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ADD / ADHD Board Index
Board Index > ADD / ADHD | 0-9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z


Re: A.d.h.d
Dec 21, 2001
Your daughter is very young for this type of diagnosis. Don't put her on stimulant medication until you get the whole picture. I'm a special education and mental health advocate, and I'd like to offer you some suggestions to help your daughter.

There's a significant problem with innacurate ADHD diagnosis and inappropriate prescription treatment in this country for ADHD. But parents wanting to have their children diagnosed properly for this disorder rarely know what to consider in such a diagnostic evaluation.

I've long maintained that diagnosis of this disorder is not the job of the general or family practitioner, and that a team of specialists must be involved to obtain a true diagnosis. Far too many GP's and FP's are willing to diagnose a child with ADHD after a ten minute appointment and write out a prescription.

In older children, school teachers and administrators often contribute to this problem. Parents are made to feel very guilty and pressured if their child does not meet the behavior norm by teachers and admins who want a problem fixed NOW...and parents panic and go for the quick fix to please everyone around them and keep their children in school. If more parents in this country who suspect that their children have attentional problems would stand up to school personnel and insist on more thorough testing for their children.... and demand the time and patience from school districts needed to get this done.... we would not be seeing the overprescription of stimulant medications that we are currently seeing.

Having a child properly evaluated for this condition is a lengthy process that should involve a team of specialists...a neurologist, a psychiatrist, a nutritionist, an allergist. I've tried to explain the thorough diagnostic process below, explaining all of the components involved. I would urge you to have as many of these services involved as possible in obtaining a diagnosis for your daughter.

If you are having a child professionally diagnosed for this disorder, this is what you can expect from start to finish. I've been through this process for my child, who was originally diagnosed ADHD but who we now know has tourette syndrome, from A to Z. The entire workup for him took about three months..


THE PSYCHIATRIC AND NEUROLOGICAL ASSESSMENTS

The psychiatric and neurological specialists usually work as a team in this phase of the diagnostic work (one will refer to the other as part of the process and the results will be combined on the final report).

These are the practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder.

MAJOR RECOMMENDATIONS:
Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with ADHD

CHILDREN AGED 6 TO 12 YEARS

Initial evaluation (a complete psychiatric assessment is indicated; see Practice Parameters for the Psychiatric Assessment of Children and Adolescents [American Academy of Child and Adolescent Psychiatry, 1995]).

