▸ Mistake 7: Confusing ADHD with an undiagnosed learning disability. Learning disabilities are more common, with an incidence of 15%–20%, compared with 6%–10% for ADHD, he said.
The physician might, for example, see a young boy who got all As and Bs in school, and, then all of sudden, starts getting Ds in third grade. It could be a learning disability arising at a time when children have to read to learn. Or it could manifest later, such as an inattentive 13- or 14-year-old girl who sits quietly in the back of class and just makes passing grades.
“Be careful of what you call it before you diagnose it,” Dr. Childers said. “Once you label the kid as 'ADHD,' the school will not be looking for anything else.”
One person attending the meeting said sometimes a school asks the physician to treat the child for ADHD on a trial basis. “Parents have told me that the child is not allowed back in school without a prescription for Ritalin,” Dr. Childers said. “I write a letter to school saying they need to make the diagnosis of a learning disability first. It's a war, and difficult if you don't have access to testing.”
The Federal Individuals with Disability Education Act (IDEA) requires schools to test for a learning disability at the parent's request, he added.
▸ Mistake 8: Undiagnosed ADHD in an adolescent. Sometimes it is easy to miss the adolescent with ADHD, inattentive subtype, Dr. Childers said. “We get so programmatic in our approach that the differential list of problems in adolescence doesn't place ADHD high on the index of suspicion.” He added, “Just because ADHD was not diagnosed in childhood doesn't mean it is not there.”
▸ Mistake 9: Insufficient dosing. “Rebound and insomnia is not subtle,” Dr. Childers said. “I use a booster dose. The problem isn't the medicine; the problem is the medicine wearing off.” If a stimulant wears off at 4 p.m. and bedtime is at 8 p.m., a small dose in the evening “can make a huge difference. Kids will be more stable and be able to fall asleep.”
It is important to note whether the insomnia predated the stimulant use. Get a basal sleep history, Dr. Childers advised. Also recommend proper sleep hygiene. “My first question is: Is there a TV in the bedroom? The answer is always yes, and I ask them “Why?” They can't answer it.” Remove the television forever, and give the child a bath and warm milk before bedtime, he said. “That is enough for most kids.”
▸ Mistake 10: Overdiagnosis of bipolar disorder. More and more parents are coming in and saying, “My teacher, aunt, therapist, neighbor, etc. said my child has 'bipolar disorder,'” Dr. Childers remarked.
The adult prevalence of bipolar disorder is 1%–1.6%, according to a National Alliance of Mental Illness Fact Sheet, January 2004. “It's not a curable illness. Bipolar is a lifelong diagnosis. So how can 7% of children have bipolar disorder?”
A much more common diagnosis is a combination of ADHD and oppositional defiant disorder (ODD) versus bipolar disorder, Dr. Childers said. “The one big difference I always look for is a trigger to the behavior. If a parent says, 'Every time I tell him no, he has a tantrum,' it is unlikely it's bipolar disorder, and more often it's ODD.”
Dr. Childers said he tells parents that they should have three goals for their child that appropriate management of ADHD can help to achieve: a happy childhood, a successful academic experience, and out the door and independent by age 18.
Dr. Childers had no relevant financial disclosures.