An Accurate ADHD Diagnosis for Children
Is it attention deficit disorder (ADD ADHD)? A learning disability? Maybe it's depression or anxiety, a mild form of autism — or chronic fatigue resulting from a sleep disorder. Maybe it's a combination of things.
Getting an answer to the question "What's wrong with my child?" can be harder than many parents expect. So can arranging appropriate treatment. In fact, experts say, the process of resolving a child's behavioral and academic problems is relatively straightforward for only about one in five families.
Glenn Bevensee, of Northfield, New Jersey, counts himself among the lucky few. When the 47-year-old father of two began to suspect that his 12-year-old daughter, Kristin, had ADHD, he consulted her pediatrician. As luck would have it, the doctor knew all about ADHD, in part because he had it himself. He was able to make an immediate diagnosis. "The pediatrician talked to my daughter for 10 seconds," Glenn recalls. "He said, 'Yep, we ADDers can spot others like us almost instantly.'"
Fortunately, the ADHD medication prescribed by the pediatrician proved to be highly effective. Kristin was better within an hour.
"Off medication, my daughter was obstinate and very loud," says Glenn. "She raced around the house like a bull in a china shop. But once Kristin was on medication, her grades improved, she got her homework done, and she was much more pleasant to be around."
Twists and turns
Glenn's experience is by no means typical. "When he was in kindergarten, I knew my son, Robb, had speech problems and immature social skills," says Kristen Wheeler Highland, a mother of three living in Bloomington, Minnesota. "By fourth grade, Robb was struggling socially, emotionally, and academically. He had trouble staying on task and got caught up in minutia. Homework was a monumental problem every night."
Since Robb had scored high on aptitude tests, his teachers felt that his academic difficulties meant nothing more than "a bad attitude." Kristen knew better. "I sought help repeatedly," she recalls, "but my district special education department told me they didn't screen for ADHD." Robb's high scores also meant that testing him for a learning disability was a low priority — even though his academic performance was dismal.
Months passed, as Kristen sought help for her son. Months turned into years. One day, when Robb was 10, Kristen reached her breaking point. Exhausted and monumentally frustrated, she walked into her boss's office, sat down, and burst into tears. "I told her I was too tired to keep doing my job all day and then go home to teach my son his schoolwork at night," she recalls.
One reason it's difficult to cope with a child's behavioral and academic problems is that there is often more than a single diagnosis.
"Fifty percent of the kids diagnosed with ADHD also have a learning, language, or motor skills disability,” says Larry Silver, M.D., clinical professor of psychiatry at Georgetown University Medical School in Washington, D.C., and the author of The Misunderstood Child: Understanding and Coping with Your Child’s Learning Disabilities (Three Rivers Press). "Approximately the same percentage of these children have a comorbid disorder, such as anxiety, depression, obsessive-compulsive disorder, oppositional defiant disorder, conduct disorder, or a tic disorder."
Given how common multiple diagnoses are, it's unrealistic to think that medicating a child will solve all his problems — at least not all of them at once.
"Parents need a realistic perspective about what medication can and cannot do," says Susan Ashley, Ph.D., of Northridge, California, author of The ADD & ADHD Answer Book(Sourcebooks). "ADHD medication is presumed to be effective, so parents have excessively high expectations. If your child doesn't respond well to medication, try another type of intervention, such as behavior modification, social skills group therapy, tutoring, 504 accommodations, or special education."
Most kids do best with a combination of drug and non-drug interventions—the so-called "multimodal" approach. For some children, non-drug interventions are all it takes; they require no medication at all.
The Diagnostic Puzzle, Part 2
Making the most of medication
According to the American Academy of Pediatrics, "at least 80 percent of children will respond to one of the stimulant medications if they are tried in a systematic way." What if your child happens to be in the other 20 percent?
You must work with a doctor who knows a thing or two about ADHD and related disorders. The doctor should have significant experience with trying out various ADHD medications and dosages, including some that are nontraditional, or “off-label” — that is, those that lack specific approval for treating ADHD. The blood pressure drugs clonidine (Catapres) and guanfacine (Tenex), for example, are often highly effective against impulsivity, hyperactivity, and sleep disturbances.
Assembling a team
"Don't hesitate to consult a specialist if traditional treatment isn't working, or if you suspect your child has a complex form of ADHD," says Brock Eide, M.D., of Edmonds, Washington, co-author of The Mislabeled Child (Hyperion). "Your pediatrician or family doctor may not be up-to-date on the latest and greatest cutting-edge diagnostic and treatment approaches."
Dr. Eide says that an ADHD child who is also affected by bipolar disorder, depression, or obsessive-compulsive disorder (OCD) should be seen by a child psychiatrist. If a child is experiencing social or emotional difficulties, a psychologist can be helpful. And if a child develops tics or has chronic headaches, it’s a good idea to consult a pediatric neurologist.
