Should Your ADHD Child See a Cardiologist Before Taking Medications?

The American Heart Association recently recommended an ECG (electrocardiogram, sometimes mistakenly called an EKG) before a child is started on a stimulant medication for ADHD. Approximately two years ago, the FDA recommended a black box warning for patients taking AD/HD medications regarding the potential for cardiovascular events in patients with serious, pre-existing structural cardiac abnormalities.

Should parents of children with AD/HD be alarmed by these recommendations? The answer is no. Medications for AD/HD are considered safe when used in appropriate doses used to treat AD/HD in children, adolescents, and adults without serious cardiovascular disease. The incidence of serious cardiovascular events in children taking medications for AD/HD is very low, and is similar to the incidence of cardiovascular events in children not taking medications.

The above recommendations were not made to limit the use of AD/HD medications, but to help identify children with pre-existing heart disease who may be at risk when taking such medications.

Your child's doctor should take a "Heart History" prior to prescribing AD/HD medications, and your child should be seen regularly (approximately every three months) to monitor their blood pressure and heart rate. A heart history should include:

1. A family history of a sudden, unexplained death at an early age; a heart attack in relatives younger than 35; a history of cardiac arrhythmias; and a family history of any cardiac "syndrome."


2. A history in the child of fainting or dizziness (particularly with exercise); a history of any chest discomfort, chest pain, or shortness of breath with exercise; a change in exercise tolerance; a history of palpitations, increased heart rate, extra beats or skipped beats, high blood pressure, or a significant heart murmur.


3. A history of prescribed medications, over-the-counter medications, and "natural" supplements taken by the child

Your child's doctor should do a physical examination looking for an abnormal heart murmur and other cardiovascular abnormalities, features of Marfan's syndrome (an inherited connective tissue disorder), and measurement of blood pressure and heart rate.

The American Heart Association is also recommending that an ECG be done prior to starting a medication for AD/HD, and if abnormal, a referral to a pediatric cardiologist. Not all doctors will order an ECG if the heart history and physical examination are normal, without evidence of heart disease, because the potential incidence of cardiac toxicity from AD/HD medications is so low. Even the American Heart Association admits that there have been no large studies proving that AD/HD medications have caused sudden cardiac events.

In summary, although recent recommendations are not cause for alarm, taking a heart history, doing a physical examination, and monitoring children, adolescents, and adults on medications used to treat AD/HD should be standard practice. No mother and child should walk into a doctor's office with a rating scale completed by the child's teacher, and walk out 15 minutes later with a prescription. An evaluation for AD/HD should be comprehensive, and should include a comprehensive history of possible medical problems, emotional problems, and problems commonly co-existing with AD/HD. A comprehensive evaluation should lead to a comprehensive treatment plan, with a specific treatment for each problem identified.

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Iron Supplements for ADHD

Iron supplements are sometimes recommended as a treatment for ADHD. Studies have found that children with ADHD are more likely to have low levels of iron than children without ADHD, and iron deficiency seems to correlate with the severity of ADHD symptoms.

Iron is needed by the body to make the neurotransmitters involved with ADHD, including dopamine, norepinephrine, and serotonin. There is not enough scientific evidence to recommend iron supplements to all children with ADHD. However, there are a few early studies, which have not been confirmed by additional research, suggesting improvement in ADHD symptoms, as well as learning problems, in children low in iron.

The recommended dose of iron sulfate is 5 mg/kg/day. High doses of iron are toxic, and rarely lethal, so caution is needed about giving the appropriate dose and keeping iron supplements in a safe place to prevent accidental poisoning by younger children.

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• Are Herbal Supplements OK for Kids?
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Technorati Tags: ADHD, ADD, iron supplements

Home DNA Testing for ADHD

Many companies are now offering self-administered genetic tests over the internet for various conditions, including ADHD and Bipolar Disorder. However, many of these tests might be misleading to the public because they offer predictions that are not scientifically proven and may provide information that is not meaningful.

Genetic testing looks at genes (DNA instructions inherited from relatives), chromosomes (contain DNA), or biochemical tests that test for enzyme levels. Genetic testing might help diagnose a disease or condition if someone already has symptoms, show whether someone is a carrier for certain genetic conditions, determine whether an unborn child will have a genetic condition, screen infants for missing proteins that can cause a disease, determine whether someone has a genetic predisposition to a disease before symptoms become apparent, and guide the selection of a particular medication or dose of medication for a particular person.

Testing is useful for rare types of cancers that run in families, for conditions such as Sickle Cell Anemia and Cystic Fibrosis, and for women who might be at risk for having a child with a chromosomal abnormality. However, I wouldn't send a sample of your saliva or cheek swab for psychiatric or behavioral conditions, along with a check for hundreds of dollars, just yet.

Where I find genetic testing sometimes useful is in determining the appropriate dose of Strattera, a medication used to treat ADHD. Genes determine how rapidly a person's liver enzymes break down Strattera. People who metabolize Strattera slowly will have higher than expected blood levels of a particular dose of Strattera, along with increased side effects, and people who rapidly metabolize Strattera have lower than expected blood levels corresponding to a poor response. I might have to use very small doses of Strattera for someone who is a slow metabolizer to achieve the appropriate response without significant side effects, and large doses for someone who is a rapid metabolizer to achieve therapeutic blood levels.

ADHD is highly heritable. If one parent or a sibling has ADHD, additional children have about a 30 percent chance of inheriting it, which increases to 50 percent if both parents have ADHD. However, I don't find genetic testing useful for ADHD as it only determines the probability of developing ADHD, not whether someone has ADHD. What you would do for a child at risk of developing ADHD would be good for every child: providing structure, a nutritious and balanced diet low in sugar and high in omega-3 fatty acids, plenty of exercise, and teaching them how to plan and organize their time for schoolwork and activities.

A child with a 30 percent chance of developing ADHD has a 70 percent chance of not developing it. Will genetic testing increase a parent's worry and change the way they interact with their child? Will everyone involved be so alert for signs and symptoms of ADHD that the child is at increased risk for getting a diagnosis when they don't have ADHD? ADHD most likely results from multiple genetic factors and the child's interactions with the environment. There is no genetic test that will diagnose ADHD, and the information provided by available tests tends to make little difference. Many internet sites are misleading, promising diets or nutritional additives that will avoid the use of medications. Someone should always check with their physician or genetic specialist prior to ordering self-administered genetic tests.

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ADHD and Other Disorders

ADHD commonly co-occurs with other disorders, such as depression, bipolar disorder, anxiety, learning disabilities, tics, and substance abuse.

These disorders tend to run in families, tend to be inherited or have a genetic component, whether occurring separately or together. While it’s suspected that there might be a genetic link between ADHD and other comorbid disorders, it’s not yet scientifically proven.

Because of familial transmission and co-occurrence of ADHD and the above disorders, evaluation of ADHD should always include a detailed family history. Over 50% of children, adolescents, and adults with ADHD have a co-occurring disorder which also needs to be treated if treatment is to be successful.

Evaluation and treatment of ADHD should always be comprehensive. Simple rating scales and medication alone are not adequate for most people with ADHD.

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Technorati Tags: ADHD, anxiety, depression, bipolar disorder, learning disabilities, mental health

ADHD Medication Prescription Process Streamlined

The Drug Enforcement Administration (FDA) is now allowing doctors to write up to three one-month prescriptions for ADHD medications during one office visit. Previously, doctors were allowed to write only one prescription per visit. The prescriptions still have to be filled on different dates, but this will streamline the process of obtaining prescriptions.

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