Thursday, January 31, 2013

Ask Dr. Momsie: New ADHD Diagnosis

One of Dr. Momsie's readers recently asked, "My grandson has recently been diagnosed with ADD. Is it normal course to go straight to drugs?"

I'm glad you asked!  It is important to be educated about your options whenever you or your child have been given a new diagnosis.  And, there are many options when it comes to ADHD.  In my experience, it heavily depends on the professional making the diagnosis as to what treatments are recommended.  A family physician or pediatrician may be more likely to prescribe medication immediately, while a psychologist or psychiatrist might recommend behavioral interventions prior to trying medications.  Research shows that a combination of medication and behavioral therapy is most effective in treating ADHD.  Unfortunately, because medication is often seen as a "quick fix" by overwhelmed teachers, parents, and other well-meaning adults involved in the child's life, the idea of behavioral therapy and interventions are often dismissed. 

Before I break down the treatment options, let me talk a little bit about making sure you have a correct diagnosis.  Unfortunately, I have heard many of my clients report that a family physician diagnosed their child with ADHD based on a quick parent report of current symptoms.  This is really poor practice! A good assessment will include a thorough developmental history that details evidence of symptoms at a very young age.  Further, a correct diagnosis will only be given after a clinician gathers information from a variety of settings and reporters (home, school, etc.).  Your doctor should rule out other factors that may be contributing to overactive or inattentive behavior such as grief, depression, trauma, anxiety, or a simple developmental transition.  If your doctor didn't look at all these factors, I might suggest seeking a second opinion.

Okay, that being said, let's assume you have a correct diagnosis.  Let's talk now about treatment options.  Most good clinicians will first suggest behavioral therapy or intervention.  Sometimes ADHD symptoms can be managed in the classroom (or at home) by modifying variables in the environment.  In simple terms, teachers and parents can learn techniques to help kids stay on-task, complete work in a timely manner, limit distractions, and limit motor overactivity.  Children can learn to self-monitor their inattentive and overactive behavior as they grow older, and learn strategies to manage the behaviors on their own.  A good school psychologist can help develop an intervention plan for your child to address your child's specific needs.  Most schools will have a school psychologist, just ask your school counselor or principal.   For those of you itching for a few tips, I'll try to share a few of my favorite strategies within the next couple weeks.

Now, to medication.  Some parents cringe at the idea, while others cheer with excitement.  There certainly are children who respond amazingly well to medication and the immediate results are amazing.  Yet many children need more than one trial of medication before they see adequate results. Dosages need to be monitored and different medications need to be tried.  And, of course, negative side effects are possible.  Many parents are aware of possible side effects, and the idea of weight loss or their child turning into a "zombie" is enough to shy them away from considering medication. 

However, the newest medications for ADHD are known for having less drastic side effects than the stimulants many of us are familiar with (eek! Ritalin!).  With a good doctor and a patient parent willing to try different trials of medications and dosages, a family is likely to find an ADHD medication that works well for their child.  There are so many new options that are proving to be effective - new stimulants that carry less side effects and can last all day such as Concerta, Vyvanse and Focalin; a nonstimulant medication - Strattera- that has been showing amazing results with many children and adolescents, and even a hypertension medication - Intuniv - that is working amazingly well. With all these options, it is SO important that a parent communicates with their physician about side effects, levels of symptoms, and overall acceptability. 

So, dear reader, maybe medication isn't the best first option.  But, if your grandson's parents decide medication is right for them and they are working with a knowledgeable professional, don't worry too much.  We've come a long way since Ritalin.  Encourage (with love) your grandson's parents to consider behavior therapy and to work with their school to implement some strategies in the classroom that might help your grandson be successful.  Most of all, encourage your grandson that he is not his diagnosis - he is more than ADHD!  He can learn strategies to monitor his inattention as he grows older and he can be very successful! The unconditional love of a grandparent can make all the difference.

(For those of you wondering, ADD stands for Attention Deficit Disorder and ADHD stands for Attention Deficit - Hyperactivity Disorder.  If your doctor gives a diagnosis of ADD, your child probably has symptoms of inattention and distractibility without the severe problems with overactivity experienced by children with ADHD. The correct lingo, actually, is ADHD - Hyperactive type - for those just with hyperactive symptoms, ADHD Inattentive type - for those with inattentive symptoms only, or ADHD Combined - for those with symptoms of both.  The distinction is important because different symptomology lends itself to different treatments or interventions).

