Book Review: 1000 Best Tips for ADHD

1000 Best Tips for ADHD, by Susan Ashley, PhD, a psychologist specializing in behavioral disorders in children, is a practical book that has helpful tips for improving various aspects of life for parents of kids with ADHD.

The book has an introduction on how to use the book, followed by a list of tips categorized by the issue at hand.  The introduction is crucial to using the book, otherwise, the book is a reference style manual meant to help parents with specific common problems faced by children with ADHD.  The book avoids being trite and it acknowledges the hard work that sometimes comes with implementing behavioral strategies, so in a sense, while this is a book of tips, it is not a book of hacks.  Some of the suggestions given are easier to implement than others, and some of them will not work for a given child's situation.

The book has many strengths.  It is very practical and is not a long treatise on a certain approach or philosophy.  The main philosophy in this book seems to be, "Do what works."  Many parents with ADHD willl appreciate that fact that this book is reference style, so you don't have to read the whole book to understand or get to the part that you want, which is a fix for your child's problems.   The book offers a wide variety of tips in a wide variety of areas such as medication, behavioral issues, school, diet, and social issues.

There are several downsides to this book.   I was looking for a book about managing behavioral issues specific to older children and teens with ADHD, things like hygiene, organizational skills, and driving.   Those issues are not specifically addressed in this book.   I  would love to see the author write a similar book about teens with ADHD.  Another omission was that the book only talked about children having difficulty in brick and mortar school situations and did not address how to alter home schooling to help a child with ADHD.  It does refer the reader to a website and there are some tips on homework and specific subjects which could be helpful, however. 

Overall, though, the book offers many useful behavioral strategies you can try to help your child with ADHD.  While it is not the only book you will ever need, and not really a "complete reference for parenting a child with ADHD" as it is advertised to be, it certainly is a solid starter book for parents new to dealing with ADHD in a younger child.

Diagnosed with ADHD: Now What?

You or your child have been diagnosed with ADHD.  Now the question is, what next?  Many people are overwhelmed with volumes of information about ADHD, especially when they first start out, so I’m going to try to break this down into only the most essential bits, and you can click on the links to other articles as needed.

Confirm diagnosis.  The diagnosis of ADHD is generally made after observer questionnaires, discussion with the doctor about your symptoms, and maybe a short examination of ears, eyes, and general health, if you haven’t had one recently.  If these raise a question about whether it could be something besides ADHD, there could be other tests.  If you feel comfortable with the diagnosis and seem to fit the profile well, then you don’t need to do anything more.  But if some things just don’t seem to fit, it’s ok to seek a second opinion. 

Learn more about ADHD.  ADHD affects many areas of life besides those listed in the diagnostic questionnaire.  Depending on what stage of life you are in, it will probably help you to understand more about the ways it is affecting your life and those around you.  Some of my favorite basic books on ADHD are:

The ADHD Effect on Marriage

Parenting Children with ADHD:  10 Things Medication Cannot Teach

Learning to Slow Down and Pay Attention (a book for kids with ADHD, and a great way to explain the diagnosis to kids ages 7-12)

Get treatment.

Find a treatment professional.  There are many professionals who treat ADHD, all with different kinds of expertise.  In some cases, the doctor who diagnoses you will do just fine in treating you.  In other cases, you may want to see someone with more or different expertise.  If you want to try medication, you need to see a doctor.  If you need more help with coping mechanisms, like getting more organized, or anger management, you may do better with a coach or counselor.  Read more about treatment professionals in :  Doctor, Psychologist, Psychiatrist:  Who’s Best for ADHD?

Learn about medicines.  Before you talk to a doctor about treatment, it’s important to learn the basics about medication.  Most of the books I listed above have sections about medication, or you can read the following articles from this blog:

Starting a Stimulant for ADHD:  What You Need to Know the First Few Days

Meds vs. No Meds for ADHD:  A Step by Step Guide to Making the Decision

Learn about Self Care.

Kids and Discipline.  ADHD kids require a different kind of discipline than most of us grew up with.  The most common issue I hear about discipline is that “spanking, yelling, and taking things away don’t work”.  And they don’t, so you may as well spend your energy learning something that will.  Start off with the article: 

Top 5 ADHD Discipline Mistakes and What To Do Instead

Sleep.  Lack of sleep makes ADHD symptoms worse, yet many people with ADHD have difficulty getting regular sleep.  Sometimes this is from a sleep disorder, or simply being unable to slow down.  Most typical sleep medicines actually make the problem worse, so it’s better to practice good sleep hygiene.  Relaxation techniques and, if needed, a little melatonin, may also be helpful.

Diet. Most ADHD diets, including the Feingold diet, probably only work for a minority of patients.  However, a healthy diet low in artificial ingredients and saturated fats probably won’t hurt anyone and seems to be better than the average American diet for academic function. 

Consider Accommodations.  Students with ADHD are entitled to reasonable accommodations in public schools in the United States. If your child has ADHD and it affects them at such a school, it is worthwhile to learn about 504 and IEP plans. 

Adults may also be entitled to accommodations under the Americans with Disabilities Act, however, disclosure of your condition can backfire and result in more problems or even termination if you aren’t careful.  Typically adults with ADHD who are struggling in the workplace do better if they try to create their own accommodations (perhaps with the help of a coach)  rather than formally ask their employer, unless something like a different office or permission to tape meetings is required.

Find Support.  It’s natural to want to tell everyone about your ADHD, don’t do it.  Not everyone will be understanding, and some people can be downright mean.  As with any other health condition, you don’t want to share your personal information unless the person really needs to know to help you (or your child).

On the other had, it is often helpful to find a support network.  You can do this by reaching out to families with similar issues (such as at school), by joining CHADD, or by participating in online forums (where you should guard your identity carefully). 

Embrace who you are.  A diagnosis of ADHD can be a relief, or it can be devastating, or it can be anything in between.  If it is your child, it's normal to feel some grief.   But don't stay there.  Choose a positive response.  Be a problem solver when it comes to challenges.  Take advantage of your ability to hyperfocus and to think outside of the box.  The world needs you, so do your best to fulfill your potential! 

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What about “Labeling” and ADHD?

Many people choose to avoid getting a formal diagnosis for their ADHD due to being afraid of  labeling.  Labeling can take various forms, but almost always a diagnosis is better than letting a disability fester un-named.

First of all, a diagnosis is privileged medical information between you and your doctor.  Period.  It is your choice to reveal your diagnosis or not reveal your diagnosis to any other person. 

