Treating ADD and ADHD: a Pediatrician’s Perspective – Part II

Last updated on March 12th, 2018 at 09:43 am

After the appropriate diagnosis is made and the correct testing and observation has been performed (see Diagnosing ADD or ADHD: a Pediatrician’s Perspective), a more secure diagnosis can now be entertained and we can move on to treatment.

At first, parents might very well take the stand of further observation as their children change classes and friends. This is not at all unreasonable, especially if medications are discussed, but medication for ADD or ADHD should be the last resort on the list of possible treatment options to help your child use all of his/her resources to reach the best goal. The first and the “easiest” intervention should be educational. Teachers should receive the results and suggestions deriving from those results that are directly related to the organizational aspects of the classroom. Many educational institutions are fully capable of employing the suggested techniques regarding the special nature of teaching children with such problems. Many schools are limited by space or funding for such programs but every effort should be made to involve the school first.

As I alluded to in part one of this series of posts, there are many conditions that mimic ADD or ADHD in presentation and actions. If any of these are found, the appropriate psychological help and input should be sought. Even in the absence of such specific emotional or psychological problems, I feel that counseling should be obtained for the entire family, as it can be a struggle for family members to deal with such a child. Counseling can help family members to handle certain situations in an appropriate and non- traumatic way to them and the children.

Finally, when all treatment options are brought to bear in an effort to ameliorate the issue and the problems still exist, medication should be discussed and considered. There are several ADD and ADHD medications available on the market right now. Generally they are broadly divided into stimulant and non-stimulant medications, and there are several medications within each division.

1. Of the stimulant medications there are derivatives of methylphenidate and amphetamines: different forms of these medications allow for various routes of administration, side effects and overall effects on the child. Side effects of all of these medications are very similar but are not very common. The most common of these side effects can be decreased appetite and even slow weight gain as a result. Others include poor sleeping, increased activity and heart rate and a period of downtime as the medications wear off. All of these are usually short lived and can be altered by changing the type and/or dosage of these medicines.
2. The second broad category of medicines are the non-stimulant variety. Although these are “non-stimulant” in chemical nature, the end effects of both types of medications can be the same, with the same side effects.

Having said all that, if the appropriate medications are used for the correct diagnosis in the proper dosage and form, the results can be astounding and lead to a much more stable and enjoyable family situation. There is much written about these medications (see recommendation below) and certainly no medicine should ever be used for an inappropriate reason.

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Dr. Joe Recommends:

• Running on Ritalin: A Physician Reflects on Children, Society, and Performance in a Pill by Lawrence Diller, M.D.

Editor’s Note:

• A terrific example of using a psychological approach to help manage some of the symptoms of ADHD can be seen in a post called ADHD and “Menditation” by pediatric psychologist Dr. Lynne Kenney.

Is Thirteen Too Old for a Pediatrician?

Last updated on August 29th, 2015 at 05:53 pm

A board-certified, properly trained pediatrician offers the best medical care for all teens. Unlike other primary care providers, a pediatrician spends three to four years or more of intense study and preparation to take care of all kids — including adolescents. None of the other primary care doctors has this level of education and training in dealing with the unique problems of teenagers. The massive physical and emotional changes brought on by puberty aren’t seen in any other age group. Teens, despite their protestations, are not young adults — and there’s no benefit to switching from a pediatrician to an adult’s physician until they are!

Celebrate International Walk to School Day

Last updated on August 29th, 2015 at 05:57 pm

I recently learned that October 5th, today, is International Walk to School Day. Originated in the UK, the day is now celebrated annually in over 40 countries around the world, including the US.

A day to celebrate walking to school??? When I was a kid that was the only way to get to school. But now, according to the US Walk to School site, only about 10% of US children walk to school on a regular basis. While that may be driven by larger distances between home and school, only 25% of children living within a mile of school walk regularly. I’ve seen that in my own town, where the schools started busing kids within a mile radius of schools last year.

There are several reasons why walking to school – or more walking in general – can be beneficial: everything from air quality and reduced traffic congestion to a greater sense of community. But one of the most pressing reasons has to be the increasing epidemic of obesity in this and most developed countries; a critical issue even among children. Data from Health, United States, 2010 from the Centers for Disease Control and Prevention (CDC) show that rates of obesity in children 6-years and older are approaching 20%. If you break down the statistics further you see rates for some minority children (such as Latino boys and African American girls) at nearly 30%!

Obesity is a potential health issue at any age, but it is particularly concerning among children. Obese children are more likely to become obese adults, and the negative health effects of obesity are thought to increase the longer a person is obese. So we are seeing children with weight issues begin to develop diseases typically only seen in adults, such as Type 2 diabetes and cardiovascular disease, and the impact of these diseases on their health may be much worse than what we see in individuals who develop these conditions later in life (source: CDC).

