Five signs school problems may be related to ADHD

For many children with ADHD, homework is an everyday nightmare.

Teachers can provide valuable information about academics, classroom behavior, and social skills. ADHD doesn't affect intelligence. If your child has attention deficit and is struggling academically, it is probably an indirect result of ADHD traits. ADHD may affect your child in the following ways:

Poor organizational skills

Your child might have trouble keeping materials organized or keeping track of books, pencils, or other school materials. He might have trouble planning projects or large assignments.

Homework challenges

For many children with ADHD, homework is an everyday nightmare. It takes several hours to complete assignments that non-ADHD children complete in 15 or 30 minutes because of the inability to stay focused. Your child might forget what the assignment is, or forget to bring home the books or materials needed to complete the homework. After spending hours doing homework, he might forget to hand it in or lose it somewhere between home and the classroom.

Inconsistency

You child might perform well one day and be totally off the following day. Inconsistency is a hallmark of ADHD and is confusing for so many parents. You wonder why your child can sit down and do his homework quickly one night and spend four hours on it the following night. Your think your child is deliberately misbehaving. This inconsistency is common in children with ADHD.

Distractibility

Lack of focus is a common symptom of ADHD. It means your child has a hard time focusing on tasks for extended periods, unless they are high-interest activities.

Trouble sitting still

Not all children with ADHD show signs of hyperactivity. However, those who do can't sit still. They need to get up and walk around, or are constantly fidgeting. Children with ADHD often get up inappropriate times during class, or they seem squirmy all of the time.

12 Steps To Smarter School Accommodations

1. Document warning signs.

Start compiling documents that substantiate the poor grades, behavior reports, and hurt feelings that

follow your child home from school.

2. Schedule a teacher meeting

Gather firsthand information while building important bridges

3. Pursue a diagnosis

Make an appointment with a medical professional who specializes in ADHD or learning disabilities, or with a neuropsychologist.

4. Request a school assessment

• Ask the school to assess your child's eligibility for special services
• Discuss the request - and supporting documents - in person with school officials.

5. Evaluate your options

Review the school's formal assessment results and recommendation of IEP, 504 Plan, or no services.

• Individualized Education Program (IEP): Children diagnosed with ADHD, who fall under the Other Health Impairments category of the Individuals with Disabilities Education Act (IDEA), may qualify for services if they also have an LD or another of the Act's named conditions.
• 504 Plan: Section 504 of the Americans with Disabilities Act (ADA) provides for in-classroom accommodations for students with disabilities. 504 Plans offer fewer protections than IEPs, but require fewer protections than IEPs, but require less extensive documentation.
• No Services Recommended: The school's evaluation concludes that the child's ADHD or learning disabilities will not be helped by accommodations.

6. If you disagree with the school's assessment

• Ask about informal classroom assistance, such as tutoring or teacher help.
• Make a formal written request for an independent evaluation.
• Request mediation or a due process hearing. (You may do this if you disagree at any stage with the IEP process.) Consider hiring an education advocate or attorney.

7. Prepare for your IEP/504 meeting

Following the school's evaluation, you will attend an IEP/504 meeting. In preparation, gather
documents demonstrating your child's strengths and weaknesses, including paperwork evaluated by the assessment team.

8. Research accommodations

• Develop a list of homework and classroom accommodations that will work for your child.
• Make copies for each person attending the IEP/504 meeting.

9. Draft IEP with the team

• Agree on your child's present levels of performance
• Develop detailed IEP goals with the school team
• Discuss proposed accommodations and services with your child's tutor, therapist, or psychologist before signing a written agreement.
• Sign the IEP. If you give only partial consent, the team will decide on the next steps.

10. Summarize the Conclusions

Follow up the IEP/504 meeting by restating all agreed-upon goals, accommodations, and processes in thank-you notes to the school team members.

11. Track progress against goals

• Agree on a communication plan with teachers
• Maintain a file for your child's schoolwork and document all contact with school.
• Schedule periodic reviews with teachers.

