Among the pesticides in common use in the United States today, I am most concerned about the organophosphates – originally commercialized as nerve agents for chemical warfare. A significant study published in the December 2006 Pediatrics links decreased brain development and increased ADHD to organophosphate levels in inner city minority children in New York City.

Researchers from Columbia University, the National Center for Environmental Health, and the CDC measured prenatal pesticide exposure levels and then followed the children for 3 years. After controlling for other variables, the researchers found that those in the high pesticide exposure group were five times more likely to be delayed on the Psychomotor Development Index, almost 2 ½ times more likely to be delayed on the Mental Development Index and significantly more likely to have attention problems, ADHD, or pervasive developmental disorder problems by the time they were 3 years old.

The average child in the U.S. today has evidence of organophosphate exposures about 3 times what the EPA considers safe – some children have 10 times the safe level.

What can be done to reduce exposure levels? The EPA has already moved to restrict the use of these pesticides indoors. I hope the EPA will now take steps to reduce the organophosphates on our food.

In the meantime, though, parents can reduce their family’s exposure by their choices at the supermarket. An encouraging February 2006 study from the NIH journal Environmental Health Perspectives found that evidence of children’s exposure to chlorpyrifos (the same organophosphate in the current New York study) virtually disappeared within 24 hours of typical suburban school kids’ switching to a mostly organic diet.

They didn’t have to learn to like any new foods; they just ate the organic version of the foods they were already eating – if readily available. If a simple substitution was not available, no switch was made.

To me, choosing organic is even more valuable during pregnancy and the first 3 years of life, when kids’ brains are growing the fastest.

Dr. Greene’s Answer:

Most kids hit or bite at some point. Those who keep it up usually feel they are getting something out of it. Either getting their way or getting attention (even negative attention), getting their siblingunhappy, or just getting a chance to express anger.

To help them go faster through this phase, immediately go to the child who is bit or hit, scoop him/her up for a hug, while saying, “No, no biting” to the biter. Then say he is in time-out and set a timer for three minutes. Don’t give him the attention to try to get him to stay in any particular place or go anyplace, just don’t pay attention for three minutes and at the end, when the timer dings, it is over.

For most kids, it is better not to have a “time-out” spot because if they leave, they are getting away with something or you pay attention to them trying to get them to stay. Either way, the time-out doesn’t work. The timer is important so that the end is not subjective. After the timer rings, treat him normally. In between, repeat the message, “In our family, we don’t bite.” Kids are trying to learn family identity at that age. In the meantime, try to teach him alternatives to get his way or express being upset.

In addition to time-outs for negative behaviors, give your child plenty of praise for positive behaviors. When your son is playing well with others and not biting or hitting, praise him for playing nicely. Children innately want a parent’s attention and affirmation. Your praise will act as strong motivating force for your child to avoid aggressive behaviors in the future.

Dr. Greene’s Answer:

With kids who are disruptive, working on empathy can be very helpful–not telling her what to do, but helping her learn to identify what others are feeling (which can lead to changes in behavior).

It is also good to keep in mind–especially if it runs in the family–that if ADHD shows up at that age, the most common symptoms are the ones you have described. It may be worth an evaluation by her pediatrician.

Dr. Greene’s Answer:

Just as habits take a long time to form, they often take a while to change. It’s not too late for this boy to learn constructive ways of behaving. One of the main ways that kids learn is by experimenting and then observing the results. If a child tries tantrums or defiance and gets results he likes, the habit becomes more deeply ingrained.

One of the first things that parents need to do is figure out which behaviors they want to change and what their child has been getting out of them. The faster they can make those behaviors unsuccessful for him, the faster he’ll let go of them.

Kids also learn a lot from imitation, stories, videos, and their peers. Finding him friends who are well behaved and reading him positive stories may help. It can be tough for kids to figure out constructive ways to get the results they want. When kids are behaving well, that should be acknowledged. Parents should make their child’s attempts at good behavior successful, engaging them with as much energy when they are sweet as when they are exasperating.

Making this change can be tough for the parents, but it is well worth it. It also may be worthwhile for both parents and their child to meet with a behaviorist who could help them recognize unhealthy patterns.

