Toddlers & Adhd: Relief for Parents, a Guide for Clinicians and Teachers

By Donna Mac LCPC

Is your toddler going through the "whacky one's,"
"terrible two's," "troublesome three's," or "fudgesicle four's/fives?" Or could their behavior be something more? ADHD is a genetic condition that usually has an onset prior to the age of 4. It presents with hyperactivity, impulsivity,
inattentiveness, irritability, and aggression. Due to the fact that all toddlers show some ADHD behavior, its
challenging to discern if behvior falls within normal limits or if it is clinically significant. Learn the distinction.
Toddlers & ADHD shares the latest research on the diagnosis and the treatment of 1-5 year olds with this condition. The goal is to reduce the childs ineffective symptoms, which will
subsequently lessen the stress level of the entire family unit. Therefore, you will learn parenting strategies specifically for a toddler with ADHD, and you will also find out how to seek help for your child, the right \questions to ask, and what to expect from Early Intervention services, preschool and
kindergarten based services, and therapeutic/psychiatric
services.

• Language: English
• Publisher: Balboa Press
• Release date: Mar 10, 2014
• ISBN: 9781452592916

Donna Mac LCPC

Donna Mac graduated from the University of Illinois and is currently a clinical therapist in a therapeutic day school, treating an array of mental health diagnoses. Donna and her husband live in the Chicagoland area with their three daughters and two puggles. Donna is not just some therapist offering therapeutic and academic ideas for selective mutism. Even more important, she is also a mom of twins diagnosed with SM. With Donna’s professional and personal experience combined, her goal is to offer hope and a sense of universality to the SM community, in addition to spreading awareness about this rare social communication anxiety disorder.

Book preview

CONTENTS

Acknowledgments

Introduction

Chapter 1 Do You Ever Hear Parents Say …

Do You Ever Hear Parents Use These Excuses?

Do You Ever Hear Parents Claim Their Toddler Must Have ADHD?

Chapter 2 What Is ADHD? Is It A Real Condition?

When Is The Onset Of ADHD?

Does ADHD Ever Go Away?

How Many Children Have ADHD?

Why Is There Controversy Over An ADHD Diagnosis?

How Is ADHD Clinically Defined?

Chapter 3 What Causes ADHD

Heredity And Genes

Environmental Factors

Brain Differences

Neurotransmitters

Brain Waves

Frontal Lobe

Limbic System (Emotion Center Of The Brain)

Gray Matter And White Matter

Caudate Nucleus

Conclusions

Chapter 4 What Mimics ADHD

You May Hear Some Of These Myths About ADHD:

These Myths Disputed

Conclusions

Chapter 5 The Issues That Delay An ADHD Diagnosis

Why ADHD Is Usually Not Diagnosed Until First Grade Or Later

Conclusions

Adverse Effects When A Child With ADHD Is Not Identified Early On

Why Do Some Parents Struggle With The Idea Of Having Their Child Evaluated?

Chapter 6 Typical Toddler Development In Comparison To Clinically Significant Behavior

Through The Eyes And Heart Of A Toddler

What Is A Typical Toddler?

Normal Movement, Activity, And Play

Excessive Hyperactivity, Chaotic Play, And Dangerous Play

Tantrums/Impulsivity/Need For Immediate Gratification

Attention–Inattention Spectrum (Including Being Distracted By External Stimuli To Hyper-Focusing)

Sensory Issues

Transitions When Ending Fun Activities

Toddlers Expressing Independence

Memory And Following Step-By-Step Sequential Directions

Egocentric Behavior And Empathy

Moral Development

Attachment Theories

Potty Training

Normal Sibling Rivalry Vs. Excessive Sibling Bullying

B. F. Skinner’s Operant Conditioning (Rewards And Consequences)

Token Economy Systems And Sticker Systems

Struggling Vs. Refusal

Scheduling Assistants

Responsiveness To Parenting Techniques

Many Factors Of Behavior And Emotion Will Have To Be Evaluated And Considered

Chapter 7 Early Intervention Services (Birth–36 Months)

Department Of Human Services

Transition Meeting

Chapter 8 Public-School Services And Special-Education Law (3–21 Years Old)

Public School Evaluation For Special Education Services

What If The Parent Does Not Want To Accept The Special-Education Eligibility?

Related Services

The At-Risk Population

Appointment-Based Services

Tuition-Paying Students And The Blended Model

Special Education Placement: Least Restrictive Environment

Iep Goals And Benchmarks

Accommodations/Interventions

Modifications

Functional Behavior Assessment/Behavior-Intervention Plan

Medication

Sample Letter

Parents’ And/Or The Legal Guardians’ Roles And Rights

Common Core State Standards And Your Child With A Disability, Including ADHD

Chapter 9 Therapeutic Services And Holistic Approaches

Play Therapy

Animal-Assisted Therapy (Aat)

Dance/Movement Therapy (Dmt)

Music Therapy

Art Therapy

Nature-Based Activities (And Recreation Therapy)

Balance-Based Sports

Craniosacral Therapy (Cs)

Chiropractic Care

Acupuncture/Chinese Medicine

Family Therapy

Conclusions

Chapter 10 How A Clinician Or Physician Diagnoses ADHD

Differential Diagnosis

Comorbid Diagnoses

What Kind Of Clinician?

