Behavior, Parenting and Discipline
> Information on ADHD and other learning and behavioral issues - START HERE!
ADHD and other learning and behavioral issues - START HERE!
Teachers and parents often are concerned about disruptive and hyperactive behavior. About 10% of people have ADHD. Many of the symptoms can be found in any child at any given time, but in children with the disorder it can cause problems at home, at school and socially.
Symptoms can include difficulty following instructions, problems with organization and losing things such as toys or homework, inattention to details or a tendency to make careless errors in schoolwork or other activities, fidgeting, excessive movements or talking, difficulty waiting in line, problems interrupting, or difficulty remaining seated.
It is important to note that often there is more than one thing contributing to behavior issues and school problems. These may mimic ADHD or co-exist with ADHD. They can make diagnosis more difficult. The most common include:
Oppositional Defiant Behavior
This involves stubbornness, temper and rule breaking.
Anxiety or depression can occur with ADHD or have symptoms such as inattention and forgetfulness that may mimic ADHD. Anxiety co-exists with ADHD at times, with worry, fear and sometimes physical symptoms, such as headache or tummy ache. Sometimes treating the ADHD helps the anxiety because kids feel more confident when they can focus on tasks, complete assignments, and not get in trouble as much. Sometimes treating the ADHD worsens anxiety because kids focus on their worry thoughts more with a medicine for focus. It is really important to investigate anxiety along with other issues that can mimic ADHD.
For more on ADHD, anxiety and depression, use these resources:
Learning disabilities can be exacerbated if there is also an attention problem.
Hearing and Vision or Other Neurological Conditions
Hearing and vision problems or absence (petit mal) seizures can appear to be attention problems.
Anemia or Iron Deficiency
Anemia or iron deficiency can cause tiredness, which can manifest in kids as hyperactivity or poor concentration.
Sleep problems can cause chronic tiredness, which can lead to hyperactivity and concentration problems. These problems might simply be not getting enough sleep, and an earlier bedtime might help. Other children have sleep apnea, shown by grinding the teeth or snoring with pauses in breathing noted throughout the night. For more information on sleep disorders, click here.
Sensory processing disorders and pervasive developmental disorders (Autism Spectrum) can co-exist with ADHD or mimic ADHD symptoms. Chronic diseases or malnutrition leading to pain or hunger can affect focus and behavior. Post-traumatic stress disorder can affect focus and behavior.
After a concussion kids can temporarily have concentration problems (but this can last several months). Medications we used to manage ADHD after diagnosis if desired One treatment used for ADHD is medication, though not all children require medicine. That will be determined by the family and the physician. However it is good that all parents learn about medicines used to decrease the anxiety associated with starting a child on a chronic medication.
Medication Treatment Options
For a list of medications commonly used to treat ADHD, please see the ADHD Medication Guide
and click that you agree to the end user agreement. (It's free and easy to access, but they are trying to limit plagarism.) The guide separates medicines by type, notes if it is able to be chewed or sprinkled, if it is available as a generic, and more. You can compare the names of the medicines to the formulary your insurance provides to find one that is appropriate for your child and hopefully covered by insurance.
For a review of the medicines, please visit Dr Stuppy's blog on Medications
. It reviews the types of medications (including their side effects), how to pick one, and how to titrate the dose.
How is ADHD Diagnosed?
There is no one test to diagnose ADHD, but we use a Vanderbilt score to help us determine if ADHD might be a cause of problems. Symptoms must be present before age 12 years, last longer than 6 months, be more severe than most children of the same age, and must occur in two settings (such as home and school).
The Vanderbilt offers several tests:
For evaluation of possible ADHD
For follow up of a child on medication for ADHD
Where do we start?
Talking with your child's doctor about behavior is an important first step to a proper diagnosis. (At this time none of our nurse practitioners treat ADHD.) This is a long process, but remember this is not a problem that developed overnight. We cannot fix the problem in one visit. It cannot be fully addressed at any visit made for any reason other than which it was scheduled so that we can have adequate time to address the issues. We recommend the following multi-step process for accurate diagnosis and management:
First we need to determine if there are any other diagnoses that should be ruled out that could mimic ADHD. At this visit we will take a history and do a physical exam. We might decide to order laboratory or radiology tests that help with diagnosis if the history or exam point to another source that can mimic ADHD. We might decide that the situation is complex and recommend an official psychologist evaluation. Having the Vanderbilt Assessment forms from at least one teacher and one parent completed before this visit can be very helpful.
Some parents want time alone with the doctor, but this can be a bit complicated. Please see Private Discussions with the Pediatrician
At this visit we score and review parent and teacher assessment tools if they are available. We can send Vanderbilts to the parents through the portal prior to the visit if you request. We can also send teachers a link to the Vanderbilt for teachers if you provide the teacher's email and let them know to expect it. Alternately, you can print the Vanderbilt tests and bring copies from each parent and teacher (or daycare provider) to your visit. Some schools have already done testing and you can bring those results as well.
