Posted tagged ‘adhd’

Your child isn’t ADD

April 23, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

Your child isn’t ADD. Nor is he ADHD. Let’s be clear: what we say is important. Your child may have ADD, but I assure you that your child isn’t ADD, and isn’t any other disorder either.

This may seem like a bit of a rant today, but I’ve realized that a lot of parents and doctors seem to be talking about ADD and ADHD (Attention Deficit Disorder) as if it defines a person. The phrase “My child is ADD” may not seem very offensive at first, but think about it for a minute. Would you say “My child is asthma” or “My child is belly ache” or “My child is depression”? Physicians seem to be doing it, too. If a doc told me “Your child is ADD”, I’d say “no he is not.”

Your child is a person, with strengths and weaknesses. He might not be very good at staying focused, and he might be fidgety and impulsive. He might need to work on getting a good nights sleep and improving his exercise habits. He might even have ADD. But is he ADD? No. Your child, I promise, is not a disorder.

Diet and ADHD: Anything new?

February 12, 2011

The Pediatric Insider

© 2011 Roy Benaroch, MD

The Lancet has published another terrible, worthless study guaranteed to confuse parents.

Back in 1998, the world-renowned British medical journal The Lancet published a study that singlehandedly created the entire MMR-autism “manufacturversy.” The study itself was an absolute fraud based on fake data, designed to make money for its lead author. Red flags about the study were ignored by The Lancet’s editorial board for years; but finally most of its authors retracted the study, and then The Lancet withdrew it. Still, the damage was done. Falling vaccine rates led to a return of measles and surging rates of pertussis. Fooled by an unscrupulous liar and a media relishing any opportunity to sensationalize garbage, many parents still distrust vaccines.

And now, The Lancet has done it again. A terrible, worthless study has been published, guaranteed to confuse parents. Maybe their motto ought to be “anything that’s fit to make headlines.”

The study, titled “Effects of a restricted elimination diet on the behaviour of children with attention-deficit hyperactivity disorder (INCA study): a randomised controlled trial”, was supposed to examine the relationship between diet and behavior in ADHD. It’s an important topic. Many children have trouble with focus and attention, and many parents feel that diet may play a role. Though many older studies have been unable to confirm a consistent effect of foods on behavior, a 2007 BMJ study did show at least a small effect of preservatives and dyes in worsening behavior in children.

What has made studying diet and behavior difficult is separating out what is called “confirmation bias.” Parents who are convinced that, say, a sugary meal will worsen their child’s behavior are very apt to notice when bad behavior follows a junk food meal. But those same parents probably don’t notice when relatively good behavior occurs after sugar, or when bad behavior doesn’t really come after a meal. This isn’t because those parents are dumb or delusional—it’s just human nature. We all subconsciously find evidence to support what we already believe, and ignore evidence to the contrary.

Good science seeks to minimize the effects of this kind of bias by using “blinded control groups”, where the observers don’t know if the child was exposed to a surgary diet or not. In the older 2007 BMJ study, the families were truly blinded: neither they nor the researchers knew which kids received a supplement that was a preservative-n-chemical cocktail, versus which ones got a supplement of “nothing”. Only after the parents made their behavioral observations, and after the researchers performed their statistics, were they allowed to know which kids got which diet. That’s good research. The BMJ study did show a statistically significant change in behavior, though the effect was fairly small. Still, it’s a tantalizing start, and the group is now pursuing a more-specific study trying to identify which chemicals and preservatives might be the culprit. It’s a slow process, but carefully-done, well-controlled research should give us a clear answer on this topic.

Unfortunately, the research group publishing in The Lancet didn’t feel the need to bother with these sorts of protocols. In the initial phase of their study, 100 kids were divided into two groups of 50. One group continued to get an ordinary diet (though they did receive counseling about healthy food choices), and the other group was put on a highly restrictive diet of mostly rice, meat, vegetables, pears, and water. But all of the parents knew exactly what group their child was in. At the end of this study period, about 60% of parents of children in the restricted diet group had improved, compared to “none” of the children in the non-restricted diet.