Information Gathering

Chapter 11 ADHD Medication

Stimulant Medication Prescribed For ADHD

Some Possible Stimulant Side Effects

Alpha-2 Adrenergic Agonists (Antihypertensives) Prescribed For ADHD

Antidepressant Medication Prescribed For ADHD:

Last Resort Medications For ADHD Or Other Disorders With Aggression

Insurance Companies/Pharmacies

Prescription Lingo

Locking Up Medication

Getting Toddlers To Take Medication

Chapter 12 Parenting Tips To Make Life Calmer For The Family Unit

Lower Your Expectations For Yourself

Limit The Amount Of Noise In The House

Keeping An Organized House

Put The Other Stuff Aside

Limit Toys, Offer Toys, And Rotate Toys

An Example Of How To Promote More Organized Play

Educational Toys Vs. Toys That Allow For Movement

Markers/Crayons

Books And Toys That Are Too Overstimulating

Messy Activities

Mimic Games

Foam Pump Soap In The Bathroom And Kitchen

Cutting Up Food

Safety In The House

Music Activities

Outdoor Activities

Transitions/Structure/Routine

Preparing For Sleep

Chapter 13 Parenting Strategies To Increase Cooperation

Bonding With A Toddler Who Presents As Irritable On A Regular Basis

Remaining In Control As The Caregiver

Safety Breaks (Time Outs)

Tantrums: Lack Of Skill Development In Assertiveness Skills And Cognitive, Emotional, And Behavioral Impulsivity

Positive Reinforcement

Token Economy System/Sticker Reward System With Toddlers With ADHD

Key Words

Sixty-Second Rule

Negative Contractions And The Word No

Role-Play

Only One Or Two Directions At A Time

How To Handle Toddler Requests

The Democratic Parenting Style

Consistency (No Warnings)

Being On The Same Page As Your Significant Other

Empty Threats

Ignoring Behaviors

Picking And Choosing Your Battles—The Art Of Compromise

Antecedent Management

Irritability In Public

Whining

What May Look Like Defiance …

Typical Scheduling Assistants Can Be Difficult For A Toddler With ADHD

How To Get Your Child To Cooperate (Hint: Criticizing Usually Does Not Work)

The Collaborative Problem-Solving (Cps) Model Of Ross Greene And J. Stuart Ablon

Building Self-Management Skills

How Do I Get My Child To Respect Me?

Conclusions

Chapter 14 Maneuvering In Public

Cost

Lowering Expectations While Being Out In Public

Potty In Advance

Leaving The House

Do Not Arrive Early

Accept That You Will Be Late

How To Get To Work On Time

Waiting In Line

The Garage-Door Opener

Leashes

Day Care Center Locations

Ice Cream Shops

Restaurants

Your Toddler’s Birthday Party

Other Toddlers’ Birthday Parties

Playdates

Photo Shoots

Fireworks Shows

Zoo

Swim Lessons

Parades

Egg Hunts

Visiting Santa Or The Easter Bunny At The Mall

The Grocery Store

Airplanes Vs. Automobiles

Driving: What Type Of Vehicle?

The Dentist

Conclusions

Chapter 15 What People Might Say To You About Your Child Or Your Parenting And How You Can Respond

Things Strangers Have Said To Me

Chapter 16 Coping Skills For Parents

Fruit Salad

Serenity Statement

Using The Fridge

Socialize

Music

Spend One-On-One Time With Your Toddler

Spend Quality Time Alone

Talk With People With Similar Issues

Self-Talk

Stay In The Here And Now

Solution-Focused Thoughts, Relaxation, And Visualization

Talk To Your Child

Counting And Breathing

Be Who You Want Your Child To Become

Lower Your Expectations For Yourself

Prepare For Bedtime Early In The Evening

Put Pictures In Frames

Read

Farmer Analogy

Pilot Of The Plane Analogy

Oxygen Mask Analogy

Place Of Worship, Prayer, And The Bible

Pleasure Your Senses

Progressive Relaxation Method

Be Creative

Do Something In Honor Of Your Child

Chiropractic Care

Exercise

Eat (Mostly) Right

Laugh

Professional Assistance

The Endodontist

Chapter 17 Your Child Might Be Meant To Swim

Works Cited

Toddlers & ADHD is written in memory of Lauren, one of my YMCA campers, whom I had the pleasure of working with for eight years. The emotions and behaviors she demonstrated associated with her ADHD intrigued me, and I wanted to learn even more about how to help children with this disorder. She is deeply missed.

This is also written in honor of my three little girls, Makenzie, Katie, and Jordyn Hailey. Every day, you three teach me about unconditional love, meaning and purpose in life, self-control, patience, and, of course, time management! Makenzie and Katie, you help me to be a better clinician daily; I now not only see the children I treat in therapy as children I treat, but I see them through the eyes of their desperate parents as well. This experience of getting to be your mom has given me new perspective on parenting, my career, and life in general. I never thought God would have blessed with me two children with ADHD to teach me my lessons in life, but I am glad this is how he chose to do it because I wouldn’t change you for the world. Your ADHD is a gift, and all three are loving girls, with a zest for life, passion about everything you do, and highly contagious energy. You girls are meant to climb high!