In her writings on population health, Pamela Russo MD, MPH – a Senior Program Officer with the Robert Wood Johnson Foundation, whose mission is to improve the health and health care of all Americans – cites several factors (many that developed for perfectly rational reasons) that have “conspired” to produce the epidemic of obesity:

• The higher density of fast food restaurants in low income neighborhoods (which offer high calorie, high fat, low nutrient, super-sized meals at very low prices)
• The presence of vending machines in schools (selling high calorie soft drinks as a source of needed revenue for the schools)
• Subsidized school lunches (containing high caloric and fat content)
• The decrease in physical education classes and near-elimination of recess periods (due to shrinking school budgets and a narrow focus on meeting academic test score requirements)
• Fewer children and adults walking or bicycling to school or other destinations (due in part to the lack of sidewalks, safe pedestrian crossings, and bicycle lanes)
• Increased busing of students (due to liability concerns)
• In urban, low income neighborhoods, few places to play or walk (due to unsafe playgrounds, crime, and violence)
• A lack of grocery stores with healthy food options, such as fresh fruit and vegetables in many neighborhoods (related to their higher cost and lower profit margins)

As we can see by the bolded items, many of these factors are very much related to the mission of the Walk to School movement, which is to create awareness of the importance of walking and physical activity – and the need for our communities to be walkable. I’m thankful that we live in an area and school district that still supports and promotes lots of childhood activity – including regular gym classes, recess and great local parks. But until recently we had limited sidewalks and bike routes outside our neighborhood – and my son does take the bus every day. Though he would like to walk home from school on occasion, when I’ve tried to arrange it I’ve met some resistance and concern from school organizers, especially since it seems no one else is walking. While safety is important, we may also have to address some new cultural barriers to kids walking.

The US Walk to School website provides information on the benefits of walking and has some great checklists for assessing the “walkability” and “bikeability” of your community – including concrete steps you can take to make improvements. The site also provides ideas and resources for local events you can organize – and an opportunity to register and highlight your efforts – all under the 2011 slogan “Hike it. Bike it. I like it!” Although it’s a little late to organize something for October 5th (I’m planning just to walk to school with my son today), many events are taking place throughout the month of October. Events can be throughout the community – or even just on school grounds.

In addition, through the National Center for Safer Routes to School, which maintains the Walk to School Program (with funding from the US Department of Transportation and the Centers for Disease Control and Prevention), communities can develop strategies for increasing the walkability of their neighborhoods year-round. And they can access grants through the 2005 legislation that created the Federal Safer Routes to School program.

So, there are lots of reasons to get up, and get walking! If you don’t make it this year, be prepared for International Walk to School Day 2012 – scheduled for October 3rd!

Is The Inside of Your Car Making Your Family Sick?

Last updated on August 29th, 2015 at 06:02 pm

Far too many of us treat our cars like second homes: We eat, drink, spill things and create piles of clutter inside.

But stop and think about it. When was the last time you really gave your car a thorough cleaning on the inside? And think back to the last time you hopped into your car with a bad cold and sneezed, spreading germs throughout your car’s cabin. Did you bother to wipe down surfaces afterwards? Didn’t think so.

Germs run rampant all around us, including the inside of our automobiles. Fortunately, there’s much you can do to keep those pesky lil’ microbes in check. Here are some tips from the country’s leading germ experts on how to sanitize your ride’s interior.

Daily Wipe-downs

“When you and your kids get in your car, you inevitably come into contact with surfaces covered with germs,” says Donna Duberg, assistant professor of clinical laboratory science at Saint Louis University’s Doisy College of Health Sciences. “Then you touch your eyes, nose and mouth. That’s how little germies from unclean surfaces make their way into our bodies.”

Stay healthy by wiping down the frequently-touched areas with a disinfectant, such as a sanitizing or disinfecting wipe, that kills viruses and bacteria (you may have to read the fine print on the label to be sure.) Look for a wipe that does not contain bleach – some have “bleach-free” right on the label – so you can use them to clean hard, nonporous surfaces like steering wheels, dashboards, knobs, chrome accents, door handles and even mirrors.

Make wiping down the inside of your vehicle part of a daily routine during cold and flu season and especially when someone in your family has been sick.

Meals on Wheels

We are becoming a nation of families eating on the go – most often in our cars. Inevitably, food particles end up on the vehicle’s upholstery, floor, seat belts, steering wheel and knobs. These crumbs are a breeding ground for bacteria, which love a warm, dark and moist environment.

