane position require constant attention to the road and one’s surroundings,’ she added.

 

Such sustained attention is difficult for the person with ADHD.
The study involved adolescents aged 16 and 17 years with or without ADHD participating in a simulated driving class which monitored driving under various conditions. In conclusion, the study clearly demonstrated that both ADHD and texting while driving present serious risks to driving performance of teens.

 
Other studies have pointed out that teen drivers with ADHD are 8 times more likely to lose their license, 4 times more likely to be involved in a collision, 3 times more likely to sustain a serious injury and 2 to 4 times more likely to receive a moving vehicle violation. These risks are not surprising considering that the core symptoms of ADHD are inattention, impulsivity, and hyperactivity—all conditions that affect focus and concentration.

 

One encouraging finding in other studies is that treatment with stimulant medication at optimum levels improve driving performance of teens with ADHD in a significant way. Thus teens with ADHD who are driving should take their prescribed medication on a regular basis without holidays.

 

Other suggestions that can help the teen drive more safely are the following commonsense precautions:

 
Always wear a seatbelt
Never drink and drive
Never drive while sleepy
No cell phone use while driving
Pay attention to surroundings—be aware if traffic is slowing, etc.
Select a radio station or recording device (CD or MP3 player) before starting the trip
Know ahead of time the directions to your destination
No speeding, follow all traffic signs
Minimize night time driving
No tailgating
Inform parents of your destination and return time.

 
Other studies suggest that teens with ADHD may need more intense driver education. Also with many teens with ADHD, delaying driving for a year or two thus allowing more time for maturity to develop would be wise.

When the ADHD Medication Does Not Seem To Be Working

Most children and adults with ADHD have a positive response with few side effects to stimulant medication. It is estimated that up to 85 to 90% of properly diagnosed children with ADHD experience significant improvement in most areas of function with the stimulants. But there are times when the physician or therapist will hear the complaint that the “Medicine is just not working!”

Dr. David Rettew, associate professor of psychiatry and pediatrics at University of Vermont, responds to this concern of medication failure in an article published in Pediatric News. In the article Dr Rettew reviews several reasons why medication may seem to be not working. Some potential causes are listed below in order of there frequency of occurrence:

1. The dose is too low. There is caution on the part of parents and clinicians when prescribing the stimulants. They wisely start off with a modest dose and push it up slowly or not at all. In fact the dose required for optimum effect varies from person to person. If the patient does not have side effects at the low dose, the dose can be increased gradually to the recommended range per weight. Many doctors and parents give up on a specific medicine before the appropriate dose is reached.

2. The medication is working but wears off early. Again, when the dose is too low, the meds might have an early beneficial effect but this positive response wears off by noon or early afternoon. This does not mean that the medicine is ineffective. It means that the doctor, parent, and patient need to modify the dose and method of taking it. First of all, it is important to make sure that the dose is at the optimal level. If the dose is adequate but the medicine effect still wears off early, it probably means that the patient metabolizes the medication more rapidly than the average person. One way of dealing with this is to have the patient take a small dose of short-acting meds after lunch.

3. Symptoms are caused by some condition other than ADHD. If the medicine is given at the proper dose with the proper timing and the patient still does not have improvement, it could mean that some other condition is causing the ADHD-like symptoms. Such conditions could be chronic sleep problems, anxiety, or other mental health disorder.

4. There is psychiatric co-morbidity. Conditions like anxiety disorder, oppositional disorder, or bipolar disorder can mimic ADHD or accompany ADHD. In this case, a thorough evaluation by a psychiatrist and/or psychologist is in order.

5. There is non-compliance. If the medicine is not working, it is important to consider that the patient is not taking the medicine as prescribed. This is often an issue with teens who are given the responsibility of taking their meds on their own without supervision.

6. There is substance abuse. If other psychoactive drugs are being abused by the patient, the benefit of the ADHD medication may be compromised.

