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ADHD: Overcoming–Rather Than Being Overcome

ADHD: Overcoming–Rather Than Being Overcome

Day-to-day experience as well as scientific observation attests to the fact that different children exposed to the same degree of stress or frustration are not affected in the same manner. Some are stymied and squelched by the obstacles in their path. Others thrive as if the obstacles were more of a stimulus than a roadblock. Many observers have asked why.

Several years ago Peter Wyman, Ph.D. and associates studied this question. They looked at demographically comparable groups of children exposed to major life-stress. They interviewed both stress-resilient and stress-affected children assessing perceptions of their care giving environments, peer relationships, and themselves. A functions analysis identified four variables that correctly classified 74% of the children in one or the other group. Stress-resilient children, compared to the stress-affected children, reported more:

 positive relationships with primary caregivers (i.e., parents)

 stable family environments

 consistent family discipline practices

 positive expectations for their futures.

These findings support the view that caregiver-child relationships play a key role in moderating children’s developmental outcomes under conditions of high stress. (J. Am Acad Child Adolescent Psychiatry, 1992:; 31 (5):904-910)

Editor’s Note: This study points out again the extreme importance of a positive parent-child relationship in helping a child overcome obstacles. Children with ADHD and learning disabilities do have plenty of reasons to be stressed. Many will grow into healthy, well-adjusted adults in spite of their difficulties. Stable families, applying consistent, loving discipline in an affirming spirit greatly enhance the chances of success for the child.
Now, read the next article.

Because of My Problems!

“Wendell Wilkie said, ‘What a man needs to get ahead is a powerful enemy.’ Edmund Burke said, ‘Our antagonist is our helper. He that wrestles with us strengthens our muscles and sharpens our skill.’ Apparently human nature must have something to push against and something to wrestle with. I suppose this is the hopeful thing about handicaps…Handicaps are the hard things we wrestle with and push against.

Dr. Marie Ray, a psychiatrist of some note, after making a wide study of the relations between handicaps and achievements, and going down the list of notable men and women, came up with this conclusion, that most of the shining lights of history were made so by their struggles with either some disability or some responsibility that seemed too great for their powers. And then she put down this definite rule as the result of her research, ‘No one succeeds without handicap. No one succeeds in spite of a handicap. When anyone succeeds, it is because of a handicap.'”

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.

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.

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.

 

Does ADHD Ever Go Away?

Just a few years ago it was thought that children with Attention Deficit Hyperactivity Disorder out-grew their symptoms by adolescence. However, by the early 1980’s the clinical evidence made it clear that this did not always happen. While some children appeared to “outgrow” their functional problems by the teen years, many had persistence of symptoms which continued to interfere significantly with their life. In addition, it was obvious that these children benefited from continued medical, psychological, and educational intervention into the teen years. Additional clinic data then pointed to the persistence of ADHD into adulthood. An important study was that by Weiss et al. (Psychiatric status of hyperactive as adults, J Am Acad Child Psychiatry 24:211-220, 1985) which reported that 66% of children with ADHD had persistence of some symptoms into adulthood.
Over the past decade, well-documented research more clearly delineated the life-cycle of attention deficit hyperactivity disorder and the various factors influencing resolution or persistence. Joseph Beiderman, M.D. and associates shed additional light on these issues in a study published in the Journal of American Academy of Child and Adolescent Psychiatry (March, 1996, vol 35:3, page 343-351).
In this well-controlled study 119 boys, aged 6 to 17 years, with ADHD for four years following diagnosis were evaluated. At the four year follow up, 85% of children with ADHD continued to have the symptoms characteristic of ADHD. Fifteen percent had remitted completely. Of those who had remitted, one half did in childhood and one-half in adolescence. These researchers documented several factors associated with persistence of symptoms. These significant factors were:

A strong family history of ADHD

nstable family life (A psychosocial adversity)
      The existence of conduct, mood, and anxiety disorders.
This well-done study helps clarified the extent to which ADHD persists into adolescence and the factors influencing such persistence. It also pointed out factors in the child=s life which, if they are present, need to be treated in order to increase the chance of a favorable outcome. Subsequent studies confirmed these earlier findings.
These studies reaffirmed what experienced clinicians have known for a good while: that most children with ADHD get better by late childhood or middle school but some still have symptoms into late adolescence. Thus parents, teachers, and physicians should work closely together to monitor children with ADHD as they progress into puberty. If it appears that the child is gaining appropriate organization and control, treatment, including medication, can be phased back. If the child is having signs of any of the complications mentioned in this article, aggressive evaluation and treatment planning will be needed.