How can parents keep track of it all? John F. Taylor, Ph.D., the Monmouth, Oregon-based author of The Survival Guide for Kids with ADD or ADHD (Free Spirit Press), urges parents to keep a written log detailing their child’s symptoms and difficulties, as well as the steps taken to address them. "Write down all your concerns, your child's symptoms, abnormalities, and anything else that marks your kid as different from other kids. Pay particular attention to what changes as a result of medication or behavioral interventions, and what doesn't."
Dr. Taylor knows from personal experience how valuable a treatment journal can be: Three of his eight children have ADHD.
What about misdiagnosis?
Some children diagnosed with ADHD, in fact, don't have the disorder. Ask Shelly Niemeyer, a 38-year-old mother of two, living in Chesterfield, Missouri. "When my son, Luke, was in third grade, the teacher found out that both his older brother and I have ADHD," she says. "Immediately, it became Luke's problem, too. Our doctor read the teacher's report and put Luke on medication.
"My older son had improved when he started taking medication, but my younger son didn't. So I decided, after two months, to stop Luke’s meds." As it turned out, Luke doesn’t have ADHD — or any other psychological problem. "He's merely an active, creative-minded nine-year-old," says Shelly.
"When you start a child on ADHD medication, you should see substantial improvement very quickly, even with the first dose,” says Dr. Eide. If the improvement in behavior is marginal, despite trying several medications at various doses, it's a clear signal to start looking for conditions other than ADHD.
"Another factor to consider," says Fernette Eide, M.D., Brock Eide's wife and collaborator, "is the possibility of a 'look-alike.'" By that she means a disease or disorder whose symptoms resemble those of ADHD.
By the time Adam Colbert, of Westford, Massachusetts, was in preschool, everyone had noticed his speech problem and his inability to pay attention. "We were concerned," says his father, Jim. Thinking that Adam might have ADHD or a learning disability, Jim and his wife had Adam assessed — and were surprised to learn that Adam has a significant hearing loss. Now wearing a hearing aid, Adam is doing great.
The Diagnostic Puzzle, Part 3
There are many possible misdiagnoses. A child who seems to meet the diagnostic criteria for attentional impairment might actually be suffering from sleep apnea, a condition that interferes with restful sleep. A child who is having trouble focusing at school may merely be bored — intellectually gifted but not stimulated by the curriculum.
Some children misdiagnosed with ADHD are showing the effects of post-traumatic stress disorder, or PTSD. "An extremely traumatic event, such as a death in the family, a severe physical injury or illness, or even an abusive home environment, can cause an inability to attend and focus," says Alessia Gottlieb, M.D., co-medical director of the UCLA Child and Family Trauma Center and staff member at the National Center for Child Traumatic Stress in Los Angeles.
Coping with comorbidities
Ten-year-old Matt Moncovich, of Wilmington, North Carolina, had done well in preschool and kindergarten. But soon after starting first grade, he began to get in trouble on a daily basis. A few weeks into second grade, Matt's mother, Yvonne, discovered that he was far behind his classmates academically. Matt's teacher suspected that he had ADHD.
A psychological evaluation confirmed the teacher's suspicions. But it also suggested that Matt might also have an anxiety disorder, and possibly OCD, in addition to ADHD. Fast-forward two years: "After trying every stimulant on the market," says Yvonne, "we've finally found one that works. Unfortunately, my son's hair-twirling and lip-sucking haven't lessened."
Yvonne now suspects that OCD and anxiety are Matt's primary problems — not secondary to ADHD. She plans to state her concerns at Matt's next doctor visit.
Dr. Taylor urges parents to do their homework. "Read all you can, not only about your child's diagnosis, but also about similar or related diagnoses," he says. You may recognize symptoms that don’t indicate ADHD alone.
Never give up!
The road you follow may have its twists and turns—but eventually you'll get there.
"Not all kids fit neatly into the diagnostic categories that have been created by the field," says Dominic Auciello, Psy.D., a clinical neuropsychologist at the New York University Child Study Center in New York City. He says some children never get a clear diagnosis, much less a treatment regimen that solves all their problems. Yet, he says, there are always ways that parents can help their children learn to live with — and work around — their problems.
Remember Robb Wheeler? He was ultimately diagnosed with ADHD, along with a form of mild depression known as dysthymic disorder, generalized anxiety disorder, and dysgraphia, which is an inability to process written language. Oh, yes, and his I.Q. falls within the superior range. Now a high school senior, Robb takes a mix of special-education and honors classes, plays sports, works part-time, and has a girlfriend. This fall, he plans to attend a technical or community college, and, after that, go on to earn a four-year degree.
Robb is doing well now—but only because his mother, Kristen, never stopped fighting for the services and academic accommodations he needed to succeed. "I know the journey's not complete," says Kristen. "I anticipate more bumps in the road, more tears and more sleepless nights. But I'm confident that my son is turning out to be the lovable nerd I always knew he'd be!"