Self-labeling.  Sometimes people are afraid that having a diagnosis of ADHD will cause a person to feel they are “stupid” or unable to achieve certain goals.  In actuality, many adults with ADHD report that they felt “stupid” until they had an explanation for their difficulties, or until they got treatment. 

Labeling by school peers.  It is true that taking trips to the special education classroom or the nurse’s office for meds daily can make your child a target.  However, most modern medications do not need to be dosed during school hours, and if your child has issues severe enough to warrant a special education pull out, chances are their issues are noticeable anyway.  The label generally won’t be as much of an issue as untreated ADHD will be. 

Labeling by education professionals.  Could your child be labeled a troublemaker in the classroom?  Chances are, if your child has untreated ADHD and no accommodations in place to help the teacher to maximize your child’s educational performance, your child will be more likely to get a “troublemaker” label, than if you explain to the teacher what is going on, and what techniques will work the best for your child.  Of course, as a parent, you should keep your requests reasonable (keep in mind there are other children in the classroom) and do your part to work with the teacher to get him or her the support he or she needs.

Another issue is being labeled as "slow" or being tracked into less demanding academics because of one's special educational designation.  A diagnosis of ADHD does not mean (a) the child's school has to know , (b) that the child qualifies for or needs an IEP (special ed) or that (c) inappropriate tracking will occur.   However, that is not to say it does not occur.  Parents need to be advocates for their children.  If a child is struggling, a label can help them get the help they need to succeed and eventually shed the special ed designation.  But if the school isn't providing appropriate help, then the  designation may be a way for them to avoid doing their job.  However, instead of letting a student suffer and fail in order to avoid a label, its important for parents to compel the school to provide the help the student needs.

Labeling in the workplace.  Getting a diagnosis and treatment shouldn’t be a matter you need to discuss in the workplace unless you need specific accommodations to get your job done.  Even then, most adults usually don’t need to pull the “disabled” card to get the permission to use headphones (brought from home), to use time management techniques,  or work in a cubicle that is less distracting.

In general, getting an official diagnosis of ADHD is beneficial if it leads to treatment of problematic behaviors or other symptoms.  It’s important not to share your diagnosis unless it is necessary to carry out your treatment plan (with a school teacher, for example) as it can lead to negative labeling.  Being respectful and reasonable with requests for accommodations can also be more helpful in avoiding negative labeling than avoiding a diagnosis. 

  

Harmonyx Genetic Test Runs Into Trouble With FDA

The FDA has recently issued a  letter to the makers of Harmonyx, a pharmacogenetic test that can be used to help determine the best medication to use for ADHD.  This letter cites concerns that the test is being marketed without appropriate FDA clearance.

The company has voluntarily pulled the test from the market as it cooperates with the FDA in its' investigation of the matter.  However, the company denies that the test is being marketed directly.to consumers, and states that it believes that it is in compliance with the FDA's regulations.

11/10/2016
Harmonyx issued a letter to consumers stating that they will not be offering testing anymore because of the overwhelming costs associated with pursuing FDA approval for direct to consumer marketing.

If You Have ADHD, Is There Something Wrong With You?

I remember it very clearly.  We were at a small group Bible study and DD had a dose of allergy medication earlier in the day owing to a wheezing episode a few weeks prior.  DD was literally bouncing off the furniture, crawling under the table, and generally running wildly around the room.  One of the other moms turned to me and asked, "What's wrong with her?"

I suspect a lot of people with ADHD get variations of that question often enough.
From themselves:  "I can't seem to do what other people can do.  What's wrong with me?"
From their friends:  "What do you mean, I have ADHD?  Do you think there's something wrong with me?"
From teachers:  "She can't focus in class.  Could there be something wrong with her?"

I also suspect that the underlying thought to that question is either, "If there is something wrong with me, then I'm less than other people."  I'm less capable.  I'm less valuable.  I'm less important.   I'm less worthy of your respect.  Or, "If you can't keep your behavior appropriate, it's because you have made an immoral choice to do so out of poor character--laziness, stupidity, selfishness, etc."

Neither of those conclusions are correct when it comes to ADHD.

Whether a person has less value due to their imperfections or not really has to do with your world view.  If you truly believe a person is less valuable because of their weaknesses, then you will do well to hide your own.  However, most wise people know that all people have weaknesses and imperfections of one kind or another, and that greatness comes not from perfection so much as it does from how we face our weaknesses and how we overcome them.

There are certainly people with ADHD who have poor character.  However, not everyone who makes poor choices does so because they choose to do so with malice aforethought.  In fact, most of the poor choices a child with ADHD makes will probably fall into the category of "I just didn't think that out to it's conclusion."

So, is there something wrong with my daughter?  Yes, but it is not her moral fiber.  It's her brain.  And while it makes some things hard for her, we are choosing to let her live out her life as the human being full of potential that she is.  Yes, she knows she has ADHD, but she also is being equipped with medication and other coping mechanisms so that hopefully, as she grows, she'll fulfill that potential and continue to amaze us by being the human being she was created to be.

Answers to FAQ’s About Diagnosing ADHD in Preschoolers

Children are being diagnosed with ADHD at younger and younger ages, even as young as the preschool years.  This is partly due to the fact that newer research has demonstrated that the diagnosis persists in a large number of children who are diagnosed before the age of 7, which was the age previously used to guide diagnosis.

How early can my child be diagnosed with ADHD?

In fact, the American Academy of Pediatrics’ newest guidelines on the diagnosis and management of ADHD now states that regular pediatricians can diagnose ADHD in children as young as the age of 4, and some children with severe symptoms may get diagnosed even earlier by pediatric psychiatrists.

Why won’t my doctor run any tests?

There aren’t any tests that can accurately rule in or rule out the diagnosis of ADHD.  As long as, after a careful interview and examination, your child doesn’t show any developmental delays or signs of physical illness, most experts recommend that no further testing be done. 

Older children may be asked to do psychometric testing to determine if they really are inattentive or if there is another reason for learning difficulties.  Some patients may undergo a special form of EEG if the diagnosis is in doubt.

The vast majority of children are diagnosed based on behavior checklists after a discussion with the doctor and an examination.  The CDC has a symptom list you can check out for free on their website.

Why is my doctor unwilling to give my 3 year old a diagnosis of ADHD?