Image01JPEG.jpg

ACKNOWLEDGMENTS

I would like to thank: Paulina Augustine, Ric Balius, Andrea Becker, Sarah Black, Aimee Brito, Carissa Frame, Lisa Gendusa, Colleen Gjataj, Dr. Anna Hammond, Jen Haselhorst, Dr. Anne Holbrook, Caron Jones, Sharalee Lewis, Dr. Eleni S. Liossis, Jason MacDonald, Diana Majerczyk, Beth Maleski, Shawna Paplaski, Bonnie Ramirez, Kim Redfield, Cindy Rousseau, Mindy Turner, Sabrina Washington, Anna Webb, Ryan Williams, Deb Zielke, and Kristine Zimmer.

I thank all of these professionals listed above for their help with this manuscript. I quote them during the different sections of Toddlers & ADHD that pertain to their specific professions, and I am so appreciative for their help and their friendship! Some of them even have (or had) their own toddlers with ADHD, and some have ADHD themselves, so they were able to give me both personal as well as professional input. To be clear and as a disclaimer, these professionals neither agree nor disagree with anything written in this book by me or by the other sources quoted, even within the same sections in which their statements might appear.

I thank Susie and Keith Ozsvath for the guidance they provided during my student teaching experience. I had the opportunity to learn from the best! I thank Dr. Richard Shaw, my graduate school academic advisor and professor, who continuously pushed me to strive for my best.

I thank the people who have guided me spiritually: Shannon Gutierrez, Carter Moss, Melissa Novacek, and Jen Vergara. I also thank all of my small group members at work for their continued prayers and support.

I have to thank my husband, Jason MacDonald. I was able to quote him in sections of this manuscript, due to his master’s degree in biomechanics (movement) and sport psychology and how these areas pertain to ADHD. He also entertained our three little girls on many occasions so I was able to write in peace; he let me escape to local coffee houses to get some quiet time to write! (Therefore, I also have to thank the all of the staff members at Starbucks for always making my writing experience comfortable and enjoyable).

I thank my friends and family, especially my mom and dad, for always welcoming us into their homes and loving my children unconditionally.

I thank the Adventist Health System for giving me the opportunity to do what I am passionate about every day, and for my bosses, Sean Fritz, Dr. John Glennon, Lisa Grigsby, and Mary Sue Parla. A special thanks goes out to my fellow clinical therapists, expressive therapists, and special education teachers because I learn from them on a daily basis. Their talent to work with these children and their wealth of knowledge on best-practice and intervention is noteworthy.

I thank Dr. Anna Hammond, Psy.D., for recommending my twins’ psychiatrists, Dr. Charlene Brown, M.D. and Dr. Paula Gewarges, D.O. I thank the twins’ pediatrician, Dr. Pamela Huang, M.D. I thank Kim Yost, LCPC, for recommending the twins’ therapist, Jack Flight, LCSW, RDDP, CSOTS. I thank all of my twins’ preschool staff members at Oswego School District #308 for their dedication to my girls. All of the professionals I have just listed- in medicine, mental health, and education- continuously help my twin girls live more peaceful lives.

Of course, I have to thank Balboa Press for the opportunity to publish this work! My coordinator, Stephanie Cornthwaite, had to deal with my crazy anxiety in her email inbox with my lists of questions sent to her in the middle of the night. I thank my editor, Kathryn Robyn, for all of her insightful, helpful, and funny comments about my manuscript. I also want to thank Staci Kern, my design team coordinator and publishing services associate. Without them, none of this could be possible!

INTRODUCTION

I am a licensed clinical therapist and also a certified school counselor working with children in a therapeutic day school who are diagnosed with attention-deficit/hyperactivity disorder (ADHD), among many other disorders. I have also taught special education with early-childhood students who had an array of diagnoses and at-risk factors and directed a nature-based day camp for nine summers with campers identified with ADHD. But more important, I am a mom of twin toddler girls diagnosed with ADHD. I live the life every day and can empathize with other moms and dads. Armed with my personal experience, my aim is to offer hope and provide relief. Because I understand the stress that any young child can put on any family, I offer Toddlers & ADHD to help those parents who feel overwhelmed by their particular child’s behavioral and emotional expression.

ADHD presents with hyperactivity, impulsivity, inattentiveness, irritability, and/or aggression. These issues can stem from deficits in several areas of the brain, including deficits in executive functioning, which is the ability to self-regulate. Due to the fact that all toddlers demonstrate some ADHD behavior, it can be challenging to discern if the child’s behavior falls within normal limits or if they actually demonstrate clinically significant behavior. This can be confusing for parents, teachers, and even clinicians, making ADHD more challenging to accurately diagnose during these early years. This book is meant to help clarify this distinction, although it is not to be used to formulate a diagnosis.

Most toddlers who have the diagnosis will not respond to typical behavior-modification programs, so this book will be helpful in aligning parenting strategies to the needs of a toddler with this condition. You will also find information on how to effectively maneuver in public with your child and ways to respond to others’ judgments. You will learn coping skills for yourself and also learn how to teach a toddler coping strategies. Newfound self-management skills for everyone involved should lessen enough stress for your family to get back to a baseline level of functioning. In addition, Toddlers & ADHD will assist you in how to find out how to seek help, the right questions to ask, and what you can expect from Early Intervention services, preschool- and kindergarten-based services, holistic, therapeutic, or psychiatric services for your child.