Wait a minute here. If something completely random happens—let’s say I ask parents to flip a coin, and tell me heads or tails—about 50% of the parents should report “tails.” In this behavioral study, if I ask parents to just decide, “did things get worse or better,” if there was just a random scatter of observations, 50% of the parents should say “worse”, and 50% should say “better.” How could “none” of the parents have seen any improvement? Surely at least some of the children had a few good weeks, even with no change in diet, no?

And if 60% improved in the restricted group, that means 40% didn’t improve, or got worse. A 60-40 split isn’t really that impressive, is it?

Besides, with no blinding whatsoever, what does it even mean?

The study gets worse. There was a phase 2 that took the “diet responders” and put them on even more restricted diets based on blood testing for allergies—but using an outdated, worthless test that’s been invalidated for years. This further phase found that the blood tests didn’t help guide parents to diets that would help, which is no surprise because those blood tests don’t work. We already knew that.

There you have it, another terrible study from The Lancet, which demonstrates nothing in a perniciously misleading way. Perhaps there is a link between diet, chemicals, preservatives, and behavior—and certainly, trying to put children on a diet that avoids these sorts of chemicals can’t do any harm. But these authors, and the editorial board of The Lancet, ought to be ashamed of publishing such a worthless study. Do you think the media, and the public, are ready to get duped again?

Let kids play

July 8, 2010

The Pediatric Insider

© 2010 Roy Benaroch, MD

School has become far more intense since I was a kid. Kindergarteners are expected to read; first graders bubble in standardized tests; third graders are doing book reports, frantically re-reading The Old Man and the Sea by candlelight with a Vente Mocha. Are we working them too hard?

Researchers at the Albert Einstein College of Medicine examined data from about 12,000 children aged 8-9, collected across many different schools in  the USA in 2001. Their study correlated classroom behavior with the availability of routine recess time—time to get outside and play. No one ought to be surprised at the results: the children with no or little recess had far-worse classroom behavior than the kids who had time to run and play. In fact, more playtime equaled better behavior. If playtime were a medicine, higher doses (as expected) worked even better than low doses. The improved behavior was seen even after correcting for factors like overall classroom achievement, the income of the families, proportion of minority and disadvantaged students, and the proportion of boys in the class. Among all groups, more playtime led to better functioning in the classroom.

Is your child tough to handle, restless, jumpy, a noodge? Get him or her outside, playing. Playtime one “drug” that everyone needs. It helps kids focus and do well in school. And it’s cheaper than a trip to Starbucks!

Behavior and diagnostics

April 22, 2010

The Pediatric Insider

© 2010 Roy Benaroch, MD

Children have always been challenging. Jacob took advantage of his hairy and slightly-older twin brother Esau by purchasing his birthright for some lentil stew; he also tricked his father into blessing the arrangement by hiding under a wig. But children like Jacob weren’t diagnosed with Oppositional Defiant Disorder, or even Expensive Soup Selling Disorder. They were just … children, each with their own skills, shortcomings, and challenges.

Now, there seems to be a quiet change taking place among those who care for children, towards more labeling and identifying of specific “problems.” I’m not so sure that’s always a good idea.

I’ve been thinking about this while trying to answer a question submitted a few months ago, by MKM:

“Would you please explain sensory integration and a ’spirted’ child? Is there a ‘checklist’ of signs/symptoms to look for? My 3 1/2 year old daughter is a very high energy child and not shy at all child who seems to be progressing as she should be. My concern is her ‘heightened’ anxiety (not sure if right word) in situations–completely clams up in new/somewhat familiar situations to the point of clinging to me and not participating, cries if startled, does not like being around men, can be somewhat sensitive. Many situations ‘change’ her personality. Is sensory integration similar to a ’spirited child’? Thanks for any information to help.”

