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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

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.)

Beware of the Help!

As a parent of a child with ADHD you are bombarded with advice and suggested help from every direction. As the prevalence of ADHD has become more known, a hoard of individuals and organizations has flooded the market with their own brand of “help.” Many of these ideas come from reputable and experienced sources. However, much of this advice and help come from groups pushing their own agenda.

So it is important for parents to carefully evaluate the advice and interventions they see on the internet, hear from friends or read in the mass media.

I would suggest that parents be wary of the following:

1. Any one offering a complete or, quick, cure. So far I have not found any “quick fix” for the developmental problems of kids with ADHD. Help is certainly available but it involves time, effort, and cooperation of many people. When fad treatments are latched onto, time as well as the family’s money, is often wasted.

2. Anyone pushing a method of treatment not known to the school personnel, your physician and other professionals in the community. You can be sure that your child’s teacher, principal and counselor as well as your pediatrician are interested in what the community has to offer. If there is someone or some program around which can help, one of these people you trust is likely to be aware of its existence. They are not likely to recommend a program that is worthless and expensive.

3. Anyone who pushes just one form of therapy. The strengths and weaknesses of each underachieving child are unique. No one treatment is a panacea for each of them. Most children will benefit from a variety of interventions—through special education, behavioral management, and maybe medical treatment. Most competent professionals will be open to any possibly effective technique.

As with all parenting advice, consider the source as well as the open and hidden expense of any suggested help you receive.

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.

Successful Coping Strategies

Successful Coping Strategies

Adults with attention-deficit hyperactivity disorder who have attained higher educational and professional status use a variety of strategies to cope with their disorder, a new study shows. The study was conducted by Robert D. Wells, Ph.D. and reported at the annual meeting of the Developmental and Behavioral Pediatrics Society.

 

Thirty-one adults who responded to a newspaper advertisement seeking people with ADHD filled out several symptom, behavioral, and intelligence measures. They were interview about their compensatory strategies. The group aged 23 to 71, included 22 women. They could be considered highly motivated for completing the study and may represent a skewed sample, the researcher noted.
Those who were relatively more successful in their education and career were more likely to do the following:

 

Set up rituals to get through repetitive tasks.
Use lists to retain large amounts of information
Control impulsive behaviors by writing down their thoughts and talking them over with someone.
Choose jobs which have a variety of different tasks each day and that allow them to be in charge of themselves and their time but that still have structure and quotas.
Learn to delegate.

 

Some of the individuals listened to “white noise” in the background to help them concentrate. “One guy had the rule of three: He only allowed himself to work on three things at once,” said Dr. Wells, Director of Pediatric Research at Valley Children’s Hospital in Fresno, California.
Many of the less successful subjects could not identify any strategies they used to avoid distractions, to retain information, or to make themselves feel successful. Only nine per cent of the variability in success could be attributed to differences in intelligence, Dr. Wells added.
Ongoing studies of junior high students and prison populations should help determine how much of the difference in success is due to skills that might be taught and how much may be due to temperament and personality.

 

Most people with ADHD do not outgrow their ADHD. But as this study shows, they can learn compensatory tools. The subjects of this study point to the way in which successful people do compensate.

Diagnostic Device Approved by FDA for Evaluating ADHD

The Federal Drug Administration recently approved a new device for assessing ADHD. This is the first medical device approved for the diagnosis of this common condition of childhood.

 
The technique, called the Neuropsychiatric EEG-Based Assessment Aid (NEBA) System, relies on deciphering encephalogram (EEG) waves. Taking 15 to 20 minutes, this non-invasive test uses computer functions to calculate the ratio of beta and theta brain wave frequencies. Previous research has shown that theta and beta ratios are higher in children and adolescents with ADHD compared to non-ADHD subjects.

 
Although officially approved, significant uncertainty exists among experts as to the NEBA technology’s value in the overall diagnosis and management of ADHD. Currently the evaluation of ADHD is a complex process utilizing observation, behavior analysis, and psychological testing. Whether the NEBA adds significant help in this process is uncertain. One concern is how much does the use of this technology add to the overall cost of an evaluation.

 
Of course, time will reveal the usefulness of this new technology. Stay tuned. We will keep you informed as additional research data comes in.

ADHD Can Persist Into Adulthood

Investigators in Rochester, Minnesota studied a large group of children born between 1976 and 1982. This group was followed from early childhood into adulthood (mean age 27 years at time of study). In this group, 232 subjects had been diagnosed with childhood ADHD. These 232 children were compared with 335 children without ADHD who served as controls. At the time of the study, the now adults were administered a variety of standardized neuro-psychiatric tests and interviews.

It was observed that ADHD persisted into adulthood in 29.3% of the individuals who had been diagnosed with childhood ADHD.

The participants who had childhood ADHD were more likely than controls (56% compared to 29%) to have one or more psychiatric disorders as adults. The most common co-morbid condition was alcohol dependence/abuse (26%). Additional diagnoses were other substance dependence/abuse conditions, anxiety disorders, mood disorders, and major depression. Those with ADHD persisting into adulthood were much more likely to have one or more psychiatric disorder (80% vs. 47%).

Several take home lesions from this study:

First of all, most children with ADHD will have resolution by adulthood.

However, ADHD does persist in a significant number of individuals (30%).

ADHD does leave significant emotional scars in a high percentage of individuals who were diagnosed with childhood ADHD. This points out the need for those diagnosed with ADHD to have ongoing mental health care into adulthood with special attention paid to potential psychiatric disorders.

Those adults with persistent ADHD (30% of those with childhood ADHD) will need to have ongoing ADHD treatment and monitoring as adults for other mental health needs.

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.

Can Exercise Help the Child with ADHD?

A recent study suggests that as little as twenty minutes of exercise a day may help kids with attention-deficit hyperactivity disorder (ADHD) function better. The study, to be published in the Journal of Pediatrics (2012), evaluated 40 eight- to ten-year-olds by looking at the short-term effects of exercise. The study compared 20 children with ADHD and 20 without signs of ADHD. All of the children took a standard test of their ability to ignore distractions and stay focused on a simple task at hand. The kids also took standard tests of reading, spelling, and math skills. Each child took the tests after either 20 minutes of treadmill exercise or 20 minutes of quiet reading on separate days.

 
Overall, the study found both groups of children performed better after exercise than after reading. On the test of focusing ability, the ADHD group was correct on about 80% of responses after reading, versus about 84% after exercise. Kids without ADHD performed better, reaching about a 90% correct rate after exercise. Both groups of kids scored higher on their reading and math tests after exercise than after the reading period.

 
The researchers noted that the effect of exercise on adults’ thinking and memory had been studied extensively, particularly older adults’. But little is known about kids, even though some parents, teachers, and doctors have subjectively seen positive effects of exercise.

 
The scientists reporting on the study state that it’s hard to say what the higher one-time scores could mean in real life. “One of the big questions is whether regular exercise would have lasting effects on kids’ ability to focus and their school performance,” they stated.

 
“We’re not suggesting that exercise is a replacement, or that parents should pull their kids off of their medication,” the scientist went on to say.

 
  This research, while preliminary, reflects the experience of parents, teachers, and others working with kids with ADHD. Since most of these kids have a drive to be active, most observers believe that facilitating active exercise during the day, especially the school day, allows the child to “run off” some of his excessive energy. Future studies in this area will be welcome.

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