Vacuum what you can with a hand-held portable vac after returning home from any outing where you or the kids were eating in the car. “Then wipe down surfaces with a disinfectant wipe and dry them completely to eliminate any lingering moisture,” says Philip Tierno, M.D., Ph.D., director of clinical microbiology and immunology at New York University School of Medicine and the author of The Secret Life of Germs. “Failing to do so allows organisms like mold to grow, which can make you and your children sick,” warns Tierno.

Sanitizer at the Ready

Once you get into the habit of wiping surfaces and vacuuming food spills in your car, why not attack the main entry point for germs into your car – your hands.

Hand sanitizers should be kept in every single vehicle, advises Duberg. After you use the handle at the gas pump or press the buttons on the ATM, your hands are covered with germs from the people who touched these surfaces before you.

So after touching commonly used surfaces, apply a hand sanitizer to avoid passing germs onto the surfaces inside your car. Go with sanitizers that contain at least 60 percent alcohol concentration. Look at the list of active ingredients for ethyl alcohol, ethanol, isopropanol or another variation. Apply to all parts of the hands (palms, nails, knuckles) and continue to rub your hands together until they are completely dry.

Car Seat Care

Little ones can equal big messes in the car – bottle spills, leaky diapers, unidentifiable crumbs. Luckily, the majority of child safety seats are made from fabric that can be removed and washed. A recent study conducted by Charles P. Gerba, Ph.D., professor of environmental microbiology at the University of Arizona and a leading authority on germs, found that car seats often have bacteria on them – and enough to make a child sick with an ear infection or strep throat.

And that’s not all. They also typically have some mold growth, which can be particularly worrisome if you or your child suffers from allergies or asthma. Gerba suggests washing your child safety seat cover a few times per month.

He also recommends wiping down the plastic shell and harness of the child safety seat with water and a mild soap on a weekly basis – or more often if your child is sick. Between washings, be sure to vacuum or shake out the car seat as often as possible to remove food droppings.

My Child is Sick: New Book Tells Parents When to Call the Doctor

Last updated on October 5th, 2015 at 11:20 pm

Have you ever debated about whether your child’s symptoms warranted a call to the doctor or not? Wondered if your kid was sick enough to go to the emergency room in the middle of the night or if it was okay to wait until the morning to go to the doctor’s office instead? Worried whether you were doing the right things to treat your child’s symptoms at home? Then a new book from Dr. Barton D. Schmitt may be just what the doctor ordered.

My Child is Sick!: Expert Advice for Managing Common Illnesses and Injuries is a new reference guide designed to help parents find answers fast to questions about treating the illnesses and injuries they are most likely to encounter while raising kids. This easy to use guide offers the same expert advice and guidance given by doctors and nurses in 10,000 practices and 400 nurse call centers in the United States and Canada and using the Pediatric Telephone Protocols which have been tested for 15 years on over 150 million phone calls. Now all of that advice is yours in one practical reference guide.

The author, Dr. Barton D. Schmitt is a professor of pediatrics at the University of Colorado School of Medicine medical director of the After-Hours Call Center at The Children’s Hospital in Aurora, Colorado. Dr. Schmitt is also the author of Pediatric Telephone Protocols: Office-Hours version (12th edition, 2009), published by the American Academy of Pediatrics (AAP), and Your Child’s Health (Bantam Books). Dr. Schmitt’s purpose in writing the book was to assist parents in determining when it is necessary to call a doctor about their child’s symptoms and how to treat the child at home if a doctor’s care is not required.

According to the American Academy of Pediatrics, “inside this practical guide, parents will find:

• Straightforward information on the most common illnesses and injuries of childhood
• Decision charts to help care givers determine when to call the doctor and when it’s safe to treat symptoms at home, as well as descriptions of which symptoms are normal during the course of an illness or recovery from an injury and which are cause for concern.
• Specific time-frame guidelines as to when to call the doctor or 911.
• In-depth advice for treating symptoms at home, taking the guesswork out of how to make little ones feel better.
• Drug dosage charts for the most commonly used non-prescription medicines.

With My Child is Sick at their fingertips, parents will never again have to worry about whether they’ve made the right decision about their child’s illness or injury.”

The 50 most common illnesses and injuries children are likely to face are outlined in order of areas of the body, and offer specific instructions on when to call the child’s doctor, when to call 911 or emergency services, and how to treat the illness or injury at home and offers information for children of all ages, from newborns to teenagers.

Parents may be tempted to think a book is unnecessary in this digital age where answers are abundant on the internet but if you’ve ever searched an illness or injury online before, you may already know that there is an overwhelming amount of information and advice to wade through and in some cases, not all of the information or advice is accurate or from an expert source. This book has accurate, expert guidance in a quick, easy to use format that can save parents time, money (if it saves you from making a trip to the doctor that wasn’t necessary), and a lot of worry.

