Online Letters to the Editor

ADHD: Management Beyond Medication

TO THE EDITOR: The article “Attention-Deficit/Hyperactivity Disorder: Management,”¹ by Drs. Szymanski and Zolotor, is a good general primer on this condition. This article addresses the major diagnostic criteria for the diagnosis of attention-deficit/hyperactivity disorder (ADHD) according to guidelines in the Diagnostic and Statistical Manual of Mental Disorders, 4^th edition (DSM-IV), and treatment with stimulants and other medications. However, the authors only briefly address parental education, school-related issues, and counseling.

Medication is an important and, sometimes, essential component in managing children with ADHD, but family physicians need to understand that simply prescribing medication and sending the child off to special education only touches the surface of the role that they can play. I urge that we as family physicians develop a better understanding of the school-related issues that face children with ADHD.

As the authors mention, children with ADHD have basic learning issues, including difficulties with concentration, attentiveness, impulsivity, hyperactivity, organizational issues, planning and other skills known as “executive functioning,” and are often poor readers. Children with ADHD are often bright, but many lack the visual processing skills needed to read, they focus poorly, and they suffer from many characteristic learning disabilities. Because of these factors, they often learn by different modalities than other children.

The traditional classroom environment is often too rigid and not easily adaptable to children with ADHD. These children often cannot do the work that other children do, and without recognition of these school issues, they often get further and further behind. Because they cannot do the work in the same way as the other children, their intelligence is rarely recognized. As a result, their behavior simply gets worse and they get bogged down with behavioral consequences instead of getting the kind of learning experience in which they can excel. Other methods of instruction and evaluation should be considered. Placing children with ADHD in special education classrooms is often not the answer. Many special education programs are underfunded, and children with ADHD are often mixed in with children who have serious developmental delays or have more serious psychiatric conditions. Teachers and educators must understand the neurophysiology of ADHD, how it impacts behavior, and how it impacts a child's ability to learn. ADHD must be recognized early, so that learning issues can be addressed with the same urgency as behavioral issues. Children with ADHD need to be evaluated by the school as early as possible; they should be instructed differently, and they should be evaluated differently according to their strengths and weaknesses.

Family physicians need to take a more aggressive stance in making sure that children with ADHD get the appropriate school evaluation, assistance, classroom modifications, support, understanding, and remediation. The school environment is essential to the success of treatment. If a school district is not providing the kinds of educational services that are required for any chance of success for these children, it is the responsibility of family physicians to involve themselves in less traditional ways.

EUGENE HEYMAN, M.D.
20 Elm St.
Pittsfield, MA 01201

REFERENCES

1. Szymanski ML, Zolotor A. Attention-deficit/hyperactivity disorder: management. Am Fam Physician 2001;64:1355-62.

IN REPLY: Many students with attention-deficit/hyperactivity disorder (ADHD), when diagnosed early and treated with an appropriate medication regimen, do not require special education services or long-term counseling. These students can return to and succeed in mainstream education. Early diagnosis and treatment can prevent the negative self-image and dysfunctional compensatory behaviors. However, there are students who have a variety of learning disabilities that exist as co-morbidities that need to be identified and addressed. The ability and/or willingness of any public school system to help identify the problem and provide the necessary assistance is extremely variable. This support is influenced by school and governmental administrations, public and parental attitudes, and the amount of federal, state, and local money budgeted for this purpose.

MICHAEL L. SZYMANSKI, M.D.
Dexter Family Practice
7300 Dexter-Ann Arbor Rd.
Dexter, MI 48130

ADHD and IQ Testing

TO THE EDITOR: In response to the article “Attention-Deficit/Hyperactivity Disorder: Management,”¹ by Drs. Szymanski and Zolotor, I would recommend that readers consider intelligence in the differential diagnosis. I have started ordering IQ testing on select patients and have found a fair number of geniuses among this population who would otherwise meet the criteria for treatment. These children, some of whom have IQs greater than the average physician’s IQ of 126, are not challenged by repetitive curricula and need additional and more complex assignments to hold their interest. They should also be placed with the best teachers because many can outsmart their adult instructors.

DON J. WOODHOUSE, M.D.
510 Bank St.
Webster City, IA 50595

REFERENCES

1. Szymanski ML, Zolotor A. Attention-deficit/hyperactivity disorder: management. Am Fam Physician 2001;64:1355-62.

IN REPLY: Dr. Woodhouse's point is well taken. However, I would not advocate routine IQ testing for all patients evaluated with attention-deficit disorder (ADD). I agree that for a select group of patients, IQ testing may reveal the bored, yet unrecognized genius, who would likely be better served by changes in the learning environment. Nevertheless, keep in mind that intelligence and attention deficits are thought to be independent factors that influence ones ability to function academically and interpersonally. A diagnosis of ADD does not indicate a low IQ, and a high IQ does not eliminate the potential existence of attention deficits. The decision to intervene in whatever fashion (e.g., medication, further neuropsychological evaluation, change of academic/work environment, counseling) is complex; this decision should be influenced by the quality and severity of initial dysfunctional behavior and academic difficulty. Further evaluation should definitely be considered before medication is prescribed in patients where there is a significant discrepancy in the observations of different persons or when the patient is in different settings. Similarly, if a medication trial fails to meet treatment goals, further evaluation might turn up a common comorbidity (e.g., depression, sleep disorder, hyperfocused/compulsive, aggressive/oppositional) as well as the learning disabled or the emotionally impaired student.

MICHAEL L. SZYMANSKI, M.D.
Dexter Family Practice
7300 Dexter-Ann Arbor Rd.
Dexter, MI 48130