If your child has been diagnosed at another office or has been seeing a psychologist or other therapist, please request that their records are sent to our office before this visit.
Please contact your insurance provider for a list of medications preferred in ADHD management if you agree that medications are an option for your child. Learn more about insurance formularies on Know Your Insurance Formulary
. We encourage investigating cost prior to initiation of a long term medication, as many medications may work well for your child, but the difference in cost can be impressive. Each insurance plan is different, so please check with your insurance prior to beginning treatment. If you need help affording medications, check out these resources
Initial Follow Up Visits
After initiating treatment with prescription medications we see your child frequently to adjust medication dosage and monitor for side effects. Having Follow Up Teacher and Follow Up Parent Vanderbilt assessment tools at these visits helps to accurately assess both home and school behaviors. These may be ordered in your portal prior to the visit. You will get a message with a task prior to the visit if this is the case!
The standard recommendation is to follow up within 30 days of starting a new stimulant medicine. We might suggesting following up anytime in the 2 - 4 week period, depending on specific issues with your child, and phone call or portal message follow ups in between as we titrate medicine doses.
Routine Follow Up Visits
To help with scheduling an appropriate amount of time for your child please let the scheduler know what type of visit you need. All of our behavioral visits are scheduled for more time than a standard "sick" visit.
We will schedule two children in the same family at back to back appointments if they are both overall well controlled this is okay with the physician. If there are problems, each child needs to be seen individually. This is to allow the proper amount of time to be dedicated to the problems at hand.
We will allow one ADHD visit a year to be a combination visit with the yearly well visit, or physical. This can be a sports physical if that is needed. This must be scheduled as a "double" visit to allow for extra time discussing medication needs. It will likely require a co pay due to the ADHD component of the visit, even though well visits are currently free without co pays. This is due to insurance regulations, not our office policy. It is generally done in the summer months, both for state sport physical requirements (even in younger kids so they are on track as they get older), and because changes are infrequently needed for ADHD medicines during the summer, making that component of the visit shorter. It is simply too much to expect a child who is struggling with ADHD symptoms to do a full well visit and a long discussion of all the troublesome symptoms followed by treatment options for ADHD. We recommend scheduling a separate visit to devote more time to ADHD if there are concerns and it is not a routine recheck for refills.
What can I expect for routine care?
In addition to working with teachers for school behaviors, we will see children and teens routinely for ADHD follow up at least every 3 months if they are on stimulant medicines and every 3-6 months if they are on non-stimulants. At times it will be appropriate for phone call or messaging follow up. Stimulant medications for ADHD are controlled substances, and the prescriptions are regulated more strictly than most prescription medications, so we usually see kids every 3 months, regardless if they are out of medicines or not. (Some kids do not take medicine on weekends, so each 30 day prescription lasts longer and they won't need a refill yet at exactly 3 months, but they should still be seen based on standard follow up recommendations to follow growth, side effects, and more.)
If you miss appointments, it may be impossible for your physician to send in a prescription for a stimulant. By law we must have seen a child for ADHD within the past 6 months to prescribe a stimulant. The pharmacist also cannot fill a prescription for a stimulant that is over 6 months old.
Even the non-controlled substances require close follow up for side effects. Once a type and strength of medication is found to be working well for a child/teen, we will see them in the office every 3-6 months for a height and weight and blood pressure check in addition to discussing how the medication is working and any side effects.
It is helpful to have parents and teachers fill in another Vanderbilt follow for each follow up, or at least have teachers write in his/her own words about behaviors in the classroom. The parent Vanderbilt can be done through the parent portal.
We can write a prescription for a 3 month mail order if you have at least 2 weeks of medication available at home and your insurance participates in this program. If you do not want a 3 month prescription, we can e-prescribe three separate prescriptions for 30 days each.
When you call the pharmacy to request the next refill, do NOT ask for a refill. There are no refills allowed on controlled substances and pharmacists tend to just say there are no refills. Ask to fill the next prescription. That works! If your child needs a dose adjustment before your medication is gone, we will need to cancel the unfilled prescriptions at the pharmacy before sending in a new prescription.
Remember to schedule your next visit at least 4 weeks in advance for improved scheduling opportunities. Most parents schedule as they leave, so if you wait much beyond that 3 month mark it becomes more difficult.
During the summer months our schedules fill up faster because of the Kansas requirement to do sports physicals after May 1st, so it is always best to schedule the next visit as you leave your current appointment. Also, plan on scheduling the appointment about 2 weeks before the medication runs out so there is time to make changes if needed.
