pediatric housecalls Robert R. Jarrett M.D. M.B.A. FAAP

ADHD, ADD, HK, ADHK, LDHK, MBD, Hyperactive, “Slow”

If you’re looking for a “first case” of this hyperactive problem don’t bother. I’ve tried and there’s nothing definitive—excepting a whole boat-load of historical people who’ve acted crazy enough that they coulda’ been!

Even the name for the thing has changed four or five times since I did research on “hyperactivity” in medical school as an honors project ty years ago!
ADHD effects both boys and girls
I continued to see hyperactive patients throughout my residency and used slide presentations for both fellow residents, doctors and patient groups but had to keep changing the slides as first sub-groups of patients were split out of the diagnosis, then other groups were added in, then split-out groups were quietly added back in. All the while names were changing right and left.

Hyperactivity… MBD… then attention deficit disorder… then attention deficit hyperkinesis… then, and then, and then!

Vested Interests Masquerading as Moral Principles

Additionally, numerous special interest groups have all had their hey-day with hyperactive patients, largely using the internet and fear to hype and sell either their “patented” medicines, or sham treatments.

To physicians these odd treatments are all bizarre, but have at least four things in common: They are all extremely lucrative to their proponents; they are all “secret,” and “proprietary”; they are all touted as “things your doctor doesn’t want you to know” or “doesn’t know”; and, they all have large numbers of vaguely defined, impossible to track down and verify, proponents making completely anecdotal observational-based claims of benefits which are impossible to either verify or repeat.

I chaired a large “new technologies” committee for a major insurance company tasked with reviewing all new treatments, methods and equipment entering the market place based on all evidence available and writing internal guidelines to compare their appropriate use, medical necessity and claims payment criteria. The committee grew to include close to 100 physicians, researchers and opinion leaders from across the US and occasionally the world.

Grossly over-represented in the committee’s agenda were the massive number of wild and unusual learning-disability/hyperactivity/attention-deficit treatments making mostly illogical claims; from prism lenses to crawling on the floor, avoiding or adding particular foods or substances, massages, purges and everything in between! None-the-less they all seemed to have die-hard patients willing to shell out big dollars for treatments which are specious at best [and usually pissed as crap that the insurance company wouldn’t buy into it and pay for it.]

“A rose by any other name”

Hyperactive: Behaviors in school have life-consequences
Childhood behaviors have life-consequences

Is a child inattentive because they’re all over the place OR all over the place because they are inattentive?

“Normal” children’s behavior isn’t any easier to predict than either of our two recent presidential candidates! [(chough) Clinton, Trump] It’s often capricious and disruptive and it changes across time—that’s called “growing up” and why your grandma told you for a lot of things: “they’ll grow out of it.”

But this is your kid we’re talking about here! And, as far as at least education is concerned, this is an issue where behaviors have life-consequences! Can they afford to have us sit back and wait for them to “grow out of it?”

For this article, let’s put aside for a moment anything about treatment and the mine-field of charlatans you may need to dodge through to get it. Let’s start even before that; what do you do when the teacher, principal or counselor tries to get hold of you for a conference about your child’s “non-success” in school?

The first thoughts in your head? Well, normally, and probably most productively, they will be: “Is it something I’m doing wrong?” Less productive, but common, are: “Why does he/she keep doing this?” and “What is this teacher doing wrong?”

Assuming the issue isn’t one strictly related to behavior, there are three clusters of issues within the problem of “school-difficulties” which your conversations will probably revolve around: “Learning Disability,” “Attention Deficits,” and “Hyperactivity.”

Your talk might be about any one—they all can lead to school failure; any combination; or, even all three together.

THAT is why all the silly letters, eponyms and labels get thrown around! In grandma’s day the problem’s were exactly the same; but, even though the labels were less precise, they were perhaps more clear: “undisciplined,” “wound up” or “slow.” Today it’s:

Attention Deficit (AD)

Attention, you pay it or sometimes give it—if you can. Smaller children are NORMALLY quite distractible. With age, the nervous system matures to where you have more and more conscious control of your attentiveness. WHY? We can guess but we really don’t know yet. Some children have this ability delayed. Some people do this less-well all their lives.

Incapable? Inattentive? Boored? Distracted? How do you tell?
Inattentive? Boored? Distracted? Incapable? Defiant? How can you tell?

Attentiveness has to do with things like: interest, abilities, understanding, presentation, prior experience, etc.; so, may vary across situations and topics.

