Attention deficit disorders (ADD and ADHD) in children

What is attention deficit disorder and how common is it in children?

ADD is a neuro-developmental disorder, and it is found in about 7-10% of the general population. The disorder develops in the first 5 years of life but does not really resolve at a particular age and is therefore found in a widespan of ages, from childhood and way past adulthood.
The main signs and symptoms are deficits in attention, hyperactivity and impulsiveness. Remember, there is no need for all these different signs to be present in order to make a diagnosis of ADD. The deficit in attention manifests in all the different aspects of life and can affect the person’s learning abilities, management capacity at work and their interpersonal skills and relationships in their daily life.
It is an inherited familial disorder, and several different genes have been found responsible for it. A parent has a 75% risk of having a child with attention deficit disorder if he/she suffers from it. On the other hand, if a child has ADD, the chances that another member of family also has it (either a parent or sibling), is about 4 times as high as in a family without any members with ADD.
As I mentioned, ADD in children leads to significant difficulties in reading and listening. Avoiding treatment may lead to further difficulties in daily activities, and this may lead to developmental delays and even the development of psychiatric and medical disorders in adolescence, some of which may increase the risk of life-threatening situations such as addiction and all sorts of accidents.
In the past decade, awareness of the disorder has increased, both within the family setting as well as in educational institutions and among teachers and counsellors.

What lies behind ADD in children and adults?

The underlying cause of the disorder is a deficit in the electric transmitters in the brain, especially in the neurotransmitter dopamine. Dopamine has a central role in cognitive functions, activities of memory, management, and reinforcement. There are lower levels of dopamine in people with attention deficit disorder than those who do not have this disorder. Therefore, medications that increase the levels of dopamine bring about a relief of symptoms.

What are the symptoms of attention deficit hyperactivity disorder (ADHD) in children?

In order to diagnose the disorder, the child needs to meet all of the following criteria:
a. Onset of the symptoms before the age of 7 years.
b. Symptoms that have persisted at least in the past 6 months.
c. Symptoms are present in at least 2 settings – school (work) and home.
ADHD is suspected if there are at least 6 symptoms of attentions deficit and 6 symptoms of hyperactivity and impulsiveness in children under the age of 16, or 5 in each group for adolescents aged 17 and older.
Of course, if a child only meets the criteria of attention deficit but does not meet the criteria of hyperactivity, they will be diagnosed with ADD.

What are the signs of ADD?

1. Easy loss of attention span due to external triggers – easily distractable.
2. Difficulty with paying attention while doing different tasks.
3. Partial listening when being talked to.
4. Difficulty with organising assignments and completing tasks.
5. Avoidance of tasks that require ongoing mental effort.
6. Difficulty with following instructions and guidance fully.
7. Difficulty with paying attention to details, causing lots of silly mistakes.
8. Forgetfulness.
9. Loss of things that are important for activities and tasks.

What are the signs of ADHD?

1. Fidgeting in the chair, moving feet frequently and playing with things in the hands.
2. Being restless, in constant motion, as if “driven by a motor”.
3. Walking around in the classroom, frequently leaving the classroom to get a drink, going to the toilet or getting some fresh air.
4. Being very talkative during class.
5. Being noisy during inappropriate times.
6. Jumping and climbing when it is not appropriate or not permitted.
7. Calling out answers before the question is complete.
8. Having difficulties with waiting for turn, impatient.
9. Bothersome to and interrupting others.

How is ADD diagnosed in children in practice?

In most places, the diagnosis is performed by one of the following medical professionals – pediatric neurologist, pediatric psychiatrist, pediatricians or primary care physician who are qualified to do so.
The duration of the diagnostic test is about 45 minutes to an hour. It is conducted in the form of an interview, where the child’s developmental, behavioural and executive functions are assessed according to the information retained from the interviews, questionnaires that are filled out by parents and teachers and computerized exams (TOVA and MOXO) and several other assessments tools. It is then finally determined whether the child has ADD or ADHD and management options are advised to the parents.

When are TOVA and MOXO assessment tools used?

MOXO and TOVA provide the assessor help when making a diagnosis, especially if the diagnosis is not clear cut. If the child’s interview results are inconclusive, these tests aid with making the diagnosis. If the child has already taken the tests prior to the interview, the results are taken into consideration as well when determining the final diagnosis.
Remember, the use of such assessment tools depends on the medical provider conducting the assessment. Some providers order them for all children with suspected ADD/ADHD.