It is normal for children ages 2-4 to be hyperactive, impulsive, and inattentive at times.  The issue with children with ADHD is that they are a lot MORE of all of those things than normal children.  However, unless your job is to work with preschoolers (ie. you are a preschool teacher or mother of multiple children) you probably are not experienced enough by yourself to determine that your child is not like other children who will grow up normally.

Also, the DSM-5 criteria for ADHD requires a child to have symptoms that interfere with functioning or development.  What this usually means in preschoolers,  is that a child fails preschool.  This is difficult to do unless your child is getting kicked out of school due to multiple episodes of violence to other children. 

What can I do now for my child if I think (s)he has ADHD but my doctor isn’t ready for a diagnosis?

• Make sure that physical problems are ruled out and/or treated appropriately.    Young children respond to any number of medical and social/emotional problems by acting out behaviorally.  They may not know to complain that their hearing or vision is off, or that they are in pain or anxious, or they may not understand that this is what is causing them to feel wrong.  It’s important to get at least a vision and hearing screening done in all children who have suspected ADHD, and to make sure that they can get a good night’s sleep on a regular basis.

• Get a handle on what is normal behavior in this age group.  Try to observe your child in several settings where there are several children his age.  If your child does not go to preschool, try a playgroup, Sunday School, or other preschool program such as MOPS or MOMS Club.

• Address developmental problems.  Preschoolers with suspected developmental delays, including social and emotional delays, usually qualify for a free evaluation by early intervention.  Also, many medical insurances will pay for therapy even with a looser diagnosis of “disruptive behavior disorder” when a doctor isn’t ready to use “ADHD”.

• Investigate  non-medical therapy.  Preschoolers often respond to behavioral therapy (in the form of special parent classes).  Also, diets free of artificial coloring and/or rich in omega 3 fatty acids have been shown to help some preschoolers. 

Reference:

Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management. "ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents." Pediatrics (2011): n. pag. Pediatrics. American Academy of Pediatrics, 16 Oct. 2011. Web. 25 Nov. 2013. <http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654.full.pdf+html>.

This article is part of a planned series on Preschool ADHD, including: Diagnosis, Treatment Options, and Medication.

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How to Answer Family Objections to Diagnosis and Medication of ADHD

Families often will respond very differently to a diagnosis of ADHD than to a diagnosis of say, diabetes.  While you may be used to discussing all of your health issues with your family, before you discuss your diagnosis of ADHD, you should consider the following:

1)  Most people don't understand ADHD unless they have treated someone with it or lived with it.  There are a lot of myths about ADHD floating around.  People will continue to doubt the existence of ADHD so long as there is no objective diagnostic test for it.  Even in the ADHD community, some people refuse to call it a disorder.  If you are getting diagnosed with ADHD, you know it is real and it interferes with life in a substantial way, but you can't expect others to feel the same, since they do not live in your body.

2)  Family members may feel guilty about ADHD since it does have a genetic component.

3)  Family members may not understand that certain behaviors and difficulties are abnormal, since they may also have ADHD.

4)  People in general often have strong opinions about medication for ADHD.

Should you discuss medication with your family?
Well, probably not.

1)  Think about how difficult making the decision to give medication was for you.  You had to weigh all of the pros and all of the cons, and wade through the information, misinformation, and myths about ADHD medication.  Medication for ADHD has significant risks, as well as benefits.  Family members probably will be scared if they know anything about the medications.  And remember, they probably don't really understand how ADHD affects your family, so how can they understand the benefits?  The only exception is minor children should discuss medication with their parents.

2)  Medication is typically with a stimulant and stimulants can be sold on the street as drugs.  Clonidine also has street value.  Unless you want addicts or dealers breaking into your home, you should not discuss medication in public, and you should only discuss it with people who need to know to do their job (school nurse, teacher, therapist, childcare provider if administering med).  Children also need to be cautioned not to discuss their medication in public as it can make them targets of drug dealers or even of peers looking for drugs.

How to deal with objections
Say you've already spilled the beans.  Or say that your spouse doesn't agree with the diagnosis or the treatment plan.   One thing is certain, arguing will not help.  If the person who objects isn't involved in treating the child (isn't giving medicine, helping with schoolwork, or supervising the child on a frequent basis) then its really none of their business.  If you asked their opinion, you're going to have to deal with it.  Don't argue. Don't expect understanding.  Politely thank them for sharing and change the topic of conversation.

If the person is intimately involved with the treatment plan, do not argue. If the issue is diagnosis, ask what makes them doubt that there is a problem.  Have your own evidence lined up, such as grades, school disciplinary records, and what the child says about him or herself.  If the child is getting diagnosed with ADHD, there must be evidence that the symptoms are negatively affecting their life.

A common objection goes somewhere along the lines of "boys will be boys".  Here you must show that your child's behavior goes beyond that of their peers--their grades are lower, they are in the principal's office more often, they have no friends, etc.   A good way to help a spouse understand that a child's behavior is beyond normal is to bring them to a doctor's appointment where the diagnosis is being discussed.

If your spouse says, "I was the same way as a kid, and I grew up fine."  ask them if they were happy with themselves as a kid or if it was a struggle.  Many adults with ADHD will say they are fine now, but will recall a childhood of being literally beaten into submission.

If the issue is medication, suggest a trial of nonmedical treatment and reevaluation in 6 months, or a trial of medication with a reevaluation in 3 to 6 months.  Be sure to reassure them that the medication can be stopped any time if there are problems they can't live with.

So, in summary, it is probably best to not discuss your child's diagnosis as a matter of family gossip.  If you do, then be prepared for some strong negative opinions.   If your child's other parent has objections, listen carefully, and gather evidence for your case.  Attending a doctor's visit or suggesting a trial of treatment often can help break down barriers.

MTHFR and ADHD: Should You Be Tested?

MTHFR is an enzyme , methylenetetrahydrofolate reductase) which is coded for by a gene of the same name.  It has been associated with a number of conditions in numerous small studies, and widely touted, particularly in the naturopathic community, as an important cause of ADHD and other mental disorders.  Others feel that MTHFR testing is just another scam.

How accurate is testing?  How is an abnormal test defined?

There are many variations of the gene for MTHFR.  The important thing to know is that not all variations cause the MTHFR enzyme to function abnormally. Many are normal variants which do not affect the health of the individual.   When the enzyme functions at less than 20% of normal, an individual becomes severely ill, with high levels of homocysteine in the urine, seizures, developmental delay, and muscular dysfunction, but this is extremely rare, with less than 1% of the world's population affected.