Sleep-Disordered Breathing and ADHD

Sleep-Disordered Breathing and ADHD

A large, population-based study demonstrated that early in life sleep-disordered breathing symptoms had a strong relationship to behavior in children later in life. Children with sleep-disordered breathing developed more behavioral difficulties such as hyperactivity and aggressiveness, as well as emotional symptoms and difficulty with peer relationships when compared with children without sleep-disordered breathing. Findings suggest that children with sleep-disordered breathing symptoms may require treatment as young as one year of age to prevent increased tendency for behavior problems.
“This is the strongest evidence to date that snoring, mouth breathing and apnea can have serious behavioral and social emotional consequences for children,” reported Karen Bonuck, PhD, one of the researchers and professor in the Family and Social Medicine Department at Albert Einstein College of Medicine.
In the study, parents completed surveys reporting on children’s snoring, mouth breathing and witnessed apnea at ages 6, 18, 30, 42, 57, and 69 months of age. More than 11,000 children were followed for more than 6 years. Parents then completed the Strengths and Difficulties Questionnaire when the children reached 4 and 7 years of age. The questionnaire has five scales: inattention/ hyperactivity; emotional symptoms (anxiety and depression); peer problems; conduct problems (aggressiveness and rule breaking); and a social scale (sharing, helpfulness and other factors). Researchers controlled for 15 potential confounders, such as socioeconomic status, maternal smoking during the first trimester of pregnancy and low birth weight.
Researchers found that children with sleep-disordered breathing were 40% to 100% more likely to develop neurobehavioral problems by age 7 years, compared with children without breathing problems. The worst symptoms were associated with the worst behavioral outcomes, and hyperactivity was most affected among the neurobehavioral domains examined, according to the researchers. “The biggest increase was in hyperactivity, but we saw significant increases across all five behavioral measures,” said Bonuck. Bonuck K.

This report published in the Journal, Pediatrics, points to one specific condition that can cause, or at least worsen, symptoms of ADHD. In evaluating a child for ADHD, the examiner should look for signs of sleep-disordered breathing with the medical history and physical exam. Causes of sleep-disordered breathing can be allergic rhinitis, large tonsils and adenoids, or congenital abnormalities of the upper airway. Essentially all of these are treatable with surgery or proper medication.
Sleep-disordered breathing is certainly not the cause of ADHD but one of many factors that can affect the expression of this common developmental problem in children.

The ADHD Child and Summer Camp

 
It is that time of year! Millions of kids across the country will be packing up their knapsacks, waving goodbye to mom and dad, and heading for the hills—literally. Yes, they will be off to summer camp.

What about camp for your ADHD child? Is camp good for him? Is she ready for camp? These are good questions. The answer, of course depends on a multitude of factors. The issues condense to two important areas:

Is your child ready for camp?

Is camp ready for your child?

Is Camp Ready for My Child?

Let’s look at the second question first. This question is really asking if the camp under consideration is one that is appropriate for a child with ADHD. Does the camp have a philosophy of inclusion in which they are interested and equipped to work with children with varying backgrounds and needs. Does the administration and staff have some knowledge about ADHD? Is the staff trained in the needed skills of reinforcement and behavioral management? If your child is taking medication, is the camp able to administer it properly.

Although few in number, camps do exist specifically for children with ADHD. These camps are designed to present a general camping experience for the child while at the same time providing specific therapy and education relating to the ADHD. To find out about such camps in your area you might check with the local chapter or the website of CH.A.D.D. (Children and Adults with Attention Deficit Disorder) or LDA (Leaning Disabilities Association). Also, check with your school counselor. He or she might have a list of summer camps that accommodate children with unique needs.

