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Attention Deficit Disorder

What are the diagnosis criteria of attention deficit?

According to the DSM-IV, a child has attention deficit disorder if he or she presents at least six symptoms in one of the following three categories: inattention, hyperactivity and impulsivity. He or she must present these symptoms before the age of 7, for at least 6 months, and to a degree that does not correspond to the mental development of a child of the same age.

Inattention: The child often cannot pay attention to details or makes absent-minded mistakes in homework, tasks or other activities; often has difficulty sustaining attention in work or games; often does not seem to be listening when spoken to directly; often does not comply with instructions and cannot finish homework, household chores or work duties (not due to oppositional behaviour or the inability to understand instructions); often has difficultly organizing tasks or activities; often avoids, dislikes, or is reluctant to perform tasks that require sustained mental effort (such as school work or home work); often loses items that are necessary for work or activities (e.g., toys, school assignments, pencils, books or tools); is often easily distracted by extraneous stimuli is often forgetful in daily activities

Hyperactivity: The child often fidgets with hands or feet or squirms in seat often leaves seat in classroom or in other situations in which remaining seated is expected; often runs or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness); often has difficultly playing or engaging in leisure activities quietly; is often "on the go" or acts as if "driven by a motor"; often talks excessively

Impulsivity: often blurts out answers before a question has been completed; often has difficulty awaiting turn; often interrupts or intrudes on others (e.g., butts into conversations or games)

NOTES: These criteria are only considered based on their frequency and intensity and based on the mental age of the child. These criteria are ranked in decreasing order of importance according to data collected during trials carried out throughout the United States based on the criteria of the DSM III-R relating to behavioural disorders. These behaviour criteria must be observed in both the family and school environment. (It should be noted, however, that certain introverted or shy children may express their ADHD either more or exclusively in the family environment; others are stimulated particularly in the presence of group peers or in a pressure situation). Source: Diagnosis and Statistical Manual of Mental Disorders, 1993, American Psychiatric Association. Source: Diagnosis and Statistical Manual of Mental Disorders, 1993, American Psychiatric Association.

Source: Diagnostic and Statistical Manual of Mental Disorders, 1993, American Psychiatric Association.

Why study sleep in relation to ADHD?

Several human functions are strongly affected by insufficient sleep and include executive functions, self regulation and arousal. These are also the key domains of dysfunction in children with ADHD.
Clinicians have reported sleep problems in an estimated 25-50% of children with ADHD, and studies have indicated that sleep disruption is associated with externalization, hyperactivity and inattention. Sleep difficulties in children with ADHD may increase daytime symptoms and present a considerable challenge for clinicians attempting to develop effective ADHD treatment strategies.

A better understanding of this issue is needed in order to develop new sleep-based therapeutic strategies for ADHD.

How do I enforce punishment to children with ADHD without affecting their self-esteem?

Children with ADHD need discipline and a structured environment. At the same time, parents have to encourage them and help reinforce their self-esteem.
Ridha Joober, MD, PhD. and Natalie Grizenko, MD, 2008

Can adults suffer from attention deficit disorder?

Yes, 40 to 50% of children with ADHD experience symptoms in adulthood.

Ridha Joober, MD, PhD. and Natalie Grizenko, MD, 2008

What is the treatment for adult ADD? Are the side effects in children the same as those in adults?

The same medications to treat children are used to treat adults. The therapeutic effects and side effects are identical. The treatments can completely eliminate symptoms to allow individuals to function at their maximum capacity. It is also possible to treat adults who have suffered from ADD since childhood.

Ridha Joober, MD, PhD. and Natalie Grizenko, MD, 2008

How can I explain ADHD to my child?

There is no one way to do this. The answer to this question will depend on each child and the child's psychological characteristics.

Ridha Joober, MD, PhD. and Natalie Grizenko, MD, 2008

Is there a link between ADD and panic disorder?

Anxiety disorders are more frequent in individuals with ADHD than in the general population.

Ridha Joober, MD, PhD. and Natalie Grizenko, MD, 2008

Can people with ADHD stop taking their medication at one point?

Yes, in certain cases. Others, however, need to take medication throughout their entire lives.

What type of doctor should I consult for adult ADD?

There are currently very few resources despite growing demand. Consult the health centre in your sector for more information. The Web sites of CADDRA and Dr Annick Vincent are very well researched.

Ridha Joober, MD, PhD. and Natalie Grizenko, MD, 2008

Can ADHD symptoms be mistaken for autism or PDD?

