November 15, 2007
For developmental behavioral pediatrician Kenneth Tellerman, the increase in the incidence of attention-deficit/hyperactivity disorder since he started treating it 20 years ago has been dramatic - affecting up to 12 percent of children today, according to the Agency for Health Care Policy and Research. Part of the reason, he adds, is an expanded definition of the disorder.
"Twenty years ago, we were looking more at the impulsive 'Dennis the Menace' type kids," Tellerman says. "By including inattentiveness, we've added an enormous number of kids."
So much so that today it's not child psychiatrists who are more often managing ADHD, but general pediatricians. Their training did not come from fellowships in behavioral medicine, as Tellerman's did, but on the job. And that's posed some challenging care issues for pediatricians, like accurately identifying ADHD and appropriately medicating patients.
"ADHD is not like diabetes, which you can measure with blood sugar," Tellerman explains. "This is still largely a behavioral diagnosis based on the observations of other people."
Those people tend to be teachers and parents who are usually on the mark but, Tellerman warns, sometimes see a problem where there isn't one. A 4-year-old's restlessness in a densely populated nursery school may be a red flag for marginal ADHD, or the child may be demonstrating normal toddler behavior in a chaotic environment. But, the child gets labeled ADHD.
Tellerman's answer is to thoroughly tease out those who have legitimate issues. He spends a lot of time talking to families and asks teachers to fill out a six-page assessment. If it looks like ADHD, pediatricians need to be aware of related disorders like anxiety and depression, learning disabilities and tic disorders. This is where a thorough family history comes in.
Tellerman takes the information and puts together an intervention package. While it may simply be an accommodation plan providing more time for directions from the teacher, it may also mean medication. But drugs, Tellerman stresses, should not be the only answer.
Noting that there's a lot of mythology surrounding ADHD meds, mostly stimulants like methylphenidate, Tellerman makes a point of explaining to parents as much as he can about therapies and side effects, including loss of appetite and insomnia. New non-stimulant medications have been developed to avoid these reactions, as well as longer-acting stimulants so students can avoid the embarrassing mid-day visit to the nurse's office. Patients age 10 and over are included in the discussion to help them counter the stigma and improve compliance, too.
The untreated, he adds, tend to suffer substance abuse, unemployment and relationship problems later on in life: "You're helping them interact with other people and succeed not only in school, but in life."