7. The expectations of medication are too great. Some parents, even some therapists, expect the medication to be a miracle worker solving all the patient’s, and the family’s problems. While medication can at times be highly effect, it is never sufficient by itself. Issues like learning disability, anxiety, and low self-esteem will need ongoing attention to help the child reach his full potential. Although medication is helping a given patient, counseling for parents and the patient is highly recommended.

Successful medical treatment for ADHD requires openness and honesty and clear communication between parent, patient, and clinician in order to evaluate and deal with these complicating issues.

ADHD and Handwriting

Even in this day of thumb-driven Twitter shorthand, handwriting continues to be a critical and needed skill. Legible, coherent handwriting is a signal measure of academic success and still plays an important role in formal and informal communication.

 

Educators and other professionals working with children with Attention Deficit Hyperactivity Disorder (ADHD) have observed that many of these children have significant problems with handwriting.

 

A recent study coming out of the Centers for Disease Control and Prevention (CDC) documents the relevance of these observations. This research, led by Slavica Katusic of the Mayo Clinic was published in Pediatrics (September, 2011). The study included 6,000 children—all those born in Rochester Minnesota between 1976 and 1982 and who was still living there after age 5.

 

Katusic and her co-workers evaluated school and medical records to see which children showed signs of ADHD, as well as how well they performed on writing, reading and general intelligence tests over their school career. A total of 379 children fit the criteria for ADHD. About 800 children scored poorly on tests of writing abilities, and most with writing problems had reading difficulties as well.

 

Writing problems were much more common in both boys and girls with ADHD, with close to two-thirds of boys with ADHD having problems with writing. That compared to one in six of their peers without ADHD. In girls, 57 percent with ADHD had a writing problem, compared to less than 10 percent without ADHD.

 

There are several reasons why children with ADHD may have problems in writing. Handwriting is a very complex task that involves cognitive activity and motor activity at the same time. A high level of mental coordination and sequencing is required—tasks that individuals with ADHD have difficulty with. Also, memory and planning problems may affect the writing process. The impairment in sustained attention experienced by children with ADHD causes them to loose track of what they are doing and they will tend to make careless errors and get confused about what is to come next in the phrase or sentence.t is my observation that when kids with ADHD are appropriately treated with medication, improvement in handwriting can be dramatic. In fact, improvement in handwriting can be one of the more objective, observable markers of effective treatment.

 

Kids who have problems with handwriting sufficient to interfere with their ability to express what they are learning can be allowed, even encouraged, to use other means of communicating what they are learning. For instance, a student may be allowed to give a report orally rather than in writing. Certainly in middle and high school the student can be encouraged to develop word processing skills and permitted to prepare homework and even classwork using the word processer. At the same time the student will need ongoing instruction and practice in handwriting. For some ADHD students, their handwriting will never be optimal but should be functional by high school.

At the same time, intentional instruction in handwriting skills is needed. The ADHD child may not develop perfect handwriting but writing skills can be enhanced with intervention. It is appropriate to help them be the best they an be in this area while compensating in other subjects. For instance their grade in science or math should not be knocked down due to messy or slow handwriting.

 

Long term observation does suggest that the writing problems do get a little better with increasing maturity. Individual education plans that address some of those related difficulties can help especially if they’re started early.

Medication in the Summer

A mom asks, “What should we do about medication in the summer-time? I have heard from some parents that they always discontinue their child’s medication during the summer. I asked my doctor what we should do and he said we could do whatever we wanted. So I am not sure. My child is active and disorganized all the time. I worry about him becoming frustrated. What do you recommend?”

This is a good question for this time of the year. Summer is right around the corner and many parents are wondering about the same issues your raise. At one time, it was assumed that the child would take stimulant mediation for attention problems and hyperactivity only during the school year. It was felt that the medication was primarily given to help with school.

The Physicians’ Desk Reference carries a recommendation that the child taking stimulants be given a “vacation” from his medication periodically. But does this mean that all children should interrupt their medical therapy for the summer?

The goal of the total treatment program for ADHD is to provide the framework in which an individual can perform up to his or her fullest potential. Medication, environmental structure, and behavioral management all play a part in maximizing a child’s function in any given situation.

