Over the last few years the health care community has been forced to take a hard look at the prescription medications that providers have been putting out into the community. The rampant misuse of doctor prescribed opiates, stimulants, and benzos has compelled clinicians to re-evaluate their methods for treating patients. But as encouraging as this trend has been, it is still important for us as patients and consumers to take an active role in our treatment. A balance must be struck between relying on the expertise of providers and being conscious of what we choose to consume.
I want to preface this by saying that the correct medication can do wonders for your mental health. The difficulty stems from (1) thinking that ONLY medications can help and (2) not taking the time to figure out the true nature of the problem before deciding on treatment.
Rule out other causes
It may be tempting to want to get your child on an ADHD medication at the first sign of problems in the home or school. The presence of inattention, difficulty concentrating, irritability, excessive activity or aggression can all be disruptive to your child’s academic success and relationships with family or friends. But, like most endeavors, mental wellness must be built on a solid foundation that cannot be rushed. And the best place to start, is with a proper diagnosis.
This is often easier said than done. For example irritability, increased sensitivity, sleeplessness, temper tantrums, and difficulty concentrating can all be seen by your clinician as signs of ADHD. However, these symptoms are also what you might expect to see with DEPRESSION, as it presents in children. Taking the time to ensure a thorough diagnosis may save you years of chasing your tale with minimal benefit (not to mention money).
Who should I have diagnose?
First and foremost, a diagnosis of ADHD has to come from a health care professional. Resist the urge to self-diagnose! While no one would argue that you aren’t the expert on your child (you almost certainly are) there are clinicians out there who are experts in mental illness, which is what you need. If your child’s school is lucky enough to have a school psychologist, try reaching out to them to discuss options. In the community, the primary clinicians diagnosing ADHD are psychiatrist. These are medical doctors, with expertise in treating mental illness, and they are the only providers (at least in Kansas and Missouri) that can prescribe medication. A Licensed Psychologist may also be a good person to reach out to for an initial diagnosis. Although they cannot prescribe, they can help you create an optimal treatment plan for your child.
With all respect to teachers out there, teachers should not be diagnosing. A well-reasoned recommendation from your child’s teacher may be worth taking into consideration, as they do spend a significant amount of time with your child in a structured environment. But teachers should never diagnose. I would also strongly encourage against letting your primary care physician prescribe psychopharmaceuticals to your child. While they may have had some training in the past on mental illness, that does not mean they’re still well versed in the subject (you likely wouldn’t let your pediatrician perform an operation on you right?). It’s far if your PCP suspects your child may be suffering from a mental illness, to just ask them for a recommendation to a good psychiatrist or psychologist.
What goes into a GOOD diagnosis?
As I previously stated, there is no definitive test for ADHD. I am fond of saying things like, there’s no thermometer for depression or blood test for inattention,. but that does not mean we should be taking shots in the dark hoping to hit something; especially when it comes to prescribing medications to a developing brain. There are some ways for you to know that your child is receiving a good, well thought out diagnosis. A thorough evaluation should include the following:
- Extensive history. Any thorough diagnostic intervention is going to include a detailed history going back to infancy or earlier. You never know where important diagnostic information may pop up, so having as much information as possible is a plus.
- Multiple settings. An often overlooked aspect of ADHD is that it appears in multiple settings. You would normally expect impairment to be fairly global, with signs of hyperactivity/inattention appearing in multiple areas of life. If you only see symptoms in one area (at school, at home, out with friends, etc.) then it would be a good idea to explore other diagnoses.*this can be accomplished through testing discussed below*
- Areas of strength, aside from the difficulties, children with ADHD almost always have tasks or topics for them that are considered strengths and aren’t impaired by symptoms of hyperactivity or inattention. When interviewing parents of children with ADHD, you almost always hear, Little Johnny just can’t focus on anything, except when it comes to ______ . With that he’s focused in. It’s important to focus on these areas (reading, video games, sports, etc.) and take them into consideration during diagnosing.