12. Review and reassess

• The IEP team must meet annually
  Parents may request a meeting at any time if they feel changes are needed or the IEP is not being followed.
• Prepare for meetings by organizing and copying all relevant materials.
• If the school remains uncompliant, request mediation or a due process hearing.

Nutritional Supplements in the Treatment of Childhood ADHD

The use of nutritional supplements is common in children with ADHD despite limited evidence for their effectiveness. These supplements include macronutrients such as proteins, fats and carbohydrates, as well as micronutrient vitamins and minerals. In clinical trials, few supplements were found of high quality, and study results are frequently inconsistent. The following is a review of the most studied supplements used for ADHD.

Macronutrients for ADHD

Essential Fatty Acids. The essential fatty acids (EFAs) include the following:

1. Omega-3 fatty acids
• Eicosapentaenoic - EPA
• Docosahexaenoic acid - DHA
2. Omega-6 fatty acids
• Arachidonic acid - AA
• Gamma linolenic acid - GLA

Children with ADHD may have low levels of EFAs, especially DHA and AA. While there have been a number of well designed studies of EFAs in children with ADHD, there is limited evidence that fatty acids improve core symptoms in such children.

A 2011 review of studies that compared the effects of omega-3 supplementation with placebo found that omega-3 was modestly effective on inattentive and hyperactivity ADHD symptoms, especially with a higher doses.

Overall, a growing body of evidence supports the use of an EFA supplement for children who have ADHD. Since there are a number of studies showing positive effects, and the risk of using EFA supplements is low, it is reasonable to embark on a trial of EFAs - especially when parents are ambivalent about medications, or medications are not effective or poorly tolerated.

It is best to use combination EFAs, such as fish oil. Fish oil is a more efficient source of EFAs than flaxseed oil. Fish oil is inexpensive and comes in a variety of flavors and chewables for children. Look for a label that specifies that the product is mercury free. An acceptable dose is 1,000 mg to 2,000 mg (with at least 500 mg EPA) per day from preschool age and up, such as this one from Amazon.

At least three months should be allowed to see results, and results may be optimal at six months. The most common side effects of fish oil include abdominal pain, belching, and a fishy aftertaste.

L-Carnitine and Acetyl L-Carnitine (ALC). L-carnitine is synthesized from lysine and methionine amino acids. The evidence to support use of L-carnitine is weak at this time. There is some, albeit weak, evidence that patients with inattentive subtype of ADHD responded better than others. Doses used in research were 500 mg to 1,500 mg twice a day and there were no safety concerns or side effects reported.

Micronutrients for ADHD

Zinc. Zinc is an essential mineral and is a cofactor of many enzymes. Zinc deficiency symptoms include concentration impairment and jitters. Several studies suggest that zinc levels may be low in children with ADHD. There is also some evidence that optimal response to stimulant medications might depend on adequate baseline zinc levels.

There is currently no evidence backing zinc supplements as a sole treatment of ADHD. However, zinc supplementation in those patients with suspected zinc deficiency may improve the patient's response to ADHD stimulant medications. Zinc might be more effective for older children with a higher body mass index, and higher doses such as zinc glycinate 15 mg twice a day might be more effective.

Iron. Some studies have found that children with ADHD have lower serum iron levels and that severity of symptoms correlates with lower levels; but other studies found no association. In addition, two studies suggest that iron deficiency might decrease the effectiveness of psychostimulant treatment.

Similar to zinc, taking iron orally might improve symptoms of ADHD in children with iron deficiency. The adverse effects of iron supplementation include abdominal pain, constipation, and vomiting.

Megavitamins

Megavitamin doses are several orders of magnitude greater than the recommended daily allowance (RDA). There is evidence that these large vitamin doses can increase chances of liver toxicity. Moreover, several studies have shown no benefits of megavitamin doses on ADHD symptoms. Due to the potential risk and lack of demonstrated benefits, megavitamin treatments are not recommended. If patients are using doses of vitamins or minerals higher than the recommended daily allowance, it is important to monitor serum or cell membrane levels of these nutrients and liver enzymes to avoid toxicity.