The role of medication in this process varies with each individual. Thus, the answer about summertime medication must be evaluated individually. In this process, we should look at three major skill areas—academic, social, and behavioral.

An important reason for using medication is to promote focus and concentration in the learning environment. Studies have shown that children with ADHD learn better when taking their medication. Medical treatment also enhances the ability to use skills that have been learned. Therefore, the use of medication helps individuals function more appropriately in the many areas where they are continuing to practice and master skills, i.e., family, school, playgrounds, sports, reading, organization.

If, then, the child will be involved in activities during the summer which put demands on his need for concentration or organization (summer school, sports, special camps, etc.), medication may be helpful.

Special circumstances need to be considered. For instance, adolescents often take driver’s education during the summer. Teenagers with ADHD have a higher rate of moving traffic violations primarily due to being easily distracted and the longer time necessary to acquire skills. Teens with ADD may need more prolonged driving practice with their medication before they become safe and proficient drivers.

Building social skills is extremely important for the child with ADHD. “Summer involves more socializing and self-planning than does the school year,” the author points out. There is much more free time, much less adult supervision, and fewer structured settings to provide the usual external controls.

A large percentage of individuals with ADHD have difficulty acquiring and applying social skills. This is often seen as difficulty with peers and siblings when they are not taking medication. Some children will have much more difficulty dealing with these social situations without the medication due to persistence of impulsiveness and over-reactivity.

So in making a decision about taking a break from ADHD medication during the summer, consider these factors:

•Does the child find medication to be helpful in managing a routine day at home with family and friends?

•Without medication, are there many more negative social interactions leading to social failure, discipline problems, and lower self-esteem?

•Does the continuation of medication during the summer allow the family to successfully participate in activities together, such as going out to dinner, attending religious services as a family, or joining large family gatherings?

If the answers to these questions suggest that medication could be helpful during the summer, it would be wise to give it all summer.

But, then, there are certain reasons to consider a medication vacation:

If the child is experiencing significant loss of appetite with slow weight gain, a vacation from medication is in order. A few individuals on stimulant medications will have difficulty maintaining growth during the school year. In the vast majority of these children, this means poor weight gain. If there is concern about a child’s growth, the time to discontinue medication to allow necessary ‘catch up’ growth is during the summer. Most children will regain weight quickly.”

The second reason for taking a “medication vacation” is if the family and physician decide that during the summer, medication is truly not needed. Many individuals with ADHD can discontinue their medication in the non-academic setting, such as summer vacation, holidays, and weekends. But still find it necessary for the extremely intense focus required for the hours of concentration on school and studies.

I am often asked by parents about medication during the summertime. As we see, the answer to this question must be individualized for each child. I point out to parents that what happens in school is important for the child. But as far as his success and happiness in life is concerned, what happens at home and on the playground is even more important. Thus if the child is having problems in his social and family relationships, continuation of medication is probably helpful. Actually, there are several optional courses of action: continue the medication on the same schedule as during the school year, stop the medication all together, or consider a reduced medication schedule.

When there is some question as to how the child will do off medication, I suggest giving a break for the first two weeks of summer. If the child does well, then it is appropriate to continue without medication for the remainder of the summer. If the child has trouble coping with the ordinary activities of his summer during this trial period, then restart the medication.

Saving on Medicine Costs

 

We all benefit from the wide choice of effective medicines available today to treat ADHD. Even a decade ago our choices were limited to two or three, mostly short acting preparations requiring multiple doses during the day. Thankfully, today we have a dozen or more formulations to select from. Many of these are sustained-release dosage forms that usually require taking the dose once a day.

However, this success comes with some increase in cost. Many factors contribute to the cost of new medicines:

Newer medicines cost a great deal to research and develop. The costs of evaluating effectiveness and safety are higher today than in the past due strict government regulation and scrutiny. Once a new drug is approved for use, the manufacturer has a patent for several years during which time the company has exclusive rights to the distribution of the product. Naturally they seek to recoup these developmental costs.