This guide is also helpful for teachers and clinicians, giving examples of why these children usually are not identified with ADHD until at least first grade and how it came about that ADHD can now officially be diagnosed in toddlerhood, in addition to when it’s recommended to medicate young children and when it’s not. I answer questions as to why a toddler who does not seem to have ADHD in certain environments or situations actually has ADHD. I offer different scenarios with different combinations of symptoms- some symptoms people may not even realize are related to ADHD because they are not qualifiers in the DSM-V. I go through examples of differential diagnosis of bipolar disorder, oppositional defiant disorder, autism spectrum disorders, anxiety disorders, and depression. Many symptoms in ADHD can look similar to any of those diagnoses, and some within the same child but in different settings.

CHAPTER 1

Do You Ever Hear Parents Say …

DO YOU EVER HEAR PARENTS USE THESE EXCUSES?

» It’s the whacky ones.

» It’s the terrible twos.

» It’s the troublesome threes.

» It’s the fudgesicle fours.

» It’s the flippin’ fives.

» Boys will be boys.

» She’s just going through a difficult phase.

» It’s just sibling rivalry. It’s normal.

A ttention-deficit/hyperactivity disorder (ADHD) is widely under diagnosed in our country (Albala, et al. 2010). Some parents frequently use these kinds of excuses, normalizing and minimizing their toddler’s behavior. However, they might actually have a toddler with a diagnosable and treatable disorder of ADHD, but they just don’t know it! These undiagnosed toddlers will struggle with changing their behavior, even if the parent uses consistent behavior-modification techniques. Once a parent learns behavior strategies specifically for ADHD, lives can begin to improve! These toddlers can make even more significant strides if they also receive therapeutic services, proper interventions at school, and/or take medication. A combination of these treatment techniques can significantly reduce the toddler’s stress level, subsequently reducing the parents’ stress levels, which in turn can improve family functioning back to a baseline level. Some relief might be possible in the near fu ture!

My twins were diagnosed with ADHD at age three. In chapter 10, you can read about the clinically significant symptoms they demonstrated beginning at ten months-old on, in order to secure a diagnosis. There is important information, new in just the last couple of years, regarding the age at which clinicians and physicians can technically diagnose ADHD, and this will be covered in chapter 5.

DO YOU EVER HEAR PARENTS CLAIM THEIR TODDLER MUST HAVE ADHD?

These parents say, My toddler…

» is hyper;

» moves around all the time;

» does not pay attention;

» does not follow directions;

» is irritable;

» is loud;

» is impulsive;

» fights with his or her siblings;

» talks excessively;

» refuses and acts out;

» switches activities quickly;

» touches everything in the store; or

» tantrums excessively.

ADHD is also widely overdiagnosed in this country (Albala, et al. 2010), and as a mental health community, that must change, so children, especially toddlers, are not unnecessarily put on medication.

JoEllen Patterson, Ph.D., A. Ari Albala, M.D., Margaret E. McCahill, M.D., and Todd M. Edwards, Ph.D. all work for the University of California, San Diego School of Medicine. They want people to be aware that the toddler might be expressing normal variations of temperament—this is perhaps the most common condition that is misdiagnosed as ADHD (Albala, et al. 2010, 185). Since a toddler’s range of normal emotional expression and behavior spans a wide range, wider than even a child’s, the toddler might simply be a typically developing toddler! Dr. Elizabeth A. Rider and Dr. Carol A. Sigelman agree. They coauthored a textbook on developmental psychology which I used in graduate school. Dr. Sigelman is a professor of psychology at George Washington University, and Dr. Rider is a professor of psychology at Elizabeth Town College in Pennsylvania. Together, they sate, Because most young children are energetic and have short attention spans, behavior must be evaluated in terms of developmental norms (Rider and Sigelman 2006, 467). It’s important to note that just because the behaviors listed here can fall within normal limits, this does not mean these behaviors are always acceptable. A typical toddler who occasionally demonstrates inappropriate actions can modify his behavior with specific parenting techniques.

To throw a curveball into the discussion, there are other circumstances that might occur in a toddler’s life that can produce symptoms that mimic ADHD. This means the child does not necessarily have a neurodevelopmental disorder at all, but rather, she is actually exhibiting a normalized response to an abnormal situation or an extreme stressor. For instance, let’s say she is missing her grandparent who passed away recently; she might externalize those feelings, which may appear like ADHD behavior. During this time, the child might benefit from additional external structure to help her regulate her internal stress, but she does not need ADHD medication! There are plenty of situations that occur within children’s lives that will make it seem like they have ADHD even though they don’t, and these will need to be addressed through specific therapeutic or parental interventions. Examples of these situations will be discussed in chapter 4.

To throw yet another curveball, symptoms of other mental-health disorders can overlap with ADHD’s symptoms, so a toddler might not have ADHD at all but a different mental-health condition altogether. If a child does not actually have ADHD, obviously he does not need ADHD medication; this type of medication will exacerbate his symptoms, making life even more of a struggle for him. (These overlapping symptoms and differential diagnosis information will be addressed in chapter 5 and chapter 10).

It’s important to remember toddlers are not meant to be miniadults. They are much different from adolescents and even elementary-aged children, so there are some situations where parents simply have to lower their expectations of what their toddler can and should be able to do. Because of situations like this, many young children, boys in particular, are misdiagnosed with ADHD. If parents, teachers, and clinicians do not understand their brains, then they cannot help them deal with their natural impulses and tendencies (Gurian 2001).