Wednesday, January 16, 2013

Pregnant? Take Your Antidepressants and an Extra Dose of Choline

Picture taken during my pregnancy with Jr.
It seems that the moment you become pregnant, the world becomes more obsessed with healthy pregnancy.  When I'm not pregnant, I don't notice many news stories or scholarly research about pregnancy.  But, the moment I know I'm pregnant, it seems like I'm inundated with new information about how to insure my baby is healthy.  For instance, lately all I hear in the media is how pregnant women need to get the flu shot (which I just did), how Princess Kate and others battle severe morning sickness, and how synthetic estrogen that used to be given in pregnancy may cause breast cancer.

I know, I know, you're thinking that I'm just more aware of this topic because it hits home.  You're right, I might be slightly biased.  But, my bias in perception has provided me with knowledge of two interesting new studies that I might not have been aware of had I not been pregnant!  Let me share.

First, a new study published in the Journal of the American Medical Association has found no significant increase in stillbirths for women taking SSRI antidepressants (Prozac, Celexa).  In a study of 1 million Nordic women, researchers found that when they controlled for a pregnant mother's general health, smoking, and age, the effects of antidepressants on pregnancy appeared "neutral".  It appears from this study that there aren't significant instances of stillbirth in women that take SSRI's, so pregnant women who have been receiving treatment for depression should feel more secure about taking their antidepressants.  But, if Dr. Momsie can share a slight warning, this study does not address other negative complications that might arise from taking medications during pregnancy, such as birth defects, infant health, etc. (although there is some evidence from other studies that babies seem to be often born okay).  Bottom line . . . be cautious and seek the advice of your OB before taking any medication during pregnancy.  But, if you are severely depressed during pregnancy, and the depression itself might negatively impact your health and/or the baby's health, don't feel too anxious about taking your SSRI.  The very slight risk is far better than the risks associated with severe depression!

Interested in giving your baby protection from schizophrenia, dementia, and even breast cancer?  It seems the magical nutrient that can help prevent a plethora of yucky illnesses is choline.  Within the last year, I've been seeing more and more research about this nutrient, which is similar to vitamin B.  The newest research, published in the American Journal of Psychiatry, suggests that taking a supplement of choline during pregnancy and nursing may actually prevent schizophrenia.  Although the researchers weren't able to assess whether the babies actually developed symptoms of schizophrenia (which usually don't manifest until adolescence or early adulthood) they were able to assess early indicators of schizophrenia. Apparently, a normal brain responds fully to an initial clicking sound but inhibits response to a second click that follows immediately. Schizophrenia patients are usually less likely to inhibit secondary responses.  So, the researchers looked at the infants ability to inhibit their responses to clicks as a measure of schizophrenia.  (Ok, I'll admit, this might not be the most fool-proof method, but maybe one of the only early indicators of schizophrenia risk).  Eighty-six percent of infants whose mothers took the choline supplement were able to inhibit responses, compared with just 43% of unexposed infants.  (This does not mean that 43% of infants were doomed to develop schizophrenia, just that they may be more at-risk.)

So, if you're pregnant, start filling your diet with choline-rich foods!  Choline is mostly found in eggs, dairy foods, fish, and meat.   Other foods that contain choline (and are more vegetarian-friendly) include peanut butter, wheat germ, broccoli, brussel sprouts, potatoes, avocados, kidney beans, navy beans, white and brown rice, and oat bran. 

I wonder if Peanut Butter Captain Crunch is rich in choline.  If so, my little peanut is going to be a-okay!

Wednesday, January 9, 2013

Restaurants and Toddlers Don't Mix

Last weekend, I decided that we should go out to eat as a family.  We have had mixed experiences eating out with Jr. lately, but because he did so fabulously during our previous outing on New Year's Eve, I completely mentally discarded all memories of public tantrums and restaurant misbehavior.  How foolish of me!