Related concepts:

Stranger anxiety, object permanence

Introduction to separation anxiety:

Your baby has been able to tell the difference between you and strangers from the earliest days of life. Young babies prefer their mothers and fathers (and others who are frequently involved), but will usually respond happily to others as well.
Until…
They begin to get upset when others come too close – even regular babysitters, grandparents (who may feel heartbroken), or one of the parents (who may feel very unsettled by this).
At about the same time, most babies begin to fuss and cry whenever you leave their sight, sometimes even to step into the next room!

What is separation anxiety?

Separation anxiety and stranger anxiety both coincide with a new intellectual skill called object permanence. They now remember objects and specific people that are not present. They will search for toys that have dropped out of sight. They are able to call up a mental image of what (or who) they are missing. They don’t want the stranger, because the stranger is not you.
They understand that people leave before they learn that people return. They can tell from your actions that you are about to leave. Anxiety begins to build even before you leave.
They can’t tell from your actions that you are about to return. They have no idea when – or even if – you will come back. And they miss you intensely. For them, each separation seems endless.
Dropping a screaming child at day care tugs at parents’ hearts. Much nighttime screaming is an expression of separation anxiety. Sleep is a scary separation.
Peek-a-boo and bye-bye are fun ways for us to interact with babies, and great ways to teach them about object permanence. For babies at this age, these are issues of great concern.

Who gets separation anxiety?

Most healthy babies and toddlers exhibit at least one phase of stranger/separation anxiety as part of normal development.
A small number of school-aged children and adolescents will develop separation anxiety disorder (SAD), an intense fear of harm to parents and a refusal to tolerate separation, even for school or sleep.

What are the symptoms of separation anxiety?

Object permanence is usually first noted when a baby searches for a toy that has fallen out of sight.
The symptoms of normal developmental separation anxiety include increasing anxiety at signs that demonstrate that you are about to leave. Upset and crying occur at the time of separation, and often at the approach of others. Sleep difficulties are common.

Is separation anxiety contagious?

Anxiety can be contagious. The more anxious you are about leave-taking or about others caring for your baby, the more anxious your baby will be.

How long does separation anxiety last?

The first peak of separation anxiety usually takes place in the second half of the first year, and lasts for about 2 to 4 months, though there is great variability in this.
There is often a second peak in the second half of the next year. At this time, toddlers have emerging language skills and a strong desire to communicate. They have developed a rich, multimedia array of ways to communicate with you that strangers just don’t understand. The second peak of separation anxiety usually fades as language skills improve.
In some children, the two peaks run together, resulting in separation anxiety for up to 8 months or so at a stretch.
Separation is usually a dominant issue from about 6 months until language is understood by strangers.

How is separation anxiety diagnosed?

Normal separation anxiety is not a diagnosis.
The uncommon separation anxiety disorder (SAD) is diagnosed by mental health professionals based in the history and interview.

How is separation anxiety treated?

Once children have learned about leaving, you want them to learn about returning. Separation/return games, and short practice separations are quite helpful.
The classic separation/return games are peek-a-boo and “where’s the baby?”
I like playing peek-a-boo with the feet. With the baby lying on his back, lift the legs “up, up, up” to hide your face, and then “Peek-a-boo!” as you open the legs wide. Often babies love to open their legs themselves to find you.
In “Where’s the Baby?”, drop a lightweight cloth over your baby’s head, ask, “Where’s the baby?” and pull the cloth again grinning and saying, “There you are!” Soon your baby will delight at pulling the cloth off and laughing. The cloth can also be placed over your own head, or you can partially hide behind a chair or around a corner where you will be easily discovered.
Hiding and finding objects is another fun form of separation/return play; under clothes or buckets, anywhere the baby can delight in finding you.
With practice separations, tell your baby that you will be going to another room and that you’ll be back soon (even though the baby will not understand the words yet). If there’s crying, repeat the reassurance that you’ll be back soon. Then pop back in smiling and say, “Hello”. “Bye-bye” is one of the first words most babies learn. You want to teach them to understand hello as soon as you can. Gradually make these practice separations longer and longer. The baby will learn that you’ll come and that it’s okay when you are gone for a bit.
When you really leave, good-byes should be brief, affectionate, and with a clear statement that you will be back. If the caregiver can engage your child with a toy or mirror, it can make your leaving easier. If you are leaving your child at a day care or someplace other than home, the separation will be easier if you spend a few minutes there with your child (and also with the new caregiver).
Transitional objects, such as blankets or stuffed animals, are healthy ways to minimize separation anxiety.
Regular routines make the “returning” lesson easier to learn.

