SelfhelpMagazine

by Thomas G. Shafer, M.D. & Susan V. Shafer, RN, B.S.N

There we were in our office. Little Johnny (all names and identifying details have been altered to protect confidentiality) was six years old and his teacher had sent him and his mother to us with a note saying, "Hyperactive. He Needs Ritalin." This was a near daily occurrence in our practice and there was no question that this child who had just finished forty five minutes disassembling every object on the desk and almost literally bouncing off the walls was hyperactive. But did he have true ADHD? We didn't think so.

Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder has been a well described clinical problem for at least the past three decades. There are extensive criteria for making the diagnosis in the current Diagnostic and Statistical Manual of the American Psychiatric Association. However, what we are basically dealing with here is a child who has more than age appropriate difficulty paying attention, problems staying on task without distraction and exhibits bodily overactivity and sometimes aggressive behavior.

There are really two types of Attention Deficit disorders, pure Attention Deficit Disorders (ADD) and Attention Deficit Hyperactivity Disorders (ADHD.) There are also several other serious medical and psychiatric conditions which may closely mimic ADD and ADHD.

Shafer's Golden Rule

So we begin with the Shafer's First Golden Rule: "All that wiggles is not hyperactive." Pure ADD is primarily characterized by inattention, often in the form of "daydreaming," distractibility and difficulty staying on task. But not all tasks are difficult. The old maxim that a child who plays video games for hour does not have ADD is simply not true.

ADD kids are often excellent at such activities and can sit through an action movie and remember every detail. The trick here is that I said "difficulty paying attention" not inability. Many of our present video games, cartoons and action thrillers are so "action packed" and stimulating that it would be difficult for anyone not clinically brain dead to ignore them.

But in a classroom situation, little Suzie is going to stare out the window, giggle at all the other children's jokes and generally be blissfully unaware of what her teacher is doing. (I say "Little Suzie not to stereotype, but because there is a noticeably higher incidence of pure ADD without hyperactivity amongst girls".) But the ADD child is quietly inattentive not disruptive so their problem may well go unnoticed in a busy classroom. Instead parents will receive notes saying the child is "a little slow" or, worse, "obviously bright but just not trying to do the work." In other words, under-diagnosis is often the rule of the day.

Then there is the ADHD child. Little Johnny can't sit still. He is constantly out of his seat and interrupting. He may be the "class clown" who puts the Whoopee Cushion on the teacher's chair. And sometimes, but not always, he may be outright aggressive, fighting with other children and perhaps even setting fires in trash cans and assaulting teachers. So little Johnny gets noticed, and he may be either labeled an ADHD child who ended up in our clinic or a "Brat who just wasn't taught any discipline" who ends up at the wrong end of a paddle in the Principal's office.

But again ask, do these two children truly have ADD and ADHD or are they having problems due to other reasons? Remember the first golden rule.

Shafer's Second Golden Rule

And this takes us to the Shafer's second Golden Rule: "When all else fails, examine the patient." Sadly, many labeled ADD and ADHD children receive a cursory physical check up and, often, no examination at all. There are numerous medical conditions which may cause inattention or hyperactivity. Hyperthyroidism for example, raises the metabolic rate to the point that older individuals report they chronically feel like they are on "Speed" or "Way too much coffee" all the time. And it can be hard to study or pay attention when your body and nervous system are idling at ninety miles and hour.

There are numerous other examples. Anemia may cause a child to be lethargic and inattentive and lead poisoning (common with children who eat flecks of paint in older housing) definitely interferes with learning. An asthmatic child may be on various stimulating medications to assist breathing which make it hard to sit still. We can even remember an "ADHD kid" who couldn't sit still because he had a scorching case of pinworms.

So, the first step in the evaluation must be a through and complete physical with a detailed history and examination and blood work, at least to evaluate for lead poisoning and anemia and, if clinical signs are present, a thyroid profile. And many medications can affect alertness and activity levels so make sure the examining physician is aware of all medications the child is taking, including over the counter medications and vitamins. (We once "cured" an "ADD" college student by determining his vitamins contained a yellow dye he was allergic to.)

This ends Part 1. In Part 2, we discuss neurologic syndromes mimicking ADD/ADHD and the effect of learning and sensory problems.

About the Authors:

The Shafers are both graduates of the University of Virginia and have worked with childhood hyperactivity syndromes as both professionals and parents.