What if we don't want to use medications?
It is certainly a big decision to start a long term medication for many parents, especially since there is not a definitive diagnosis or a test that "proves" it is the correct diagnosis. Many families hope that with behavior modifications, diet changes, or supplements they can alter behaviors.
Get schools involved:
Work with your child's school to see what they can offer. Seating changes, fidget items, weighted blankets, and more are sometimes found to be of benefit. Talk to your child's teacher if one of the consequences for not finishing work includes staying in from recess. This is very contrary to what your child probably needs to focus and finish later work! Schools will help with evaluations and behavioral management. You must ask in writing specifically for your request and they will evaluate to see what assessments must be done and what accommodations can be made. Check out Understood.org for information on federally mandated accommodations.
Work with a behavioral therapist:
If you are in need of a therapist to help with behavioral modification, start with your insurance company. Mental health professionals typically do not need referrals. Find out if the psychologist or clinical social worker sees children your child's age for the concerns you have. If they have a different area of expertise or work with a different age group, they will not likely be the best help. We do have a list of providers that you can reference on our Finding More Help page
. The Psychology Today
resource is fantastic. You start with your zip code, then use modifiers along the left side of the page to limit to certain features, including insurance, male vs female, concerns to address, and more.
Natural and alternative treatments
: A comprehensive review of "natural" treatments is found at Natural Medicines in the Clinical Management of Attention-Deficit/Hyperactivity Disorder
. They have a helpful review of fish oil, evening primrose oil, vitamins, sugar, and more. Dr. Stuppy has also covered alternative treatments in several blogs (see the list below).
Fish oil has been shown to be as beneficial as Ritalin in some older studies, but further studies have not been as encouraging. Click here
for more information on fish oil. It is certainly reasonable to try behavioral modifications and dietary changes/nutritional supplements first unless there is a crisis situation.
When your treatment's aren't working:
If those interventions fail, medication is the treatment that has been proven to be most effective. If this was a medical condition, most parents would not hesitate to start a medicine, since they can see the benefit more clearly.
For instance, no parent with hypertension would try to just think about lowering the critically high blood pressure. Being a "brain" disorder, parents often mistakenly think that the child can learn to control it. Unfortunately, even many adults are finding that they need to take medication to help their concentration, since they have trouble sustaining relationships, making deadlines at work, and suffer from depression from recurrent failures.
Are there risks to delaying or not treating ADHD?
Untreated ADHD can lead to poor self-esteem, depression, drug and alcohol abuse, and early sexual intercourse. Of course, this does not happen with all kids who are not treated, but you can easily see how recurrently failing with school work, being reminded constantly to stay on task (seen as nagging by the child), and having immature behavior with peers (fidgeting, touching, talking out of turn, easy to lose control of emotions) can lead to poor self-esteem. Early on this can lead to the "class clown" personality. A child might think that if people are going to laugh at me, it should be on my own terms. Then the child gets labeled as a behavior problem at school, so there are consequences, which leads to lower self-esteem. This low self-esteem can make a child truly depressed, or at least make poor choices in dangerous relationships (only he understands me, even if he hits me), early sexual experiences (I want someone to care for me, I'm not good enough, but he'll like me if...), and drugs and alcohol to make them feel better about themselves.
Dr. Russell Barkley is a psychologist who has studied ADHD for over 40 years. He has compelling data about the risks of not treating ADHD. It is correlated with a shortened life span of 9 years. Learn why in What if we don't treat ADHD
If you are worried about the association of ADHD and drug or alcohol abuse, read this helpful article from ImpactADHD. The same author has a follow up article
ADHD & Addiction Part 2: ADHD Treatment in Recovery that you might find helpful as well.
Note: the author happens to be the founder of our local ADHDKC.org support groups (both for parents of kids with ADHD and a separate one for adults with ADHD). I highly suggest subscribing to their newsletter and going to their meetings. See ADHDKC.org for details.
Obviously not all people with ADHD end up with these extremes, but we can prevent much of this if we manage the impulse control and concentration with the right medication. Many kids feel so much better about themselves on medications because they finally get good grades without being hounded to get the work done and turned in. They make better friendships because they can listen and not bother other people. They feel like they can succeed instead of fail.
Where can I get more information?
(Note: we cannot be responsible for information found on other sites, but offer these suggestions as reliable.)
Local Support Groups
- ADHDKC.org: A local parent support group that is an affiliate of CHADD. They offer a number of resources, including a website, Facebook page, and local meetings.
- ADHDKCTeen: A local support group for middle and high school students with ADHD (even those who aren't diagnosed but struggle with executive functioning, impulsivity, organization, and more). Follow them on Facebook, Instagram, and Snapchat!
Book Suggestions ADHD: