CHILDREN'S HEALTH

Dr. Bill Knappenberger

Kids Live In Hyper-stimulating Environment

IN THE TIME it takes you to read this article, you will be distracted by a phone, computer, TV, text message, child, pet, job, snack, kitchen or laundry appliance, or some combination of these.  Does this mean the reader is diagnosable as having Attention Deficit Hyperactivity Disorder (ADHD), or is this just the American life?  Our environment shapes our development and helps set the level of arousal necessary each day.

When kids live in a hyperstimulating environment that resembles a video arcade, then a schoolteacher who is merely human has trouble commanding the child’s attention for long periods.  After all, she has no special effects, flashing lights, camera angles or fast forwards that constantly change.

Approximately 4 percent of our population (including children) can be classified as having this disorder, so each of us will likely encounter it in someone each day.  If that someone is our child, then life is made more complicated as we maneuver through the issues involved.  If that someone is our student, then the classroom environment and functionality is potentially threatened.

ATTENTION DEFICIT HYPERACTIVITY DISORDER affects the ability to concentrate on tasks, avoid distractions, to sit still, and to think about consequences. ADHD is the most common behavioral disorder in school-aged children with the ratio at 9 boys to 1 girl.

ADHD is defined as a “neurobehavioral disorder characterized by inattention, distractibility, impulsivity, hyperactivity – all behaviors that are more frequent and severe than typically observed in children of the same developmental age.” That last part of the definition is especially important when considering children who were premature (at birth) or may be victims of prior traumatic brain injury or intrauterine drug exposure.

Diagnosing ADHD
Pediatricians are frequently confronted with children who may be affected by this disorder and must develop some level of ability to distinguish it from the myriad of situations and diagnoses that may easily mimic ADHD.

• Children who are under stress from family strife, death of a relative or pet, bullying, relocation to a new home, or illness may very much appear as if they have ADHD, but only transiently.
• Children with even mild hearing or vision impairment will have classroom (and home) problems, so any child who is being considered for such a diagnosis should undergo competent screening for these problems.
• Children whose allergies are inadequately controlled will often be so distracted that they mimic ADHD kids.
• Children with mild epilepsy (petit mal seizures) will often have such brief spells that they appear to have only blinked, but have lost focus just long enough each time that they sabotage their academic performance.

If a teacher, parent, grandparent, school counselor, or health professional suspects such a diagnosis, then it is appropriate to submit a standardized questionnaire surveying the child’s behaviors.  The most popular are the Connors and the Vanderbilt instruments which can be obtained from the school or from the pediatrician.

These consist of a series of questions for the teacher or parent (different questions for each) that can be scored as behaviors that are frequent, occasional, never, etc.  The form can be scored to give a rating of the likelihood that the child may have ADHD, but it also screens for other problems, such as depression and other psychiatric disorders that can mimic or coexist with ADHD.

It is imperative that multiple people be asked to rate any child, so as to give as broad a measure as possible (one teacher may think a child has a problem, but if no one else has ever thought this, then it may just be a “teacher-pupil mismatch”).  It is central to the diagnosis that a child must have exhibited symptoms before about six years of age, and that evidence of impairment exists across multiple areas of his life, such as school, home, sports, and peer relationships.

ADHD Unrelated to Intelligence
During a visit to the doctor (or counselor or psychologist) for an ADHD evaluation, it is important to establish for the child that it has virtually nothing to do with intelligence, and that the child is not simply being punished for some real or imagined misbehavior.

IT IS CENTRAL to the ADHD diagnosis that a child must have exhibited symptoms before about 6 years of age, and that evidence of impairment exists across multiple areas of his life, such as school, home, sports and peer relationships.

If a parent has some especially damaging history or opinion to relay, it is often best done during a brief hiatus while the child is absent from the room.  They are usually quite sensitive about these issues and may suffer further erosion of self esteem if they are bombarded with negative statements from a parent during such a visit.

It is time to go for evaluation of your child if he/she is going to fail to be promoted to the next grade (beyond kindergarten), unable to pass standardized tests (such as the FCAT), unable to maintain peer relationships, has declining self esteem, or is frustrating the family to the point of distraction.  Sometimes other causes for these problems become evident during the evaluation.  Sometimes younger children are diagnosed and treated partly to help avoid significant injury, since extremely hyperactive children are much more accident-prone.  This does not apply to 2-year olds, who can often seem “wild,” and are actually going through what is often characterized as “the terrible twos.”

If a child is diagnosed and treated with medication, it is still necessary to follow up with extra one-on-one tutoring, surveillance of growth and development, possible counseling, etc.  If a child is being considered as a candidate for medication, it is also important to review family history for possible cardiac rhythm disturbances, including early unexpected deaths.  This might make some cardiac tests, such as an EKG and/or echocardiogram desirable before starting stimulant-type medicine.

Parents often have concerns regarding addiction to medication for ADHD.  This has not been an issue.  Conversely, untreated patients who do poorly in school often do not do well with jobs, relationships, etc., and are actually more likely to be substance abusers than their treated counterparts.  This has been repeatedly shown in different studies from different times and geographic locations.

Response to Medication Prompt, Dramatic
All of us are distractible; some more than others.  If we gave medication for ADHD to all the children in the local school, they would all likely show improvement in grades, test scores and attention.  The usage of medication should only be after a process of observation, temporizing, information-gathering and joint consultation.

If you or others suspect that your child may have ADHD, there is little to lose by initiating an evaluation.  Delay in diagnosis despite mounting evidence can cause even worse problems for your child.  You may be pleasantly surprised to learn of something simple and correctable (like a need for glasses).  In the meantime, try and reduce the number of distractions in your child’s study environment and be sure he gets adequate sleep and nutrition.  If some form of learning disability is found, then he/she may qualify for additional tutoring, etc. at school.  Above all, don’t let misconceptions cause a delay in at least initiating some type of evaluation.

Dr. Knappenberger is the Medical Director of Children’s Medical Services for Brevard County and a member of Pediatrics of Brevard. He received his bachelor’s degree in Chemistry before attending medical school at the University of Pittsburgh. He completed his Pediatric training at the University of Florida before moving to the Space Coast. He is actively involved in the community and has received numerous commendations including Child Advocate of the Year. Dr. Knappenberger has served as a member of the Brevard County Child Protection team, which evaluates children suspected of being abused or neglected.

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