It does sound like this girl can be a challenge. She’s clingy at times, can be sensitive, and doesn’t like men. But does that mean that she has a specific diagnosis that can be labeled, like “Sensory Integration Disorder,” or is she a “Spirited Child”?

The idea that problems should be diagnosed goes back to Hippocrates, or maybe further. In medical tradition, the patient presents with a symptom– “Why did you come to the doctor?”. The physician examines the patient, and then determines the “diagnosis.” From knowledge of the diagnosis comes the therapy. You’ve got pneumonia? Here’s the antibiotics. Your appendix is about to burst? Off to surgery you go. Know the diagnosis, then you know the therapy.

That way of thinking works quite well for medical problems. But I’m not so sure it’s a good fit for children with everyday behavioral challenges. After all, once you’ve settled on a diagnosis– let’s say, Attention Deficit Disorder– then therapy is going to be one of a few choices that work best for ADD. But children and their behaviors are far more complex than this one-to-one system of diagnosis and therapy. Different children even with the same “diagnosis”, like ADD, may have different challenges, strengths, and weaknesses. Worse, once you diagnose something like “ADD” it tends to mold the way you think about the child: all of the behavior problems are considered part of that one diagnosis, and if therapy doesn’t help, well, you’re stuck. In other words, specific diagnoses oversimplify children and their issues, and work against reformulating and refining treatment strategies. It’s like thinking along a “rut” in the road– the more times you diagnose the same problem and use the same therapy, the more “stuck” you’ll be in that rut, and pretty soon that’s the way you’re going to diagnose and treat all sorts of problems.

MKM mentioned two “diagnoses” that I don’t think are very useful for most families. “Sensory Integration Disorder” is a vague, poorly-defined entity that seems to encompass all sorts of behavior issues, and is treated with open-ended occupational therapy. Children who are to me completely normal– those that don’t like the sound of toilets flushing, or don’t like the feel of tags in their clothes– are labeled with this “illness,” whether or not the “symptoms” are actually causing any harm at all. Now, some kids do have intense tactile defensiveness, and have a hard time doing ordinary things. These kids do need OT, as well as family therapy to work through what can be debilitating symptoms. But simply crying when startled doesn’t make a child in any way abnormal.

Several books have been written about raising “spirited” or “high energy” children, and often do contain useful tidbits of advice. But no book could possibly identify the specific problem areas of any one specific child any more than one diagnosis could encompass all of the behavior issues that a family faces. Kids are just too complex to label in a meaningful way.

So for MKM’s daughter, I recommend staying away from the specific behavioral labels like “spirited child” and “Sensory Integration Disorder”. A more useful approach would be to make a list of specific behavioral challenges that prevent her and her family from doing normal things. The list might look like this:

1. Clingy in new situations

2. Cries if startled

3. Doesn’t like being around men

Now, put that list in order, putting the most problematic item first– let’s say in this case the clinginess. Then come up with a behavioral solution for the top problem, and continue to address issues one by one.

1. For clinginess- practice new situations more gradually, with warnings and “dry runs.” As these improve, back off on the extra support. Can also bring lovies or family photos to some of the most challenging new occasions to help them go easier.

Anticipate new challenges and problems– they will occur, and “The List” will need to be revised and reordered. Some therapies will work, and some won’t, so be prepared to learn and adapt.

In contrast to the one-diagnosis, one-therapy system implied by the medical model, my system is more individualized. It’s designed to identify unique characteristics and challenges for each child, rather than to pigeon-hole children into preexisting categories of problems and fixed solutions. I think it’s better, and I think Hippocrates and Isaac would agree.

Who has ADHD?

September 10, 2009

The Pediatric Insider

© 2009 Roy Benaroch, MD

Kristin would like to know, “How do you actually ‘diagnose’ a nine year old boy with ADHD? Descriptions of ADHD are so vague. Most of what is described as ADHD symptoms seem like normal boy behavior to us. Can a child be a straight A student and still have ADHD?”

