From the June 2019 issue

ADHD in Kids: Identifying and Treating This Mental Health Issue

ADHD in kids is a common and a nuanced condition that evolves with time. No wonder it can still be so misunderstood. Here's what to know about ADHD in kids.

A child with ADHD caught in a maze of vines and thoughts
Illustration by Lainey Yehl

Editor’s note: This report on ADHD in kids is part III of III in a series on mental illness in kids. Read about anxiety in kids and depression in kids, too.

“He’s a very creative little boy,” says Rebecca Calappi of her 7-year-old son. “He’s such a problem solver. If someone has a problem, he’s the first one to try to come up with a solution.” And he’s a little inventor, too. “He loves Legos and he’s always building things. My favorite thing is he came up with this fart machine to channel the bad smells away,” Calappi says with a laugh.

Yet the St. Clair Shores mom also noticed her son struggled to hold in his emotions. Even as a toddler, she found her son’s tantrums were more intense than other children’s.

Once he entered preschool, Calappi started getting regular updates from her son’s teacher about bad behavior in class – from outbursts like hitting other kids to acting like the class clown. “About twice a week the teacher would let me know, ‘We had an issue today,'” Calappi says.

The problems intensified in kindergarten. “Right there is my biggest regret – that I didn’t do more back then,” she adds. “I let it roll, thinking, ‘He’s too young, he’s just immature.’ I should have listened to my gut and nipped it earlier.”

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After ongoing conversations with her son’s kindergarten teacher, Calappi sought help from the pediatrician and then other specialists. Extensive testing revealed her son had attention deficit hyperactivity disorder.

“The way I explain it to him is that his brain runs like a race car, but mine is like a regular car.” Extending the metaphor, Calappi adds, “For kids with ADHD, it’s like having a race car brain with regular breaks.”

Many parents have experienced a similar dilemma to Calappi – wondering whether their child might outgrow certain behaviors, or if there’s something else going on. And that’s especially true with ADHD in kids – from symptoms to how it’s classified.

“It’s in the DSM-V with a lot of other mental health descriptions. Insurance groups ADHD under mental health,” says Stefani Hines, M.D., FAAP, medical director at the Center for Human Development at Beaumont Children’s in Southfield. “I consider it both – mental and medical. It’s all housed in the brain. It’s both neurological and biologic – it’s a matter of semantics.”

Stats are similarly fuzzy, Hines says, with the figure ranging from 5-10 percent of kids. The National Institute of Mental Health put its estimate at 11 percent of ages 4-17 as of 2011, the most recent number available – a 42 percent increase from 2003, when that figure was 7.8 percent. However, the exact number is still in question, in large part due to the difficulty in diagnosing.

And it gets more complex still. A University of Michigan report released in early 2019 found half of all U.S. kids diagnosed with the three most common, and treatable, mental health disorders – anxiety, depression and ADHD – weren’t getting treatment. In Michigan, that number is 40 percent, or about 100,000 kids.

Here, we look in depth at signs for parents that your child may have ADHD, along with how the disorder is diagnosed and treated.

ADHD signs vary by age

When it comes to pinpointing clues your child may have ADHD, says Hines with Beaumont Children’s, “it really depends on what age you’re dealing with.” In the past, mental health experts distinguished between ADHD and ADD (attention deficit disorder). Today ADHD is instead divided into three subtypes that often – but not always – present within certain age groups.

“What we see in younger children, preschoolers age 3 to 5, is typically hyperactive-impulsive, and it’s more common in boys than in girls,” Hines says. “With these children, they’re acting out physically – hitting, slapping, taking toys a lot. They have great difficulty sitting still.”

“The biggest misconception sometimes people feel is that ADHD is the fault of something going on at home or the fault of the parents or the family. That’s simply not the case. And I truly believe, although it’s difficult to prove, that (ADHD) probably results from some sort of biochemical imbalance in the brain.”

– Leonard Pollack, M.D., Henry Ford System pediatrician

In the elementary school ages, a combined type of ADHD, where the children have difficulty with impulse control and inattention, tends to be more predominate, Hines continues. “(They) have a restlessness and they’re constantly squirming and fidgeting. They have difficulty paying attention, focusing and completing their homework.”

Moving into middle school, the third subtype, inattention, is more visible, in part because it’s more challenging for children with ADHD to continue navigating school without encountering issues.

“That’s because the academic demands take on a different feel. There’s more independent schoolwork,” Hines says. Planning out how to get multiple homework assignments done becomes difficult; and the topics covered in school require more focus and concentration.

“What’s hitting the wall at that age is the increased demand for organization and time management,” Hines says. “(Children with ADHD) have been under the radar because they haven’t had the behavior problems, they’re not hyperactive, they’re not lashing out at other kids.”

Detective work in diagnosing

There’s no blood test to figure out whether someone has ADHD. Leonard Pollack, M.D., a Henry Ford Health System pediatrician, puts it simply: “It is a challenge.”

Oftentimes, parents will seek out professional care at the suggestion of their child’s teacher or other school personnel who interact regularly with him or her.

