ADHD - to medicate or not?

Posted by: Brigitte Rozario Post(s) by this blogger

By SHAMALA VELU

Attention Deficit Hyperactivity Disorder (ADHD) is a chronic pervasive childhood disorder characterised by developmentally inappropriate activity level, low frustration tolerance, impulsiveness, poor organisation of behaviour, hyperactivity and inattentiveness. ADHD children may sometimes seem like difficult kids at school or home.

It is one of the more common childhood disorders, occurring in 3-7% of school-age children and representing one-third to 50% of referrals to child mental health services, even here in Malaysia.

Some doctors consider giving medication to manage the condition after making an in-depth diagnosis. However, there are many parents and experts who look for other options to treat ADHD. Two experts give their opinions on whether ADHD kids should be medicated.

Sara Brenneman

Sara Brenneman, learning specialist, teacher and director of The Learning Connection:
 
"Our centre has a range of students with varying abilities and disabilities. Many of our children are on the autistic spectrum. Others have global developmental delays and language delays. We do have children with ADHD, however this is typically in combination with other diagnoses.

I am not against the use of medication. However, I am an advocate for trying every alternative before I suggest the option of medication. Some students at the centre are on medication.

In my opinion, the following learning programmes or exercise techniques are best suited for children with ADHD:

- Very structured environment and routine - everything has a set time and place including daily activities such as meal times, homework, relaxation and play, bedtime, etc.

- Be clear about what your expectations are for each activity in your daily routine.

- Be consistent with behaviour expectations and with consequences and rewards.

- Work times which are broken up by 'down time' where the child can have a choice of activities.

- Minimal environmental stimulation - keep the work area neat and clean, with not a lot of distractions.

- Behaviour plans - reinforce positive behaviour.

- Break down specific tasks into steps - step 1, step 2, etc.

- Pay attention to the physical environment which may be affecting a child - lighting, air-conds, bright colours, noises, smells, etc.

- Pay attention to diet!

- Encourage movement in daily routine - sports or outdoor play.

- You may need to actually 'teach' some social skills and tasks that come naturally to many children, such as how to make friends, how to greet people, etc.

- Making things as 'multi-sensory' as possible will make learning easier. In traditional schools, most of the learning is through the 'auditory' mode. This is often the most difficult for ADHD children. Often, they learn best by using their other senses, such as visual, touch, smell, kinesthetic movement, that is going through motions of a task in order to learn it.

- Communicate with your child's teacher and work as a team to help your child. They may need to make individual accommodations for your child, that is the physical arrangement of class and where she/he sits, type and amount of homework assignments, etc.

My advice to parents is to first try every possible alternative. Find a doctor who you can trust and who you feel can explain ADHD, and how the medication will modify behaviour and attention span in a way you can understand.

Parents must ask questions if they don't understand and get a second opinion. Ask your doctor to give you information about side effects and use the medication exactly as prescribed and take notes on your observations of  behaviours.

Parents must schedule regular followups with the doctor, especially at the beginning because the dosage may need to be adjusted to best suit the needs of your child. Each child reacts differently to the drug so careful monitoring is crucial. Also, make sure you are communicating with your child's teacher on a regular basis and give them information about the drug and side effects.
Ask the teachers for regular feedback as well, as they will likely notice different behaviours at school that you may miss in the home environment.

I would recommend trying all alternatives before medicating. Other therapies such as acupuncture, kid's yoga, diet, swimming or other sports, such as horseback riding, are some things that I have seen make a difference in the past.

Pets can also benefit ADHD children. They can help teach your kid responsibility and get him or her outside. They can also help to 'blow off steam.'

I think parents of special needs kids have a tremendous task and that they always need to be patient and strong, whether on medication or not. They need to look for the small positive steps they see from their children every day and celebrate those small things. They need to catch their child doing something right on a daily basis and offer specific praise for that. Children will appreciate knowing that the adults in their lives are supportive and notice them doing things right, because all too often the messages they get from the adults in their lives are that they are doing things wrong."

Dr Aili Hanim Hashim

Child and adolescent psychiatrist Dr Aili Hanim Hashim:

"ADHD is a medical disorder and diagnosis should be made by a proper medical doctor and professional. It is made by taking a thorough history from the child and parents.

- In children, information is also often gathered from their educators. While taking their history, the clinicians often focus on:

- The presence of the symptoms of the disorder, the duration, age of onset, how frequent and severe, including the impact of the symptoms on the child and his/ her functioning.

- The child's academic/intellectual progress, looking out for symptoms of other difficulties, such as learning difficulties, symptoms of depression or anxiety.

- The history taking will also include looking for other mental health difficulties present and the family history and functioning.

There are no specific test(s) to make a diagnosis of ADHD. In making a diagnosis of ADHD too, additional tests (scan, neuro-imaging) are not necessarily done unless there are indications of other medical illnesses, or the presence of low intellectual ability or learning difficulties, for example reading and writing.

Doctors usually consider medication after gathering a thorough history, especially from the parents.

For me too, I often take into consideration the input of the family. I find that if parents are not keen or ready to consider using medication for their children, they would not usually cooperate in giving the medication to the children.

In younger children, most parents would like to consider non-medication options or therapy, such as behavioural therapy and school intervention before considering the use of medication.

At the Psychiatry Adolescent and Child (PAC) Unit at Universiti Malaya Medical Centre where I work, there is an increase in the number of cases seen as we have been conducting public talks to help teachers and parents recognise children with behavioural, academic, emotional and/or interactional difficulties. Many teachers have responded by using the knowledge gained, to pick and talk to the parents to consider having their children assessed.

Generally, there is an increase of children with academic, behavioural and/or emotional difficulties who are brought for assessment to see a general pracitioner or paediatrician and later a referral is made to mental health services.

Much attention has focused on the role of food components, in particular, food additives/ artificial colouring as an etiological link to ADHD. Thus far, there is not enough scientific evidence to support the above hypotheses, as only a small subset of children have been identified to have or is sensitive to artificial flavours, preservatives, and colouring.

Parents and adults need to understand that even if children are on medication, medication alone is not the answer. It is usually the combination of medication, and the adults working with the children that will result in the best outcome.
A lot of people now know about ADHD, mainly from the media including the Internet. It helps in some cases, but it can often be 'mis-information' rather than information.

People are scared by the amount of information regarding the use of medication in children, turning children into drug addicts - in these instances, it frightens them to even come seek assessment and advice or in many cases that I have, they drop out and only return years later when the difficulties in the children are very severe.

Critics claim that ADHD is over-diagnosed and that children are receiving unnecessary and inappropriate treatment. Contrary to this claim, research on treatment utilisation and from my experience, many more children are not being screened or even assessed. Worst still, they are struggling in schools, yet adults feel they are just lazy, they can do it, they will outgrow it or they should push themselves.

Some children can, but others either will turn delinquent or have emotional difficulties as they cannot cope.

There are now many more child psychiatric services in major public hospitals around the country. There are also increases in the number of private child psychiatrists, especially in major cities. Paediatricians too see and some manage children with ADHD, especially developmental paediatricians."