The first thing I want to say about medication and attention problems is that I have no affiliation with any drug company. Everything I discuss is based on anecdotal evidence based on seeing hundreds of kids with attention problems and personal experience with my own children, not scientific research. I am a psychologist so I do not prescribe medication. Psychiatrists, and sometimes pediatricians or general physicians, prescribe medication for attention deficits. I work in the same office with a group of six pediatricians that have known me for over five years. They know what my assessments consist of and have grown to trust my methods. They will, in most cases, start medication if I send the kids I see to them for a medical evaluation.
When I first started in our clinic, I would walk down the hall and ask the doctors if they would consider medication. Now, I almost always ask parents to make a separate appointment to talk to their pediatrician about medicine. Each pediatrician has their own information they like to discuss and they also get a baseline height, weight, and blood pressure. Some pediatricians would rather I refer to a psychiatrist because they do not feel comfortable prescribing any medication to address behavioral health needs. I respect their positions. It is their license, not mine.
Unfortunately, there is no blood test for attention problems. There is also no definitive test, just agreed upon types of information that should be collected for determining if a child has attention problems. A complete family and academic history should be collected. I collect this information in an interview format by asking direct questions.
When I do an evaluation for attention problems, I also randomly go through the diagnostic criteria for ADHD. We have a book that psychologists and psychiatrists use that lists all the criteria for all behavioral health “disorders.” (read my other ADHD posts to see how I feel about the word disorder) For kids, that includes diagnoses like reading, toileting, separation, habit, and feeding disorders. When they meet a preset number of the 18 characteristics academics think are indicative of significant attention problems, then I collect rating scales.
I use rating scales that I like. A rating scale is a standardized comparison of a child’s behavior with a large number of other same-aged children’s behavior. The one I use has a parent, teacher, and, if the child is over 11, a self version of the same scale. You have to have a Ph.D. to order them, they cost money to get them, and they are copyrighted, so they are not supposed to be copied. The rating scale I use has over 100 questions. I like it because it is not so obvious that I am trying to see if someone has attention problems. When I get the rating scales back, I computer score them and get a printout of how the child I am evaluating compares to other children their age in several different areas like mood, social, attention, and conduct. There are a variety of scales that could be used. Many psychologists use free scales published online.
Some psychologists will do some form of a computer generated test called a continuous performance test. Professional literature does not support this type of test to be necessary nor always reliable. There is often an additional charge for the testing and it appears as though a definitive answer has been reached as to whether or not the child being evaluated has attention problems. It certainly won’t hurt to get the computer testing, but it is not necessary.
Once all of the information is collected, I look at it as a whole in order to make or defer a diagnosis of Attention Deficit Hyperactivity Disorder. It can be Attention Deficit Hyperactivity Disorder Primarily Hyper-Impulsive Type, Attention Deficit Hyperactivity Disorder Primarily Inattentive Type (what we usually call ADD), or Attention Deficit Hyperactivity Disorder Combined Type.
I can not always “see” if a child has an attention problem in my office. You can not see inattention. I can sometimes see the behavioral result of an attention problem. Children who have not been to school or are having problems in school are often much more distractible and disruptive in my office. If a child has been to school, usually they have learned to sit still and behave well because that is what is expected of them at school or they get into trouble. Parents often get stressed out if a child does not behave in my office. If the busyness or “naughtiness” represents their typical behavior, I love it! It helps me in making an accurate diagnosis.
I also can not “talk” a child who has attention problems out of them. Attention problems are hardwired into our bodies, I can not talk them better. I offer a lot of behavioral strategies that can be tried that work in my other posts, but sometimes medication needs to be added. The behavioral symptoms, like walking around the classroom, can often be managed by others like teachers, the attention problems, like daydreaming and distractibility, are often only changed by medication.
When these temperament characteristics are causing significant problems at home and school, and behavioral interventions have been tried but a child is still having problems, it may be time to think about medication. These are the kids that when I hear their stories I feel like life should just not have to be that hard for them. It’s the smart kid reading at the 20th percentile and who can’t remember how to spell sight words from one week to the next. It’s the sweet kid whose classmates walk up to his parents and ask, “Why is he so bad?” It’s the kid who is suffering depression and anxiety because they “can’t work to potential” or they are afraid they are going to accidentally lose another worksheet.
For simplicity purposes, for the rest of the post, I will call all types of ADHD (Inattentive, Hyper-Impulsive, and Combined type) just ADHD. The same medication is used for the three types of ADHD. ADHD medication is stimulant medication. Stimulant medications are controlled substances so they can not be prescribed over the telephone. They need to be picked up at the prescriber’s office every month and signed for by a parent or guardian or a person 18-years-old or older.