The genetic variant associated with ADHD is the A1298C variant, which doesn't do anything to the ability of MTHFR's ability to process folate, produce methyltetrahydrofolate and or moderate homocysteine levels.  Instead it affects the production of tetrahydrobiopterin, which is needed for production of certain neurotransmitters (dopamine, serotonin, and norepinephrine included), among other things like melatonin.  This variant is not associated with heart disease, recurrent pregnancy loss, Alzheimer's disease, neural tube defects (includes spina bifida) or schizophrenia.

Is there any mutation specific treatment that can help people with MTHFR variants with their ADHD?

The short answer to this is, for most patients, we don't know.  No studies have been done to show whether  supplementing with any kind of vitamin or metabolite of a vitamin helps ADHD symptoms in patients with any MTHFR variant.  While it may seem to be sensible to supplement with methylfolate or BH4, there have been many cases in medicine where the sensible thing ended up to be detrimental when clinical studies were done.

In patients who have phenylketonuria (PKU), an uncommon genetic metabolic disease usually detected on newborn screening, small trials indicate that treatment with BH4 (drug name:  sapropterin) may decrease symptoms of inattentiveness.  However, this could be due to it lowering levels of phenylalanine, which accumulates in people who have PKU, but not in people without PKU.

Could treatment be harmful?

Its hard to believe that increasing one's intake of green, leafy vegetables could be harmful.  If anything, at least it should help digestion.  However, taking megadoses could be another story.

If a patient takes BH4 (sapropterin), there can be serious side effects such as bleeding from the stomach and allergic reactions.  Hyperactivity can also occur.  Headache, runny nose, and diarrhea or vomitting have been observed commonly with significant replacement doses used in treating phenylketonuria, a genetic metabolic disease.  Because of the way it works, sapropterin can cause several important drug interactions.

Methylfolate in larger doses may have some mild side effects as well in some patients, such as agitation, anxiety, irritability, nausea, and headache, although usually it does not.

It would seem unnecessary to treat the MTHFR A1298C variant with methylfolate, however, since this variant does not cause problems with the metabolism of folate.

Is there any harm to genetic testing?

Yes.   While your individual health information is protected, there is always the possibility that it could be hacked, leading to a privacy breech. 

Many of the services offering genetic test interpretation are by doctors who do not ever meet you and therefore cannot do as good a job counseling you as to your test results as a doctor who knows you.  This could lead to you making important medical decisions without the right information.  It is important to note that while some genetic variants have been associated with certain diseases, these are still only associations.  We do not know if these genetic variations cause these problems or if there are other factors involved.

Having genetic information about yourself can lead to unpleasant surprises.  When you get tested for MTHFR variants, you get full genome sequencing, which gives you a lot of other information.  One of the most difficult issues may be finding out things that you don't want to know--like that you are not related to your father, or that you are suceptible to a disease that has no cure.

Finally, having interpreted genetic information could become a problem if it is required to be released to an insurance provider.  While you are protected from certain forms of discrimination by the Genetics Information Nondiscrimination Act (GINA), the GINA does not cover life, long term care, or disability insurance.

Bottom line:

Testing for MTHFR does not help us understand or treat a patient's ADHD at this time because of the lack of proven gene specific treatments, the risk of treatments that "make metabolic sense", and because of the inherent risks of genetic testing itself.

References:

"KUVAN® (sapropterin Dihydrochloride) Tablets for Oral Use and Powder for Oral Solution for PKU." BioMarin : Products : KUVAN®. BioMarin Pharmaceutical, Inc., 2015. Web. 26 Oct. 2015.

"Methylenetetrahydrofolate Reductase." Wikipedia. Wikimedia Foundation, 3 Oct. 2015. Web. 26 Oct. 2015.

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Pharmacogenetic Testing For ADHD: Is Testing Worth It?

A few companies (Harmonyx and GeneSight)  have been marketing genetic tests for ADHD, claiming that they will allow you to predict the medications that will work the best for a given patient.  This sounds great, because normally a patient has to find the best medication for ADHD symptoms through a sometimes lengthy and painful process of trial and error.  But do these genetic tests really work?

Well, they do for certain types of patients, but the information could be unhelpful or misleading for others.

How the tests work

Pharmacogenetic testing is based on the idea that genes regulate how medications are used and metabolized in the body and that different people carry different variations of those genes. 

The tests offered by Harmonyx and GeneSight are actually a bundle of several tests which look for variations in the genes CYP2B6 (Harmonyx only), CYP2D6 (both enzymes in the liver that change the drug you ingest into something else) and ADRA2A and COMT (both related to how stimulants work in the brain).    The company sends you a report of which drugs are green (most likely to be effective), yellow (use with caution) , or red (avoid), and the specifics of your genetic variations.

How effective is testing in predicting which medication will work the best?

The short answer is, generally not very effective, with the exception of atomoxetine (Strattera).  For atomoxetine, studies have shown that people who break down atomoxetine slowly due to a genetic variation in CYP2D6 experience a higher incidence of side effects at lower doses.

The main problem is that for all other drugs besides atomoxetine, there have been either no studies, or conflicting studies of poor quality (unrandomized, open label, small,  etc.)  of whether genetic variants exhibit different responses to medication in ways that are important to patients.  Almost all studies in the pharmacogenetics of ADHD have been done with methylphenidate, which means that testing cannot distinguish between the different stimulants.

For a more technical breakdown of each individual test and references for the above conclusion, please see Pharmacogenetic Testing For ADHD:  Why It is Not Ready for Prime Time

Disadvantages of Testing

Cost

The price tag on the Harmonyx test is relatively low for a battery of 4 laboratory tests.  The company states that it hopes to keep the cost at less than $100. 

The cost of Genesight testing is not disclosed on their website, though there is a patient assistance program available.

Unhelpful test results

The Harmonyx and Genesight tests do not provide enough information to definitely identify which drug will be the most effective.  The genetic testing provided cannot allow a doctor to choose among stimulants or formulations of the same medication(liquid, capsule, extended/immediate/intermediate/combined release), for example.  Unfortunately,  clincial experience has shown that these details can be important in finding a drug and dose that works and does not have intolerable side effects.

Misleading test results

Particularly when it comes to ADRA2a and COMT, it is difficult to know whether genetic status really makes a difference in predicting response to stimulants, guanfacine or clonidine.  If a patient has a genetic profile associated with nonresponse in one study, it does not mean they will not respond, only that their chances are less.