CHAPTER 2

What Is ADHD? Is It a Real Condition?

A DHD is a neurodevelopmental disorder that stems from inability to self-regulate. It reveals itself through inattention, hyperactivity, and/or impulsivity. It can also present with irritability, mood lability (frequent mood shifts), and aggression. Symptoms can vary greatly, depending on the environment or the situation. Within a person, this condition can present itself differently across a lifespan depending on any number of changes in external or internal circumstances. Toddlers with ADHD can demonstrate many of these symptoms. A person’s symptoms may remain stagnant as he or she grows, and they might also change over time, increasing or decrea sing.

While understandable, it is a common misconception that if children with ADHD just had an opportunity for more exercise, they would be fine. Can exercise help? Certainly. Exercise has benefits for many physical conditions and mental health disorders. In fact, cardiovascular exercise increases blood flow to the frontal lobe of the brain, which can aid in the ability to focus. However, lack of exercise is not the cause of ADHD, and therefore, just adding exercise does not cure ADHD. It can help ADHD by bringing glucose and oxygen to the frontal lobe, and there will be more on this in chapter 8.

It’s also understandable that people might think children with ADHD have brains that process faster than their peers. However, in the latest version of the Diagnostic and Statistical Manual (DSM-V), the mental health bible, the authors report that people with ADHD actually suffer from an increased amount of slow brain waves, as evidenced by electroencephalograms (EEGs) (American Psychiatric Association 2013). These slow waves are the sleepy theta waves that are seen in ultimate relaxation or stage-two sleep. This means they are producing theta slow waves (4–8Hz) when they should be producing beta fast waves (12–21Hz), (Brain and Body Solutions n.d.). Due to about 30 percent more theta waves in ADHD patients, this disorder is "related to ‘under arousal’ of the frontal and prefrontal brain systems that regulate attention and impulse control. Children who demonstrate symptoms of ADHD often show smaller and/or slower than normal physiological reactions to stimuli," and this shows that that their brains operate at lower levels of excitement (Behavioral Medicine Associates, Inc. n.d.).

Because their brains have lower levels of excitement and are understimulated, such children can tend to seek stimulation from their external environment, which can present as hyperactivity and/or impulsivity (Albala, et al. 2010). This is why it seems as though children with ADHD need to get their energy out in a very excessive manner! They appear almost like energy junkies. They gravitate toward activities that produce emotional and sensory stimulation, which seem to be more action-oriented, offering immediate rewards. Things such as loud music, colorful toys, big-motion outside activities, action-packed video games, and so forth, offer the right stimulation (Managing Your ADHD Child 2000–2011).

For these children, hyperactivity is actually a coping mechanism to maintain normal arousal in their brains (Behavioral Medicine Associates, Inc. n.d.). The ADD/ADHD patient compensates for the increased theta production with hyperactivity. For example, have you ever driven down a road late at night and found yourself becoming sleepy? What do you do? Open the window, turn up the volume on the radio [and sing loudly], or tap the dashboard? You make yourself hyperactive to stay awake! The ADD/ADHD patient that is producing too many slow waves is in a perpetual state of fogginess and is constantly trying to stay awake—hence the hyperactivity (Brain and Body Solutions n.d.). This is what students with ADHD do in school—they fidget, wiggle, shift body position, and tap their pencils in an attempt to stay focused and awake, which are observations I make on a daily basis at the therapeutic day school where I work.

Due to the nature of this disorder, what a child with ADHD actually needs is more stimulation within his brain, so he doesn’t need to gain that stimulation from the environment around him. Have you ever noticed a child with ADHD jumping on a coffee table when he is at an age where he is well aware that this is not acceptable behavior? He is trying to self-stimulate through this type of inappropriate movement, to get his brain to a baseline level of arousal. Another common misconception of ADHD is this child just has to learn he isn’t supposed to jump on tables. However, ADHD is not a disorder of inability to learn; it’s a disorder of an inability to self-regulate. Therefore, he has learned he isn’t supposed to do this. All toddlers obviously crave movement, and movement is crucial for proper brain development. However, there is a normal range and an excessive range for movement in toddlerhood, which will be discussed further in chapter 6.

WHEN IS THE ONSET OF ADHD?

The onset of symptoms can occur anytime through the age of twelve (American Psychiatric Association 2013). However, most people with ADHD will have an onset prior to age four (Papolos and Papolos 2006). Furthermore, the condition "often reveals itself in infancy … with these babies being very active, possibly showing difficult temperaments or irregular sleeping and eating patterns (Rider and Sigelman 2006, 467). Obviously, this doesn’t mean all people with ADHD presented this way as babies, particularly if the condition didn’t manifest until later in childhood.

If the child does in fact have an early onset, depending on the presentation, these toddlers will struggle when they first have to meet social standards and expectations (O’Neal, Preston and Talaga 2010, 72), and they will seem more active than their peers: As preschool children, they are perpetually in motion, moving from one activity to another (Rider and Sigelman 2006, 467), even more so than a typical toddler.

One might ask: How do I know if my toddler is more active than she is supposed to be? Don’t they all move from one activity to another? Yes they do. Even the DSM-V admits, Many parents first observe excessive motor activity when the child is a toddler, but symptoms are difficult to distinguish from highly variable normative behaviors before age four (American Psychiatric Association 2013, 62).