Medication for ADHD is a tool, not a cure. It is a tool to help show the brain how it feels to pay attention when someone is bored, doesn’t understand, or doesn’t want to do something. It’s that simple. The example I use, taught to me a long time ago by a mentor, Edward Christophersen, is learning how to ride a bike. A parent spends 30 minutes telling their child how to ride a bike. The parent may even draw diagrams and physically make the motions of how to ride a bike. Then the parent asks the child if s/he knows how to ride a bike and the child says, “Yes, I know how to ride a bike. Thanks for teaching me.”
Everyone goes outside, the child gets on the bike and immediately falls over. “You said that you knew how to ride a bike!” the parent scolds. “Did you lie to me when you said you knew how? Where you not listening to what I said? We went over how to ride a bike just a few minutes ago!” The point is, no one can teach balance by talking. A person also doesn’t know if they have learned how to ride a bike until they feel what it feels like to balance successfully. They weren’t lying when they said they understood and knew how to ride a bike. A person just doesn’t know what they are going for until they are successfully balancing.
People with ADHD don’t know what it feels like to pay attention when they are bored, don’t understand, or don’t want to do something. Until they do it successfully, they won’t know what it feels like to pay attention during those times. If they are interested or passionate about something, they have no problems. If fact, they often pay attention better than other people when they are passionate or determined to do something.
Technically, I can give a diagnosis of ADHD when a child is 4-years-old. I rarely give an ADHD diagnosis before 1st grade. I prefer to wait until a child is in 3rd grade, and typically ask teachers and parents to use behavioral techniques instead of medication in children younger than 3rd grade. See some of my other ADHD posts for behavioral recommendations.
I have a layman’s explanation for why stimulant medication works. Medical doctors may object, but it is the best way I know to explain. It seems strange that hyperactive boys bouncing off the walls would be given a stimulant. People with all types of ADHD are actually UNDER stimulated. Our brains need stimulation. People with ADHD get the stimulation their brain needs by getting it manually. How they get the stimulation their brain needs DOES depend on the type of ADHD they have.
Hyper-Impulsive kids get what their brain is looking for by touching, moving, and, well, bouncing off the walls. These are the kids that are usually recognized at a young age, many times in kindergarten. They are often, but not always, boys. It is very difficult to distinguish some very typical and age appropriate “boy” behavior that will improve with maturity and hyperactivity associated with ADHD. Girls who are having trouble with aggression, sometimes only at home, could also fit an ADHD diagnosis.
It has taken me awhile, but after seeing hundreds of ADHD kids and teens I finally understand that the brains of people with what we usually call ADD are also UNDER stimulated. They manually get the stimulation their brain needs not by moving and reacting to their environment, but by thinking about things that are more interesting to them than what they are doing. In short, they daydream to get the stimulation their brain needs. Many people with ADHD and ADD are highly intelligent. Therefore, they may be thinking about theories, a new art project, a tangent of the information being presented in class, or they may just be thinking about what they are going to have for lunch or doing after school.
Medication is a tool that helps both ADHD and ADD brains move through life. It makes moving through life more efficient. If I have a schedule and will suffer a lot of negative consequences, like having to stay late and finish paperwork, I will force myself to stay on track. When I don’t have a formal schedule, I am scattered all over the place. I have to constantly tell myself, “focus, finish.” People with ADHD have difficulty with change and transition. Medication helps them move through times when a consistent schedule isn’t available or cannot be followed.
I also have trouble letting things go, especially, when I am alone. It’s almost as if I “wake up” and realize I have been hyper-focused on a problem or an idea. Kids often get hyper-focused on a toy or game and just can not think about anything else until they have fulfilled the idea. This type of brain may also get hyper-focused on “I don’t understand this and I can’t do it,” in which case we tend to stick our head in the sand. Medication is a tool that moves you through the hyper-focus and you just get things accomplished instead of obsessing, procrastinating, or being scattered.
This is the way this type of brain is hardwired. People would not choose to be forgetful, unorganized, lose things, procrastinate, or make silly mistakes on purpose! It causes a lot of ongoing stress. It is the lens through which they need to be viewed by others. One of the most satisfying parts of my job is after much, very necessary, debate, parents choose to try medication for their child who has struggled and been thoughtfully diagnosed with ADHD. When it’s successful, kids come back confident and parents come back with a new understanding of just how much their child’s hardwiring was getting in the way. The right medication, used correctly, can and does change lives.
Use, common side effects, and names of medications used to treat ADHD will be discussed in my next post.