Is My Child Ready for Camp?

Is your child ready for camp? The answer to this question is somewhat more complicated. Most importantly, the child’s attention deficit should be sufficiently controlled so that he will have a positive and helpful experience. His behavior should be at the point that undue re-direction or behavior modification will not be required.

Look for the following readiness cues: Does your child make friends easily? Does she adapt well to new situations? Does she respond well to adult supervision? Does she enjoy successful sleep-overs at the homes of her friends or relatives?

In addition, if your child hasn’t experienced success in most of these areas, she probably is not ready for sleep-away camp. But she might be ready for a less socially demanding experience such as day camp. If day camp is too big a step, encourage your child to spend a few days with a favorite friend or relative. Then be sure to praise her success at being away from home.

In general, I would suggest that most children with ADHD are not ready for a week-long sleep away camp until ten or older. For many, this time will not come until their early teens. Of course there could be exceptions with the more mature child. Day camp could be a very good alternative for the child with ADHD.

What Are the Benefits of Camp?

Attending camp gives children an opportunity to learn many new skills—how to swim, ride a horse, sail a boat, hit a tennis ball, use a bow and arrow, tie a knot. It also gives them a chance to master important emotional, developmental, and social skills—how to get along with other people, establish peer relationships, tolerate differences, work as a team, and become more independent. Camp also gives parents and kids a chance to practice the art of letting go. The experience lets children develop autonomy and a sense of self-respect. A successful camp experience can be a big boost to self-esteem. For parents, the separation allows them to take a break, care for some of their own needs, and recharge their parenting batteries. They also need to experience autonomy from their child—in preparation for what is to come in the very near future.

How to Prepare the Child for Camp?

Since children can be fearful of the unknown, it is a good idea to share as much information as possible about the camp. If the facility is within driving distance, you might plan a visit ahead of time. Such a visit allows the child to see the place as well as talk with some of the staff. The mystique as well as the fear is thus removed.

If a personal visit is not possible, ask the camp for whatever information they may have: brochures, pictures, videos of the camp.

Above all, talk with the child about his hopes, dreams, and fears about camp. Listen to what he has to say. Discuss any concerns. Certainly, do not belittle the worries and fears. Let the child know that while you think the camp experience will be good for all of you, you will miss him and will look forward to his return. It also helps if the child is able to attend camp with a friend.

 

Redemptive Features of ADHD

Children with ADHD have very real challenges. The disruptiveness of the child’s behavior and the struggles in learning can make life difficult. These dysfunctions tend to drive professionals as well as parents to focus largely on the negative connotations of attention deficits. But redeeming features do exist, even though they may be difficult to see. However, this positive side to ADHD often begins to show itself in adolescence and young adulthood if we look for it.

—The inattention to detail that is so frustrating to student and teacher alike can lead to strengths in conceptual ability. A result can be an enhanced ability to see the big picture. Such individuals can become adept at global problem solving and may be an asset in leadership roles.

—The inability to be easily satisfied can be associated with ambition and initiative. Could this be one reason why so many individuals with attention deficits have been successful in a wide variety of fields?

—Distractibility is intimately linked to creativity. A student who notices things no one else sees is in a position to detect meaningful interrelationships that elude more disciplined minds.

—A student who is highly impulsive may ultimately evolve into an adult with a strong bent for closure, a person who accomplishes a great deal during the working day.

—It is not unusual to encounter adolescents with attention deficits who have superb sense of humor, appealing personalities, true leadership skills, and striking individuality.

Yes, the struggles that children with ADHD face are real. It is important to intervene and provide healthy management such as academic accommodations, medical treatment, counseling when needed. In doing so we can avoid some of the unhealthy consequences such as poor self-esteem and discouragement.

However, we should have an optimistic anticipation of the ultimate success of the child with ADHD. We should be looking for ways to help the teen discover his or her strengths and help them see that they can turn a weakness into an asset.

 

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)

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