ADHD and Other Disorders

ADHD can coexist with a number of psychological conditions, including conduct disorders, mood disorders (such as depression), anxiety disorders, and impulse control disorders (such as eating disorders and alcohol abuse). Some children may be depressed as a result of having ADHD, whereas others may have a mood disorder that exists independently of ADHD. Nearly half of all children with ADHD also have oppositional defiant disorder characterized by stubbornness, outbursts of temper, and defiance.

Many children with ADHD also have a specific learning disability, which means that they might have trouble mastering language or other skills, such as math, reading, or handwriting. Although ADHD is not categorized as a learning disability, its interference with concentration and attention can make it even more difficult for a child to perform well in school. The issue of coexisting conditions makes diagnosis, treatment, and understanding of ADHD particularly complex.

Treatment

There is no cure for ADHD, but a combined program of medication and behavioral therapy can help and is often prescribed to treat ADHD. With the advice and cooperation of a child's pediatrician, teachers, counselors, and family members, the child can have a normal life in spite of this disorder.

For most children and adults with ADHD, medication is an important part of treatment that is not used to "control" behavior but to ease the symptoms of ADHD and to help the child cope. Stimulants appear to work by altering the levels of transmitters in the brain by which the different nerve cells communicate.

Between 70 and 80 percent of children with ADHD respond positively to these medications, with improvements in attention span, impulsivity, and behavior, especially in structured environments. Some children also demonstrate improvements in frustration tolerance, compliance, and even handwriting. Relationships with parents, peers, and teachers may also improve.

This medication may also be effective in adults who have ADHD. The reaction to these medications can be similar to that experienced by children with ADHD—a decrease in impulsivity and an increase in attention. Many ADHD adults treated with medication report that they are able to bring more control and organization to their lives. Other medications, such as antidepressants, can be help ful when depression, phobic, panic, anxiety and/or obsessive-compulsive disorders are present.

The newest drug used to treat ADHD is strat-tera (atomoxetine), the first nonstimulant medication approved for the treatment of ADHD in children, adolescents, and adults. Strattera is a selective norepinephrine reuptake inhibitor, a class of drugs that works differently from the other ADHD medications available. It works by selectively blocking the reuptake of norepinephrine, a chemical neurotransmitter, by certain nerve cells in the brain. This action increases the availability of norepinephrine, which experts believe is essential in regulating impulse control, organization, and attention. The precise mechanism by which Strat-tera works on ADHD is not known.

Because Strattera does not appear to have a potential for abuse, it is not classified as a controlled substance, although it is a prescription drug. Strattera is an oral capsule and can be taken once or twice a day to provide full-day relief from ADHD symptoms. While parents may notice improvements in ADHD symptoms after the first week of use, it may take up to a month to see the full therapeutic benefit of the medication.

The drugs usually include regular, fairly small doses of stimulants such as ritalin (methylphenidate), Dexedrine or Dextrostat (dextroamphetamine), adderall (single entity amphetamine), or cylert (pemoline). While these drugs can be addictive in teenagers and adults, they do not seem to be addictive in children. Nine out of 10 children improve on one of these stimulants, so if one does not work, others are tried. It may seem strange to give stimulants to children with hyper-activity and attention deficit problems, but instead of making the child act out more, these drugs reduce the hyperactivity and increase the attention span. The drugs also help children with ADHD control their behavior. A child using these drugs actually becomes quieter and more attentive.

Sometimes, however, none of these medications work. In this case, some children may respond well to antihistamines usually prescribed for allergies, or antidepressants like Elavil, Prozac, Tofranil, or Norpramin. clonidine, a drug normally used to treat high blood pressure, may ease some symptoms of ADHD. With any of these medications, adjusting the dosage for each child is vital for treating the symptoms of ADHD.

Stimulant drugs do cause side effects. Most doctors feel the potential side effects should be carefully weighed against the benefits before prescribing drugs to children with ADHD. While taking these medications, some children may lose weight, have stomachaches or have less appetite, and temporarily grow more slowly. others may have trouble falling asleep and become irritable. Some doctors worry that stimulants may worsen the symptoms of tourette's syndrome, although recent research suggests this is not true. Many doctors believe if they carefully monitor a child's height, weight, and overall development, the benefits of medication far outweigh the potential side effects. Side effects that do occur can often be handled by reducing the dosage.

unfortunately, the long-term effects of taking these drugs is not known. Cylert may cause more serious side effects and is therefore not considered to be a first-line medication for ADHD. Otherwise, side effects are usually dose related.