This naive reaction was probably because the New Year's Eve outing was such a test, and Jr. did SO well.  My husband had made reservations at a very nice restaurant several weeks in advance.  He had thoughtfully made the reservations at an hour that only the geriatric or toddler crowds enjoy a meal, thinking that we would avoid the groups of party-goers and romance-seeking couples looking for a night away from their own screaming children.  But, he chose a restaurant that probably had never enjoyed the pleasure of a toddler guest.  This was a cloth-napkin, dim-lighting, candle-centerpiece type of place.  I shared my worries and doubts with my husband and prayed for the best.  I made sure Jr. had a nice long nap, was adequately hungry, and had a few distracting toys.  Despite my preparation, my anxiety spiked when we checked in for our reservations and the hostess wasn't even sure if they owned a highchair for the joint.  "Oh great," I thought, "We're in for a wild ride."

Our beautiful, calm NYE dinner.  The pacifier really helped.

But, they found a high chair and  Jr. did awesome.  He immediately sat in his high chair and chowed down on an over sized "cracker" (the server had a much fancier name for it, but to us it was a cracker).  We ordered quickly - drinks, appetizers, main course all at once.  No time for dessert.  We're realized we were working within a small window of toddler attention-span that could zip away in an instant and be replaced by screams, running around the restaurant, and food throwing.  We made it through the appetizer before Jr. began to refuse his high chair. This usually occurs much earlier in the dinner service, but thanks to the giant cracker, we were spared a few extra minutes.  He happily moved to Daddy's lap in time for the main course and became totally enraptured by Daddy's crab-stuffed shrimp.  Before we knew it, we had finished our meal and were ready to leave.  No tantrums and no drama!  Wowza!

So, coming off this huge success, I was overconfident when we decided to eat out last weekend.  We hopped into the car headed for a local pizza joint - very kid-friendly - without a smidgen of anxiety.  I brought blank paper, Jr.'s new favorite truck book and markers (only a very brave, confident mother would dare to bring markers to a restaurant.)

We started off well.  We were seated in a room filled with other children, so we didn't need to worry a bit about Jr. using his "inside voice." (By the way, toddlers don't have "inside voices.").  I sat him in the high chair, which this establishment had in bulk, and handed over the markers and paper.   He smiled and yelled in his toddler inside-voice, "Trucks!" when I pulled out his book.  Ah, all was well.

Things started to decline when he quickly lost interest in the markers and truck book.  How could that be?  He LOVES those things!  Before the appetizer even arrived, he wanted on Daddy's lap.  He ate a couple of chips and then absolutely NEEDED to sit on Mommy's lap.  For two minutes.  Then, back to Daddy.  Back and forth. Back and forth.

Luckily, our pizza came out quickly.  And, he loves pizza.  He screamed (in his inside-voice) "Peee-paaaa!"  And, continued screaming as I quickly cut and blew on the pizza, begging him to please wait.  He became more and more agitated, and this darn pizza held it's heat well.  When it was finally cool enough to eat, Jr. calmed down a bit and happily shoved some in his mouth.

Not even one piece into the pizza, and Jr.'s kryptonite walked in the room - the one thing that could take his attention from his pizza and revert him into a screaming, one-track-minded, egocentric toddler.  A baby.  In came a family with a baby in a carseat, covered and sleeping.  Jr. loves babies.  We aren't sure why.  Maybe it is because he was the oldest in his infant class at daycare and was around so many infants.  Whatever the reason, he goes nuts for babies.  He's very gentle and appropriate with them, but a protective mother wouldn't know that from the way he screams "Baby!" and jumps up and down.  This poor mother was surely thinking that the crazed toddler running her way would not only wake her baby, but maybe even devour him.  We tried to distract, corale, or just slow Jr. down.  Nothing worked.  The more the mother looked fearful, the more we tried to keep Jr. away, and the more he was determined to get to that baby.  People were starting to stare. While I wrestled Jr., my hubby quickly packed up the uneaten pizza, packed up the worthless markers and book, and asked for the bill. 

Just as we started out the door, the baby woke up.  Jr. quietly walked over and said, "Hi baby!"  He touched the little baby's hand ever so softly, and turned around and walked out the door with us. 

As we drove away, hubby asked, "Do you think we should NEVER eat out again?"

"Oh, no, silly," Dr. Momsie replied.  "Jr. must be exposed to eating at restaurants in order to learn how to behave himself in a restaurant.  Typical toddler stuff.  No worries."

But, really, I think it might be awhile before we venture out again. Maybe restaurants and toddlers just don't mix.
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