ADHD experts offer tips on diagnosis and treatment

Published: July 2010

How is attention deficit hyperactivity disorder diagnosed in children? What are the symptoms to look out for? And once the condition has been formally recognized, what are the best ways to manage medications?

To find the answers to these questions, our medical adviser, Orly Avitzur, M.D., interviewed two ADHD experts: Michael L. Goldstein, M.D., a child neurologist with Western Neurological Associates in Salt Lake City, and Martin L. Kutscher, M.D., a child neurologist in Rye Brook, N.Y., who has more than 20 years of experience diagnosing and treating ADHD.

And the symptoms aren't always what they seem to be. Consumer Reports' survey research associate Andrew Schwartz, Ph.D., a licensed clinical psychologist who assesses children for ADHD and other learning disabilities, discusses the cases of an 11-year-old boy and a 9-year-old girl.

What parents should know about ADHD

Michael L. Goldstein, M.D.

For an expert's overview of ADHD information and what parents should know, Orly Avitzur, M.D., medical adviser to Consumer Reports, interviewed Michael L. Goldstein, M.D., a child neurologist with Western Neurological Associates in Salt Lake City, and a former vice president of the American Academy of Neurology.

What is attention deficit hyperactivity disorder (ADHD)?
The cardinal traits of ADHD are hyperactivity, impulsivity, and inattentiveness. But since all children have some of these behaviors some of the time, the question that must be addressed is whether the child is outside the norm and requires treatment. Whether those characteristics are considered abnormal or not is also dependent on the situation. For example, behavior that may be helpful on the ball field may be unacceptable at school.

There are three subtypes of ADHD (inattentive, hyperactive, and combined). The inattentive subtype is more common in girls, less responsive to medication, and often goes undiagnosed; the hyperactive subtype is often identified early.

How is ADHD diagnosed?
Most commonly, ADHD is diagnosed using a set of rules developed by the American Psychiatric Association. There are no blood tests or scans that are more helpful than collecting information from those who observe the child directly. Information is often gathered from parents, teachers, and others by the use of questionnaires.

What is reasonable for a parent to expect from the diagnostic process?
There are direct tests, including interaction between the examiner and the child. Other types of testing that are often used include questionnaires filled out by teachers and family. The goal is to increase understanding of the strengths and weaknesses of the child, and devise a plan for how to build on the strengths and overcome the weaknesses. Many children with ADHD have additional issues to consider, including social-skill deficits, anxiety, depression or learning disabilities. Some children have ADHD alone but many children present with a much greater complexity of problems and elements of other disorders. The best diagnostic process will look at all those other aspects and help the family understand the range of a child's strengths and weaknesses. Some situations are complex and many even require a neuropsychologist to spend 5 to 10 hours testing the child to determine all the factors leading to a child's difficulties.

What factors make it difficult to diagnose?
A broad evaluation of a child's problems may require more than an evaluation for ADHD. If a child has a learning disability, it will not be picked up by the standard Conners' Rating Scale. A limited evaluation may not uncover social interaction problems or an adjustment disorder, a psychological response to stress. If parents, teachers, or others have strong opinions, it may be difficult to initiate a dialogue and build a consensus about what to do. Some parents with ADHD children have particular difficulty dealing with distractible, inattentive, and impulsive behavior.

What steps can a parent take if a child has been diagnosed with ADHD?
The first consideration is changing the demands on the child. Changing the environment is one of the most effective treatments for ADHD. For example, in a classroom, the teacher can separate the child from children who are a distraction, have him or her sit in the front of the room, and make frequent simple requests for attention. At home, parents should be encouraged to give simple, one-step instructions. For example, when asking a child to go to his or her room and clean it up, escort the child to the room and give instructions during the cleaning. This type of intervention doesn't require a diagnosis and may also help unaffected children.

Having ADHD is not an excuse for deliberate misbehavior; however, children with ADHD often have variable performance periods. Sometimes a child will be able to complete a task on one day but not on another, leading parents to wonder if he or she is not "trying." Sometimes learning disabilities, poor social skills, or depression can at first be confused with ADHD. If initial treatment is not successful, re-evaluation should be a consideration.

Who should be on medication?
There are no generally accepted criteria for which children with ADHD should be on medication and which can get along without it. No aspect of ADHD diagnosis and treatment is more controversial. Scientific studies demonstrate that medication is generally both safe and effective for ADHD, but most children who fulfill the diagnosis of ADHD do not need medication.

The effect of stimulant medication on ADHD can be very dramatic. The medications are very good at controlling hyperactivity but not as effective in improving learning. Grades may improve if the previous poor grades were due to not being able to handle homework and other demands.