Fortunately several options are available which can significantly reduce the cost of medications:

Use Generics when appropriate.

Generic drugs are those which are chemically identical to a brand-name product. In general, generics which have outlived the original patent can be produced for less cost than the brand-name counterpart. While appropriate much of the time, generic substitution is not always the best move. Even when drugs are chemically identical, there can be differences in the way they are handled by the body. For example, he generic may be in a pill form the patient cannot swallow, or that tastes so badly that he will not take it. In my experience, there is functional equivalency between the generic and non-generic forms of the stimulants used to treat ADHD. However, there is the occasional child in which the effectiveness of the medication differs between generic and non-generic forms. In these patients, subtle differences in adsorption of the drug from the gastrointestinal tract probably accounts for the differences.

Discuss the possible use of generics with your physician. If he or she agrees that a generic is worth a try, then you may well manage real savings on costs. I would suggest you pick one form of the drug, generic or non-generic, and stick with it over time to avoid confusion.

Do comparison shopping.
Prescription prices vary considerably from one pharmacy to another. Do compare prices and services. But in making comparisons, consider factors important to you. Does the pharmacy have after-hours service? Does it deliver? Does it have a credit policy or does it file insurance?

Consider a mail-order pharmacy.
Many insurance plans now provide an option on drugs where you can buy from a mail-order pharmacy at significant savings. Many of these will provide up to a month supply for a flat fee that is much less than what you would pay at the pharmacy window. This type of service is quite appropriate for ADHD where the patient may require long-term medication.

Ask only for what you need.
Some people feel that their visit to the doctor is a waste if they do not come away with a prescription. Let the doctor know that you are open to his suggestions on how you might save on medication. Let him know that if a medicine is not necessary, you are not pushing for it. If medication is necessary, more is not necessarily better. The least dose that accomplishes the functional goals is best. A cooperative working relationship between doctor, parent, and child will open the door to the best medical care with the least possible bite on the budget.

ADHD and Self-Esteem

Helping the child with ADHD to grow up with a balanced sense of self‑worth requires care and effort by all who impact on his life. At every turn the child is met with situations that tend to tear down and warp the self‑image. Among these are the following:

 

1. From an early age, he finds himself in constant conflict with the limits placed on him by parents, teachers, and other authority figures. Since much of the behavior producing this conflict is not purposeful disobedience on his part, he is confused and frustrated. He gets the message, “There must be something wrong with me. I can’t do anything right!”

2. Lack of achievement in school reinforces the sense of being abnormal and inferior. A child who sees himself getting further and further behind his peers in achievement easily loses his self‑confidence. If this continues long enough, he may come to say, “Why try, I’m no good anyway.”

3. The child who is uneven in his development and who has significant discrepancies in his abilities may be confused by the contrast between what he can do easily and that which requires an inordinate amount of effort for rather minimal achievement. He may be puzzled as he tries to understand what his capacities really are. The amount of study, including testing, that is needed in the diagnosis of a learning disability also can create worry about himself. The child and his parents may be the victims of professionals disagreeing about diagnosis and treatment.

4. The child may be jealous of other children and siblings for whom achievement comes easily. There may be problems around school work at home; particularly if his brothers and sisters degrade him in any way for his less than perfect work. He may hear from school personnel or family the fallacy, “If you just work harder, you can do better.” The child may be upset by the kinds of work that he must do because of his disability: for example, a fourth‑grade boy cried because he was doing the same kind of work his first‑grade sister was doing.

5. Poor coordination resulting in unsuccessful performance on the playground is also detrimental to the self‑image. Other children often ridicule the one who is poorly coordinated. And ridicule from a peer burns deeply.

How to Help

While it can be difficult to overcome these problems, parents and professionals have some practical strategies to help the child retain a balanced sense of self‑worth in spite of the odds:

1. When the child breaks the rules or oversteps the limits, we should discipline firmly but kindly. We should aim the punishment at the offense and not at the child or his personality.