Genetic discrimination

If ADRA2a or COMT are proven to be causes of ADHD or other psychiatric illnesses, insurance companies or employers may be able to use genetic information to discriminate against you if that information is out there.

When testing might be helpful

For most patients, pharmacogenetic testing may be an unnecessary expense and possibly misleading.  However in the following situations, testing could become useful.

When the patient is taking or considering several medications

Several commonly used antidepressants or antipsychotics--medications not necesssarily considered ADHD medications, but often used for symptoms indirectly related to ADHD, such as aggression, anxiety, or depression, are known to be subject to variations in drug metabolism in the liver. 

Patients considering atomoxetine.

Testing can reveal the liver's inability to process atomoxetine normally, allowing a patient to avoid a drug that would either be unlikely to reach therapeutic levels or likely build up to toxic levels.

Bottom line:  Is pharmacogenetic testing worth it?

Because it takes a certain amount of sophisticated medical knowledge to decide if these tests will be useful and to interpret the results, and because this field is rapidly evolving, I don't think it is a great idea for a person to just walk into a pharmacy and order one of these tests for themselves on a whim.  Test results could be disappointing, unnecessarily anxiety provoking, and at worst, misleading or wrong.

However, if you fit one of the above criteria, it may be an excellent idea to discuss testing with your physician (I would recommend a psychiatrist) to help you weigh the pros and cons and get a perspective on the latest research.  The Harmonyx test is particularly inexpensive and it may be hard to find an alternative (there are alternative genetic tests for the same genes available to your physician) that is cheaper. 

References:

"ADHD Medication Testing." Harmonyx. YX Genomics, 2015. Web. 02 Oct. 2015.

"Find the Right Medication for ADHD with GeneSight." Find the Right Medication for ADHD with GeneSight. AssureRxHealth, Inc., 2015. Web. 02 Oct. 2015.

Strattera [package insert]. Lilly USA, LLC., Indianapolis, IN; August 2012. http://pi.lilly.com/us/strattera-pi.pdf.  Accessed April 16, 2013.

Wellbutrin [package insert]. GlaxoSmithKline, Research Triangle Park, NC; March 2013. http://us.gsk.com/products/assets/us_wellbutrin_tablets.pdf.  Accessed September 30, 2015.

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Pharmacogenetic Testing for ADHD: Why It's Not Ready For Prime Time

Pharmacogenetic testing for ADHD is testing a patient who has ADHD for certain variant genes which scientists think may affect their response to  certain medications.  The idea is that patient genetics could guide the selection of medication better than the trial and error approach.

Currently patients can access the following tests on demand at a prescribing pharmacy as part of a battery of tests:  CYPD6, CY2B6, ADRA2A, and COMT.

 

CYP2D6 changes atomoxetine into an inactive state.  People who are fast metabolizers will need more medication for the drug to be effective.  However, having this genetic information does not change the practice of slowly increasing the dose of the medication until it works.  People who are slow metabolizers (about 5% of whites), on the other hand, are more likely to have side effects, and the manufacturer recommends a lower starting dose for these patients.

CYP2B6 is thought to  be responsible for the formation of the most potent active metabolite of bupropion (Wellbutrin).  However, the evidence suggests there probably are more ways that bupropion is metabolized outside of CYP2B6.   No study has directly tested the effect of CYP2B6 variations on the response of ADHD to bupropion, so we don't really know if bupropion would be ineffective, more effective, or have more or fewer side effects based on genetic information alone.

ADRA2A codes for  receptors for several different drugs, especially for guanfacine and clonidine, but also for stimulants like methylphenidate.  Studies conflict as to whether the presence of genetic variations of this gene predict response to methylphenidate  .   Even in the most positive studies, the correlation is not 100%, meaning that the gene might predict no response, but there were still patients who responded to the medication.  No studies have been done to test whether variations in ADRA2A  are associated with response of ADHD to guanfacine or clonidine.

COMT codes for an enzyme that breaks down norepinephrine (a stimulant neurotransmitter) and dopamine (another neurotransmitter with mixed properties).

Studies conflict as to whether genetic status allows us to predict whether a patient will respond to methylphenidate.  No studies have been done on the relation of COMT to response to other ADHD medications.

What is needed is more studies which use outcomes important to patients to link their genetic information with which drug will or will not be successful.  At present, pharmacogenetic testing mostly yields information that isn't specific enough to guide decision making or to change trial and error selection of medication.

References:

"ADHD Medication Testing." Harmonyx. YX Genomics, 2015. Web. 02 Oct. 2015.

DaSilva, T. L. , T. G. Pianca, T. Roman, M. H. Hutz, S. V. Faraone, M. Schmitz, and L. A. Rohde. "Adrenergic α2A Receptor Gene and Response to Methylphenidate in Attention-deficit/hyperactivity Disorder-predominantly Inattentive Type." Journal of Neural Transmission J Neural Transm 115.2 (2008): 341-45. Web.

"Find the Right Medication for ADHD with GeneSight." Find the Right Medication for ADHD with GeneSight. AssureRxHealth, Inc., 2015. Web. 02 Oct. 2015.

Froehlich, Tanya E., Jeffery N. Epstein, Todd G. Nick, Maria S. Melguizo Castro, Mark A. Stein, William B. Brinkman, Amanda J. Graham, Joshua M. Langberg, and Robert S. Kahn. "Pharmacogenetic Predictors of Methylphenidate Dose-Response in Attention-Deficit/Hyperactivity Disorder." Journal of the American Academy of Child & Adolescent Psychiatry 50.11 (2011): n. pag. Web.

Kieling, Christian, Julia P. Genro, Mara H. Hutz, and Luis A. Rhode. "A Current Update on ADHD Pharmacogenomics." Pharmacogenomics 11.3 (2010): 407-19. Medscape Family Medicine. Medscape. Web. 02 Oct. 2015.

Park, S., J.-W. Kim, B.-N. Kim, S.-B. Hong, M.-S. Shin, H.-J. Yoo, and S.-C. Cho. "No Significant Association between the Alpha-2A-Adrenergic Receptor Gene and Treatment Response in Combined or Inattentive Subtypes of Attention-Deficit Hyperactivity Disorder."Pharmacopsychiatry 46.05 (2013): 169-74. Web.

Polanczyk, Guilherme, Cristian Zeni, Julia P. Genro, Ana P. Guimarães, Tatiana Roman, Mara H. Hutz, and Luis A. Rohde. "Association of the Adrenergic α2A Receptor Gene With Methylphenidate Improvement of Inattentive Symptoms in Children and Adolescents With Attention-Deficit/Hyperactivity Disorder." Arch Gen Psychiatry Archives of General Psychiatry 64.2 (2007): 218. Web.