Interview with parents.
Child's history.
Developmental history.
DSM-IV symptoms of ADHD.
Presence or absence (may use symptom or criterion checklist).
Development and context of symptoms and resulting impairment, including school (learning, academic productivity, and behavior), family, and peers.
DSM-IV symptoms of possible alternate or comorbid psychiatric diagnoses.
History of psychiatric, psychological, pediatric, or neurological treatment for ADHD; details of medication trials.
Areas of relative strength (e.g., talents and abilities).
Medical history.
Medical or neurological primary diagnosis (e.g., fetal alcohol syndrome, lead intoxication, thyroid disease, seizure disorder, migraine, head trauma, genetic or metabolic disorder, primary sleep disorder).
Medications that could cause symptoms (e.g., phenobarbital, antihistamines, theophylline, sympathomimetics, steroids).
Family history.
ADHD, tic disorders, substance-use disorders, CD, personality disorders, mood disorders, obsessive-compulsive disorder and other anxiety disorders, schizophrenia.
Developmental and learning disorders.
Family coping style, level of organization, and resources.
Past and present family stressors, crises, changes in family constellation.
Abuse or neglect.
Standardized rating scales completed by parents.
School information from as many current and past teachers as possible.
Standardized rating scales.
Verbal reports of learning, academic productivity, and behavior.
Testing reports (e.g., standardized group achievement tests, individual evaluations).
Grade and attendance records.
Individual Educational Plan (IEP), if applicable.
Observations at school if feasible and if case is complex.
Child diagnostic interview: history and mental status examination.
Symptoms of ADHD (note: may not be observable during interview and may be denied by child).
Oppositional behavior.
Aggressive behavior.
Mood and affect.
Anxiety.
Obsessions or compulsions.
Form, content, and logic of thinking and perception.
Fine and gross motor coordination.
Tics, stereotypies, or mannerisms.
Speech and language abilities.
Clinical estimate of intelligence.
Family diagnostic interview.
Patient's behavior with parents and siblings.
Parental interventions and results.
Physical evaluation.
Medical history and examination within past 12 months or more recently if the clinical condition has changed.
Documentation of health history, immunizations, screening for lead level, etc.
Measurement of lead level (if not already done) only if history suggests pica or environmental exposure.
Documentation or evaluation of visual acuity.
Documentation or evaluation of hearing acuity.
Further medical or neurological evaluation as indicated.
In preparation for pharmacotherapy.
Baseline documentation of height, weight, vital signs, and abnormal movements.
ECG before TCA or clonidine.
Consider EEG before TCA or bupropion, if indicated.
Liver function studies before pemoline.
Referral for additional evaluations if indicated.
Psychoeducational evaluation (administered individually).
IQ.
Academic achievement.
Learning disorders.
Neuropsychological testing.
Speech and language evaluation.
Occupational therapy evaluation.
Recreational therapy evaluation.
Psychiatric differential diagnosis.
ODD.
CD.
Mood disorders - depression or mania.
Anxiety disorders.
Tic disorder (including Tourette's disorder).
Pica.
Substance use disorder.
Learning disorder.
Pervasive developmental disorder.
Mental retardation or borderline intellectual functioning.
Treatment planning.
Establish target symptoms and baseline impairment (rating scales may be useful).
Consider treatment for comorbid conditions.
Prioritize modalities to fit target symptoms and available resources.
Education about ADHD.
Classroom placement and resources.
Medication.
Other modalities may assist with remaining target symptoms.
Monitor multiple domains of functioning.
Learning in key subjects (achievement tests, classroom tests, homework, classwork).
Academic productivity (homework, classwork).
Emotional functioning.
Family interactions.
Peer relationships.
If on medication, appropriate monitoring of height, weight, vital signs, and relevant laboratory parameters.
Reevaluate efficacy and need for additional interventions.
Maintain long-term supportive contact with patient, family, and school.
Ensure compliance with treatment.
Address problems at new developmental stages or in response to family or environmental changes.
Treatment.
Education of parents, child, and significant adults.
School interventions.
Ensure appropriate class placement and availability of needed resources (e.g., tutoring).
Consult or collaborate with teachers and other school personnel.
Information about ADHD.
Educational techniques.
Behavior management.
Direct behavior modification program when possible and if problems are severe in school setting.
Medication.
Stimulants.
Bupropion.
TCAs.
Other antidepressants.
Clonidine or guanfacine (primarily as an adjunct to a stimulant).
Neuroleptics—risks usually exceed benefits in treatment of ADHD; consider carefully before use.
Anticonvulsants-few data support use in the absence of seizure disorder or brain damage.
Psychosocial interventions.
Parent behavior modification training.
Referral to parent support group, such as CHADD.
Family psychotherapy if family dysfunction is present.
Social skills group therapy for peer problems.
Individual therapy for comorbid problems, not core ADHD.
Summer day treatment.
Ancillary treatments.
Speech and language therapy.
Occupational therapy.
Recreational therapy.
Dietary treatment rarely useful.
Other treatments are outside the realm of the usual practice of child and adolescent psychiatry and are not recommended.
CHILDREN AGED 3 TO 5 YEARS

Same protocol as above, except for the following:

Evaluation.
Higher index of suspicion for neglect, abuse, or other environmental factors.
More likely to require evaluation of lead level.
More likely to require evaluation of:
Speech and language disorders.
Cognitive development.
Treatment.
Increased emphasis on parent training.
Highly structured preschool.
Additive-free diet occasionally may be useful.
If medications are used, exercise more caution, use lower doses, and monitor more frequently.
ADOLESCENTS

Same protocol as for children aged 6 to 12 years, except for the following:

Higher index of suspicion for comorbidity with:
CD.
Substance-use disorder.
Suicidality.
Teacher reports less useful in middle and high school than in grammar school.
Patient must participate actively in treatment.
Increased risk of medication abuse by patient or peers.
Greater need for vocational evaluation, counseling, or training.
Evaluate patient's safe driving practices.
ADULTS

Initial evaluation (a complete psychiatric assessment is indicated; see American Psychiatric Association Work Group on Psychiatric Evaluation of Adults [1995]).
Interview with patient.
Developmental history.
Present and past DSM-IV symptoms of ADHD (may use symptom or criterion checklist or self-report form).
History of development and context of symptoms and resulting past and present impairment.
School (learning, academic productivity, and behavior).
Work.
Family.
Peers.
History of other psychiatric disorders.
History of psychiatric treatment.
DSM-IV symptoms of possible alternate or comorbid psychiatric diagnoses, especially:
Personality disorder.
Mood disorders—depression or mania.
Anxiety disorders.
Dissociative disorder.
Tic disorder (including Tourette's disorder).
Substance use disorder.
Learning disorders.
Strengths (e.g., talents and abilities).
Mental status examination.
Standardized rating scales completed by the patient's parent.
Medical history.
Medical or neurological primary diagnosis (e.g., thyroid disease, seizure disorder, migraine, head trauma).
Medications that could be causing symptoms (e.g., phenobarbital, antihistamines, theophylline, sympathomimetics, steroids).
Family history.
ADHD, tic disorders, substance use disorders, CD, personality disorders, mood disorders, anxiety disorders.
Developmental and learning disorders.
Family coping style, level of organization, and resources.
Family stressors.
Abuse or neglect (as victim or perpetrator).
Interview with significant other or parent, if available.
Physical evaluation.
Examination within 12 months or more recently if clinical condition has changed.
Further medical or neurological evaluation as indicated.
School information.
Standardized rating scales if completed during childhood.
Narrative childhood reports regarding learning, academic productivity, and behavior.
Reports of testing (e.g., standardized group achievement tests and individual evaluations).
Grades and attendance records.
Referral for additional evaluations if indicated.
Psychoeducational evaluation.
IQ.
Academic achievement.
Learning disorders evaluation.
Neuropsychological testing.
Vocational evaluation.
Treatment planning.
Establish target symptoms of ADHD and baseline levels of impairment.
Consider treatment for comorbid conditions (monitor possible drug-seeking behavior).
Prioritize modalities to fit target symptoms and available resources.
Monitor multiple domains of functioning.
Academic or vocational.
Daily living skills.
Emotional adjustment.
Family interactions.
Social relationships.
Medication response.
Periodically re-evaluate the efficacy of and need for additional interventions.
Maintain long-term supportive contact with the patient and family to ensure compliance with treatment and to address new problems that arise.
Treatment.
Education for patient, spouse, or other significant persons.
Consideration of vocational evaluation, counseling, or training.
Medication.
Stimulants.
Tricyclic antidepressants.
Other antidepressants.
Other drugs (buspirone, propranolol).
Psychosocial interventions.
Individual cognitive therapy; "coaching."
Family psychotherapy if family dysfunction is present.
Referral to support group, such as CHADD.
Other treatments are outside the realm of the usual practice of psychiatry.


GUIDELINE STATUS:
This is the current release of the guideline.

_______________________________

The psychiatric doctor will then send the child on for further testing with a nutritionist and an allergist before making the final recommendations. Most psychiatrists will recommend this testing: If for some reason the psychiatric doctor does not suggest this the parent should insist upon it. The findings of the allergist and nutritionist should be added to the childs' treatment records and considered in the final treatment program.


_______________________________

2. NUTRITIONAL ASSESSMENTS

There are three components to the nutritional assessment for ADHD...the Elemental Analysis, the Amino Acid Analysis, and the Fatty Acid Analysis.

THE ELEMENTAL ANALYSIS
Elemental Analysis examines hair, blood and urine samples for levels of toxic and nutrient elements. Toxicities and nutrient insufficiencies are identified, allowing for precise intervention. This analysis consists of two parts: the toxic element exposure assessment and the toxic element clearance profile.