Symptoms of ADHD are often observed in children suffering from pervasive developmental disorder (PDD).

Ridha Joober, MD, PhD. and Natalie Grizenko, MD, 2008

What are the risk factors for ADHD: genetics, environment?

Genetic factors explain 80% of cases, while environmental factors account for 20%. No specific gene has been formally implicated as of yet. There are multiple suspected environmental factors: tobacco or alcohol consumption during pregnancy, a lack of oxygen during delivery, severe stress during pregnancy, etc.

Ridha Joober, MD, PhD. and Natalie Grizenko, MD, 2008

Can attention deficit disorder appear with symptoms of confabulation?

Yes, ADD can be concomitant with confabulation.
Ridha Joober, MD, PhD. and Natalie Grizenko, MD, 2008

What is the difference between attention deficit with and without hyperactivity?

Attention deficit can be present by itself; in this case, it is called attention deficit disorder (ADD). However, this symptom is usually associated with motor hyperactivity and impulsivity. When these symptoms are present, the disorder is called attention deficit hyperactivity disorder (ADHD). There are also rare cases of hyperactivity without attention disorder.

- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

How can we help our 30-year-old son who suffers from ADHD?

He's an adult. Encourage him to seek out assistance from specialized services.

Ridha Joober, MD, PhD. and Natalie Grizenko, MD, 2008

Why do some children and adults respond to certain medications, while others do not?

Approximately 80% of people who use stimulant medications, such as Ritalin, have positive results, many of them dramatically so. The remaining 20% have no response to the medications or experience side effects that render it impossible to continue use. If we better understand how the stimulant medications benefit 80% of people, we can learn more about what is causing the disorder and be able to better screen people before stimulant medications are prescribed. (In these cases, often a different type of medication will be successfully prescribed in the place of stimulant medication.) Research conducted at the Douglas Institute supports the theory that most people with ADHD respond best to a combination of clinical therapy (ex. counselling or group therapy) and medication. The team of Natalie Grizenko MD is now investigating which combinations of therapies and medications are most effective.

What should I do with a 15-year-old teenager who refuses to take medication?

You need to find out the reason for the refusal and encourage the teenager to discuss the problem with a doctor or other health care worker.

Ridha Joober, MD, PhD. and Natalie Grizenko, MD, 2008

What is the effectiveness of natural or homeopathic products?

No systematic study has been carried out, but in any case, I do not believe that these products are very effective compared to currently available medications. I would like to point out that the effect of psychostimulants on behaviour is probably one of the strongest among psychiatric pharmacotherapies. The effect is almost immediate in contrast to all other medications. People are always looking for natural products, medications or treatments that are effective. Finding them would be fantastic, but to my knowledge, they do not exist yet.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Why do people stop concentrating after a long period of time?

There could be a number of reasons. You might be distracted by alternative stimuli. Or you could simply be bored or uninspired by the material you have to attend to. One of the outstanding features of the brain is that it doesn't like to be bored! If you're bored by something, then you try and stimulate your brain. One of the theories about AD/HD is that children who are very hyperactive are trying to stimulate themselves because they are bored. That is one reason why they're prescribed Ritalin, which is a stimulant. A stimulant artificially increases the level of arousal of the brain, so the child doesn't have to engage in behavioural strategies to try and overcome his boredom.

Finally, your brain sets limits on what it can take in within a period of time. After about 20-30 minutes, the brain says, “Enough, let me process what I have been given so far, don't give me anymore until I process what I have”. This is why, when you are studying for an exam, it is best to take 10 minute breaks every 30-45 minutes or so, to let your brain assimilate what you have studied to that point, without trying to force more information in.

- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

Are there long-term risks for an 18-year-old who takes Strattera everyday?

If the medication is well tolerated, then there are no risks per se. Strattera can cause some side effects, such as an increase in hepatic enzymes, but this is very rare. No long-term study has been carried out to determine if Strattera is devoid of risk, but I have not heard that taking Stattera over the long-term leads to adverse effects. This medicine is well tolerated, but you still need to be careful.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Can someone develop ADHD or attention problems because of an inadequate environment, parental negligence, or understimulation during childhood?