How are ADD and ADHD diagnosed in children under the age of 6 years?

These diagnoses can also be made in children under the age of 6. However, in most settings, only neurologists and certified psychiatrist can diagnose children these ages.

What is the difference between learning disabilities and attention deficit disorder?

Often the school will suggest that a student undergo attention deficit assessments when in reality what the student has is rather a learning disability or difficulty.
In such situations, the child’s learning difficulties can be managed with the help of remedial education, learning strategies, and teaching accommodations.
Nowadays, sometimes the educational system which is supposed to aid with identifying the child’s problem is unaware of all the nuances and differences between the different possible conditions and sends all of the children for an attention deficit assessment. In order to detect a learning disability or difficulty, a psycho-educational assessment must be performed – this is the type of assessment that eventually allows for the provision of the right support and assistance for exams and learning.

How is ADD managed in children?

The management of ADD can be behavioural, emotional, medicinal or through learning techniques. Often the management is a combination of all four of these and it is individualized to the personal needs of the patient at hand. The importance of the non-medicinal treatment options is tremendous in this young age group. The management is often paramedical and includes occupational therapy, psychological therapy or focused remedial education that provides the child with the right tools to help him deal with the disorder without the need for medication.

What do I have to say about avoiding medication and referring to alternative management methods?

One must distinguish between supportive/alternative treatment options which may include occupational therapy, emotional therapy, group therapy, biofeedback and more. In mild cases, these management methods can either provide an alternative to the medicinal therapy or, of-course be supplementary to it.
As for homeopathic pharmaceuticals and other non-conventional therapies (the list is endless for those), – these usually do not address the real issue and do not really provide treatment. On the other hand, every parent is entitled to try whatever they wish with their own child.

What is the main medicinal treatment for ADD in children (and adults)?

Medicinal treatment includes two main types of stimulants:
Medication that belongs to the Ritalin family and drugs that belon to the amphetamine family. Usually, when a provider believes medication is required, they will start with prescribing Ritalin and will only resort to amphetamine if side effects develop when the patient is taking Ritalin.
Stimulants act on the central nervous system and while it may sometimes seem like they “calm the person down,” their mechanism of action is the exact opposite, i.e they are awakening medications. They increase the levels of the neurotransmitter dopamine in the brain and by doing so “correct” the dopamine-flow disorder. The increased level of dopamine allows those who suffer from ADD improved self-control, better attention spans, and improved memory capabilities in school and at work.

The medication chosen by the physician depends on the length of activity of drug desired. The immediate-release form of Ritalin lasts about 4 hours, the long-acting Ritalin lasts about 8 hours and Concerta lasts about 12 hours. Within the amphetamine group of drugs, we have Attent which lasts about 6 hours and Attent XR or Mix Amphetamine which lasts about 12 hours.

Do these medications have side-effects?

Different children are affected by drugs differently – some will have lots of side effects that will require them to switch their medications and others won’t have a single side effect. The only way to find out how a medication will affect a child is by providing it to him and monitoring its effects.
Side effects may include:
1. Decreased appetite and sleeping difficulties. The medication must therefore be taken with a good meal or sandwich and should not be taken on an empty stomach nor in the evening hours.
2. Loss of weight. Weight and height measurements should be taken every 6 months.
3. An increased sensitivity to triggers.
4. Irritability.
5. Abdominal pain.
6. Headaches.
7. A sensation of palpitations that does not have a detrimental effect on the cardiac function.

Can children get addicted to these medications?

It’s important for you to know that one cannot become addicted to ADD and ADHD medications and as soon as their duration of action comes to an end, they are secreted in the urine and so they do not accumulate in the blood. One can stop taking these medications at any given time.

Does my child need to undergo any tests prior to the start of treatment?

Since the use of stimulants may cause lack of appetite and palpitations, prior to putting children on these drugs providers typically measure their height, weight and blood pressure.
Once the medication has been started, these measurements are taken once every 6 months to monitor any changes in weight or blood pressure.
There are no strict guidelines regarding blood tests or cardiac function tests in healthy children prior to the onset of treatment.

I am concerned my child may have attention deficit disorder. What should I do?

If you are concerned that you child suffers from signs and symptoms of ADD I suggest consulting with your primary care medical provider and requesting a referral for assessment by a certified professional.
If you find out they do indeed have ADD or ADHD, the assessment will provide you with the appropriate tools for your child and your family to be able to live with this disorder in peace.

Good luck!