What about the role of diet?
Some parents are convinced that diets are the answer. Studies have repeatedly shown that dietary change alone does not result in a change in behavior. A child's misbehavior the day after a birthday party might be inaccurately attributed by a parent to foods eaten during the party, but the excitement, stimulation, and routine change is more likely to blame.

What makes this condition most challenging for parents?
Children with ADHD are inconsistent. This causes a lot of trouble. Parents and teachers think the child is not trying because he or she was able to do something yesterday but cannot do the same thing today. In fact, inconsistency is one of the hallmarks of ADHD. Parents should not be surprised by differential attention; kids with ADHD have a hard time paying attention to things that are boring, but may have a great attention span for things they find interesting. They may be able to watch television or play sports or some other activity for hours without interruption but may not be able to pay attention to schoolwork, what their parents are saying, or other activities they perceive as uninteresting.

ADHD symptoms can be deceiving

Andrew Schwartz, Ph.D.

Andrew Schwartz, Ph.D., a Consumer Reports survey research associate and licensed clinical psychologist who assesses children for attention deficit hyperactivity disorder and other learning disabilities, discusses two cases.

An 11-year-old boy I'll call Joseph was brought to my office by his concerned parents. He was throwing fits every morning because he hated to go to school.

As a psychologist with a part-time practice assessing attention and emotional disorders, my first thought was that Joseph's refusal to go to school might be related to either separation anxiety or a behavior disorder. But as I questioned the parents, I learned that Joseph didn't have trouble separating from his parents when it was time for his soccer games or to play with his friends. In general he was a well-behaved, compliant boy who, except for school refusal, showed no signs of defiant behavior.

On further questioning, the father revealed that he himself had some trouble with reading and often lost interest in activities at work. When I asked about Joseph's reading and attention, his parents said they knew he was a smart boy, but the teacher had mentioned that he had been missing details and tended to space out during reading assignments.

After a learning evaluation with a clinical neuropsychologist that included getting feedback from the school, Joseph was diagnosed with a minor reading disability and attention deficit disorder. It turned out that he was avoiding school because he was embarrassed about his declining performance and inability to complete reading assignments as quickly as his peers.

Joseph's parents asked the school to make recommended accommodations, including sessions with a reading specialist, extended time for reading assignments, and moving his seat to the front of the classroom. This helped improve Joseph's performance and attitude. He was soon able to go to school without the morning outburst.

While most people think of children with ADHD as screaming and climbing the walls, a number of children like Joseph suffer primarily from symptoms of inattention, such as missing details, losing things, being forgetful, or avoiding disliked activities. It can be difficult to untangle learning and attention problems from the emotional consequences of experiencing these issues.

The survey team at Consumer Reports Health recently polled 934 parents who had a child diagnosed with ADHD and found that well-established clinical guidelines for making a diagnosis are not always followed. For example, medical screenings and feedback from the schools may not be included in the assessment. This is unfortunate, because without a 360-degree view it's hard to reach the correct diagnosis and implement the right strategies for helping the child.

Consider the case of Ruby, a 9-year-old girl. Her parents complained that she was "in her own world" most of the day and was missing information at school. While assessing her, I, too noticed these symptoms, but observed that Ruby had a nasal tone to her speech and was breathing through her mouth. When I asked if she had a cold, she said, "No, I always breathe like this." I referred her for a sleep test and it turned out that she had sleep apnea, which caused poor sleep at night and left her exhausted during the school day. When Ruby's sleep apnea was treated and she began to get a good night's sleep, her behavior and attention problems gradually resolved themselves.

It's important for parents and professionals alike not to jump to conclusions about what's causing a child's behavior. Our report on ADHD can help guide you through the diagnostic process and learn how to insist that your child get the right kind of evaluation.

Best ways to manage ADHD medications

Martin L. Kutscher, M.D.

For an expert's overview of ADHD medications, Orly Avitzur, M.D., medical adviser to Consumer Reports, interviewed Martin L. Kutscher, M.D., a child neurologist in Rye Brook, N.Y., who has more than 20 years of experience diagnosing and treating ADHD. He is also the author of "Organizing the Disorganized Child" (with Marcella Moran, HarperCollins, 2009) and "ADHD: Living without Brakes" (Jessica Kingsley Publishers, 2008).

How do you select which medication to start a child on?
Stimulant medications are generally considered the first line of medical treatment for a typical child with ADHD. Stimulants include amphetamine- and methylphenidate-based medications.