Children react in a behavioural way, notably through hyperactivity or impulsiveness. Sometimes, these behaviours can be a reaction to a very difficult situation. Child abuse and negligence, for example, can be associated with attention deficits. Attention is very fragile during development. Genetic factors can also play a role. It has also been shown that any early brain trauma can impair attention. In fact, extremely premature babies will often have attention difficulties, as this function is very fragile and can easily can be disrupted by environmental factors.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Why is Adderall not available in Canada and why is it so different from other drugs?

It is available, although it was withdrawn from the market about five years ago for a period of two years due to a warning about sudden death, which turned out to be somewhat unsubstantiated. Adderall is what is known as a “d-amphetamine” (amphetamines come in two forms: the “l” and “d” forms, Adderall being the “d” form). It is in the same class of medications as Ritalin and Dexadrine, which are psychostimulants. It is actually quite a potent medication for treating ADHD symptoms and compares very well, if not better, to Ritalin, for example.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Does eating sugar cause hyperactivity?

This is a common question. I myself have noted in my personal life that certain people become more agitated when they eat sugar. However, I don't know of any scientifically rigorous study that has evaluated the effect of products containing sugar. Many parents are convinced that sugar does cause hyperactivity; however, when their children are tested with sugar or artificial sweeteners, they do not see any behaviour difference.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Are psychologists allowed to assess ADHD?

Since 2009, psychologists can assess mental disorders, including ADHD. Just like psychiatrists, psychologists must use the ADHD assessment criteria listed in the DSM-5 manual. They can therefore also assess the presence of associated or concomitant disorders.

Can learning a musical instrument help cure ADHD?

Music is a useful exercise, but its effect on ADHD has not been proven.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

Should people who are suspected of having ADHD and who are depressed be treated more for ADHD?

That depends. If the depression is major, I would start by treating the depression and see what happens. On the other hand, if the depression is not severe, the signs clearly indicate ADHD, and the depression is a reaction to life's ups and downs, I sometimes start by treating the ADHD. I use my clinical judgement in each case.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Other than medication, are there other strategies that we can use to control ADHD?

Medication is very effective in controlling the symptoms, and there are studies that have compared medication and other  treatments. In most cases, medication alone will help very significantly. Other interventions, such as social skills training, education, school remediation, problem solving, and parental skills training, are also very helpful. The Douglas offers them specifically in cases of ADHD with a coexisting oppositional disorder or conduct disorder. These kinds of interventions become very important.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

When can you determine that medications should be stopped because of side effects?

If you have major side effects, stop the medication. For example, if a child is not able to sleep because of Ritalin, I will stop the medication and prescribe something else, such as Strattera, which does not have as great an impact on sleep. There can be other extremely serious complications though, such as hallucinations, which can lead to psychotic disorders. Psychotic disorders are related to an increase of dopamine in certain parts of the brain. If you prescribe medications that increase dopamine, such as psychostimulants, there is a minor risk of hallucinations or even visions. Overall, I stop the medications, look for other solutions, or add backup medications or other therapies to compensate for the side effects.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

How do you know whether someone has ADHD and not some other kind of psychological distress or family problems?

This question is very important. If a child is hyperactive because of psychological distress within the family and this is constant, the child will always be prone to suffering and dysfunction. The child's developmental history will often give clues to help us determine the cause. If a child has never presented with hyperactivity before the age of eight and then suddenly becomes impulsive, refuses to work, is inattentive, and does nothing at school, then this change is drastic. We then need to look at the family environment to see what could have triggered this change. If it is a type of distress, then resolving this distress could change the child's clinical profile. In these cases, it is probably unnecessary to prescribe medication.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Will interrupting Ritalin have an adverse effect on the child's psychological well-being?

Stopping medication can produce varying effects from child to child. Speak to your doctor before making a decision.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

Is there an alternative treatment to Ritalin that could be effective without such side effects?

We are all working to find this kind of treatment. The purpose of our work is to find alternative treatments that are effective without side effects. For now, most of the treatments we use have side effects. I can say that the side effects observed with Ritalin are not to the magnitude of the side effects we see in other treatments.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

What natural products help children diagnosed with ADHD?

To date, there is no conclusive data regarding the use of supplements, such as: Omega-3, Magnesium, LTO3, ADD, Caffeine, Sugar-free diet, Acupuncture.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

Has TV and/or video games led to an increase in ADHD?

There are studies that indeed show a relationship between attention deficit hyperactivity and extended TV watching, along with a higher risk of being overweight. Often parents say that their child is capable of concentrating on TV. The problem is not being able to concentrate on TV; it’s that sitting there, just like playing computer games, is a passive activity. ADHD appears or manifests when people have to put effort into an activity. The effort is what is very painful for people with ADHD.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Can an eight-year-old child with unmedicated ADHD have problems with insomnia?

