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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 m

Conditions That Complicate Management

Attention deficit/hyperactivity disorder is a specific developmental condition with a defined set of characteristics. Although a varied spectrum of severity exists, children with ADHD demonstrate a consistent and typical pattern of behavior and neurological function.

 
However, this “pure”@ picture is often complicated by the presence of other developmental or emotional dysfunctions. Several co-morbid conditions are described by professionals working with A DHD children.

 
Common Co-Morbid Conditions
Let’s look at some of the more common co-morbid conditions which may exist with ADHD:

 
Language-based learning disabilities. Central language processing disorders can mimic, and certainly complicate, the expression of attention disorders. For decades clinicians and educators have observed a significant overlap between children with ADHD and various language-based learning disabilities. As recently as two decades ago, professionals in the field tended to lump children with these related developmental disabilities together into the diagnostic category of minimal brain dysfunction. Attention, hyperactivity, and language-processing disorders were thought to be different ends of the continuum within this diagnosis. Recently the trend is to define the various diagnostic categories more precisely.

 
While many children with ADHD have no evidence of language-based learning disability, there are many children in which ADHD and a learning disability co-exist. I have seen children who have gone for years without treatment for their ADHD because all their academic problems were blamed on their language dysfunction. The attention problems and poor organization were thought to be secondary. On the other hand, I know of children who have not received serious evaluation of their reading and spelling under-achievement because their poor grades were blamed on their attention deficit disorder. When a child has been diagnosed with either ADHD or language processing dysfunction, the child should be carefully observe for evidence of the other condition.

 
Oppositional Defiant Disorder. While children with ADHD may disobey and at times seems to resist discipline, they are not typically defiant. Their lack of compliance is most likely due to impulsiveness and failure to think before they act. They also have difficulty associating their behaviors with consequences. But they want to please and tend to be unhappy with their failure to live up to expectations.

 
Oppositional defiant disorder (ODD) is characterized by a pattern of negative, hostile, and defiant behavior. Children with this disorder easily lose their temper, purposely annoy others, openly defy authority, refuse to comply with rules, and argue often. They may be resentful, angry, spiteful, and vindictive. ODD is defined by a pattern of such behavior over a long period which is not due to temporary stresses or provocations. Oppositional defiant disorder is more common in males. Over time ODD is likely to be associated with low self-esteem, low frustration tolerance, temper outbursts, poor peer relationships, and school underachievement.

 
Conduct Disorder. Children with conduct disorder exhibit a basic disregard for the rights of others and ignore age-appropriate norms of behavior. They may be cruel to other people and animals, fail to respect others rights (i.e., steal, misuse property), and ignore common rules of conduct. This pattern of behavior exists over a long period of time. It significantly disrupts the child’s relationships and adjustments to common life situations such as home and school.

 
Poor school performance, a greater frequency of school suspensions, and incidence of substance abuse are seen in children and adolescents with conduct disorders. These dysfunctional behaviors may begin in middle childhood but become more prominent in adolescence.

 
! Tourette’s Syndrome. Tourette’s syndrome (or Tourette’s disorder as it is sometimes called today) is characterized by the onset during childhood of multiple tics of various kinds (both motor tics and vocal tics) which may fluctuate in severity. The currently accepted essential diagnostic criteria include onset before the age of 21 years, multiple involuntary motor tics, one or more vocal tics, the waxing and waning of the tics, the gradual replacement of old tics with new ones, the absence of other medical explanations for the tics, and the presence of tics for more than one year.

 
Along with the tics, there may be obsessive compulsive tendencies, excessive anxiety, sleep disorders, learning difficulties, and impulsive behaviors. A variety of behavior/emotional problems have been identified in children with Tourette’s syndrome. Whether these behavioral problems are related to tic severity, a direct consequence of having a stigmatizing condition or an underlying part of the developmental condition is not clearly delineated.
ADHD has been reported to occur in 35% to 65% of children with Tourette’s syndrome. The treatment of children with attention deficit/hyperactivity disorder with co-morbid Tourette’s syndrome is controversial. The major confounding factor is that stimulant medications may provoke or intensify the tics. The stimulants do not cause the tics but if a child is predisposed to tics, the use of the stimulants may hasten the expression of tics, or aggravate them when they are present. While the stimulants may help the child with ADHD and Tourette’s, they should be used with caution.