The child should not be told, “Would you stop? You’re nothing but trouble.” Instead we might say, “Johnny, your jumping around is really bugging me. I think you should go to your room for 15 minutes and see if you can stop.” We then send him immediately to his room. If he doesn’t go willingly and quickly, we take him by the shoulder and lead him to his room.

Rather than say, “Don’t be stupid. I’ve told you that a hundred times,” we should say something like, “I’ve explained that rule before. Please do what I asked.”

Everyone should remember that one can discipline firmly without attacking the person or worth of the child.

2. We should not punish the child for things he really cannot help such as fidgeting or being clumsy.

3. As much as possible we should positively reinforce appropriate and desired behavior. “Catch them being good and tell them so” is a healthy working motto. Always be on the lookout for the opportunity to honestly say something affirmative.

4. If we suspect the child of having a behavior or learning problem, we should seek help as soon as possible so that the proper diagnosis and treatment may be instituted. Often such early intervention can circumvent much of the stress and conflict that blocks their success.

5. We must seek an educational environment which treats the child as an individual, recognizes his strengths and weaknesses, and helps him learn in his own way at a pace appropriate for his skills.

6. We should help the child to discover his good qualities and superior skills. All of us, even those with special problems, do have some good points and superior abilities. We all have a deep psychological need to excel in some area of life. Your child’s hidden talent may be an isolated academic skill, a sport, a hobby, or music ability.

For instance, many children with ADHD are not very good at the traditional sports such as football, basketball, and track because of their lack of coordination. But often these children are quite well coordinated in water and are excellent swimmers. Thus swimming for fun and competition can be pursued as their area of excellence. One boy was a very poor reader but had perfect pitch and became a good musician in spite of his inability to read well.

7. We should not use language that attacks the child’s dignity or personal worth. Children who are belittled as youngsters are likely to grow up with a poor self‑image. They literally continue to belittle themselves throughout life. Such belittling adjectives as “rude”, “ugly”, “stupid”, or “clumsy” should not be used to describe children. Rude, stupid, ugly, etc. may be used to describe actions, if necessary, but they should not be used against the child himself. The danger is that the child may accept such an evaluation and make it a part of his  self‑image. If he thinks himself as rude, ugly, or stupid, he is likely, in the end, to behave that way: it is only natural for a rude boy to behave rudely.

Such precautions do not imply parents should not correct a child or criticize his behavior. There is, however, a big difference between criticizing the behavior and criticizing the child.

Rather than say “You are a rude boy,” a parent can say, “That was a rude thing to do. Apologize and go to your room.” Such a statement is not an attack on the child’s personality but  does show disapproval of his behavior.

To the child who brings home a poor report card a parent can say something like this: “Cathy, this doesn’t look like you. I guess we will have to set up a regular homework time.” To say “I knew you were lazy, but I never expected this from a child of  mine!” is to whittle away at the child’s ego.

It is a hard lesson for us parents to remember but discipline should be directed toward the misdeed and  not toward the child’s personality. Even if the child’s personality leaves something to be desired, to attack it will only make it worse. Remember, we get a lot more out of a child, or anyone else, with positive reinforcement of good traits than we do by criticizing the undesirable traits.

 

ADHD in the Pre-school Child

Bobby’s parents were concerned. Following his fourth birthday in the summer he had been enrolled in preschool three months ago. The teacher had already requested several conferences with the parents regarding Bobby=s work and play habits as well as his behavior in the classroom.

His mother brought along a note his teacher had recently sent home: Bobby has trouble sitting for more than two minutes before he is up and running about the classroom. He is restless at circle time and wanders around the room. He disrupts the other children who are trying to work. He cannot concentrate for more than a minute or two on a task because he  is so easily distracted.

 Bobby’s Story

I learned that Bobby was the first child in his family. His mother reported that he had always been difficult to manage at home. Always active and restless, he had difficulty staying at the table through a meal and getting to sleep at night. He acted without thinking and was repeatedly in trouble for things like jumping on the furniture or getting into places that were off limits.