One indicator that my own twin toddlers, beginning at ten months old, were more active than they were supposed to be was that other people didn’t want to visit my house, because the girls were always in Energizer Bunny mode, which made visitors feel completely overwhelmed. Again, this concept of excessive movement will be further explored during chapter 6.

Toddlers with the hyperactive presentation of ADHD are usually noticed first, before an inattentive presentation. If a child has the inattentive presentation, it can emerge early on, but it may not become an issue until she is around six or seven years old, as school expectations increase, or possibly even as late as high school. As for the differences among the presentations, it depends how the disorder manifests within a person, in addition to how it is expressed outwardly.

DOES ADHD EVER GO AWAY?

Everyone with ADHD will present a little differently, even amongst the same presentation. Some will have overtly noticeable symptoms, and for others, outsiders may not even notice their symptomology. It’s important to note that ADHD is a treatable condition but not a curable condition; this means there is not medication that will make it go away. There have been studies that people with ADHD on stimulant medication show more normal brain development over time, but this does not mean the person is cured entirely, nor does not mean this happens in every case. Medication, in combination with coping strategies can help manage the condition, and people can be successful in life if they are treated properly and take ownership for working on their own self-regulation skills. For toddlers, it will be the caretakers’ responsibility to teach these skills to them.

With that said, when children with ADHD grow into adolescence, most will actually experience a noticeable reduction in motoric restlessness or hyperactivity (O’Neal, Preston and Talaga 2010, 71), but their other symptoms will remain, possibly (and hopefully) to a lesser degree. This can be due to how their brains continue to grow and develop throughout their adolescence and early adulthood. There may be an opportunity for rewiring of the brain during a period in adolescence in which neurons proliferate and then are pruned back to complete the development of the frontal lobes (Rider and Sigelman 2006, 467). However, this doesn’t happen in every case. I have seen studies showing anywhere from 33-66 percent of people will remain with an ADHD diagnosis as an adult. In an article published on this topic by Brian Krans, he referenced lead investigator Dr. William Barbaresi, MD. We suffer from the misconception that ADHD is just an annoying childhood disorder that’s over-treated…this couldn’t be further from the truth. We need to have a chronic disease approach to ADHD as we do diabetes (Krans 2013). If some people with ADHD don’t display symptoms as adults, have they been cured? Well, think about it like this: Brain maturation and efficiency has to do with genetics and also environmental factors playing key roles in the disorder that cannot be predicted. It’s not a "do something specific approach, and then a you will be cured result. The do something specific" method is great at symptom reduction, but it will not guarantee an absence of symptomology.

Dr. John D. Preston, Psy.D., ABPP, is a neuropsychologist and professor emeritus at Alliant National University and has authored over twenty books on psychotherapy, neurobiology, and psychopharmacology. He coauthored a book with Dr. John H. O’Neal, M.D., a board certified psychiatrist at Kaiser Sacramento Medical Center and assistant clinical professor in the department of psychiatry at University of California, and also with Dr. Mary C. Talaga, R.Ph., Ph.D., a pharmacist for over thirty years with a specialty in psychiatric pharmacy. These three authors agree that children’s hyperactive symptoms should diminish significantly in adolescence and adulthood, but the core symptoms of ADHD (impulsivity, impaired attention, and lack of intrinsic motivation) will most likely continue (O’Neal, Preston and Talaga 2010, 71).

HOW MANY CHILDREN HAVE ADHD?

According to Dr. Russell A. Barkley Ph.D., leading researcher on ADHD, more than 50 percent of parents report that their toddler is hyperactive (R. A. Barkley 2013), although only an average of 5 percent of children actually ever obtain an ADHD diagnosis (which is why chapter 6 will be important to read to distinguish between normal hyperactivity in a toddler versus an excessive amount). Out of the 5 percent of children with ADHD, there are at least twice as many more boys than girls (O’Neal, Preston and Talaga 2010). Furthermore, the highest increase in medication-use in the preschool and kindergarten age group is among boys; of medication used, nearly 70 percent is given to boys (Gurian 2001, 119).

Many people think ADHD is on the rise, especially because ADHD medication is actually on the rise. However, most researchers say that ADHD has always been around but was possibly recognized as some other syndrome or just as an out-of-control kid in generations past.

To find more specific information on population statistics, you can visit the Centers for Disease Control and Prevention website at http://www.cdc.gov

WHY IS THERE CONTROVERSY OVER AN ADHD DIAGNOSIS?

There is controversy over ADHD for several reasons. The first is that sometimes children are misdiagnosed. There can be difficulty with obtaining an accurate diagnosis due to a variety of issues that will be explored throughout this book, but because misdiagnosis does occur, people become confused by their child’s so-called disorder and end up thinking it’s not real. I’m here to tell you, it’s not the tooth fairy, people—it’s real!

There are also those who think ADHD is just an excuse for negative behavior, and therefore, it must just be a made-up disorder. These people might assume hyperactive or impulsive children with ADHD are just bad kids, or they might even think these out-of-control kids just have bad parents. Some might assume children who present as inattentive might just be lazy or defiant. Part of the reason that people are unsure about ADHD being real is that ADHD really can look like these things noted above.

