Posted tagged ‘hyperactivity’

Exercise: A simple treatment for ADHD

May 30, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Many years ago, I worked as a counselor at the city camp in North Miami Beach, Florida. Camp “No Mi Be” was attended by what seemed to be a countless number of very active, very inquisitive, and pretty-much-unstoppable 10 year old boys.

We learned quickly that the best way to start the day was with running. Run, run, run. We’d make the kids run back and forth to the fence, or run around the building, or whatever we could come up with. We’d challenge them to race us—it turned out that 16 year old legs, even on a non-athletic type like me, were long enough to beat any 10 year old. And it turned out that 10 year old boys, having lost races to their counselor 4 weeks in a row, would be more than happy to try again the next day.

Good times.

On those unfortunate rainy days, we’d run ‘em anyway. But on really really rainy days with lightning and hail, the wimp camp director would make us keep our monsters indoors all day. Those days were called “nightmares.” We counselors would end up hiding under desks.

So: a 2012 study looked at 20 kids with ADHD and 20 matched controls to see how they did on tests of attention and cognitive functioning after a twenty minute period of exercise, versus after a twenty minute period of sitting around. Surprise—both groups performed better on arithmetic and reading after exercise. The ADHD kids also showed improvements in their ability to regulate their behavior, with improved self-control after exercise.

Not a huge study—but it confirms what experienced teachers and 16 year old camp counselors know. Kids need exercise to settle their minds and get to work.

The AAP has weighed in on this, too. Recess at school is crucial and necessary, and it should be part of every school curriculum. Recess should not be withheld as a punishment for misbehavior or poor grades.

Kids of all ages, whether they have ADHD or not, need time for active play. I don’t think anyone is saying that exercise can “cure” ADHD, but it does seem to be one simple, safe intervention that ought to be part of every child’s day. Though I’m not sure it would be fair to expect the teachers to run back and forth to the fence, too….

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Are sweets at bedtime a bad idea?

April 18, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Jack wrote, “What is the deal with not allowing kids to eat dessert before bed? That’s how I was brought up, and how my kids have been brought up. My fiancée doesn’t allow her kids to have sweets after about 7:30 because she fears it will interfere with their sleep. Any truth to that theory? Or is it an old wives tale like not swimming after eating?”

That’d be one of those handy “little white lies.” Medically speaking, there’s no particular reason not to have sweets before bed, or (gasp!) not to eat prior to swimming.

I suppose if Junior does have a big bowl of ice cream, he’d better be sure to brush his teeth at bedtime. And a full belly at bedtime might just increase the chance of a nightmare. But I don’t think it really matters what the bedtime snack is.

There is a persistent feeling among many parents (and grandparents) that sugary, junky food gets kids hyper. I think that’s because these kinds of foods are often eaten at birthdays and happy occasions, when kids do get worked up. But when it’s been studied, simple carb meals don’t seem to change behavior in children, at least not when the kids and the observers are blinded. One study even looked at a small number of children with attention-deficit disorder, and found that sugar didn’t worsen their behavior. Those authors suggested that the perception of worse behavior may be related to those kids’ difficulty in adjusting back to classroom behavior after a snack.

In any case, I’ve found that it’s just about impossible to dispel the sugar-misbehavior contention, and I suspect it will be just as hard to convince parents that desserts before bed are no worse than desserts with dinner. It’s never bothered me or my kids, but if you’ve found it’s better to not have sweets later, that’s fine with me. It will at least make your dentist happy too.

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!