When his cousin of the same age visited, he pushed and shoved and was over-excited. But he was not angry and seemed genuinely sorrowful when confronted about what he had done.

His mother had noted these behaviors but did not know what to make of them since Bobby was here first child. AI thought maybe it was because he was a boy.

Once he began to have persistent trouble at preschool the parents suspected that something was not right. The teacher suggested that he might be hyperactive, the father volunteered.

But I thought he was too young. Doesn’t that problem only occur in older kids?@ his mom asked.

In fact, most children with attention problems and hyperactivity are not recognized until early elementary school.

However, the characteristic symptoms of ADHD are typically present from early in life. Often parents as they present a detailed history of the older child recall that the one with ADHD was different from early in life. These difficult behaviors at the time were not clearly different form the typical toddler and preschool pattern. Because no one could put a finger on these differences, they were ignored, or at least tolerated, during the early years. Confusing the picture is the fact that toddlers and preschoolers are by nature active, impulsive, and easily distracted. So the child with developmental problems may be somewhat difficult to separate out at this age.

But, then, along comes a Bobby whose restlessness, impulsiveness, and pure motor hyperactivity cannot be ignored. Such a child has problems paying attention, following directions, and participating in cooperative play appropriate for their age. They are over stimulated easily in large groups or when excited. In a one-on-one situation they may be more attentive and cooperative but even here the short attention span is likely to be noticeable.

For instance, they may have difficulty sitting still at the table through a meal. They will want you to read to them but may listen for only a few minutes before they are up and running or asking for another book. They may hit, push, and shove impulsively, but yet, they are not angry or mean. One common symptom at this age is an incessant need to talk without any control.

 The Diagnosis

Indeed, Bobby did have attention deficit disorder.

After detailed observations were obtained from his parents and teachers, developmental tests were administered. He was cognitively advanced being particularly strong  in verbal skills. However, his motor skills were mildly delayed. The examiner noted that he had a very hard time keeping Bobby focused on the tasks.

Following this evaluation, Bobby was treated with a small dose of Methylphenidate. There was marked improvement in his activity level and degree of impulsiveness. He was much more controlled in school as well as in the home setting.

His teacher later wrote: Now Bobby is able to realize when he has done something wrong. He more often chooses positive options. He is able to sit and concentrate. He is choosing to ask for work which requires that he sit for 10-15 minutes at time. The amount of detail in his daily journal has changed tremendously. Before, he would draw just few lines with dark color in his interpretation was usually something violent and aggressive. This week, however he is taking his time and the colors and the details of his drawings are bright and clear.

 Management

The management of the young child with ADHD is certainly more difficult and complicated than with older children.

First, as we have discussed, it is not always easy to separate the attention behaviors from those behaviors which are typical of preschoolers. Not only is the initial diagnosis more confusing but it is also more difficult for parents to decide how to respond to a specific behavior.

Secondly, the preschooler is not sufficiently mature cognitively to understand the consequences of his disruptive behaviors. Thus verbal signals are often not well understood or received. Parents find themselves constantly interrupting and re-directing behaviors.

The excessive impulsiveness leads the preschooler to behaviors that can be dangerous to themselves and others. Parents must be on their guard for things like climbing to dangerous heights, playing with matches or fire, running into the street, etc. The children must be watched compulsively.

To complicate all of this, the preschooler’s response to stimulant medication is more erratic and unpredictable. Many physicians simply will not attempt to treat the young child with medication because they have had bad experiences with it or they are uncertain about how to administer it to this age child.

 The Use of Mediation With the Preschooler

Recent studies, however, have verified the fact that, indeed, preschoolers can be effectively and safely treated with stimulants with good response when the medication is managed appropriately for their age. The main problem is the narrow window between effective dose and side effects. However, by starting with a low dose and gradually moving upward, side effects can usually be avoided while finding that effective therapeutic window. While most stimulants are available in pill or capsule form only, there are some liquid form available. However, the liquids are all short-acting and require multiple doses during the day, however.

