SPECIAL- Attention, please: ADHD poses challenges, risks

Is your child restless? Bored? Fidgety? Hyper? Spacey?

For most parents, the answer to all of those questions is yes, at least some of the time. So how can a parent tell the difference between what's normal and when a child's behavior is so extreme that it requires medical intervention?

Diagnosis is "tricky," admits Vanessa Camperlengo, a child psychiatrist who treats many children for Attention Deficit Hyperactivity Disorder, or ADHD. According to a recent report from the Centers for Disease Control and Prevention, seven percent of children have been diagnosed with the disorder.

Locally, UVA's Department of Child and Family psychiatry handles 7,000 patient visits per year, with ADHD among the most common reasons for visits, says psychiatrist Roger Burket, director of the department.

But Camperlengo says that since there are no absolute physical markers of the illness, physicians rely on other evidence. For an official diagnosis of ADHD, she says there must be "persistent and pervasive impairment present in two or more settings." 

If a child is out of control at school but fine at home– or vice versa– other possibilities should be considered before labeling the child, according to Camperlengo. Even when the "impairment" is present in all settings, psychiatrists must rule out other possible reasons for a child's behavior and inability to concentrate.

She laughs as she recalls one six-year-old referred to her because he couldn't sit still at school.

"He had pinworms!" she says. 

Another child kept leaving his desk during the school day, and the parents wanted him evaluated for ADHD. Camperlengo says she learned another important detail in that case: the child always touched his teacher's desk three times before returning to his seat. "That's Obsessive Compulsive Disorder," she says, a diagnosis that requires different treatment. Sleep disorders can also cause hyperactivity and attention problems, so ruling those out is a priority, she says.

"When I meet a child and take a history, I ask if child snores at night," she says. "If I hear that she has frequent strep throat, I tell the parents they need to go to an [ear, nose, and throat specialist] and call me later. A lot of kids end up going and getting their tonsils out. It might not eliminate all of the symptoms, but it can decrease them."

Among the symptoms of ADHD: an inability to stay "on task" long enough to retain information, which can result in poor performance in school. Impulsive behavior is another marker. Children with ADHD also often have trouble socially, as their erratic behavior and inability to listen can alienate peers.

Camperlengo says for those reasons, early diagnosis and treatment are important if a child is to reach his or her potential socially and academically. While there are alternative treatments– behavior modification and other cognitive techniques– the most common form of treatment is medication, typically stimulants such as Ritalin, Adderall, or Concerta. And these are not without controversy.

Among the possible side effects in children are weight loss and stunted growth, sleeplessness, loss of appetite, depression.

The child psychotherapist who, until a year ago, ran UVA's Under Five Study Program for 14 years, fears that doctors may be prescribing medication even when all other avenues have not been explored– in part because parents and teachers are looking for quick solutions.

"The professionals are in a difficult position," says the psychotherapist, Pamela Sorensen. "If they don't prescribe, somebody else will."

Child psychiatrist Brad Manning agrees that there can be pressure. Because other cirumstances– parents' divorce, the death of a loved one, even the birth of a sibling– can cause a child to have symptoms similar to ADHD, he says it's critical to ask questions. 

"Looking for such underlying emotions could feel risky," says Manning. "We want so much for our children to be happy that we might choose to avoid the possibility of discovering they are not.  Perhaps the doctor's visit is made more bearable for the family– even for the doctor– if there's a straightforward, biologically based diagnosis and prescription."

Sorensen bemoans the fact that so little data is available on how many children are medicated and what other treatments had been attempted before turning to pills. Indeed, neither the Charlottesville nor the Albemarle County schools keep track of how many students take medication for ADHD, according to heads of special education in each system.

Despite the professional concerns, Dan Hallahan, a professor at UVA's Curry School and an expert in special education, cites research published in the February 2005 issue of the Journal of Family Practice as scientific evidence that the most effective form of treatment for ADHD may be medication.

According the article, the combination of stimulants and behavior therapy provided the strongest improvements in academics and behavior. Side effects from the pills, the Journal found, were "mild and have short duration."

Two local mothers say they have been pleased with results they've seen since putting their children on such meds. (Perhaps a sign of the stigma such a diagnosis still carries, however, is that neither wanted their names to be used in this story to protect their children's privacy.)

"His problems started in third grade," says Ann Ingham (a pseudonym), mother of "Jon," 11, now a rising sixth grader. Though Jon was "never really hyperactive," teachers began reporting that he was disruptive in class and found himself in "la-la land."

Ingham had Jon evaluated at school and then by a doctor. In fourth grade, after he began taking Ritalin, a prescription stimulant, the effect was immediate.

"He noticed a difference; teachers noticed a difference," says his mother, recalling a once-struggling student. "He now gets all As and Bs and is easier to be around." She adds that he's also now better at sports.

Ingham says one factor influenced her more than others in her decision to put Jon on medication: future substance abuse. Ingham says substance abuse runs in the family, and after some doctors' warnings, she feared if she didn't get her son help early, he might eventually end up "self-medicating."

Allison Ecker (also a pseudonym) says her 12-year-old son, "Peter," a rising seventh grader in a county school, benefited from taking another stimulant, Concerta, in third through fifth grades.

"The teacher started complaining a lot that he wasn't staying on task," says Ecker, "that he was fidgety and distracted and he was also distracting other students."

Though he has since gone off the time-release medication, Ecker says her son now asks about taking it again.

"Socially, he does have difficulty making friends," she says. "He gets frustrated. He feels a little like an outcast."

Both Ecker and Ingham say they've had positive experiences with medications, but both admit to mixed feelings about dosing their children.

"I had big medical concerns and misgivings," says Ingham.

"I didn't want to face that he has this issue," says Ecker of her son. 

Child psychiatrist Camperlengo says those mixed feelings and concerns are normal and should be discussed with a doctor. Given the long-term problems that can result from untreated ADHD, Camperlengo says parents concerned about the risks of medicating their child need to ask themselves another risk question. "What are the risks of not treating with a medication?" 

"It's really important for parents coming in with their child for an evaluation to know that they are always in control of it," she says of deciding to start medication. "They can make the choice to start it and also make the choice to stop it."