Yes. In fact, difficulties falling asleep are often observed in children with ADHD. I have also seen some cases of advanced sleep phase syndrome or delayed sleep phase syndrome. Advanced sleep phase syndrome is when people tend to go to sleep very early and wake up very early. Although a rare condition, it does impair attention levels, because if children wake up at 5:00 a.m., they will of course be very tired by 10:00 a.m., which can lead people to think that the child has attention deficit disorder. Delayed sleep phase syndrome, which is much more frequent, produces the opposite effect. People tend to go to sleep very late and wake up very late. If children go to bed late, they still have to wake up early for the beginning of classes and will be tired.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Are boys and girls affected differently by attention deficit disorders?

Yes, boys suffer from attention deficit hyperactivity disorder more often than girls, who suffer more often from pure attention disorder. Boys with this disorder are also at greater risk of suffering from related disorders, such as oppositional defiant disorder, learning disabilities and depression.

- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

Is ADHD becoming more and more frequent in children?

Personally, I do not believe there is an increase in prevalence. The official diagnosis of ADHD is based on five or six predefined criteria. If experts come to a new consensus that decreases the number of criteria, the number of cases of ADHD would increase. I believe that differences in the prevalence of psychiatric diseases stem from changes in diagnostic criteria, which in turn arise from a new concept of psychiatric disorders within society and from the questions: "What do we want to treat? What do we not want to treat?" Answering these important questions is the responsibility not only of doctors but all of society, which includes the general public, experts, pharmaceutical lobby groups, and patient and parent groups—entities that are always evolving. The basic element in all of this is suffering or dysfunction and what we can do to help.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Where can I find help if I have ADHD?

Different programs exist in Quebec, such as the program at the Douglas Institute, and these can provide help in appropriate cases. We suggest that families first consult a general practitioner, who will refer them to a specialist if he or she thinks that a psychiatric consultation is required. There are other types of support for families and children, such as PANDA associations (for parents living with attention deficit disorder) and LDAQ (Learning Disabilities Association of Quebec).
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

Why do doctors give stimulants to hyperactive people?

The term "stimulant" is probably misleading. They are called psychostimulants because, when given to rats and mice, the animals move around quite a lot. In humans, these medicines improve attention and concentration in a remarkable way and do not lead to hyperactivity. I think that there are very big differences between the animal model and the effects observed in humans. The term "psychostimulant" is not really appropriate in this case.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Do children with ADHD have to take medication all their lives?

Yes, they may need to if the attention deficit remains during adulthood and significantly impacts their functioning. We now have more and more adults who take medication for ADHD. In other cases, medication is no longer necessary after a number of years, specifically when these children get to high school, as they may not feel the need to take medication anymore.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

How can parents learn to help their child with ADHD and oppositional disorder?

What they first need is a lot of good documentation. There are also very good Web sites available, such as the site of CADDRA (Canadian ADHD Resource Alliance). Dr. Annick Vincent from Quebec also has a very good site on ADHD. Good educational books are also available, as are the treatment programs we offer here at the Douglas on Saturdays. These programs provide children with physical activities and social skills training and parents with parenting skills training.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

My son was diagnosed with inattentive-type ADHD in Grade 2, which was then confirmed in Grade 9. Recently, at 22, he was diagnosed as bipolar. Was the original diagnosis incorrect?

No, I don’t think that the initial diagnosis was incorrect. The child’s psychopathology is a little bit diffused, making it difficult to put in a single category. For example, children with bipolar disorder have very frequent temperament changes during the day, fluctuate a lot in mood, and exhibit frequent angry outbursts. People with ADHD have a mood that is very reactive along with hyperactivity that constantly changes over the day. There are ways of differentiating the two diagnoses, but this is sometimes difficult to do in children.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Are sports beneficial for ADHD?

Sports are very beneficial for everyone, but they can indeed help hyperactive children burn excess energy. However, no study has evaluated specific sports programs. Here at the Douglas, we let children participate in sports activities, such as swimming. Since ADHD is associated with a certain immaturity in motor skills, our program helps them improve in this area. It is a myth that hyperactive children become top athletes, as they generally lack the necessary precision and motor skills. There are exceptions: Michael Phelps, who won 7 or 8 Olympic medals, was diagnosed with ADHD as a child.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

At what age does the relationship between ADHD and borderline personality disorder appear?