 Other Management Steps

In addition to medication when needed, other management steps are extremely important.

It is important for the home and school environment to be as calm and under-stimulating as possible while providing opportunities for learning. A consistent routine of living: eating, sleeping, play time, nap time, school, etc is essential.

An effective behavior modification plan is also important. Often behavioral counseling for the parents will be necessary to help them formulate discipline strategies and techniques to hand the specific bothersome behaviors of their preschooler. A developmental psychologist who understands preschoolers in a great help.

The preschooler with ADHD will often benefit from enrollment in a preschool at age three or four. The school should be quiet, structured, yet affirming in its atmosphere. Consistent behavioral management should be used.

Most of all, parents need relief. The supervision of the preschooler with ADHD is a very demanding, full-time job. This job can easily over-whelm the most energetic and well-meaning parents. Parents need to make good use of a competent preschool and mature sitters and relatives to get away and recharge their own batteries. Otherwise, they will collapse, emotionally, if not physically.

When confronted with the preschooler with ADHD we need to remember the natural tendency of ADHD to get better with chronological maturity. It we can provide right combinations of management at this early stage, we set the stage for more healthy growth later.

Medication for ADHD: No Effect on the Heart

In recent years there has been concern that stimulant drugs used to treat ADHD might pose some cardiovascular danger to the children taking them. In fact, this alarm led to the placement of a “black box” warning by the FDA in the package insert for such drugs. This then led to a debate among pediatricians and cardiologists as to the wisdom of obtaining an EKG prior to starting a child on medication. The concerns were real although the data showing a relationship was inconclusive.

Now a new study has soothed these concerns.  This study suggests that there is little, if any, cardiovascular risk with these drugs. An analysis of the cardiovascular safety of the stimulants in a population of more than 1.2 million children and young adults from 4 geographically diverse health plans with more than 2.5 million person years of follow-up found no evidence that these drugs increased the risk of serious cardiovascular events. Study data ranging from 1986 to 2002 was obtained from computerized health records of patients aged 2 to 24 years receiving an ADHD medication such as methylphenidate (Ritalin), Adderall, or other commonly used forms of these drugs.

For each patient receiving an AHDH medication, the investigators randomly selected for comparison two non-user controls from the health plans.  The rate of serious cardiovascular event did not differ significantly among current users of AHDH medications and controls.

This large, controlled study is reassuring to physicians and their patients. It strongly suggests that routine EKG screening of ADHD patients prior to starting medication is not needed.

This study was published in the New England Journal of Medicine in November, 2011 (365(20): pages 1896-1904)

Positive Relationships Sets the Stage for Success

Our chance of success in parenting is greatly increased as we positively meet the normal, healthy needs of our children for love, acceptance, meaning, and mastery. As these needs are met our children will be less tempted to seek a place for themselves through deviant, undesirable behavior.

Our children need to know that we love them in spite of what they do. Our love and concern as parents is not conditioned on their behavior. By honestly accepting our children and liking them while not necessarily accepting or liking their behavior,  we keep the door open to change and growth. Love is, and has always been, the most powerful force in the world.

When it comes to relating to children, patience is a virtue but is not always easy to express.
“Stop acting like a child,” I overhead one frustrated mother say to her six-year-old. Although I could understand why this mother erupted in such frustration in the middle of the supermarket, her remark mirrors our frequent inappropriate expectations of our children. Much of the behavior of children that is so frustrating to us as adults is simply our children being, well, children.

To be effective as parents, we need to  Our love and concern as parents is not conditioned on the child’s behavior.have some idea of what is appropriate behavior for our children’s age and stage of development and not attack them for things they cannot help. A young father got very angry with his three-year-old son for using a paper cup as a football during a formal reception. Actually this was pretty normal behavior for a toddler who was ignored in the midst of all the adult activity.

