ADHD Spinoff (Page 3)

the original post was:
 
TriRSquared - 2009-05-14 12:22 PM Yeah that's out of line... I would agree with....

"You know what autism ADHD is? I'll tell you what autism ADHD is. In 99 percent of the cases, it's a brat who hasn't been told to cut the act out. That's what autism ADHD is."

....however

This is the attitude that bothers me.  I did not mean to imply the poster attitude was as egregious as that specific teacher's.  I was more explaining why I tend to react poorly to that attitude.  That teacher used my sons ADD to justify her behavior toward him and when I pushed  back she pulled about the dirtiest form of attack you can on a parent.  Imagine what it is like to sit across from the people who can swoop in and take your child from you and defend yourself against patently false accusations.  The stakes of that conversation are hugely high.

There are two general things going on with this.

 1- The biggest issue is with differential diagnosis. For example, studies of brain scans show promise in identifying an ADHD brain from a normal sample. However, if you know something is wrong, but don't know exactly what - we are not yet able to identify the difference between a scan for ADHD and a similar disorder in the prefrontal orbital.  However, this research is ongoing.

2 - It is standard for new assessment instruments to use correlations with established assessments on the same sample to ascertain validity and reliability of the instrument.  However, this is not the problem.  If you go back to Gearboy, Aces, and my posts -- the issue is in ruling out alternative explanations.  It is easy to determine if someone if more hyperactive than same-age peers of same cognitive level to a statistically significant degree. These days, you don't even need to understand a Chi-square, ANOVA, or regression analysis... the computers can do it all for you.

The tough question is: Is the hyperactivity from drugs, stress, anxiety, a medical condition, a manic episode, etc.etc. etc.?

Same thing with inattentiveness: is it ADHD or lowered level of consciousness, petit mal seizure, sleep disorder, psychotic disorder, hearing impairment, central auditory processing disorder, etc?

this is a diagnosis of "exclusion".
Imagine the carnival game where you throw baseballs at the dolls that fall down.
Each doll is an alternative explanation for the presenting symptomology, you can ethically diagnose ADHD when you have knocked all of the reasonable explanations down, and ADHD is the only one standing.

Most of the time, this can be done with a general physical, hearing and vision screening, and a thorough assessment that includes really good history. 



Unfortunately, too many practitioners do not even do this...
For example, my favorite thing to do for screening is to make a timeline with the educational file.
I lay out all of the report cards and annual standardized tests.
I can see longitudinal trends before I even do my first assessment.

Example: I get a referral from parent and teacher for the "Classic inattentive" -supported by current grades, parent, and teacher observations.   Let's look at the cum... Grade K-6, Good grades, positive teachers comments, high-average standardized academic scores.  Grade 7-8 grades drop, teacher comments about peers and socializing in class, standardize test scores flatten (which means 5ile scores drop).

Hmmm what happenned?  Oh look, suspension letters for drugs - starting in 7th grade.

Not only do I not get a lot of requests from practitioners for this longitudinal - and readily available data, I have offered to provide to practitioners with whom I have had a release.  They denied my offer and looked at me like I was crazy for thinking that they would want it.

I have also had parents rescind HIPAA when they realized that this data would contradict their desired outcome.



Ok, time for me to realize someone did the same post in a far more concise/powerful manner.

When I used to consult in a drug and alcohol rehab, I saw a lot of people who had been diagnosed at one point with ADHD.  If the diagnosis had been made in early childhood, I would usually let the diagnosis stand, and try to find a non-abusable treatment.  If it was made in adolescence or later, I would usually tell them that I could not say for sure whether or not they really did nave ADHD, and until they had 6-12 months of sobriety behind them, I would not be able to gauge whatever symptoms they might "really" have (the quotes because they might indeed have symptoms of SOMETHING, but I souldn't be able to say WHAT when they were still in early phases of recovery).  And in any case, they would not get stimulants from me.

But the whole addiction issue is another story altogether.

I;m not sure that will fly.  I remember when I was in training all the hype about how the epidemic of "crack babies" was going to result in an epidemic of severely behaviorally disturbed kids.  Recently I saw an article that said that really hasn't panned out, or at least not from the biology.  Growing up with an addicted parent does tend to have an impact, though.

I figured this is what you meant by "out of whack".  But I also get concerned when people think that a diagnosis is somehow an excuse for behaviors that are within the norms.  And having conduct disorder is not a legitimate excuse for criminal behavior.  Pretty much everyone in jail has it.  But the people who like to study it are interested in understanding how things get derailed so badly for someone, and the way to do that is to categorize things for study.  If we understand what makes people become antisocial, perhaps we can stop the process before it is too late.

We are seeing radically different treatment regiments out here.

A lot of our ADHD/pre-natally exposed kids are being treated with a lot of anti-psychotics or high blood pressure meds to take the edge off of their hyperactivity/violent tendancies. With them the CNS stimulants make them worse.

This is an anecdotal observation, as I have not read up on my lit.