It’s a fair question. There is no objective test for any psychiatric or mental health disorder, including ADD (Attention Deficit Disorder; one subtype is ADHD, or Attention Deficit-Hyperactivity Disorder), depression, anxiety disorders, autism—none of these can in any way be “tested for” or diagnosed with the kind of precision expected of ordinary medical diagnoses. I’m convinced that in 100 years, doctors will look back at my generation of physicians and chuckle knowingly, saying things like “¡ssǝ1ǝn1ɔ ʍoɥ ‘suɐıɹɐqɹɐq ǝsoɥʇ”. (Apparently, in the future, people speak upside down.)

In an effort to codify and standardize the language and diagnoses of psychiatry, the American Psychiatric Association first published the “Diagnostic and Statistical Manual of Mental Disorders” in 1952. The current version, last revised in 2000, is called the DSM-4-TR. It’s been criticized as “cookbooky”, relying on lists of symptoms to establish mental health diagnoses using checklists reminiscent of ordering a family meal at a Chinese Restaurant. Choose at least one from Column A (eg “inability to sit still”) and one from column B (“starting not older than seven years”), plus some qualifiers, and you’ve either got Mongolian Beef or Major Depression, maybe even both.

Though there are legitimate criticisms of the DSM, in fairness to psychiatry there are important caveats that are often overlooked. The book states explicitly that the diagnostic labels are mainly useful as “convenient shorthand for professionals,”  and that only well-trained professionals should interpret the standards and apply diagnostic criteria. So consider the DSM as a starting point for mental health diagnoses, not a straightjacket (sorry, poor time for a straightjacket joke).

DSM-IV Criteria for ADHD

I. Either A or B

A. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level.

Inattention

  • Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
  • Often has trouble keeping attention on tasks or play activities.
  • Often does not seem to listen when spoken to directly.
  • Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
  • Often has trouble organizing activities.
  • Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
  • Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
  • Is often easily distracted.
  • Is often forgetful in daily activities.

B. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level.

Hyperactivity

  • Often fidgets with hands or feet or squirms in seat.
  • Often gets up from seat when remaining in seat is expected.
  • Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
  • Often has trouble playing or enjoying leisure activities quietly.
  • Is often “on the go” or often acts as if “driven by a motor.”
  • Often talks excessively.

Impulsivity

  • Often blurts out answers before questions have been finished.
  • Often has trouble waiting one’s turn.
  • Often interrupts or intrudes on others (e.g., butts into conversations or games).

II. Some symptoms that cause impairment were present before age 7 years.

III. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

IV. There must be clear evidence of significant impairment in social, school, or work functioning.

V. The symptoms do not happen only during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder. The symptoms are not better accounted for by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

In summary: children with ADD have either inattention or impulsivity & hyperactivity, have these to a greater extent than expected for the developmental age, have these starting in early childhood, and have these as a more-or-less permanent part of their behavioral makeup. The symptoms must occur in multiple settings, and must occur to such an extent that they interfere with social, school, or occupational functioning. Part V is especially helpful—it says, essentially, that it’s ADD unless it is something else. Clearly, attorneys were involved in the preparation of this document.

To help “standardize” the diagnosis and hopefully make the assessment more objective, many clinicians rely on standardized testing instruments. Parents and teachers are asked a number of questions, like “How often does he fidget,” and answer something like always, sometimes, or never. The answers are decoded in a manner similar to the quizzes in Glamour Magazine (“What kind of guy is perfect for you?”), and the total score can be compared with thousands of other children who took the test. The “outliers”—the ones with the highest scores, above some set statistical set point—are said to have ADD.