In general, the goal is to utilize a long-acting preparation in order to help the child through the entire school day and homework time. Children who do not respond well to stimulants, and those with co-occurring conditions such as tics or anxiety, are candidates for nonstimulant medications such as atomoxetine (Strattera) or guanfacine (Intuniv). A significant proportion of children will respond better to one medication or the other in terms of both efficacy and side effects.

How often do you see the patient in follow-up after starting a medication?
I personally see children a month or so after starting medication, with phone calls in between for any questions, adjustments, or problems. Once a child is stabilized, I usually see the child every few months. Simple questions and adjustments might be handled over the phone in between visits after that.

How often should children have their medications evaluated?
Medications are evaluated at each follow-up visit. We ask about side effects as well as effectiveness at school, homework time, morning and evening routines, and weekends. At each visit we seek clear evidence of effectiveness via feedback from parents and teachers (including comments in report cards).

Often, we keep the teachers "blinded" to the initial onset of medication use in order to get objective feedback. Once we get this objective observation of usefulness of the medication by the teachers, we let them know about the medication use so they can more effectively give feedback regarding the extent of usefulness and side effects of the medication at different times through the day.

What are the common side effects and how are they managed best?
Appetite suppression (particularly at lunch) can be handled by "frontloading" the child with a large breakfast and lots of (hopefully healthy) snacks in the afternoon and after dinner. Height and weight should be monitored by a medical professional. Stomach upset can be minimized by giving the medication on a full stomach.

Sleep onset problems are common to begin with in children with ADHD but can be exacerbated by stimulants. The occurrence of insomnia does not always correlate with the time of the last dose of medication. Sleep hygiene can be recommended, including no caffeinated drinks after dinner, a consistent bedtime routine, a calm activity before sleep, a snack, and clear expectations. Sometimes the doctor might suggest use of a medication such as melatonin, which works best if taken several hours before desire sleep time.

Irritability can occur during or after the time that the medication is working. If the irritability is occurring during the first hours of medication use, then consider a preparation with a smoother release profile, a lower dose, or another medication.

If your child is experiencing "rebound," which is a brief period of tearful, irrational nastiness as the medication level drops too rapidly in the late afternoon, then your doctor needs to provide a medical regimen that provides a smoother "tail" as the medication wears off. This can be done as above, or by adding a tiny dose of a short-acting preparation just before the rebound starts (typically some time in the afternoon). Be sure that the stimulants are not exacerbating an underlying mood disorder. I also warn the family to watch for any tics (sudden, repetitive movements).

When do you decide to change a medication?
We change medication:

  • When the time frame that the child needs support with changes; for example, as the child gets more homework, we may need to switch to a longer-lasting preparation or add an afternoon dose of a short-acting preparation.
  • When there are side effects that cannot be handled as above or with dose adjustments.
  • When other medical or psychological conditions occur that might be better treated with a different type of medication.

If one class of drug fails, can another work?
Yes, and frequently so. This may lead to an unpleasant sensation of "experimenting" with your child, but it may be necessary.

What are the most common misconceptions about ADHD and drugs?
Short attention span.
ADHD is much more than just a short attention span. If all a child needed were a tap on the shoulder every 5 minutes to return to task—and if the child said, "Thanks for the reminder! Can you please come back again soon?"—then we would not need all of these interventions.

Rather, ADHD is more powerfully conceived as a problem with the brain's executive functions. This includes the abilities to apply "brakes" to one's behavior, organizational skills, foresight, hindsight, and calmly talking to oneself. This explains the traditional view of ADHD as involving distractibility; failure to put the brakes on internal distractions results in impulsivity, and getting up to check out those distractions results in hyperactivity. However, it extends our understanding, and thus empathy, much further to include trouble with putting brakes on our reactions (leading to "overreactions") and trouble with time management.

Stimulants work "paradoxically". There is nothing paradoxical about how stimulants work in children or adults. At any age, stimulants work by waking up the person's own attention functions. Think of caffeine. We "quiet down" and get back to work after coffee break because we're now awake, not because we're too tired after drinking a cup of coffee to bother milling around the room and chatting. If we think of ADHD kids as bicycles without brakes, then think of stimulants as giving the child effective brake pads.

Stimulants cure everything. Stimulants typically do a great job at controlling attention, impulsivity, and hyperactivity, which have traditionally been thought of as forming the core symptoms of ADHD. However, medications often do not help enough in the other areas of executive function, such as organizational skills, foresight, and hindsight. That's where organizational interventions from the school and parents come in. Caring adults will likely need to provide a "safety net" of organizational support while the skills are being taught and internalized. Sometimes a tutor or coach needs to be brought in if the child does not tolerate a parent in this role.

What can parents do to help the doctor? Provide accurate feedback from the school and home as to the child's progress and problems, and stay positive and calm.

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