Still, the use of stimulants for children with ADHD—especially Ritalin—is not without controversy. Critics worry that Ritalin and other stimulant drugs are prescribed unnecessarily for too many children, since many things—including anxiety, depression, allergies, seizures, or problems at home or school—can make children seem overactive, impulsive, or inattentive. They argue that many children who do not have ADHD are drugged anyway as a way to control disruptive behaviors.

Critics also worry that so many of the nation's children are given these drugs without any real understanding of the future side effects. Although Ritalin is one of the most commonly prescribed drugs for children, there are concerns about its long-term effects.

There are no studies on children who have taken Ritalin for more than 14 months. Ritalin affects the brain in a way very similar to cocaine, one of the most addictive substances known. Critics worry that children who take Ritalin may be more likely to use illegal drugs in the future, or that they might be more likely to smoke as adults. These concerns are fueled by research showing that rats who were exposed to stimulants were more likely to choose cocaine, suggesting that early exposure to some drugs may make a person more likely to abuse drugs in the future. However, the data on whether there is a link between Ritalin and later substance abuse are controversial. Some studies show that Ritalin makes people more prone to addiction to certain substances, but other researchers insist that ADHD children are not more likely to use drugs of any type later in life.

Many experts believe that the best way to manage the symptoms of ADHD is to combine drug treatment with behavioral methods. Medication can help to control some of the behavior problems that may have led to family turmoil, but more often there are other aspects of a child's problem that medication will not affect.

Even though ADHD primarily affects a person's behavior, the simple fact of having ADHD can trigger serious emotional problems as well. Some of these children have very few experiences that build their sense of worth and competence. If they are hyperactive, they are often punished for being disruptive. If they are too disorganized and unfocused to complete tasks, they may be branded "lazy." If they are impulsive, shove classmates, and interrupt, they may lose friends. If they are unlucky enough to have a related conduct disorder, they may get in trouble at school or with the police.

The daily frustrations that are a part of having ADHD can make people feel abnormal or stupid. In many cases, the cycle of frustration and anger has persisted for so long that it may take years to alleviate.

For this reason, parents and children may need special help to develop techniques to manage the behavior patterns that have become ingrained. In such cases, mental health professionals can help the child and family develop new attitudes and ways of relating to each other.

Behavior treatments include coaching, a process of individual support that focuses on understanding maladaptive patterns of behavior, identifying goals and strategies for change, and providing consistent reinforcement and feedback. For younger children, such an approach may involve behavioral rating scales, consistent feedback, and reinforcement for positive behavioral change. For adults, the approach may focus on identifying and describing goals and strategies. In either case, focusing on the role of individual responsibility and choice is a vital component, as is developing a consistent pattern of feedback and reinforcement.

In individual counseling, the therapist helps children or adults with ADHD learn to feel better about themselves. The therapist can also help people with ADHD identify and build on their strengths, cope with daily problems, and control their attention and aggression.

In group counseling, people learn that they are not alone in their frustration and that others want to help. Sometimes only the child with ADHD needs counseling, but often the entire family can benefit from support. If the child is young, parents can learn techniques for coping with and improving their child's behavior.

Several intervention approaches are available and different therapists tend to prefer one approach or another. Knowing something about the various types of interventions makes it easier for families to choose the best therapist for their own situation.

In psychotherapy, patients talk with the therapist about their thoughts and feelings, explore problem behaviors, and learn different ways to handle their emotions. If someone who has ADHD wants to gain control of symptoms more directly, more direct kinds of intervention are available.

Cognitive-behavioral therapy helps people directly change their behavior instead of only concentrating on understanding their feelings and actions. The therapist may help an individual learn to think through tasks and organize work, or encourage new behavior by giving praise each time the person acts in the desired way. A cognitive-behavioral therapist can use these techniques to help an ADHD child learn to control his fighting, or an impulsive teenager to think before speaking.

Social skills training can help children learn new behaviors by watching the therapist model appropriate behavior like waiting for a turn, sharing toys, or responding to a bully.

Support groups can also be helpful, linking people who have common concerns. Many adults with ADHD and parents of children with ADHD find it useful to join a local or national support group.

Many groups deal with issues of children's disorders. Members of support groups share frustrations and successes and provide referrals.

Because ADHD affects all aspects of a child's home and school life, experts recommend parent education and support groups to help family members learn how to help the child cope with frustrations, organize environments, and develop problem-solving skills. Special parenting skills are often needed because children with ADHD may not respond as well to typical parenting practices— especially punishment. Instead, children with ADHD should learn how to reinforce their positive behaviors themselves and also learn how to solve problems. Children who take medications and practice these behavior techniques do better than those who rely on medication alone.

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