How can separation anxiety be prevented?

Helping your child select a transitional object can help reduce separation anxiety.
During the ages when separation is a big issue, you want to avoid prolonged absences and avoid having your child cared for by someone who will not look at her and smile.
When you must leave, do not make a big fuss over leaving and do not sneak out. Children need a simple, direct, “Bye-bye, I’ll be back.” Be sure to tell them when you’ll be back.
Separation anxiety is more pronounced when children are tired, hungry, or sick. Try to time separations when they are happy and satisfied.

Related A-to-Z Information:

Nightmares, Tantrums

Related concepts:

Head rolling, Body rocking

Introduction to head banging:

When children develop a habit of head banging, their parents are often concerned. They express fear that this habit might hurt their child, perhaps even causing brain damage. The unspoken fear is that their child might have autism.

What is head banging?

Head banging, head rolling, and body rocking are all common rhythmic habits (as is thumb sucking). Many theories have been put forward to explain them. Perhaps the rocking and even the head banging provide a form of pleasure related to the movement. This joy in movement is called our kinesthetic drive.
All infants are rocked by their mothers when they are carried about in utero. Later on, they enjoy being held and rocked in parents’ arms. Movement activities continue as kids grow: the pleasure of jump rope, swings, slides, amusement park rides (bumper cars!) and dancing. These activities all engage the vestibular system of the brain. The amount and type of movement that provides pleasure varies from child to child.
Kids who are under-stimulated (those who are blind, deaf, bored, or lonely) head bang for stimulation. But children who are overstimulated (in an overwhelming environment) find these rhythmic movements soothing.
For some children, head banging is a way to release tension and prepare for sleep. Some kids head-bang for relief when they are teething or have an ear infection.
Some kids bang their heads out of frustration or anger, as in a temper tantrum. Head banging is an effective attention-seeking maneuver. The more reaction children get from parents or other adults, the more likely they are to continue this habit.
Generally, healthy children do not head-bang in order to injure themselves.

Who gets head banging?

Up to 20 percent of healthy children are head-bangers for a time. Typically, head banging appears in the latter half of the first year of life and generally ends spontaneously by four years of age. Boys are three or four times more likely to be head-bangers than girls.
Head banging, head rolling, and body rocking are also each far more common in autistic children, children with developmental delays, and children who have suffered abuse or neglect.

What are the symptoms of head banging?

The child seems compelled to rhythmically move his head against a solid object such as a wall or the side of a crib. Often he rocks his entire body. For most children it occurs at sleepy times or when upset (often as part of tantrums). This behavior can last for minutes at a time — or sometimes for hours. It can even continue once the child has fallen asleep.

Is head banging contagious?

No, although other people’s actions can promote head banging.

How long does head banging last?

These rhythmic motor activities are part of normal behavior in healthy infants and young children (and healthy young monkeys for that matter!). This behavior is abnormal, though, if it persists beyond the early years. Normal head banging usually goes away by age four. Any child who is still head banging beyond three years of age deserves further evaluation to be sure it is a normal habit.

How is head banging diagnosed?

Three hallmark behaviors are the key signs that distinguish kids with autism-associated head banging and those with normal head banging:

1. Lack of pointing — By fourteen months of age most children will point at objects in order to get another person to look.
2. Lack of gaze-following — By fourteen months, infants will often turn to look in the same direction an adult is looking.
3. Lack of pretend play — By fourteen months, children will begin to play using object substitution, e.g. pretending to comb the hair with a block.

All three of these behaviors are typically absent in children with autism.If a child begins even one of these three behaviors by 18 months, the chances of ever developing true autism are very small.
Again, head banging beyond age three deserves further evaluation.

How is head banging treated?