Though these tests are helpful, it’s easy to see how parent or teacher preconceptions could color their answers. There are strong feelings about ADD and medication for ADD, and I’m not sure that making adults bubble in answers recalling a child’s behavior is likely to cut through their own feelings in a way that can reliably reveal what’s going on with a child. ADD “testing” has a role—in my mind, chiefly to rule out learning disorders and other problems that often go together with or appear very much like ADD—but a more reliable diagnosis I believe requires a thorough medical history and evaluation, as well as multiple observations over time by a skilled examiner. It’s not easy, and not quick, to do it right.

In answer to the final question, “Can a straight A student have ADHD?”—according to the DSM criteria, ADD characteristics like hyperactivity and inattention must occur to a degree to cause problems in school, home, or work. If your child is getting along well at home and with friends, and is getting straight As at school, he would not meet DSM criteria for ADD and should not be diagnosed as having ADD. Nonetheless, he may  benefit from behavioral interventions to encourage better sustained attention—but that’s a subject for a future post!

Special needs misadventures

April 17, 2009

Deb posted: “I’m wondering if you can guide me here. My 8 yr old son with mild-moderate special needs was having regular behavior problems at school and was up for a 3 yr reevaluation though the school. After a thorough private neuropsychiatric evaluation we were sent to another psychiatrist to rule out some of the neuropsych’s concerns. This Dr did rule out the concerns, asserting different ones in their place. Upon seeking another opinion because the two specialists’ assessments were so different, we received yet another ‘suggested’ diagnosis. The only point these specialists agreed on was that my child needed intensive therapy (4-5 days/week) and medication, although they could not agree on which kind and what for. Amazingly enough, during the period of time that we met and were evaluated by these specialists my son ‘remembered how he was supposed to behave’ and almost all of his problems at school disappeared. So my question is, at what point should a parent stop seeking out additional opinions in hope of finding some consensus in evaluating their child’s special needs? I want to give my child every support possible to be successful but frankly it’s often hard to remember why we went through all the testing in the first place. Can you offer some guidelines for how much is enough?”

This is a fair but tough question—I don’t really have enough information to speculate on what kind of problems Deb’s child is having, or what kinds of diagnoses or treatments would be appropriate. But it does raise the question of how to approach children with special needs and learning difficulties, and Deb’s post illustrates a frustration many parents have felt when trying to get help for their kids.

Part of the problem lies with the very nature of psychiatric diagnoses. In other realms of medicine, a diagnosis is made firmly on fairly objective data: take a history, ask about the symptoms, do an exam, maybe some tests—viola, you’ve got a diagnosis, or at least a very likely stab at a diagnosis, and treatment follows logically from there. The psychiatrists have tried to codify and objectify their diagnoses, too, in a huge book called the Diagnostic and Statistical Manual of Mental Disorders, or DSM, now in its fourth edition. To have “Attention Deficit Disorder,” for instance, you have to have 6 of 9 listed characteristics along with four required features. The DSM is an effort to make diagnoses in the realm of mental health standardized and objective, so practitioners are more clear and precise.

But in issues of mental health, especially in children, over-reliance on the DSM tends to oversimplify problems. It shoves kids into little boxes with clear labels on them: this one has ADD, that one has expressive language disorder, this other one has autism, this one has a processing disorder, etc. But in my experience many kids who need extra help in school have a combination of many features of each of these problems, and every one of these kids is unique. The labels themselves can become a distraction, forcing children into loops of expensive testing and diagnostic pigeonholing that doesn’t really help delineate exactly what kind of help would be best for the individual child.

Complicating matters further: children change and develop. A child who seems to mostly have problems with speech and language may later on have more problems with memory. And health and social circumstances can certainly have a big impact on a child’s success. If obstructive sleep apnea is preventing a good night sleep, a child might have symptoms identical to Attention Deficit Disorder; a child who’s being bullied may retaliate and be labeled with “Oppositional Defiant Disorder”; a child with a hearing deficit may seem autistic. Performance on testing to help determine a child’s diagnosis may depend on the rapport developed with the psychologist, and may be influenced by how well the child slept the night before and what was had for breakfast. A very good psychologist can work through these complications, at least most of the time. But it’s tricky.