Multivitamins

Many children with ADHD do not eat a balanced diet, or are picky eaters, or have appetite suppression from psychostimulant medications. In any of these cases, the use of a multivitamin supplement at regular RDA doses can be recommended for those at risk for nutritional deficiencies.

Summary

At this time, the evidence for use of nutritional supplements for the treatment of ADHD is limited. Treatments with the best evidence include omega-3 and omega-6 fatty acid combinations (such as in fish oil), zinc as an adjunct to stimulant treatment, iron for children with iron deficiency, and multivitamins for children at risk for nutritional deficiencies. It is important to have an open-minded attitude that invites discussion with parents of their use of alternative medicine treatments.

Treating ADHD may prevent smoking

Studies have found that young people with attention deficit and hyperactivity disorder (ADHD) were more likely to pick up cigarette smoking, start earlier when they do and become more seriously addicted to tobacco than peers without the disorder.

One reason for this, says Firas Rabi, MD, a pediatrician in private practice in Dublin, Ohio, is that the nicotine in cigarettes can improve attentiveness and performance. Teens and young adults with ADHD may find that nicotine enhances their attention and, in essence, use cigarette smoking as a form of self-medication. Another reason that smoking is more common is that children with ADHD often experience social difficulties and peer rejection as a result of behaviors or poor social skills. Adding insult to injury, smokers with ADHD are likely to have more severe nicotine dependence and more severe withdrawal symptoms when trying to quit.

Reducing the risk for smoking

There are no specific interventions that can be recommended to reduce the risk of smoking in children with ADHD. Treating people who have ADHD with stimulant medication could reduce their likelihood of taking up smoking, according to research from Duke Medicine in Durham, NC. Publishing their results in the journal Pediatrics, the Duke researchers found "a significant association" between stimulant treatment for ADHD and lower smoking rates. In addition, they concluded that those who took their medication consistently and for a longer period of time had an even lower risk of smoking. The findings are important given concerns raised about long-term impact of stimulant treatment on substance abuse in general and cigarette smoking in particular.

For clinicians treating patients with ADHD who are already smokers, it seems that use of stimulant medication does not have a negative impact on cessation for those interested in quitting. It is currently unclear if there is an effect on those who are not interested in quitting.

Nicotine replacement therapy seems to work equally as well for smokers with ADHD as it does for the general population.

Can a 2-year old have ADHD?

According to the Centers for Disease Control and Prevention (CDC), about 11% of children aged 4 to 17 years old have been diagnosed with ADHD as of 2011. The average age of ADHD diagnosis was 7 years of age, but there is recent evidence that toddlers as young as 2-years old are being diagnosed with ADHD and placed on stimulant medications. A study by the CDC estimated that 10,000 toddlers — children age 2 and 3 years old — are receiving medication for ADHD. This is despite the fact that the American Academy of Pediatrics has very specific criteria for the diagnosis of ADHD, but the guidelines do not apply to children younger than 4 years of age. Even for younger patients diagnosed with the disorder — those 4 to 5 years old — the CDC recommends behavioral treatment first and medication only after behavior interventions don't result in any improvement.

"A 2-year old who is hyperactive and difficult to control doesn't necessarily have ADHD," says Dr. Firas Rabi, a pediatrician who treats children with ADHD in Ohio. Some doctors say ADHD medications could be a last resort physicians turn to when toddlers might harm themselves, but others note having lots of energy and acting out is simply a part of being a young child. "Toddlers are naturally curious, strong willed, fidgety and come with never-ending energy," adds Dr. Rabi.

“Treating babies with stimulants is based on no research, is reckless and takes no account of the possible harmful, long-term effects of bathing baby brains with powerful neurotransmitter drugs,” Allen Frances, a professor emeritus at Duke University, wrote in a piece for the Huffington Post regarding the CDC’s recent findings.

