Attention defecit disorder is one of the most common diagnoses in pediatrics. Although many treatments are available, many patients find themselves with less than stellar outcomes. There are two common causes for suboptimal response to treatment. The first is that ADD/ADHD should be a diagnosis of exclusion. This means that you can only make the diagnosis of ADD/ADHD after other conditions and problems have been excluded. Most people have some of the findings of ADD/ADHD so it is easy to diagnose a group of symptoms as ADD, when in fact another explanation is really the cause of that group of symptoms. The second problem is that attention is dependent on a wide range of variables, and unless the other variables are addressed, the medication treatment falls short of both patient and parents expectations.

Diagnosis of Exclusion. There are many approaches to the evaluation of ADD/ADHD. This first recommendation is that a complete history and physical with hearing and vision testing is performed. An anemic child who can not see the board or easily hear the instructions will be easily mistaken for ADD. The second important step is to follow a good discipline plan that is consistently applied by both parents. Let's repeat that. Both parents have to be equally consistent! A child who lacks discipline and fear of consequences is very inattentive, and continuously exploring. This is not the kind of behavour that is easily modified in a classroom full of other children. Perhaps the most important step in the intial evaluation is to address motivation. It has been my experience that a child who has no motivation will not respond to medications. If your child has everything that he/she ever wants, chances are that he/she may be spoiled and lack motivation. Parents who are highly sucessful often came from humble backgrounds, and so had lot's of motivation to work hard for a better life. Even if they create a huge inheritance for their child, chances are the child will not be able to manage the money for long. Think of lottery winners who win 37 million dollars. A year later they are back intheir previous circumstances. It is important to attach positive consequences to good behavior, and not simply grant all requests. A child who learns that good behavior or achievement leads to postive consequences (rewards), soon learns motivation, as well as self confidence. Presents, trips, televsion/Game Boy time may all be earned.

Medical Exclusions. The next step is to make sure that you child has symptoms consistent with the diagnosis of ADD/ADHD. Your pediatrician should be able to address those questions for you. But the school system should also do an independent evaluation to exclude Learning Disabilities, Depresssion, Obessessive Complusive Disorder, and high/low IQ. Some experienced ADD specialists have been mistaken and accidentally misdiagnosed a child with one of the former conditions with ADD. It was only when the medication stopped working that the proper evaluation was pursued to lead and the correct diagnosis.

Inattention: In life many questions have more that one answer. Our experience is that even when the child or adult does have ADD/ADHD, the condition is only part of the solution to the inattentiveness. The first step is to make sure that the child is getting an appropriate amount of sleep. Everyone has trouble being attentive and learning when they are sleepy. Make sure that the diet is not a carbohydrate excessive diet. Sugar highs and sugar lows make it difficult to concentrate. Fruit loops, sandwhiches and cookies are not the same as oatmeals, salads and fruits. Good nutrition with steady sugar release (instead of peaks and valleys) will make your child more attentive. Regular exercise is also key to keeping a young mind fresh and alert.

Treatment: Once a complete evaluation to exclude other problems is completed and your child has had a few visits with your doctor, and you have done your part with discipline, motivation and taken care of alternative causes of inattention outlined above, the last step is medication. Keep in mind a diagnosis of ADD/ADHD does not necessarily mean that your child needs medication. If you have dotted your I's, and crossed your T's as outlined above, sometimes those steps are enough to treat the problem. For those who need medication, Straterra, Adderall, and Concerta are the most commonly prescribed medications. Straterra has the advantage of not being a stimulant medication, but takes a little longer to work. Adderrall and Concerta a stimulants that will help your child focus, however, more frequent visits are required to monitor blood pressure, and weight, and can cause appetite suppression and sleep disturbances. It is important to diagnose and treat any other coexisting problems, i.e. depression, motivation, or a learning disability. When everyone does their part the outcomes are often excellent, but a good evaluation and treatment plan takes months to develop and execute so don't be in a hurry.

Copyright Tareq Abedin, MD 2007