- Psychological testing. I know, I know, I said there’s no DEFINITIVE test for ADHD. But there are assessments that can lend some measure of objectivity to the diagnosing process and help rule out other issues besides ADHD. These tests include the Conners 3, BASC-3, or Brown ADD Scales and should be administered and interpreted only by a qualified professional. A good psychological assessment should include 1) a developmental history, (2) a parent rating scale, (3) a teacher rating scale, (4) a self-report, and (5) observation.
Now, clinicians certainly don’t HAVE to go through all of these steps before giving an ADHD diagnosis. In fact, there are plenty out there that will give your child a diagnosis and prescription after one, 50 minute interview. But like any treatment, you want to be sure your provider is treating the correct thing. Just like you would want testing done to confirm lung cancer, rather than asthma for example, before starting chemotherapy. Before your provider prescribes your child stimulants, it’s worth taking the time to rule out other causes; like depression.
There are plenty of good and effective medications and treatments available to help manage ADHD symptoms in your child. But, there are ZERO shortcuts. Before you invest the time, energy, and money into your child’s treatment, it’s crucial that you insist your clinician take the time to ensure an accurate diagnosis.
School refusal is becoming and evermore common concern for parents of children and teens. School anxiety effects 25% of school aged children, with 2-5% refusing to attend school altogether. With its short- and long-term consequences being particularly concerning, parents often feel unsure about how to address the problem.
For our purposes, school refusal should be considered separate from general truancy, due to the presence of emotional distress (specifically around attending school) and an absence of antisocial behaviors. School refusal is a psychosocial problem, meaning it can be considered the result of both psychological and environmental issues. This may manifest as complaints of physical symptoms shortly before it is time to leave for school or asking to the nurse, but once allowed to stay home, the symptoms quickly disappear. Common physical symptoms include headaches, stomachaches, nausea, or diarrhea with behavioral symptoms manifesting in tantrums, inflexibility, separation anxiety, avoidance, or defiance.
The emotional distress that is frequently associated with school refusal often manifests as fear or anxiety, with about 50% considered to have anxiety disorders. However, while it is often characterized as anxiety driven avoidance of school and school-based activities, there seems to be no absolute-uniformity in the development of these behaviors. Depression has also been shown to be associated with poor school attendance. And although mood-related issues are often centered around school or school related activities, that is not always necessarily the case. For example, the presence of depression often manifests in symptoms that may result in poor attendance yet not be directly related to school, such as general lethargy and/or loss of interest.
The question then becomes, what can be done to help combat school refusal problems? Most of the research done on school refusal interventions has centered around Cognitive Behavioral Therapy (CBT), behavioral interventions, and psychopharmacological interventions. A 2016 study that examined the effects of combined intervention of CBT and fluoxetine (Prozac) showed significant improvement in school attendance and mood concerns; with the improvements showing stability at 6 and 12 months. Behavioral interventions often draw upon principles of operant conditioning, focusing on how school refusal has become reinforced; either positively or negatively. Graded or In Vivo exposure both have a long history of use in anxiety management and can be implemented to help re-acclimate the child to being in school. Parents can also help support consistent attendance by emphasizing the positive aspects of school, helping to develop a support system within the school, meet regularly with teachers/counselors, encourage distractions such as hobbies and interests, and talking with your child about their feelings/fears about school.
4 Ways to Help Encourage Your Children to Attend School
Although it can be scary and troubling when your son or daughter starts refusing to go to school, it’s important to remember there are things you can do to help.
- Don’t panic! It’s tempting to interpret refusal as disrespect, rather fear or distress. Keep your cool.
- Intervene early, as it will improve outcomes.
- Utilize outside support; spouse, teachers, counselors, therapists, etc. You don’t have to do it on your own.
- Be supportive.
For more information about helping your child or teen manage their anxiety reach out to Armstrong Family Counseling, (913) 204.0582 or at ArmstrongFamilyCounseling.com