Until we have more data regarding the long-term effects on neurostimulant medications on the developing brains of toddlers, and until physicians are better able to differentiate ADHD symptoms from those of the anxious or depressed toddler, it is best that current ADHD medications not be prescribed to those younger than 4 years old.

Anxiety in Children with ADHD

Up to half of children with ADHD also have anxiety, but the effect anxiety has on the functioning abilities of children with ADHD has received little attention. There is some evidence that children with both ADHD and anxiety are less impulsive, and other evidence that these children have more attentional difficulties than those with ADHD alone. Some studies have shown that anxiety may exacerbate social problems for children with ADHD, but this notion has been challenged by other researchers.

A recent Australian study examined the association between anxiety and the functioning in 561 children with ADHD. Sixty-five percent of these children had anxiety with their ADHD, with social phobia being the most common, followed by generalized anxiety, separation anxiety, obsessive compulsive, post-traumatic stress, and panic disorders. Eighty-five percent of these children were taking medication for their ADHD.

An interesting finding was that those children with ADHD and an anxiety disorder were more likely to have moderate or severe sleep problems, had more severe symptoms of ADHD, and were more likely to have parents with elevated mental health symptoms.

Because anxiety is common in children with ADHD, and since anxiety has a tendency to lead to worse ADHD symptoms, it is very important to screen all ADHD patients for anxiety. My practice at Northwest Pediatrics in Dublin, OH includes screening for anxiety in each of our ADHD initial conferences and during each successive follow-up visit. Systematically assessing and treating anxiety in children with ADHD has the potential to improve functioning in children with ADHD.

The details in this Australian study were published in Pediatrics April 2014 edition.

Suspicions

Do you remember when you first suspected that your child had ADHD? How old was he or she? What did you notice? Did both parents agree on the suspicion? Comment below and let me learn from you!

ADHD Facts

I suppose the first post on an ADHD page should provide some basic information about this disorder. While many people think that any child who is fidgety and inattentive can be classified as having ADHD, the reality is that there are specific criteria to meet this diagnosis. Per the CDC guidelines, a child with inattentive-type ADHD have SIX of the following features:

• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.

• Often has trouble holding attention on tasks or play activities.

• Often does not seem to listen when spoken to directly.

• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).

• Often has trouble organizing tasks and activities.

• Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).

• Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

• Is often easily distracted

• Is often forgetful in daily activities.

A child with hyperactive-predominant ADHD have five or six (depending on age) of the following:

• Often fidgets with or taps hands or feet, or squirms in seat.
• Often leaves seat in situations when remaining seated is expected.
• Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
• Often unable to play or take part in leisure activities quietly.
• Is often "on the go" acting as if "driven by a motor".
• Often talks excessively.
• Often blurts out an answer before a question has been completed.
• Often has trouble waiting his/her turn.
• Often interrupts or intrudes on others (e.g., butts into conversations or games)

There are other criteria that must be met, and a diagnosis should not be made based simply on a checklist.

Firas Rabi, MD

About Me

My name is Firas Rabi. I've been a pediatrician since I completed training in New York City in 2005. Since then, I've completed a fellowship in pediatric critical care and have served on regional as well as national committees to advance the field of pediatrics. My forte is teaching and for a long time I enjoyed teaching medical students, residents, and fellows how to recognize severe illnesses and the various approaches of treatment based on the underlying physiology. My interaction with patients was intense was relatively short-term and I soon longed to return to the roots of pediatrics - the care of children and being a part of their life as they grow up.

That's why I have recently turned my attention to practicing pediatrics and teaching parents and children how to maintain their health. The satisfaction of being a long-term part of a child's health, growth, and development is incomparable.

I've taken a particular interest in helping children with learning difficulties, particularly those with attention deficit [and hyperactivity] disorder (ADD and ADHD). The goal of this blog is to chronicle the new developments in the diagnosis and treatment of ADD and ADHD. It is not my intent to provide medical advice, because only your (or your child's doctor) should do so. However, I would like to hear the stories of parents who have raised a child with ADHD, and it would be great to hear stories from people with ADHD themselves.