“You want to get the input from the teacher, but you also need input from the PCP (primary care provider or pediatrician),” Pollack says. “The way we generally diagnose is using some standard questions we ask the parents, the teachers. If the child is old enough, we ask the child as well. Some questions help us diagnosis ADHD; some rule out other diagnoses.”

“There are so many misconceptions, and it’s so sad because ADHD kids – they’re kids who have no monitor. They have no way to control or filter their emotions. (Their emotions) are laid bare for people to see.”

– Rebecca Calappi, St. Clair Shores mom of a son with ADHD

For example, a child who is severely depressed may not be paying attention in class, or he or she may have a learning disability – or any number of other explanations for the child’s hyperactivity or inattention.

“The way I describe it to parents is, ‘Imagine we put you with a first-grade class and the subject is 1+1=2. If we had a hidden camera in that classroom, we’d probably catch you being fidgety, too, because you’re bored,'” Pollack explains. Another scenario Pollack offers: “If I put you back in that first grade class and this time the topic was advanced Chinese and you don’t know a word of Chinese, you’re probably going to have difficulty concentrating – not because you have ADHD, but because you have a learning issue.”

Determining a diagnosis, then, becomes a matter of evaluating the results from the testing, along with information gathered from teachers, parents and family members, and even other adults who may work with your child, like piano teachers, coaches and scout leaders. “We gather data from different people,” Hines says. “We want to see what’s happening with the child in multiple settings.”

She recalls one patient who seemed to be fine at home and at school, but a gymnastics coach noticed the child’s inattention, eventually leading to her evaluation and diagnosis.

In other words, when it comes to diagnosing, there is no one scenario or set of definitive symptoms. It’s bringing together all the relevant information about the child’s behavior by a professional to determine whether it’s ADHD.

Treating ADHD in kids

There’s no known cause of ADHD; medical experts believe that multiple factors are at work. Genetics and environmental factors, like smoking and alcohol use in pregnancy, may play a role – but what that role may be hasn’t been determined.

While the causes for ADHD in kids are unclear, the treatment has been well-established – most children with ADHD benefit from a combination of medication and behavioral therapy. The National Institute of Mental Health notes more than 69 percent of kids diagnosed with ADHD take medication (again per its 2011 data).

“I think the most important thing I try to explain to parents is that we’re trying to help this child do as well as he possibly can,” Pollack says. “The goals of treatment are to maximize the child’s ability educationally and socially, but not necessarily that quote-unquote ‘perfect child’ whose behavior never bothers anybody.”

Finding the right combination of therapy for the child and the family, along with a right medication dosage, takes time – and the appropriate dosing may change as the child ages. “Some children learn to compensate as they get older and need less; some need bigger doses because they’re bigger.”

For Calappi, it took about three months to find the right dose for her son. “There’s nothing quick about it.” The first, and lowest, dose seemed to have little impact on her son’s behavior, but when they upped the medication, Calappi recalls, “He lost his personality and was just sitting around.”

After finding the right dose, and starting both individual and family therapy, Calappi says her son has been improving, “He’s still got his spunk, he’s still charming – but he’s calmer, he can focus.”

Family therapy, too, has helped Calappi understand how to support her son, who she sees at times struggling with self-confidence and trying hard to fit in at school and socially, but not always understanding how.

“Parenting a child with ADHD is like asking a square peg to fit into a round hole,” Calappi says. “People just don’t understand why he’s not paying attention or acting a certain way. When your son has a tantrum or an outburst, that’s part of the disease. And ADHD is a disease.”

“With ADHD, there used to be this idea that kids would kind of outgrow it. Parents would ask me, ‘What are the chances at 15 or 16 my child will still have this?'”

– Stefani Hines, M.D., FAAP, medical director, Center for Human Development at Beaumont Children’s

Potential breakthrough ADHD treatment?

On April 19, 2019, the U.S. Food and Drug Administration announced the approval of the first medical device – as opposed to a prescription – for use in treating ADHD. The statement reads, in part, “The prescription-only device, called the Monarch external Trigeminal Nerve Stimulation (eTNS) System, is indicated for patients ages 7 to 12 years old who are not currently taking prescription ADHD medication and is the first non-drug treatment for ADHD granted marketing authorization by the FDA.”

When asked for her reaction, Hines with Beaumont Children’s in Southfield says, “Proceed with caution. It’s a promising development because it’s non-invasive, but it’s still a device and you have to look at what the side effects may be.”

She notes that doctors still don’t know a lot about those side effects. “We do know the kids in the treatment group had headaches, fatigue and increased heart rates, but we don’t know the full realm of side effects.” Other questions remain about the treatment, too – like will insurance cover the cost?

The cellphone-sized device works by creating “a low-level electrical pulse and connects via a wire to a small patch that adheres to a patient’s forehead, just above the eyebrows, and should feel like a tingling sensation on the skin.”

“The system delivers the low-level electrical stimulation to the branches of the trigeminal nerve, which sends therapeutic signals to the parts of the brain thought to be involved in ADHD,” the FDA release notes.

“While the exact mechanism of eTNS is not yet known, neuroimaging studies have shown that eTNS increases activity in the brain regions that are known to be important in regulating attention, emotion and behavior.”

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