How to Diagnose and Treat ADHD in Children
A parent's guide to ADHD in children: recognizing symptoms, finding a doctor, evaluating medications, and helping your child thrive.
Imagine a child whose ADHD has been diagnosed and who is getting appropriate treatment. His symptoms are under control, and he's doing reasonably well, socially and academically. Let's call this "Point B." Now imagine the same child before receiving a diagnosis. He's having difficulty at home and at school. Let's call this "Point A."
How do you get from A to B? There's no definitive diagnostic test for ADHD in children -- no blood analysis, no brain scan, no genetic screen -- so it's not easy to tell whether a child has the disorder. And doctors vary in their abilities to diagnose and treat the disorder, so it's easy to go down blind alleys before getting the help your child needs.
Susan Skok knows all about blind alleys. The mother of two boys with ADHD, this Melbourne, Florida, resident spent thousands of dollars on mental-health professionals before she found a doctor who provided real help.
Jill Hogan, of Elgin, Illinois, tells a similar story. "My poor son, Sam, had to endure several psychologists and psychiatrists, some of whom actually got their techniques from radio or television talk shows," she says.
The good news is that, if you take matters step by step, as outlined below, you can avoid such pitfalls--and make it to Point B more smoothly than you might have imagined possible.
The "Aha" moment
The ADHD journey inevitably begins with the "Aha" moment, when it dawns on you that your child's problems may be caused by ADHD or another biologically-based disorder.
For some parents, this moment comes when a teacher calls to say that the child is disruptive in class or falling behind academically. For others, it comes after they read an article about ADHD or see something about it on TV—or hear that another child at school has been diagnosed with the disorder.
Whatever triggers your "Aha" moment, seek help at once. Without a prompt diagnosis, an ADHD child is apt to be branded "slow" or "lazy" (or worse). Such labels undermine self-esteem and can lead to years of underachievement and family turmoil.
Perhaps most important, don't panic. With appropriate treatment, ADHD children do well. And if your child does have the disorder, you can take solace in the fact that it is about biology and is in no way your fault.
Jennifer Haus, of Clinton, Mississippi, knew that her young son's shoe-tossing, bookcase-toppling meltdowns weren't normal. But friends and family members repeatedly told her that Mitchell's tantrums resulted from poor discipline. She tried time-outs, reward charts, withdrawal of privileges--nothing worked. Then, one day Mitchell came home from school crying. He said that he felt "different" from his classmates. "That," Haus recalls, "is when I called his pediatrician."
Consulting the doctor
After your "Aha" moment, your first impulse will probably be to consult a pediatrician. That makes sense. "Most pediatricians are comfortable diagnosing and treating ADHD," says Larry Silver, M.D., clinical professor of psychiatry at Georgetown University Medical School in Washington, D.C. "Usually, that's the only medical professional you need."
Still, just because your pediatrician feels comfortable doesn't mean you should. Before agreeing to have your child treated, "ask how many other cases of ADHD the doctor has treated, and what the plans and outcomes were," says Russell Barkley, Ph.D., research professor of psychiatry at SUNY Upstate Medical University in Syracuse, New York. If the doctor has handled only a few cases, you might be better off going to a developmental pediatrician, child psychiatrist, or another specialist who has significant experience with ADHD.
"Regardless of how experienced your pediatrician is," says Barkley, "you should strongly consider a medical specialist if your child's ADHD is accompanied by another diagnosed disorder, such as oppositional behavior, depression, anxiety, bipolar disorder, emotional problems, or learning disabilities, or if there are urgent issues involved, such as your child's hurting himself or getting kicked out of school."
Your pediatrician or health insurer can probably steer you to a qualified specialist. If not, contact your local chapter of Children and Adults with Attention-Deficit Hyperactivity Disorder (CHADD). Ask family and friends for their recommendations. "Every positive step we have taken has been inspired by another family's recommendation," says Susan Skok.
The ADHD Road Map, Part 3
Given the risk of side effects--and the persistent stigma surrounding the use of psychotropic medications--parents are often reluctant to start their children on drug therapy. In many cases, some family members oppose drug therapy, while others figure it's worth a try. In any case, drug therapy is a matter that warrants thorough discussion by all parties involved, including the parents, of course, the doctor who would prescribe the drugs, and, depending on his or her age, the child.
Finding the right drug
With most pediatric medications, the proper dosage depends upon the age and/or weight of the child. But with the stimulants used to treat ADHD, proper dosage depends upon how rapidly the child's body metabolizes the drug—body weight is seldom the deciding factor. Consequently, finding the right dosage—and the right drug—typically involves trial and error.
