ADHD Treatment By Jay D. Tarnow, M.D.
As parents of children with ADHD/ADD, we are most concerned about what the future will bring for our children. The reason that we often choose to put our children on stimulants is to hopefully prevent problems in their future. We are concerned about our children's ability to take care of themselves as adults and to be productive members of society. Therefore, in using medication our goal is to help our children learn, keep up with their peers, and to reach their potential. In addition, we want to maintain their self-esteem and help them achieve the highest level of psychological, emotional, and social development. This is not an easy task with a child who has ADHD/ADD. Their attention problems interfere with multiple areas of their development. This is the reason that I believe that the use of only medication to treat children with ADHD/ADD is not in the child's best interest. We must approach this disorder in a comprehensive manner dealing with any impediments of their development. A child's work is school. This is a time in life when learning is of major importance. During our childhood, we learn at a faster pace and more than in the rest of our lives. This work of learning has a major effect on our future. This has been underscored repeatedly in research in terms of the difficulties that occur when a child has Attention Deficit Disorder, as well as a learning disability. Therefore, in my evaluation of children, their educational status is of the utmost importance.
There is recent research that underscores the importance of identifying children with language disorders. There is abundant evidence that children with speech and language impairments are at increased risk for psychiatric disorders and behavioral problems. Studies in psychiatric clinics have shown reported elevated rates in speech and language problems varying from 30 to 50%. What was very surprising was that most of these children were unsuspected of having these speech and language impairments. Follow-up studies have also shown that children identified with speech/language impairments in preschool have increased rates of behavior problems when reassessed in later childhood. More recently, a study emerged out of Canada entitled the "Ottowa Language Study", which is a 14-year prospective language study of speech/language impaired and control children from a community represented sample. Previous findings revealed that age 5 children with speech and language impairments have increased rates of concurrent ADHD and anxiety disorders, and increased rates of psychiatric disorders at age 12. Furthermore, at age 5, speech and language impairments were associated with adolescent disorders even after controlling for disorders in early childhood. Children with auditory comprehension and pervasive language problems at age 5 were more likely to experience concurrent and early adolescent behavior problems compared with those with speech impairments alone, as well as control participants.
Just recently, there is the first long-term follow-up study of children with speech and language problems (14 years). The prospective study results support the association between early childhood speech and language functioning and young adult psychiatric disorders over this 14-year period. Both clinic and community studies have reported increased rates of anxiety disorders and withdrawn behaviors among speech and language impaired groups entering adolescence. New findings of this 14-year prospective Canadian study find that this association was also seen in young adulthood. The most common anxiety disorder found in these young adults was social phobia. Also, boys with speech and language impairment were more likely to develop antisocial personality disorder as young adults than controls.
So what do all of these findings say to us in light of ADHD/ADD? In my opinion, it says that it is extremely important to evaluate children for speech and language disorders. Many of these children are misdiagnosed with ADD because they are inattentive, distractible, have difficulty following directions, and do poorly in school. In addition, many of them have social difficulties because of their language problems. It is very difficult to distinguish central auditory processing disorders from ADD, inattentive type. So what happens when a child has both ADHD/ADD and a language disorder? At the Tarnow Center for Self-Management we are very concerned about this issue since we have a speech and language therapist, as well as a learning diagnostician on staff. Our findings show that these children develop high levels of anxiety in addition to their ADHD. This anxiety worsens their ADD symptomatology and they are often children who do not respond well to stimulants. This would make sense since one of the effects of stimulants is to potentially increase jitteriness and anxiety. Therefore, the child may become more hyperactive on the stimulant, become withdrawn, have increased stomachaches, headaches, or express "just not feeling right." My experience has been that these children require first the treatment of their anxiety disorder, as well as effectively intervening with their language disorder. Then, the use of a stimulant can be very, very helpful, particularly in helping them compensate for their language disorder. We find that if untreated, these children have a higher incidence of conduct disorders, oppositional defiant disorder, and substance abuse in adolescence.
Therefore, the bottom line is that ADHD/ADD is not simple and should not just be treated with medication. These speech and language disorders can be very tricky in evaluating and even more so in treating. Luckily, at this point in time, we have found a more effective treatment for speech and language disorders entitled "Fast ForWord." This new technique uses computer technology and has effects on brain pathways. We have found it particularly helpful with children with the combined ADHD/ADD and language disorder. Now that we have new technologies, especially brain imaging, the underlying causes of these problems are being identified. This will lead to newer technologies to treat these complicated disorders.