Attention Problems – Beyond the Controversy

Attention problems in children, often called attention deficits, have become a hot topic of discussion in the last 30 years. What is it? Who has it? Are we diagnosing it too much? Too little? Are we using too much medicine to treat it, or too little? Who’s at fault for the “epidemic” of ADHD (Attention Deficit Hyperactivity Disorder)? The parents? The school? Television? Genetics? Diet? Or are we just better at recognizing a problem that was there all along and more quickly and effectively trying to deal with it?  All of these questions have sparked much debate among parents, teachers, pediatricians, psychologists and just about anyone else with an opinion on the subject and the desire to share it. What I hope to do in this blog submission is discuss some points about attention deficits that I think most rational people could agree upon in considering this controversial problem.

First, what is the problem? In medicine, before there is any consideration of treatment, there needs to be a reasonable and well-thought-out diagnosis. Unfortunately, there are no totally objective diagnostic tests for this condition. The most accepted criteria for diagnosing ADHD, involves concerns of inattention, impulsivity, and hyperactivity.  Tests, called “behavioral rating scales” are commonly used to determine if a child’s behavior is outside of the normal range for children their age.  These scales are usually completed by parents and teachers. The best scales are able to separate children whose problems are due to attention from children who might have other reasons for their problems.  But, it’s not that simple.  One third of children diagnosed as ADHD are felt to have “co-morbid” conditions, meaning problems in addition to (and maybe as important to deal with as) the attention disabilities.  Social and environmental factors may also affect a child and skew the results.  If these co-morbid conditions are not recognized and dealt with, treatment of the attention problem will be ineffective or disappointing. With that having been said, initial evaluation of attention problems should involve a complete assessment of a child’s overall health, intellectual and academic capabilities, social and environmental situation and psychological makeup.  Often, no one person or professional can make all these assessments, so a partnership of parents, teachers, psychologists, social workers and pediatricians may be needed to do a good job. This is the same team that will be needed to help the child, when help is needed.  But first, make the right diagnosis.
            
Second, how big is the problem? If a child is suffering enough academically or behaviorally so that his present and future life will be significantly affected, then it is reasonable to consider treating the problem. This is called being functionally impaired by the problem. Many children have only a mild degree of functional impairment, and possess “compensatory skills” that will make pharmacologic treatment unnecessary.
            
Third, what helps? Certain drugs, called stimulants, are the most effective treatment for children with attention problems that require intervention.  They work better and with less side-effects than other drugs, both short and long term, and they work better than intensive behavior therapy and other non-pharmacological interventions when compared head to head. Over the last few years, other medications have also been found to help in certain situations.  There is still controversy as to how stimulants work with attention problems, but there is some evidence that some children with “classic ADHD” have blood flow differences to certain areas of the brain from children without symptoms and these blood flow differences “normalized” after stimulant drugs were administered.  We think that the medicine makes these changes through changes in neuro-transmitters in the brain.  We have learned that many conditions of brain function are affected by natural and pharmacologic changes in neuro-transmitters.

One analogy that helps me think about how this works is a personal one.  I’ve worn eyeglasses since I was seven.  My eyes (which are part of my brain) don’t allow me to focus my vision appropriately on distant objects.  Luckily for me, eyeglasses focus the light coming into my eyes so I can see normally.  Without glasses, I am definitely functionally impaired.  Fortunately for me, eyeglasses are quite acceptable tools to allow me to function normally.  I like to think of these medicines as tools that help the brain focus in a similar way.  I think there are many “tools” in life that we learn to use to help us with challenges we face.  You need to be able to use more than one tool, but you also need the best tool for the job.

Fourth, does it help? This point should be the most obvious of all, but some parents and teachers think that the job is finished once therapy is started.  Given the complexity and subjective nature of attention, behavior and learning problems, follow-up is critical. Changes in dosing amounts and times are necessary, at some time, in almost all children. Co-morbid conditions may change with time and begin to affect the effectiveness of treatment. Also, all of these problems change with time – the older child with attention problems may be able to control himself “behaviorally” as he matures, but the effect of his problem on memory and learning may become more important academically as he gets into higher grades.

I believe that there will one day be more specific treatments for these problems than the stimulant drugs we now use, but new therapies must undergo rigorous head-to-head comparisons before believable claims can be made. At the present, complete and appropriate evaluations, including searching for significant co-morbid conditions, and, when appropriate, safe and effective treatments with good follow-up to make sure the goals of therapy are being met, constitute the best and most rational way to help children and adolescents with attention problems.   

Martin F. Beals, Jr., M.D., FAAP at Alaska Center for Pediatrics