Not a lot of attention has been paid to this question, and few studies have been carried out in this area. A number of symptoms of borderline personality disorder and attention deficit disorder are similar, such as impulsiveness and instability. Although I don't have scientific arguments to prove this, I believe that a large number of people with borderline personalities also suffer from attention deficit disorder. Psychosis is also commonly associated with ADHD. For example, among the youth in our clinic who suffer from a psychotic disorder, we determined that up to 25% of them have an attention deficit disorder. I think that this problem is widely underestimated and should be examined more closely.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

If you don’t know the genetic background of a child, is it more risky to administer medication given the potential for cardiac problems?

It is important to ask questions about the cardiac health of any child, as there is a possibility of what is called cardiac myopathy, meaning that the heart is bigger in size due to a muscle disease. If its pace increases, there is a risk of sudden stoppage. This is an extremely rare condition, but it’s important to be careful nonetheless. I always ask parents about a child's cardiac history, and if I have any doubts, I do an electrocardiogram. If I see abnormalities, then I will refer to a cardiologist and abstain most of the time from treating with psychostimulants, as there are other treatments.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

How serious is ADHD?

Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed childhood disorder in Quebec and in Canada affecting 3-5% of all children and accounting for the most referrals to mental health centers, special education, and behavioural visits to primary care physicians.

ADHD seriously impairs many areas of childhood functioning, including school, family, self, and peer domains. In addition, a significant burden can be placed on the parents and teachers of children with the disorder. In the majority of ADHD individuals, the difficulties persist into adulthood, which may lead to problems with the justice system or abuse of alcohol and/or other drugs. Therefore, effective intervention for ADHD children should be a major public health concern for Quebec and Canada.

Ridha Joober, MD, PhD. and Natalie Grizenko, MD, 2008

Can taking medication (such as Ritalin or Concerta) lead to dependency?

The literature indicates that Ritalin and Concerta do not lead to dependency. Concerta has the same active ingredient as Ritalin, whose long-term effectiveness has been established.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

I have ADD. Will my two daughters automatically get this disorder?

No, but they are at greater risk than children whose parents do not have ADHD.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

Can ADHD be confused with the manic phase of bipolar disorder?

It is especially the manic phase that poses a problem. When we deal with full manic phases, the diagnosis is obvious. But if a person is experiencing hypomania, which manifests as accelerated ideas, mild euphoria, a lack of sleep, racing thoughts, and motor hyperactivity, these symptoms can resemble hyperactivity. In this case, the two conditions may be confused. However, if the person has a history of depressive phases, the diagnosis is clearly bipolar disorder.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

At what age can parents begin suspecting ADHD in a child? At what age can a child begin medication?

Symptoms can appear before the age of 3 in the form of motor hyperactivity and impulsivity. However, a diagnosis is often only made once the child has reached school age. It should also be pointed out that a number of children who are hyperactive before school age become less so later on. The question of treatment before school age is currently the subject of much debate in the literature, but guidelines have not yet been established.

- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

How can I know whether my child has attention deficit disorder or simply excess energy?

Behaviour disorders and ADHD are separate disorders that are defined by different and precise criteria; however, they can co-exist in the same child. The same is true for learning disabilities. A psychiatric evaluation is necessary in all cases. Only doctors and specialists in mental health who are experts in ADHD can make a diagnosis. Parents can ask their family doctors to refer them to a specialist.

- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

Will the state of health of my child with ADHD improve as he gets older?

Hyperactivity tends to decrease with age, but inattention and impulsivity persist in many cases.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

What is the treatment for ADD without hyperactivity? Is Ritalin necessary in this case?

Medication, social skills workshops, and psychoeducation are useful, but each case must be assessed individually.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

What are the long-term side effects of taking medication for an attention deficit?

This medication can slow growth (by a few centimetres). Apart from slowed growth, the literature has not arrived at a unanimous opinion in terms of the long-term side effects. Ritalin and Concerta have the same active ingredient (methylphenidate), but they have different durations of action.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

Do you think that all children with ADHD need to be medicated?

These children often need to be medicated. Medication allows them to concentrate better and therefore get a better handle on everyday life.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

How can Ritalin be stopped? Are there withdrawal symptoms?