A. The Toxic Element Exposure Assessment
The Toxic Element Exposure Profile assesses levels of 20 potentially damaging elements using a hair sample. A substantial body of scientific literature supports hair analysis as an accurate, reliable gauge of long-term toxic exposure. Because hair follicles are exposed to the blood supply during growth, element concentrations in hair reflect concentration in other body tissues. Should levels be elevated, a variety of clinical and lifestyle interventions can be implemented to reduce toxic burden; follow-up hair testing provides a good indication of long-term treatment effectiveness (after 3-4 months).

Aluminum
Antimony
Arsenic
Barium
Bismuth Cadmium
Copper
Gallium
Germanium
Lead Mercury
Nickel
Palladium
Platinum
Tellurium Thallium
Thorium
Tin
Tungsten
Uranium

B. The Toxic Element Clearance Profile

The Toxic Element Clearance Profile offers an advanced, comprehensive assessment of 30 toxic and potentially toxic elements excreted in urine. In addition to measuring classic elemental toxics, this profile includes elements used in the medical, aerospace, nuclear, and high-tech electronic industries. Use of these potential toxins is increasing because of their growing commercial, industrial, and medical applications.

* - Heavy Metals

Aluminum
Antimony*
Arsenic*
Barium*
Bismuth*
Cadmium
Cesium
Chromium
Cobalt
Copper
Gadolinium
Gallium
Lead
Lithium
Manganese
Mercury* Molybdenum
Nickel
Niobium
Platinum
Rubidium
Selenium
Tellurium
Thallium Thorium
Tin
Titanium
Tungsten
Uranium
Zinc
Creatinine


THE AMINO ACIDS ANALYSIS

Amino Acids Analysis examines fasting blood or 24-hour urine samples for 40+ amino acids. With the precise results provided by Amino Acids Analysis, nutritional deficits, metabolic impairments, and amino acid transport disorders can be accurately identified and corrected.

The Amino Acids Analysis employs state-of-the-art high performance liquid chromatography (HPLC) to perform the most comprehensive and sensitive assay available for urine or plasma analytes. More than 40+ analytes can now be measured, providing information on a wide spectrum of metabolic and nutritional disorders, including: protein inadequacy, gastrointestinal insufficiencies, inflammatory responses, vitamin and mineral dysfunctions, detoxification impairments, cardiovascular disease, ammonia toxicity, food and chemical sensitivities, depression, neurological dysfunction, and inborn errors of metabolism.

Amino Acids Analysis is an important part of any thorough nutritional and metabolic workup done for an individual. The test is also indicated in cases of chronic conditions that have proven to be diagnostic dilemmas and/or have failed to respond to treatment.


THE FATTY ACIDS ANALYSIS

Essential and Metabolic Fatty Acids Analysis evaluates the level of red cell membrane or plasma fatty acids. Utilizing a combination of Gas Chromatography and Mass Spectroscopy, the analysis provides a complete and detailed evaluation of a patient's fatty acid status, measuring a total of 30 fatty acids and 5 fatty acid ratios.


________________________________________________

3. ALLERGEN TESTING

The Comprehensive Antibody Assessment (allergen testing)

The Comprehensive Antibody Assessment is absolutely indicated in the diagnosis of adhd. It identifies hypersensitivities to over 120 of the most commonly encountered types of food and environmental substances. It
targets not only likely causes of immediate (IgE) allergic reactions, but also possible sources of delayed (IgG) reactions–the so-called "hidden allergies," whose effects may not show up for hours or even days after exposure to an antigenic substance. Hidden allergies can trigger a wide range of symptoms in virtually every part of the body.


I'm hopeful that the above information will clarily what is involved in an appropriate diagnostic evaluation for this disorder. Just my two cents here...until you have a very clear picture about what is causing such a level of hyperactivity in your little one, don't commit to medication.

For immediate help, you may want to try supplementing her diet with omega three fatty acids (fish oil capsules) if the capsules are small enough and she can swallow them. Or try adding fish products to her diet, like tuna fish and salmon.





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