As an example, you might notice a child who is able to focus intently on something he really likes to do, such as a video game, but the child struggles with homework completion. People might assume the child is just lazy and defiant and making excuses. If someone is unaware of how ADHD can present, it is definitely possible to presume the video-game-playing child does not have ADHD—since they obviously have the ability to pay attention to something. In actuality, this assumption can be wrong: Children with ADHD will show limited intrinsic motivation to stay focused, especially on mundane, non-exciting, or low-stimulus–value tasks (O’Neal, Preston and Talaga 2010, 73), such as schoolwork, specifically because of certain factors associated with ADHD. (These factors will be further discussed in chapter 5). Some children also may hyper-focus on what they enjoy (the video game in this instance), meaning they struggle with paying attention to anything else around them during these times.

There is also controversy over an ADHD diagnosis (in toddlers specifically) because previously, it wasn’t research-based practice to give a preschooler or kindergartner an actual diagnosis. This has changed, and you will read about it in chapter 5.

Although there may be some minor physical abnormalities that occur in people with mental health issues more so than the general population, such as eyes more widespread, webbed toes, etc., these are not usually overtly noticeable to the general public, unless pointed out, and these issues don’t occur in every child with ADHD. Therefore, children with ADHD do not physically look any different from their typically developing peers; ADHD is not something that can be seen. These children’s behaviors can be seen, but because they look normal, people assume that ADHD is not a real condition.

Kerri Houston is national field director for the American Conservative Union and has two children with ADHD. The following quote comes from her article, Time to Focus Correctly on ADHD.

No other childhood illness is viewed with more prejudice than is ADHD. When its symptoms and effects are misrepresented and misreported, the implication is that victims of this disease—children already at great risk as they struggle with academic requirements and appropriate peer interactions—are somehow at fault. Would we find a victim of juvenile diabetes at fault for the dysfunction of his pancreas? Of course not! Then why is it acceptable to imply that children with ADHD symptoms are somehow responsible for the visible manifestations of their dysfunctional brains? (Houston 2002).

It’s important to note that attention-deficit disorders were previously called minimal brain dysfunction. Not that I think this title should have remained, but I think that more people would accept that as a diagnosis of something real.

HOW IS ADHD CLINICALLY DEFINED?

According to the DSM-V, the manual that mental-health clinicians and physicians reference, attention-deficit/hyperactivity disorder (ADHD) consists of a pattern of behavior that is present in multiple settings, where it gives rise to social, educational, or work-performance difficulties for at least six months. There are three presentations of the disorder: predominantly inattentive presentation, predominantly hyperactive/impulsive presentation, and combined presentation. There are a specific amount of symptoms needed to qualify for each of these presentations. It seems as if these presentations are on a continuum of severity depending on the amount of symptoms one has and also the symptoms’ intensity levels. (There are two other forms of ADHD as well. These forms are other specified ADHD and unspecified ADHD. In both of these, the person does not display the full criteria necessary for the disorder).

Predominantly Inattentive Presentation

In the inattentive presentation, people with ADHD can become distracted by an extraneous stimuli equally as often, slightly more often, or excessively more often than those without ADHD, but the reality is that a person with ADHD-inattention definitely has a harder time becoming refocused on what they were doing before they became distracted. They also tend to hyper-focus on things that they are particularly interested in, and then they can’t pay attention to anything else around them: someone’s voice, a doorbell, etc. These people also tend to lose items, find it difficult to keep appointments, seem disorganized, forgetful, and need directions repeated several times. They tend to rush through things, avoiding attention to detail, or often not completing what it was they had started. More symptoms follow.

Some people may say that there is a specific set of symptoms that are on the ADHD inattentive presentation continuum: Sluggish Cognitive Tempo symptoms- or SCT. It’s important to note that an SCT clarification is not actually in the latest DSM-V, which came out in May of 2013. (Some say SCT its own disorder all together, which then can present either on its own or in combination with any of the ADHD presentations). Wanting further information, I sought out a study: Validity of the Sluggish Cognitive Tempo Symptom Dimension in Children: Sluggish Cognitive Tempo and ADHD-Inattention as Distinct Symptom Dimensions in the Journal of Abnormal Child Psychology by SoYean Lee, G. Leonard Burns, Jerry Snell, and Keith McBurnett. They state that an alternative proposal is that attention problems without HI [hyperactive-impulsive] symptoms represent two different disorders with each disorder involving a different type of attention problem (Lee, et al. 2014, 8). They claim SCT symptoms seem to be more of a daydreamy and passive type of inattention, rather than the typical distractible type of inattention. They claim SCT seems to be characterized by confusion, daydreaming, mental fogginess, hypoactivity, and social passiveness and withdrawal. These people lose their train of thought, their attention fluctuates, their thinking and movements are slow, and they show low initiative (Lee, et al. 2014). I have always included these types of symptoms in an ADHD inattentive presentation, and you will notice that as I discus ADHD throughout this book, I discus some of these symptoms. I just want you to be aware of what some term SCT because this term is coming up more and more these days.

Predominantly Hyperactive-Impulsive Presentation

A person with the hyperactive/impulsive presentation is usually noticed before an inattentive presentation. This person with ADHD may struggle to wait his turn, interrupts others, take over activities, is hyper-responsive (overreacts), struggles to remain seated or fidgets in his seat, has a loud voice (and loud feet), is hyperverbal, runs, jumps, and climbs in inappropriate places, and/or seems as if he is driven by a motor.

Combined Presentation

The combined presentation obviously combines symptoms together from the hyperactive impulsive and inattentive presentations.