So what’s a parent to do? Concentrate on what’s holding your child back, right now. Is it learning, or remembering? Conduct? Attention? Handwriting? Speaking? Getting along with others? All of these skills can be reinforced and tutored. As children grow, expect their strengths and weaknesses to change, and reassess how things are going and whether specific therapies are still leading to measurable, significant, and important improvements. If input from testing doesn’t make sense, don’t automatically accept suggestions. Even if you do follow a new course, reassess whether there really has been an improvement before continuing long-term. A certain amount of trial-and-error is unavoidable, but don’t feel locked into any sort of therapy that just isn’t working.

I like to think that a pediatrician can help get to know your child well, and hopefully provide guidance and a good objective viewpoint as parents try to digest these sorts of decisions. Our job is also to stay alert for medical conditions that can affect school performance and behavior.

I know some of our regulars have special needs kids—I’d love to hear from parents about their experiences with these problems, first hand.

ADD and head injuries

December 18, 2008

A recent study from the British Medical Journal concerning the causes of Attention Deficit Disorder (ADD) illustrates the power of using epidemiologic studies to determine the cause of a disease.

Epidemiology looks at factors in a population that might or might not be associated with illness. Researchers look at large groups of people with and without a certain disease, and try to tease out what wakes the two populations different. Does one group exercise more? Or eat more of a certain food? Does one group have more of a family history of that disease? Or maybe a certain environmental exposure? Studies like these can get quite complex, because human lives themselves are so complex.

As an example, we know that lung cancer used to be very rare—almost unheard of, in fact. It started becoming more common in men during the 1930s. Factors that may have correlated with the rise of lung cancer could have been increased living in cities, increased use of automobiles, or increased reading of newspapers. But careful observations of these and other factors found that it was cigarette smoking that contributed most heavily to lung cancer. Over the following years, as more women started to smoke, their rates of lung cancer rose to about the same level as men. No clinical trials have ever been done in people proving that smoking causes lung cancer—that is, no one has deliberately exposed people to cigarette smoke to see if they get cancer—but the overwhelming weight of epidemiology has been instrumental in demonstrating the risks.

ADD affects 5-8% of schoolchildren, and contributes to poor school performance, delinquency, and substance abuse. We know that genetics plays a part, but environmental influences also seem to be important. One observation that has been made is that many children with ADD have a history of some sort of head injury in early childhood—so is it possible that minor brain damage from these kinds of injuries is a cause of ADD? That’s what the BMJ study tried to figure out.

The study looked at 62,000 children in the United Kingdom, using a heath database that records diagnoses and medical problems. They found that in this group, children with ADD were about twice as likely as children without ADD to have had been seen at a medical facility for some kind of head injury in the past.

Does that mean that head injuries cause ADD? Maybe. But perhaps it’s the other way around. After all, we know kids with ADD are more impulsive and hyperactive—maybe they’re more likely to hurt themselves. Which comes first, the ADD or the head injury?

To answer that question, the authors looked at another health observation among the children: a history of any burn injury. A burn on some other part of the body wouldn’t cause injury the brain, but would be another way of showing that the kids with ADD are more injury-prone in general. Sure enough, in the database the children with ADD were also about twice as likely to have had a burn injury than kids without ADD. So it’s not just head injuries that are associated with ADD, it’s injuries of any kind—which fits the hypothesis that kids with ADD are reckless, and hurt themselves more. That’s why they more often have a history of a head injury. It’s not the head injury that caused the ADD, but rather the ADD that caused the head injury.

So: don’t worry about the inevitable minor head bonks. They’re a part of childhood that can’t always been avoided. But children who are especially reckless and get injured a lot might just be telling their parents what kind of person they are.