Another mother was frustrated because her thirteen-year-old daughter ran to her room  slamming the door when her mother disapproved of the dress she was wearing. Actually, such pouting and anger are quite typical of the adolescent. We need to remember that children are uniquely children—growing organisms who have not yet reached perfection. Punishment of the child for things he or she cannot help or does not understand will only create frustration, confusion and, likely, rebellion.

We often use up so much energy nagging and correcting our children that we have little energy left to relate to them in positive ways. This is particularly true with ADHD children. In the happy families I have known, however, the interactions have a positive tone and direction. In angry, unhappy families, most interactions have a negative tone. This is one area where all of us as parents can work toward a better record. We can tip the balance in our families in a more positive direction by applying some of the following principles to our relationships:

Listen to the child. Listen without interrupting or correcting. Listen to just hear what he or she has to say.

Do something the child likes. For some this may be reading and talking, others playing touch football, others working on a craft project, or repairing the car.

Give the child some space. Let the child do his or her own thing as long as the activity does not infringe on the rights of others. We are saying, in essence, “I trust you to make some choices for yourself about what you will do with your time.”

Avoid conflict when possible. Conflict, at times and to some degree, is inevitable. While most parents seek to avoid conflict, some seem to delight in having a head on collision with their children. However, both parents and children gain when potential conflict is avoided. A power struggle only creates hostility and negative feelings which hurts everyone. When you do need to draw the line and establish a limit, do so firmly and quickly with as little verbal combat as possible.

Look for the child’s good points. Everyone has some gift. Everyone does something well. Everyone has some redeeming features. The sparkle is there if we only look for it. Ours will be a much happier family if we look for the other persons talents rather than their faults.

As parents we teach through relationships .

We show our children what love is by loving. We teach forgiveness by forgiving. We teach honesty by being honest. We cannot substitute things for affection. Often adults have been heard to say, “I received everything I needed form my parents except the love and understanding I needed most.”

The child with ADHD draws criticism and negative feedback like a magnet. Relationships in the family often mushroom into a back hole of negativism. Parents find themselves constantly correcting, redirecting, and limiting. The child too often responds in sullenness and more self-defeating behavior. It takes effort to reorient the family atmosphere to a more positive spin. But it can be done. And it is well worth the effort.

ADHD and Handwriting

Even in this day of thumb-driven Twitter shorthand, handwriting continues to be a critical skill. Legible, coherent handwriting is a signal measure of academic success. And it still plays an important role in formal and informal communication.

Educators and other professionals working with children with Attention Deficit Hyperactivity Disorder (ADHD) have observed that many of these children have significant problems with handwriting.

A recent study coming out of the Centers for Disease Control and Prevention (CDC) documents the relevance of these observations. This research, led by Slavica Katusic of the Mayo Clinic was published in Pediatrics (September, 2011).  The study included 6,000 children: all those born in Rochester Minnesota between 1976 and 1982 and who was still living there after age 5.

Katusic and her co-workers evaluated school and medical records to see which children showed signs of ADHD, as well as how well they performed on writing, reading and general intelligence tests over their school career. A total of 379 children fit the criteria for ADHD. About 800 children scored poorly on tests of writing abilities, and most with writing problems had reading difficulties as well.

Writing problems were much more common in both boys and girls with ADHD, with close to two-thirds of boys with ADHD having problems with writing. That compared to one in six of their peers without ADHD. In girls, 57 percent with ADHD had a writing problem, compared to less than 10 percent without ADHD.

There are several reasons why children with ADHD may have problems in writing. Writing is a very complex task that involves cognitive activity and motor activity at the same time. A high level of mental coordination and sequencing is required—tasks that individuals with ADHD have difficulty with. Also, memory and planning problems may affect the writing process. The impairment in sustained attention experienced by children with ADHD causes them to loose track of what they are doing and they will tend to make careless errors and get confused about what is to come next in the phrase or sentence.

Long term observation does suggest that the writing problems do get better with increasing maturity. Individual education plans that address some of those related difficulties can help especially if they’re started early.

It is my observation that when kids with ADHD are appropriately treated with medication, improvement in handwriting can be dramatic. In fact, improvement is often noted immediately

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