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Attention-deficit/hyperactivity disorder (ADHD) is a common disorder, with symptoms often evident from a young age.
The disorder will manifest itself in a variety of different functions, with variations between children.
Difficulty in regulating attention, difficulty in focusing, difficulty in concentrating on the one hand, and dividing attention on the other, difficulty in retrieving knowledge at the time and place required (difficulty with working memory) and more.
These difficulties are reflected in everyday life and hinder the child, and subsequently the adult affected by it, making it a challange to function effectively and to integrate in the company of peers.
Difficulty in behavioral regulation, considerable impulsivity, impatience, bullying and physical overactivity in all its forms. Attention deficit disorder, in most cases, does not appear on its own, and many of those with it have accompanying difficulties such as difficulties in sensory regulation, difficulty in estimating time, developmental delays, other developmental neurological problems such as learning disabilities, clumsiness, difficulties or delays in language development, social difficulties and more.
A considerable number of children and adults with ADHD also have accompanying psychiatric disorders with a much higher frequency than the general population such as: anxiety, depression, conduct disorder, obsessive compulsive disorder and more.
Lack of attention to details and errors of inattention, short attention span, seems like isn't listening when spoken to, tendency to start tasks and not finish, or skips parts, reluctance to do things requiring prolonged mental effort, difficulty in organization, losing essential things, suceptible to distraction and forgetfulness.
Physical restlessness while sitting, difficulty sitting in place for a long time without getting up, intense and excessive running or climbing, difficulty playing or engaging in quiet leisure activities, constant mobility, excessive talkativeness, inturrupting others' and answering questions even before teacher has finished speaking, difficulty waiting and queuing, often interrupting or bullying others.
At least six symptoms in one of the above groups (ADD or ADHD) must be present for a diagnosis. In addition, several other conditions must be met such as: some of the symptoms appeared already before the age of 7, there is no other psychiatric disorder such as retardation or autism, there is a significant executive functional disorder in the child's life, and more.
The clinical interview with the child and parents is the main part of the diagnosis. Some doctors will prefer to talk with the parents/child separately during the interview. The more information the doctor has, the more accurate the diagnosis will be.
Most doctors use questionnaires/assessment scales as an integral part of the diagnostic process. The questionnaires include questions about the child's behavior at school and at home, so it is important that they are filled out by the school staff and the parents. There are also questionnaires to be self-filled by teenagers and adults.
There are several computerized tests that test attention and continuous function. The common denominator is testing executive ability over time as a response to a single stimulus.
EEG, CT, MRI - Although studies have shown functional and structural changes in the brains of people with ADHD, these tests are used for research purposes only and have not yet been introduced as a diagnostic tool.
Due to the complexity of the disorder and especially due to the many neurological and psychiatric co-morbidities that accompany it, as well as the conditions that can appear as attention deficit disorder if they are not correctly diagnosed such as - retardation or giftedness, visual/hearing disorders, epilepsy, learning disabilities and more - it is important that a professional perform the diagnosis.
In the past, only specialist doctors (neurologists, psychiatrists, pediatricians and family doctors who underwent special training by the Ministry of Health) were authorized to make a diagnosis and start treatment with Ritalin. Today, clinical psychologists can also diagnose ADHD, and offer a referral to specialists if drug treatment is necessary.
If during the medical diagnosis, presence of accompanying difficulties such as learning disabilities, emotional problems, etc., are suspected, it is important to refer the completion of the diagnosis to the relevant professionals.
In the many studies carried out over the years, it was found that stimulants are the most effective in treating the main symptoms of ADHD, dealing with the underlying biochemical mechanisms. The fact that stimulants help mellow the symptoms in hyperactive children was discovered as early as 1937 and has been extensively studied ever since.
The most popular drug, and in fact the only official representative of the group of stimulants in Israel is Ritalin. Ritalin works through several mechanisms, the main one a more efficient release of dopamine in the areas of the brain responsible for the dysfunction in ADHD. This stimulating activity, for the areas responsible for the administrative functions, increases the ability to concentrate for longer periods of time, to pay more attention to details, to focus on the task without being distracted by any environmental stimulus and more. This allows those who take it to function closer to their intellectual potential in a variety of settings, the main one being school.
In addition, the stimulants also work in the areas responsible for the ability to regulate behavior and allowing those who take it to be more relaxed, to think before they act, and to stop moving consistantly. This allows for better function within the framework of classroom rules, at home and in social situations.
In Israel there are several medications that contain the same active substance - methylphenidate, the difference between them the release into the blood mechanisms. The meaning of this difference is in the number of hours in which the active substance will work in the body, and in some cases in the observed side effects. Ritalin works for 4 hours, Ritalin SR 6-8 hours, Ritalin LA 8 hours and Concerta 10-12 hours.
It is very important to match the medication to each child's personal needs, and track the effect and effectivness. Not all children of the same age or weight will receive similar treatment.
Other known stimulants ATTENT, FOCALIN, VYVANSE and more.
All medications from the stimulant group have simillar side effects, with that - individual people may exhibit side effects with one medication and not another, so the therapeutic adjustment is unique to each person.
Stimulants may cause:
These side effects are not particularly common, but when they appear, a change of treatment should be considered.
Another phenomenon is the rebound phenomenon, in which a worsening of the behavioral symptoms is observed with the decrease in the effect of Ritalin. In this situation, switching to long-term drug treatment may solve the problem.
Stimulants can slightly increase blood pressure and heart rate and sometimes cause a feeling similar to extreme excitement.
The only two situations in which there is a partial contraindication to treatment with stimulants:
ATOMIC/STRATTERA is a medication that belongs to the group of selective noradrenaline reuptake blockers. Unlike Ritalin and the other stimulants, this medication must be taken continuously, without break. The full effect appears only after several weeks.
Other drugs that have been tried over the years, including antidepressants and even anti-epileptic drugs, show very low effectiveness, if at all, in improving attention.
It is important not to neglect the emotional aspects, offering tools to cope with the difficulties, enhance social skills, shaping behavior and more.
In teenagers and adults, personal training can be substituted or added to this, helpoing with ineffective daily skills.
Therapeutic riding, therapeutic swimming, sports activities - there are no studies done in this area, so they cannot be fully recommended as "treatment".
Neuro biofeedback - although this is not a new field in medicine, in recent years more research resources have been directed to the subject. There is no unequivocal agreement as to whether brain training improves executive functions and impulsivity over time. There are studies here and there.
Parental guidance is of utmost importance. In order for the parent to be able to deal better with the child's own difficulties, and the variety of challenges these pose to the entire family, they must first understand the essence of the problem and get the practical tools to cope.
It should be remembered that in the vast majority of cases at least one of the parents also hasADD/ADHD, and often there is more than one child with it. Participating in these workshops/trainings poses a special challenge to the inattentive, procrastinating parent who does not finish tasks and does not arrive on time for meetings.
The class teacher, counselor and school psychologist should be an active part of the help and tools provided to the child within the school. Their understanding of the child's difficulties, and the parents' attempts to find a solution can sometimes be an important turning point in the staff's treatment of the child and conduct.
It is important that the child be a central and active part in all forms of care, including the indirect ones, so that gradually, with constant mediation, it will be possible to transfer the responsibility for conduct and care to them.
ADHD has many accompanying underlying conditions and diseases. It is important to be aware of this when diagnosing and treating the child and addresing the various difficulties.