After reviewing Part 1: Head or Brain Symptoms, which covers crying, head injuries, and headaches, I was glad to find that it is not written in “medical jargon” or “doctor speak” but easy to understand with clear instructions on what to do. I highly recommend parents have this book on hand in an handy location where it is easy to find in an emergency. It would even make a great baby shower gift for new parents. The book can be purchased online at the major online book retailer’s websites and may be available in your local bookstore.

When Having an Only Child Is The Only Choice

Last updated on August 29th, 2015 at 07:54 pm

In reading Dr Borba’s post from last week (July 25, 2011) on raising only children, it brought back my own experience. I have an only child, but not by choice. I was caught by the trend in delaying childbearing – due to an earlier focus on education and career, and marrying later.

Why Have Another?

When my husband and I first got married we weren’t entirely sure we wanted any children, let alone more than one. But we did finally decide to start a family and were really happy with our little guy. When it came time to consider whether to have more, what Dr Borba highlighted as the benefits of an only child did figure in our thinking. We both had hectic full-time careers, so dividing our attention amongst multiple children seemed like a disservice to our son – and we enjoyed the close parenting relationship we had with him. Plus, having more kids might have meant not working so much, so finances were a concern.

However, there were powerful arguments in favor of having more children. We fell so much in love with our first baby that we really liked the idea of having a second. Plus I am an only child and I always wanted siblings when growing up. In fact, even now I would like to have a brother or sister – for my own benefit – but also for my son’s.

At the end though, one of the most powerful drivers was that he was always asking for a sibling – just like I did.

Our Sibling Odyssey

Getting pregnant the first time was fairly straightforward, even though I had already reached “advanced maternal age”. We decided to try for a second when Elliott was three and I was nearing 40. Since it was so easy the first time, we thought it would be fairly easy the second time – and it more or less was – until we discovered it was an ectopic pregnancy, resulting in emergency surgery and the loss of one tube. So, with my chances of getting pregnant halved – and now informed of the significantly reduced fertility at my age – we embarked on a series of IVF procedures. Clearly we had no idea of the journey yet to come.

Mistake #1: Despite my age and the statistics, we were over-optimistic about our chances of conceiving through IVF. Since I’d gotten pregnant twice, and carried a baby to term, it seemed like just a matter of time. Which might explain our second mistake.

Mistake #2: We were much too open and optimistic with our son about trying to have another baby, especially at the beginning of the process. Eventually, we had to start managing expectations since several months of IVF procedures went by without success. Finally one succeeded…but this resulted in ANOTHER ectopic pregnancy (very rare with IVF). And it was a huge saga as it was discovered on an overseas trip and involved emergency surgery in a foreign city, 3 days in hospital, a week in a hotel waiting for the all-clear to fly home, wheelchair transport through airports on the way back, and 2 months recovery off work. We managed one more unsuccessful attempt a few months later, and finally gave up – leading to our final mistake….

Mistake #3: We avoided telling our son we had stopped trying to have another baby. It was just too painful. I couldn’t talk about it – or even see a little baby on the street – without crying, and I think the idea of telling him made the decision feel so irrevocable. Unfortunately one evening on the way home from friends with a house full of kids, we accidentally let it slip out in conversation. But he picked up on it right away – and what an UPSET!! There was so much crying going on in the car that we had to pull over for a while. That night is still very clear to me.

Helping Our Son (and Us) Adjust

After making the decision not to keep trying for another child, and despite our mistakes, we did take some steps that helped everyone adjust to this new and initially painful reality:

Talked about the benefits – Once everyone had a chance to calm down, we sat with our son and talked about why we wouldn’t be having another baby, and about the benefits of being an only child, in a way he might understand: having his own room, getting to spend more time with Mom and Dad, and no one to steal or break his toys.

Got a surrogate sibling – Yes, we got a puppy. And for the next few years, Nelson (the dog) was his brother – four legs and fur notwithstanding. This worked very well, until Elliott’s school class learned about family roles and he insisted his dog was a brother…while his teacher insisted this wasn’t possible.

Found social opportunities – Due to our dual-career life Elliott had always been involved in external social settings with other kids. But now we had even more reason to sign him up for sports, clubs, summer camp and Cub Scouts.

Created a “flexible” family concept – Soon after our painful odyssey we had the opportunity to become god-parents to the daughter of a dear friend. We embraced this new responsibility and more or less “adopted” my friend and her family. This gave me some consolation – both for my loss and my son’s. Elliott became a “god-brother” and Nelson, a “god-dog!” While it’s not exactly the same – and he really only started enjoying her once she turned three – he is experiencing many aspects of being a brother: her adoration, looking out for her safety, playing with and performing for her, and protecting his possessions from her. And on a recent shopping trip he picked out a pair of pajamas for himself that proclaimed “big brother” on the front. There’s definitely more than one way to “make” a family.

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