A variance in this ability which is effecting a person’s progress, goals or success is usually considered a “deficit” (even if we don’t know what “normal” is). A problem or condition which produces such a deficit can be called a “disorder“—like in the (now antiquated) term: ADD, attention deficit disorder.

And, yes, there are ways of working around issues of attention, including using medicines, but first you have to identify what the specific issues are.

Learning Disability (LD)

One of the things we DO get, about all this jumbled stuff, is that every kid… every person, learns differently. Easier, harder, slower, faster—we all know about differences in memory ability, retention, IQ and all those other things we see between us and our own friends; well, it’s no different for kids.

And, you may say “well, if they don’t pay attention like you’re saying above, they won’t learn”; but, that is NOT what we are talking about when we say: “learning disability.” To doctors, “learning disability” refers to the nervous system’s ability to do things like: integrate spatial relationships; code and decode symbols; calculate and comprehend math relationships; and recall and order instructions.

The prefix “dys” means: bad, ill, difficult, abnormal etc. and “lexia” has to do with language. Specifically, dyslexia is difficulty coding and decoding letters and words—and it’s a substantial problem for those who have it. But, there are also a whole host of other “dys”-es which also interfere with learning, like dyscalcula—or difficulty with math.

And, yes, there are ways of working around issues with learning ability too; although not with medicine. But, first you have to identify what the specific issues are.

Hyperactivity (HK)

Hyperactive or Happy?
Hyperactive or Happy? How can you tell?

Hyperkinesis—Latin for basically “too much movement.” Unfortunately, this is the most misunderstood of all the “clusters of issues” in this discussion.

It DOES NOT MEAN that the child doesn’t do what he is told to do when you want him to do it. It doesn’t even mean that he or she is into everything and on the move more than you’d like; or that they can’t sit still through church.

“Activity” is normal. Activity is desired. Activity is how children explore and learn. The question is: how much is “hyper” or “more than usual”? Define for us just what is “usual” and you’ll know what is “hyper.” Keep in mind though the huge differences in activity levels between all the children there are in the world.

AND, keep in mind that cultural expectations also are vastly different—I doubt that any of the kids I know would fit in too terribly well at Buckingham Palace. Older children from southern states who are adopted into New Yorker homes can have a terribly tough life-adjustment merely due to pace-of-life differences; and vice-versa.

How much is too much? We have to use definitions laden with wording about “results” or “outcomes.” Too much activity is: that amount where it begins to interfere with a persons ability to learn and/or live amicably in society. The “pinch point,” for those children living in a country where education is mandatory, is usually at school; because that’s usually where demands are highest.

Combined with “AD,” “HK” can be particularly devastating to a child’s education. And throwing in “LD” too… well, you get the picture.

Fortunately, there are ways of working around issues with hyperactivity. We have well tested medicines that can be a big help, and counseling/parenting techniques which are effective—a bit more difficult and time consuming but perhaps more lasting. But… first you have to identify what the specific issues are.

First Things First

Due largely to the deaths of some high-profile sports figures, there is more research being done now on how the brain works than there ever has been.

In some situations it's good to be hyperactive
Is it sheer joy or hyperactivitiy?

We don’t know many of the key things we need to know in order to understand what we ought to know about our children’s learning. BUT, we do have better hope of finding them out now than we ever have had before.

Until then, we must not loose sight of the fact that we CAN TELL what is going on in our child’s life at the moment and WE CAN at least make our best efforts to help solve the problems that we know about.

Even if we don’t know what started it, we do know that our child isn’t doing well right now and we can at least take steps to understand what the specific issues are and do things we know from experience will help.

In part two of this series I’ll list the things parents should know about what ought to be done to diagnose potential issues that might be causing school learning difficulties. The “vested interests” all over the internet seem to have made a shambles out of parents’ abilities to tell what the “real” specific issues are; so, let’s see if we can get back to even-ground on this.

In part three, I’ll present a typical patient who is referred to a pediatricians office for school difficulties so you can get a feel for what it’s like and some of the decisions that need to be made.

Then Part four will give an overview of the treatments which we have actually seen make a difference and therefore are the “pillars” of the “best practices” in the treatment of ADHD.

When we’re all through you should have a great understanding of how things “should” go through all this, a much better understanding of how and what doctors are thinking when they see your child and be a lot more capable of making sure your child obtains the best care possible.

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10 Posts in This Series