At first, your child may need to see the doctor every few days or so. If your child becomes unusually irritable or tearful or seems to be "in a cloud," the dosage should probably be reduced. If side effects continue, or if there's no change in your child's behavior, a different medication should be tried.
In most cases, the right drug and dosage can be discovered within a month. But there are exceptions.
For Mitchell Haus, the process took eight months. During that time, says his mom, Mitchell suffered insomnia and "zombie-like" behavior. But once the right medication was found, she says, "Mitchell's behavior calmed down. He's still a handful, and his ADHD symptoms haven't disappeared, but they're manageable—which makes a huge difference."
As medication questions are being resolved, it's a good idea to sit down with the doctor to discuss other forms of treatment. Your family might benefit from sessions with a family therapist--especially if there are disagreements over how the child should be treated.
In addition, your child might benefit from sessions with a child psychologist who specializes in behavioral therapy. And many parents benefit from "parent-training" classes, in which they learn new ways to set and reinforce rules governing their child's behavior. (To find parent-training classes in your area, go to taalliance.org.)
If testing indicates that your child has a learning disability, your school is required to develop a treatment program to address the problem. Don't be shy about asking the school for "reasonable accommodations" for your child--for example, letting her sit at the front of the class to minimize distractions, permitting occasional breaks for physical activity, or allowing extra time for test-taking.
Within three months of your "Aha" moment, this is how things should look:
- If your child is on stimulant medication, you should now be calling in monthly to your pediatrician (or other physician) to get the prescription renewed, with visits scheduled every few months to monitor progress.
- All of the supplemental treatments (psychotherapy, parenting training, and so on) should also be up and running, if not completed.
- If your child has a program of special education (or accommodations) at school, it may be reviewed and extended on a year-by-year basis, depending on future test results.
Whew. You've made it--welcome to Point B!
To diagnose a child with ADHD, a doctor must complete several different assessments:
- Behavioral history. Your initial meeting with the doctor (pediatrician or specialist) should focus on your child's behavioral symptoms. Leave your child at home, and bring along written or verbal descriptions of your child's behavior from current or former teachers, as well as copies of any psychological test results you might have.
You'll be asked where and when your child's symptoms occur and when you first noticed them. In addition, the doctor may ask you (and your child's teachers) to complete the Conners' Rating Scale, a questionnaire that helps determine the nature and severity of your child's symptoms. And don't be surprised if the doctor asks about family or marital stresses that could be making your child anxious.
- Medical history and exam. If your answers convince the doctor that your child's symptoms are chronic and pervasive, he or she will probably take a detailed medical history of your child. The goal here is to rule out anxiety, depression, sleep problems, seizure disorders, vision or hearing problems, and other medical conditions that can mimic ADHD. Certain medications can also cause symptoms of hyperactivity or distractibility in some children.Some of this history may be taken in the initial parent-doctor interview, but the doctor will also schedule an appointment to examine your child.
- Review of records. The doctor should review relevant school reports and medical records. (If you didn't bring copies of the records to your initial appointment, call the school and have them sent to your doctor.) The doctor will want to have at least one phone conversation with your child's teacher(s) or school psychologist.
Awaiting the diagnosis
At this point, you want the answer to one big question: "Does my child have ADHD?" But don't expect an answer overnight. The diagnostic process typically takes a week or two.
As you await the diagnosis, inform your child's teachers and any other school officials that your child is being evaluated for ADHD. Ask for a meeting with the school psychologist or special education teacher to discuss having your child evaluated for learning disabilities (which affect 30 to 50 percent of ADHD kids).
If your school is unable or unwilling to administer the appropriate testing, you may have it done by a private educational psychologist - typically at a cost of several hundred dollars.
"I always tell parents to work both the medical and the school tracks in parallel," says Barkley. "If you wait to do one after the other, you're stalling."
The treatment plan
A month or so into your journey, your child's diagnosis should be complete. Now, you, your child, and your doctor are ready for the treatment phase.
If your child has been evaluated by a specialist, he or she will likely take the lead in formulating a treatment plan (which should be communicated to your pediatrician and other caregivers). If your child was evaluated by a psychologist, he or she will probably need to confer with your pediatrician about starting your child on one of the many ADHD medications available.
Studies show that ADHD medications are generally safe and effective for about 80 percent of the children who take them. Many experts feel that treatment with medication is essential: "If your child had a cavity, wouldn't you treat it?" asks Joseph Biederman, M.D., head of pediatric psychopharmacology at Massachusetts General Hospital in Boston. "Medication management represents the most important component of the treatment of ADHD."
Dr. Silver agrees. "Sometimes medication is all it takes to solve the problem," he says. "Even if it isn't, it's important to evaluate how the child is doing on medication before you start dealing with other psychosocial issues."