I am actually teaching an undergrad Bio-psychology course this summer, so I am going to use it as an excuse to read up.

Edited by eabeam 2009-05-15 6:46 PM

This was just one sample, I still have kids with good test grades and scores, but parent teacher conference notes...

"Eric is a smart kid, so his grades aren't the ones that suffer when I need to stop teaching to re-direct him 30 times a day."


I just don't think a lot of non-school people know what type of good data we have readily available.

In CA, normed standardized tests occur every year, and many districts can whip up a report on a computer in seconds.

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Steve

Off the cuff impression, those kids are probably getting diagnosed as bipolar if they are being given anti-psychotics and/or get worse with stimulants.  THAT would be a whole new controversial area to delve into. But they are useful at low doses for aggression (wihtout getting into the issues of metabolic syndrome). The anti-hypertensives have been used for hyperactivity for years, but in my own opinion they are really only useful for sleep at nightime (at least that's the case for clonidine).  Guanfacine/Tenex is popular with some docs, but I haven't found a niche for it in my own practice. Not calling it good or bad medicine, I just haven't found I needed to prescribe it as much. We used to use them a lot more in my residency for aggression, but I think the antipsychotics (which were not available at that time) work more effectively with fewer doses and generally less sedation.

This user's post has been ignored.

I spent 2 hours today with my son's principal, school nurse, guidance counselor, my advocate and the district rep for student services. My son gets good grades (A's & B's) but he has some issues with staying on task, and more importantly anxiety (he has had multiple panic attacks and until you witness one you have NO idea what they are actually like). For YEARS his elementary school(s) encouraged us to get him tested (we resisted, didn't want him medicated, he is very smart, etc), when we finally did get him tested for no other reason than to get the school to back off we were surprised by his Asperger's diagnosis with ADD tendancies. Now we have the diagnosis but the school won't give him ANY accomodations because he "doesn't suffer academically". I could frankly care less about his grades then his mental health.

Yesterday his math teacher questioned him IN FRONT OF THE ENTIRE CLASS as to why he was running for class treasurer as he "is distracted often and not very organized". He kept it together in school but spent over an hour crying last night as "my behavior made my teacher say that" and thinking that "he got the teacher in trouble". The teacher is 100% correct in his observation but they should have NEVER been made in front of the entire class. Did the school do anything? No, (the teacher did subsequently apologize following an email from my husband), why didn't the school act? It didn't impact his grade.

Standardized tests 2 weeks ago. Felt so stressed that after writing 2 short sentenances for the writing prompt he closed the book and just stopped. Had he been given the extra time we requested so he didn't feel pressured by the time deadline he MIGHT have done better. I won't know. Why I do know is getting my son on some meds for his anxiety has turned my son from someone who worried about everything, went nowhere and had no friends into someone who smiles, enjoys life and I don't spend my whole day worrying that the school will call with another meltdown.

Is ADD overdiagnosed, YES! Do parents AND schools use it as a cope out YES. Are there plenty of kids not diagnosed YES but I see both sides of the arguement. Schools need to use their resources wisely and not grant every request that is made parents need to stop expecting the schools to raise their children but until we start taking responsibility for our actions and thinking we are "entitled" to more than we are things will not change.

I'll be happy when parents - often not only with doc's okay but their encouragement - stop taking their kids off meds for the summer. In what other condition in any part of the population do we decide to "give [someone] a break" from their meds??? (obviously I'm not talking about prn meds) Especially when they rip their meds out of their system and then send them to a place that is highly organized with a LOT of tasks and learning for not just the six hours of school but the 12+ hours of summer camp!

If they have a disorder, then they need meds all the time. If they can successfully go without meds for three months, then they likely don't need them the rest of the year. Maybe they need other coping mechanisms, but I have yet to see a kid off their meds who wasn't either just fine or absolutely out of control.

Last year was our sons first year on meds. Dr. suggested taking him off for the summer so we could assess how he was doing. Seemed like a good idea. Was a VERY BAD ONE. Especially when instead of putting him back on same meds suggested we try something different to see if there was more improvement. It backfired. We were at back before where we started. Lost all the ground we had made. Talked to doc this year (now that he is back on original meds and doing well), he WILL be staying on them for the summer. Thankfully she agreedd.

I hope that when you capped "WILL" you meant that there was zero debate and you told the doctor how it was going to be

I absolutely need to take time off meds.
Granted I was prescribed at at the age of 19.
When I started, I only needed 10 mg of Ritalin to get a benefit.

That made the difference between barely scraping by with a 2.7 (and there were some serious blow-off electives) to a 3.7.

The problem is, by the end of the semester, I am so habituated to the meds, that I need almost twice as much to get a therapeutic benefit. If I have to double the dose, you better believe that I have side effects.

Same thing this year.
I am on 36mg of Concerta (same medication as Ritalin, better time release) morning and lunch (+ dinner when I was working on my dissertation).

If I did not take time off, doubling this dose to get the same benefit would be medically dangerous for me.