It depends on the medication. You should discuss this with your doctor.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

Are there known methods, other than medication, that can help children deal with an attention deficit?

Yes, psychoeducation for families and a number of educational initiatives that increase children's social skills are important and sometimes necessary. However, the effectiveness of these actions often increases in combination with pharmacological treatment.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

Are physicians prescribing Ritalin as a quick fix for children who don't have ADHD?

This is an often-asked question. Psychiatric disorders vary in terms of symptoms, but have one common criteria: dysfunction. If you have hallucinations and you are not dysfunctional, it doesn't matter. If you have a child and he has AD/HD, but is not dysfunctional, it doesn't matter.

However, if you have a child with AD/HD and his interaction with you is becoming a nightmare and his interactions at school are disastrous, we know that medication can help a lot. The problem is knowing where to set the limits. What is a functional child? What is a dysfunctional child? This is a matter of clinical judgement and has to be discussed between parents, the school and the child.

A child with behavioural problems, who is not acquiring what he needs to develop normally, has an increased possibility of experiencing addiction, drug abuse, lower school achievement, greater family and professional problems, more car accidents etc. When you treat a child very early in life, you're taking a preventative approach—using the same logic you would use in physical disorders.

- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

Why is there a controversy in the medical community about the use of psychostimulants in the treatment of ADHD?

Most medical articles acknowledge that current medications are effective in treating ADHD.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

What are the long-term effects of Concerta and Ritalin, and how are doses reduced?

Dosage is essential when it comes to psychostimulants. In children, we first prescribe a mild dose and then increase it until there is a significant effect and remission. Our goal is always to normalize behaviour or at least achieve a level of quasi-normality, but the limiting factors are side effects, which need to be managed. Full remission without side effects is possible, but generally we have to look for a balance between side effects and benefits. In certain cases these are lifelong treatments, but some people will no longer suffer from an attention deficit when they reach adulthood.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

My son's medication seems to make him depressed and numb. What is the long-term social impact of these symptoms?

Discuss your concerns with your doctor; clearly explain the objectives that you and your child wish to achieve through medication.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

What causes ADHD?

Douglas' research thus far supports the theory that most people with ADHD have a genetic predisposition to the disorder. It seems that, when people with this genetic predisposition are further stressed by factors such as exposure to toxins before or after birth or a lack of oxygen during birth, ADHD symptoms are most likely to emerge. A developing brain is exquisitely sensitive to outside influences. We already know that, when an area at the front part of the brain called the frontal cortex is traumatized, the delicate transmission of neurotransmitters can be permanently disturbed. By better understanding how these neurotransmitters are disturbed, chances increase that we can better compensate for the damage to the brain system.

- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

At what age can you start medication?

Most of the time, medications are started in the first grade and up. Extremely rarely, probably 2 or 3 cases in over 500, the medication is started before school.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Is it good to stop the medication of a child with ADHD for 1-2 days to give his body a rest?

This is possible if the child's behaviour is not too difficult to manage on the weekend.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

Can we get dopamine from other sources, like food?

I don’t think there are ways of manipulating dopamine by dietary means. In terms of serotonin, you can take tryptophan-rich drinks or tryptophan pills to increase serotonin, but this does not work for dopamine.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Are autism and ADHD related?

They are not related, but a good proportion of people with autism have a clinical profile of ADHD. Autistic children can also have comorbid ADHD, which occurs in probably 30% of cases. Another condition that is also highly comorbid with ADHD is Tourette syndrome (the tic disorder), as 60% of these patients will also have ADHD.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Is there a link between ADHD in childhood and psychosis later in life?

The epidemiologic link between the two is probably not very obvious. What we know is that the pathways of ADHD can lead to psychotic disorders, which is a subject that requires further research. For example, we know that people with ADHD are at a high risk of using drugs and dropping out of school. People with this condition don’t always have the healthiest lifestyles. There are also pathways that can lead to psychosis. Although this question has not been on the radar of researchers for a long time, we have started looking at it in our own programs, such as the PEPP. We find that about 25% of young people who experience psychotic disorders have either diagnosed ADHD or a large number of similar symptoms even if they are not diagnosed. At least in the first episode, we see quite a bit and probably a higher proportion of ADHD than in the general population. What complicates things is that people with ADHD can forget to take their medication and tend to “rebel” against medication, which can make things worse. I think we have to be very attentive to this potential issue, particularly during the first episode.
- Ridha Joober, MD, PhD, Mini-Psych School 2012

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