 
If behavior and educational approaches are not successful for the child with Tourette’s and ADHD, then a trial with other types of medication should be considered.

 
Depression. It is well know that psychological depression is the most common emotional disorder affecting adults. The fact that depression is also very common in children and adolescents is less well known. Pre-teens and adolescents are particularly vulnerable to some degree of depression even under the best of circumstances. The child living with the stresses of ADHD are even more vulnerable. The frustration due to having to work harder to keep up academically, the constant negative feedback that is all too common and the difficulty getting along with peers sets the child up for depression. The usual low self-esteem experienced by many children with ADHD underlies their vulnerability.

 
Signs that suggest depression are a sudden drop in grades and performance in other activities such as sports or music. The depressed child or adolescent will tend to be moody and easily frustrated. They seem sad and have more trouble enjoying things they have enjoyed in the past. They often will withdraw and be less able to cope socially.

 
Depression in children and adolescents is likely to be a reaction to circumstances and come on over a short period of time. Chronic, long-term depression is less common.

 
This reactive depression is probably the most common co-morbid condition seen in children with ADHD. Fortunately, depression is also the most effectively treated of all the co-morbid conditions. Recognition, counseling, and sometimes short-term antidepressant medication will usually overcome the depression fairly quickly.

 
These are some of the more common co-morbid disorders. If is important to look for such conditions as a child is evaluated for ADHD. When they exist, success depends on managing the ADHD and co-morbid condition together.

ADHD Associated With Early Death

Individuals diagnosed with attention deficit disorder (ADHD) are at a higher risk of dying young, usually as the result of automobile crashes and other accidents. This is the conclusion from the largest study to date on the relationship of ADHD and mortality. This study, an analysis of nearly 2 million Danish medical records, The presence of related disorders such as drug abuse, or oppositional disorder the odds of early death. The study also noted that the risk of early death is even higher in those diagnosed after age 18.

 

While increased morbidity and mortality due to trauma has been known for many years, this new study gives a more precise picture of the risks due to its large size.

 
Most experts feel that this increase vulnerability is due to the impulsiveness and perceptual deficiencies along with general delayed maturity seen in individuals with ADHD

 
The findings of this study should not cause panic in parents and caretakers of children with ADHD, it does point out the importance of early diagnosis and effective treatment of children and teens with ADHD .

 
Other studies furnish evidence that treatment with behavioral intervention, academic support and medication has the highest rate of success. (Seem previous editions of this blog for management and treatment recommendations.)

ADHD and Prevalence of Depression

Attention Deficit in early childhood predisposes to adolescent depression according to research published  October 2010  in the Archives of General Psychiatry. This risk of depression in young children with ADHD is greater in girls, in those with associated conduct disorder, and in those whose mothers were depressed according to the study.

The Researchers evaluated 125 children age 4 to 6 who met the criteria for ADHD and 123 matched controls without any sign of ADHD. These subjects were followed for up to 14 years. All of the children in the study lived with their biological mothers.

ADHD at 4 to 6 years resulted in increased risk of major depression during the teen years by more than 15 times. Girls with ADHD had twice the risk of later depression than boys. Maternal depression increased the chance of depression in the children with ADHD by more than 7 times.

Comment: This study documents what many clinicians working with children and families have observed informally. The reasons for this increased risk of depression and mood disorders in teens who are diagnosed with ADHD are not yet clear. There may be biological factors common to both disorders. It is also likely that the stress of trying to live with the symptoms of ADHD would predispose one to depression. The very fact that the person with ADHD experiences the frustration of not being able to perform at the level they know they are capable of is, in itself, a significant stress.

Proper management of the ADHD as outlined in the book, ADHD Strategies for Success, will help minimize the stresses of living and learning for children with ADHD.

Certainly, parents and professionals working with children with ADHD, especially adolescents, should be diligent is watching for signs of depression and follow up on such signs when noted.

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.

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 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)

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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