Strattera [package insert]. Lilly USA, LLC., Indianapolis, IN; August 2012. http://pi.lilly.com/us/strattera-pi.pdf.  Accessed April 16, 2013.

Wellbutrin [package insert]. GlaxoSmithKline, Research Triangle Park, NC; March 2013. http://us.gsk.com/products/assets/us_wellbutrin_tablets.pdf.  Accessed September 30, 2015.

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What to Share With Your Child's School About Your Child's ADHD

A common question parents have at the beginning of the school year is:  What should I share with the school/teacher about my child's ADHD?  This may come up as part of discussions you have with the child's teacher, or with their IEP team.   Some questions may be well meaning, but overly intrusive.   Your child's diagnosis and treatment information are privileged medical information.  It is your job as a parent to protect that information.  However, since school is a place where your child spends the majority of his or her waking hours, the school may need certain information to keep your child safe and help with treatment.

Your child's teacher probably should know your child's diagnosis.  A teacher who is aware can be a valuable help in securing and suggesting appropriate accommodations.   Their feedback is vital in making an accurate diagnosis and in adjusting your child's treatment plan.    If you make a change in your child's medication regimen, notify the teacher and ask for their feedback.   If the psychologist or therapist is working on certain areas which impact school, definitely tell the teacher.   Many times behavioral therapies will not work as well if they are not consistently applied at both school and home.

However, do not discuss your child's diagnosis or medical treatment in public areas.  Its best not to mention the name or dose of your child's medicine at all to teaching or administrative staff.   This is important because children with ADHD can be preyed upon by drug seekers and dealers.   No one should know your child has access to a controlled substance but you and those providing medical treatment.  If a teacher asks for this information, politely tell them that for the sake of your child's safety, you cannot release this information.  Medication names and doses are not necessary.   It is inappropriate for teachers to pressure you to treat your child with medication or certain medications as they are not licensed medical professionals.

Sometimes parents wish to reassure school officials that they are doing their part in addressing their child's ADHD.  Sometimes this is necessary if there has been no progress, in order to avert suspicion of medical neglect.   In this case, you may mention that you are bringing the child to the doctor/specialist regularly and that you have tried a certain number of different medications and doses, or different behavioral techniques, without necessarily bringing in unnecessary specifics.  If they press you for more, you may wish to point out that discussing unnecessary details is a hazard to your child's safety.

Busy teachers may wish to discuss matters with you in front of other children or parents. It is important to respect and encourage the teacher's desire to communicate.   In this case, you might want to say something like, "I agree that we really should talk about this, but its important to me to keep my child's medical information private.  Can I set up a conference with you, email you, etc?"   Be aware that a child with ADHD may or may not be a reliable messenger and phone conversations cannot be considered private.

Your school nurse or clinic may need to know all or only some of the details of the treatment plan.  Even if your child is not receiving medication in school if there is an emergency, the medication they are taking may become very important information for the treating doctor.  It is best for the nurse's office to have this information on record should you not be available.  If your child is receiving treatment for ADHD or other behavioral issues through school, then other treatment details may become important and should be released to the persons doing the treatment only.

Most of the time, unnecessarily intrusive questioning from the school is either innocent curiousity or a desire to be helpful, but in an inappropriate way.  Always do your best to keep your teacher and school on your side, but protect what you can of your child's medical information as it is a safety issue.

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NEBA Test for ADHD: Historic but Problematic

On July 15, 2013 the FDA approved the marketing of the first device to be used in the diagnosis of ADHD.   The NEBA (Neuropsychiatric EEG-Based Assessment Aid) system is based on the observation that on average, people with ADHD have different brain waves than people who do not have ADHD.  Approval of the device is potentially  historic on several levels.

Before the approval of NEBA, no objective test has ever been approved for the diagnosis of ADHD.  For generations, ADHD has been diagnosed using a combination of a doctor's evaluation and parent and teacher rating questionnaires.  The accuracy of the diagnosis is highly subjective:   dependent on the evaluating doctor, the parents, and the teachers providing the information.  Traditional diagnosis based only on clinician evaluation and review of parent and teacher questionnaire has been shown to be somewhat unreliable as compared to expert evaluation.  The addition of the NEBA system to the diagnostic procedure may improve accuracy in the diagnosis of ADHD for primary care doctors and other clinicians who are not experts in pediatric ADHD.

If NEBA is really as good as it seems, then a few important consequences could be forseen.

1)  Diagnosis of ADHD will become more objective, legitimizing the diagnosis and freeing it from accusations that it is a behavioral problem only, caused by poor parenting, or by the might of the psychopharmaceutical industry.

2)  People who are looking for prescription medication for ADHD for other reasons, like addiction or drug dealing, will be easier to weed out, hopefully stemming the growing tide of overdoses and prescription drug addiction.

There are several problems, however, with NEBA, that make it less than ideal.

First, the numbers presented in the trial which convinced the FDA to allow the device to be marketed show elevated diagnostic accuracy when compared to other trials using EEG for diagnosis of ADHD in children.   The company making the NEBA system has not had verification of its numbers by researchers who are not also stockholders of their company.

Second, the brain wave changes noted on average in the ADHD population are just averages.  A large proportion of people--16% in one study--with ADHD by current diagnostic criteria do not have the brain wave changes detected by NEBA. A doctor certainly couldn't deny a prescription based on those numbers, but he or she might ask for more evaluation.

Third, while its reassuring that the NEBA provides an objective number, the fact is that it doesn't really add anything to a properly done expert evaluation.  The NEBA can only partially replace an expert evaluation, since in some studies, more than 60% of children presenting with symptoms of ADHD have more than one diagnosis, including autism, anxiety, depression, and oppositional defiant disorder.  NEBA cannot diagnoses any of those.  In the face of ballooning numbers of ADHD diagnoses, the country is in need of more experts, not necessarily more devices.

Reference:

Loo, Sandra K., and Scott Makeig. "Clinical Utility of EEG in Attention-deficit/hyperactivity Disorder: A Research Update." Neurotherapeutics 9.3 (2012): 569-87. Print.

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New Research: Brain scans and ADHD

Newly published research out of the University of Michigan Department of Psychiatry shows that children with ADHD show slower development of brain connectivity than neurotypical children.  The studies were done with functional MRI scans of a pool of 750 people who had allowed their brain scans to be used for general research.