More Clinical Features

As for ADHD in general, the DSM-V also details diagnostic features, associated features supporting diagnosis, prevalence, developmental course, risk and prognostic factors, culture-related diagnostic issues, gender-related diagnostic issues, functional consequences of ADHD, differential diagnosis, and comorbidity (dual diagnosis). In the DSM-V, these sections go on for several pages! In short, these areas discuss how people with ADHD have a high potential for harm due to lack of impulse control (darting into the street was an example listed in the manual). They can have elevated novelty-seeking. They may have a significant need for immediate gratification and struggle with the ability to delay gratification. They can have low frustration tolerance, irritability, and mood lability. They may struggle with memory and their executive functioning skills and have delays in language, motor, or social, or speech development. Some have reduced school performance and social rejection. The DSM-V also confirms prevalence in the population to be 5 percent in children and 2.5 percent in adults and that the ratio is 2:1 for boys and girls.

As for prevalence across different racial groups, regions of the world, and socioeconomic status, its reported that people in minority communities tend to be underdiagnosed and undertreated for ADHD for a number of reasons, including, among other factors, cultural perceptions and access to health care. As is the case with the general population living with ADHD, a lack of treatment and support can lead to serious consequences across the lifespan for people in racial/ethnic minority communities (NAMI n.d.).

The DSM-V also states that among first-degree relatives, the prevalence of ADHD is substantial, although inheriting the genes correlated with the disorder is not necessary, showing that environmental causes (such as alcohol during pregnancy or external injury to the frontal lobe) can also influence the illness’s outcome. The authors mention that very low birth weight—lower than three pounds, four ounces—conveys a two-to-threefold risk for ADHD, but states most children with low birth weight do not develop ADHD. The comorbidity rates with ADHD and other disorders are substantial (American Psychiatric Association 2013). In fact, even if a child does not have another actual diagnosis, even by adolescence, it’s likely she shows signs and symptoms of depression and anxiety (without meeting the full DSM-V criteria for these other disorders). These symptoms of depression and anxiety have to be closely monitored because they may seem like depression and/or anxiety, but they could just be symptoms from the child’s ADHD. In chapter 5, you will learn about the overlapping symptoms.

When mental-health professionals investigate a toddler’s current symptoms, they look to see if they do in fact match the ADHD indicators based on the child’s chronological age and where he should be developmentally. They also look to the past and require information regarding the onset of symptoms and a detailed family history. While gathering this information, they will attempt to rule out these factors:

» normal temperament

» situations or stressors leading to externalizing behaviors

» medical issues

» other mental illnesses presenting similarly with overlapping symptoms

CHAPTER 3

What Causes ADHD

W hat causes ADHD? Evidence shows that genes influence brain chemicals, brain waves, and brain structure, which then can lead to ADHD symptoms. There is also evidence to suggest environmental factors significantly increase symptomology in a person predisposed to the disorder. While an anatomical analysis of the brain is beyond the scope of this book, most parents and clinicians are concerned about both aspects of these causes, so let me at least touch the surface of the t opic.

HEREDITY AND GENES

This is of personal interest to me, since my twins were confirmed identical by a DNA test, and the twin studies are always so fascinating for the nature/nurture debates. I have identical twins, with an identical pregnancy, with identical brain structure, with identical onset of symptoms, and with identical upbringing. I thought of asking the DSM-V committee to formulate a new diagnosis: Identical-Twin–Induced Hyperactivity Disorder. I didn’t think they’d go for it, so I refrained from asking the team! The DSM-V states that infants with low birth weight have a higher chance of ADHD. However, my twins were not born early, nor did they have low birth-weights: thirty-eight week scheduled C-section and fourteen pounds. They were strong, healthy baby girls at birth. My other toddler (typically developing and twenty-five months younger than them) does not show any signs or symptoms of ADHD yet, nor does she have a speech delay as the twins did. She obviously has different genes but is being raised in the same environment. I have my own research study playing out in my own house!

Maggie Fox is a senior writer for NBC News, and she interviewed Dr. Jordan Smoller of Massachusetts General Hospital, who led a study of mental illness and DNA roots. As far as the genetics, the statistics show that if one parent has ADHD, 60 percent of the children will have it. If both parents have ADHD, this increases the chances to 90 percent of their children (Fox n.d.). Based on these heredity studies, it seems as if genes play a major role in addition to environmental factors affecting these genes in various ways. When genes are studied, many different ones seem to be involved in this illness. Jacob Silverman is a contributing writer to the website Discovery Fit and Health. He claims, Researchers have not found one single cause or one single gene … General consensus among researchers now points to some genes playing major roles in ADHD’s development, with numerous…genes likely playing smaller parts (Silverman n.d.). Chiropractor, Dr. J.G. Moellendorf has more to add: From the 1990 research findings of Dr. Kenneth Blum, the A1 allele of the DRD2 dopamine receptor gene on chromosome 11 appears to be the most frequent cause of ADHD (Moellendorf n.d.). The DRD4 gene is also a dopamine gene, and people with ADHD tend to have this gene in a longer form. This gene may make their dopamine nerve cells in the brain less sensitive to normal amounts of dopamine, (R. A. Barkley 2013, 85). Because of this, the person will need more dopamine in their brain to get their brain to a baseline level or arousal. As stated earlier, this can be a reason for novelty seeking in the ADHD patient. Next,