Functional MRI scans of the brain involve two things:

1)  MRI scanning:  The patient goes into a huge magnet and then a pulse of magnetic energy is applied.  Chemical bonds in the body respond differently to the pulse of magnetic energy, releasing a signal that can be measured and plotted on an image of the body.

2)  functional scanning:  This involves a chemical tracer, usually delivered via an injection or IV line.  The chemical tracer usually is used in some kind of metabolic pathway of interest.  For example, 

While some media are touting the research as a possible new way to diagnose ADHD, some caution is necessary.    The research wasn't really designed as a tool to detect ADHD, so we don't know how good such a test would be if it were applied in a sample of the typical people showing up in a primary care doctor's office.  It is too soon to tell if the tools used for this study could be used to improve diagnosis.

However, the results of this research do point the way toward answers to some of our most pressing questions about ADHD, such as:

Why do some people grow out of ADHD and some don't?

Why do people have ADHD?

What brain chemistry can we target to better treat ADHD, and promote better long term outcomes?

The researchers who published this research are currently looking for volunteers for followup studies.  They are looking for people aged 7-adult with and without ADHD.  Since the studies involve MRI  (a huge magnet) volunteers may not have metal implants anywhere in their body.

Please note:  I have no financial connection with this research project and I make no representation as to whether participation in the research studies mentioned above are worth the investment of your time or potential physical risks you may encounter.

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Doctor, psychologist, psychiatrist--who's best for ADHD?

Many types of professionals diagnose and treat ADHD.   Different types of professionals have different types of strengths and biases in their treatment style.  There are also geographical variations among different states and school districts in whom is allowed to make a diagnosis for the purposes of obtaining school accommodations, an important part of treatment.  This is  post is a guide to different types of professionals who may diagnose and treat ADHD.

Pediatrician/family doctor/internist.  Generalist physicians are trained to diagnose and treat a variety of common bodily and mental conditions.   Young children especially should be first seen by their generalist doctor to rule out physical conditions, such as hearing and vision issues, that may be affecting their behavior.  Generalists may refer to a specialist if the doctor or the patient has doubts as to the diagnosis, or if treatment is not going well.  Some generalists will refer all patients with ADHD, but many feel comfortable with the first few medications.   They may not feel comfortable if there are a lot of other mental conditions in addition to ADHD, such as anxiety or autism.  However, they may feel more comfortable than a specialist if there are many other physical conditions in addition to ADHD, such as asthma or sleep apnea.  A generalist is usually easier to get an appointment with than a specialist, which is handy if you have side effects from medications and need to see someone right away.  However, a generalist may not have a long time to spend with you if you have many concerns.  

Psychologist/mental health therapist/social worker/coach.  Generalist mental health professionals are trained to diagnose and treat a variety of mental conditions using counseling or behavioral means.  They are unable to prescribe medication, but they may suggest particular medications as possibilities.  Mental health professionals generally have more time to spend with their patients than medical doctors.  They usually have more to offer in the way of specific strategies that can be used to address specific behavioral or emotional issues.  At times a psychologist may be hired by a school district to suggest specific strategies to be used in the classroom.  ADHD coaches typically work with adults who already carry a diagnosis of ADHD, on specific life issues, such as organization, time management, parenting, or job problems.  You should look for one who has training in counseling or professional certification, as ADHD coaching is a new field with variable regulation.  

Developmental pediatrician.  This medical specialist deals with children who have developmental delays.  Now, most patients with garden variety ADHD would not necessarily be considered developmentally delayed like a child with cerebral palsy is, and yet their performance may not match that of their peers socially and academically.  If your child has other developmental delays, though, this is the best person to sort out what component of the behavioral difficulties you see are due to ADHD and what may be due to autism or other types of delay.

Neurologist.  This medical specialist deals with people with nervous system and brain disorders.  While they do see patients with ADHD only, people with ADHD and other neurological issues such as tics, seizures, or sleep disorders, may benefit most from seeing a neurologist.

Psychiatrist.  This medical specialist deals mostly with mental health related medication.  Gone are the days when psychiatrists would spend hours listening to your problems.  Typical psychiatrist visits are brief medication checkups only--the talk therapy is left to the psychologists.  Still, psychiatrists are experts in dealing with ADHD medication, and if your child has failed several medications or if there is suspicion of other mental disorders, such as bipolar disorder, depression, or anxiety, this may be the person to see.

Neuropsychologist.  This type of specialized psychologist usually only gets involved for diagnosis.  They administer highly specialized testing to understand your brain's specific strengths and weaknesses, and they may suggest specific types of behavioral strategies to address the weaknesses.

Optometrist.  Optometrists typically are not able to diagnose ADHD on their own.  However, some children with ADHD like symptoms have actually have difficulty with visual tracking (that is, following a moving target with their eyes, or moving their eyes along a line to read).   An optometrist may be helpful in diagnosing and treating this condition.  If your child seems to have difficulty with reading, has visual complaints, or seems to have difficulty with tasks requiring visual tracking (such as playing catch), an optometrist may come into play.

Occupational Therapist.  Occupational therapists may be able to give an occupational therapy diagnosis of impaired function due to attention deficits, or sensory processing disorder,  but usually refer to a medical doctor for a diagnosis of ADHD.  Typically, an occupational therapist prescribes devices, exercises,  and strategies to deal with difficulties a person may have functioning in their daily life.  For example, they may prescribe grippers and a writing program for children who have trouble with handwriting.  If you want a weighted vest, typically it is prescribed by an occupational therapist.  Sometimes occupational therapy may be part of a program administered by a school and may be paid for by a school district.  

I may have left some important people out.  This is because many people treat ADHD and the people who do vary somewhat from region to region.   If you can think of any professional you have seen who treats ADHD, whom I have left out, please leave a comment!

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Brain Iron and ADHD

A newly published study in the journal Radiology showed a correlation between brain iron when patients with ADHD were compared to medicated patients with ADHD and when compared to neurotypical ("normal") patients.  Iron deficiency has long been thought a culprit when it comes to ADHD syptoms, but in this study, patients had comparable blood iron levels.  The only difference was in the levels of iron in the brain, as measured by MRI.

While on the surface, you would think that taking more iron should increase the brain iron level.  However, this study actually supports the idea that it doesn't matter how much iron you ingest.  Its the amount that the brain absorbs that is important.  Unfortunately, the only way that they demonstrated normalization of brain iron was stimulant medication.

If the study doesn't suggest a treatment for ADHD, at least it shows promise for a possible way to objectively diagnose ADHD.    The study was small, but if there is enough interest, perhaps a test based on this finding will be developed that will help the problems of over and under diagnosis.

This study is also important because it demostrates that the ADHD brain is different from the neurotypical brain, and that ADHD is not something that can simply be corrected by better parenting/school behavioral management.  This study is one of many brain function studies that demonstrate that these things may be important but are not the root cause of ADHD.

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Testing for ADHD

Many people often wonder why ADHD seems to be diagnosed mostly on the basis of a questionnaire, like the Connors or the Vanderbilt.  There are a lot of reasons, mainly having to do with the inaccuracy of other kinds of testing and the lack of availability of child neurologists, psychiatrists, and psychologists to make the diagnosis in difficult cases.

Most reputable pediatricians and family doctors should also be looking for alternative diagnoses, like sleep disorders, autism, allergies, digestive issues and the like.  But it isn't always easy to make the diagnosis even when you know a child well.   Kids are well known for acting out behaviorally whenever something is bothering them physically or mentally, so a lot of things can look like ADHD even if they are not.  One way to weed out behavioral acting out due to poor parenting or poor teaching, is to compare how a child acts in school versus at home, but when there is disagreement, that's when a lot of people wish there was some kind of objective test.

Unfortunately, there isn't a good objective test for ADHD.  The best test we have is the multidisciplinary assessment, which means that several types of practitioners (like a neurologist, general pediatrician, psychiatrist, and neuropsychologist) interview the parents and child and maybe do neuropsychological testing and/or IQ testing, along with the standard questionnaires.  The newest test we have out there is the NEBA test, which is based on EEG (electrical signals from the brain, measured externally).  This test isn't 100% though, because many people with ADHD may not exhibit the changes that are being looked for.

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Overdiagnosis?

There are a whole host of articles out there about ADHD being overdiagnosed.  A summary of the arguments are that:

• in the past kids who were active had outlets for their energy (PE class, more free time, recess) but now they are required to sit still (for testing, for teachers to meet benchmarks for funding)
• kids who don't behave don't all have ADHD, some have bad parents either incapable, lazy (especially if they are American and not French or Asian) or trying to scam the system to get SSI
• pharmaceutical companies are funding the drive for medicating children instead of letting them have what they need (good parents, an outlet for their energy)
• the economy is so bad that adults find they have to focus more than normal and so they are turning to drugs to help them to pull things together.

I'm a doctor, not a social scientist.  I know what I have seen, and that is that all of the above explanations are partially true and yet none offer a complete explanation for the behaviors of many of the children I have met with symptoms of ADHD.  

I do think, though, that patients need to be aware that there is bias in the medical system.

 The first is in diagnosis.  That is, that many educators (who are not doctors) push for the diagnosis before all of the medical facts are available.    For hints on what makes a proper medical diagnosis, see my article 

Top 10 Things to Do when Your Child Has Been Diagnosed with ADHD

Second, is in medication.  I don't mean to be harsh, but I do think that many children with ADHD could be handled differently by their parents and teachers.  I have made many mistakes myself.  There is definitely a set of children with ADHD who could probably get along with less medication or no medication at all if parents and teachers were trained properly in the special techniques necessary for children with ADHD.  If you start your child (or yourself) on medication, do yourself a favor and see a psychologist or counselor specially trained in ADHD.  Make sure the teacher is on board with what you are doing.  Medication is overrated and doesn't help everything.  You can't expect all your problems to go away just with a medicine.  Any doctor who lets you believe this is mistaken.

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Why Medicate? Reflections on the Vanderbilt Questionnaire

We are in the process of deciding whether DD should get on medication at this time, or wait for a bit longer.

The AAP recommends against treating with medication if the child's ADHD is mild, or if the child is in preschool (unless other methods have failed).

Well, DD's ADHD is probably more than mild, but there aren't any universally recognized criteria for grading severity of ADHD, so the judgment is probably subjective.  I definitely think medication would be worthwhile if she were failing school or having problems making and keeping friends.  That is not the case.  She is very bright.  Once I get her going doing schoolwork, she can usually do it (although I have to hang over her to keep her going).

When I look at the Vanderbilt Questionnaire, the questions seem to target behaviors that we see but are not really the problem.  So why are we considering medication again?  Well, I think more than anything, I am tired of correcting her, tired of nagging her, just plain tired....  But parental tiredness isn't something you treat by medicating a child.  So what do I want?

I want her to be able to start school without several reminders and threats.

I want her to be able to get dressed in the morning without being nagged.

I want her to be able to face math problems and piano practice without becoming a lump of jelly on the floor.

I want her to not impulsively hit or scream at her brother (or anyone else) because she's mad.

I want her to be able to eat her food without getting half of it on the table and the floor.

I want her to be able to sit for an entire meal without getting up to see what is going on elsewhere in the house.

I want her to sit for evening Bible reading.

I want her to be able to bathe herself.  

I want her to be able to put on her pajamas without being threatened or nagged.

Of those things, it is very possible that medication will not treat morning or evening symptoms (stimulants usually wear off after 4-12 hours to enable the patient to sleep and eat).  So then, what I will get is that she'll be a bit better at meals and not be a lump of jelly.   There might be less conflict with her brother.   This would be an improvement, but is it worth the risk of taking meds?  Not so sure.    I think what I need to do is make a list of the problem behaviors and do a little report card to see how frequent they are before we talk with the doctor.

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When Your Kid Won't Listen

DD occasionally goes into these periods where you can't get her attention unless you physically touch her or wave your hand in front of her face.  She is perfectly willing to obey you, if you aren't already losing it by the time you finally get her attention.  What's the problem?

Well, its ear wax, actually.  The symptoms are subtly different from inattentive ADHD because they seem to get worse all of a sudden (when the wax finally plugs the ear canal entirely), and they don't really seem to (pardon the pun) wax and wane like attention usually does with straight ADHD.  The weird thing is, DD, who is 6, doesn't really even seem to notice that her hearing isn't working.  She just tells us how much better she can hear after her canal has been cleaned out.

This is one of the many reasons why you should never base a diagnosis on a checklist alone.   And always make sure you keep up on your regular pediatrician visits (this most recent time, the pediatrician caught the problem at a routine checkup).  And if your child has excessive ear wax, don't accept that the symptoms are due to ADHD until someone has looked in your child's ear!

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