Most children will outgrow the habit on their own. You can speed up this process by reacting to it in a matter-of-fact way. Pretend not to notice. And if it is part of a tantrum, do not give her whatever she threw the tantrum to get. When you notice her head banging, you might be able to get her to stop for the moment by distracting her or engaging her in a different activity. By decreasing the amount of time she spends in this habitual activity, she will outgrow it more quickly.

How can head banging be prevented?

Preventing head banging from becoming a habit is best accomplished by responding to it as described in the treatment section above.
How do you prevent head injury?
Typically, healthy toddlers don’t seriously injure themselves with this habit. Pain prevents them from banging too hard, but even if it didn’t, children under 3 don’t generate enough force to cause brain damage or neurologic problems. The front or front/side of the head is the most frequently struck. A toddler’s head is built to take all of the minor head trauma that is a normal part of learning to walk and climb. Healthy infants and toddlers who are head-bangers grow up to be coordinated and completely normal children.
Curiously, one large study of this habit in healthy children found head-bangers to be measurably advanced compared to their peers. If anything, then, head banging in healthy children can be a sign of increased intelligence.

Related A-to-Z Information:

Attention Deficit Hyperactivity Disorder (ADHD), Breath Holding, Concussion, Deafness, Ear Infection, Epilepsy, Febrile seizures, Fragile X Syndrome, Hemophilia, Motion sickness, Nightmares, Otitis Media with Effusion (OME), Sexual Curiosity in Young Children, Tantrums, Teething, Thumb-sucking, Tourette’s Syndrome

Related concepts:

Major Depression, Mood Disorders, Dysthymic Disorder, Childhood Depression, Infant Depression.

Introduction to depression:

United States Surgeon General David Satcher released a report in January 2001 describing a mental health crisis in children. Mental illness severe enough to hinder kids from learning or developing appropriately is quite common — but fewer than one in five affected children get the help they need. Mental disorders are a major untreated problem in children. Recognizing and treating conditions such as depression can be a powerful contribution to children’s lives. Some children’s depression is missed because they appear to have ADHD.

What is depression?

Major depression is a mood disorder that affects sleep, eating, growth, mood, and interest level. Dysthymic disorder is a milder (but often longer lasting) variant, where the child has a depressed mood for at least a year.
Not long ago, people used to think that young children did not suffer from depression. Now we know that depression in children is both real and common – although the symptoms are often different from those seen in adults.
Depression of Infancy and Early Childhood is defined as a pattern of depressed or irritable mood with diminished interest or pleasure in developmentally appropriate activities, diminished capacity to protest, excessive whining, and diminished social interactions and initiative. This is accompanied by disturbances in sleep or eating and lasts for at least 2 weeks.

Who gets depression?

Depression affects up to one in 40 children. It involves the interplay of a genetic predisposition to depression, an imbalance of brain chemicals, and events in the child’s life.
There is a strong link between mental disorders in parents and their children. When parents have major depression, their children are at increased risk for emotional and behavioral problems of their own. Depression in parents is associated with depression, social phobia, disruptive behavior disorder, separation anxiety disorder, multiple anxiety disorder, and/or poorer social functioning in children.
Yet when parents are diagnosed, the children are often not even considered. I hope that this will prompt caregivers to notice whether the children are in any distress and to provide support for them, even at a very young age. And of course, I hope that parents will get the treatment and support that they themselves deserve, both for their own sake and for their children.

What are the symptoms of depression?

Children may have many of the same symptoms as adults. In general, though, children may be less likely to report sadness or depressed mood, and more likely to develop phobias, anxieties, physical complaints, behavior problems and hallucinations. In addition, the pattern of symptoms in children can vary by age.

• Infants and toddlers – developmental regression, increased crying, increased clinginess, increased anxiety, irritability, head banging, increased sleep issues, increased feeding problems, falling off growth curves, developmental delay, limited speech, limited social interaction
• Preschoolers – uncontrollable behavior, hyperactivity, tantrums, breath-holding, biting, kicking, scratching, nightmares, toileting problems (refusal, withholding, smearing, bedwetting, increased “accidents”)
• School-age children – worsening school performance, worsening homework performance, increasing school and homework resistance, headaches, tummy aches, fatigue, lack of motivation, anxiety, increased lying, stealing, masturbation
• Teens – school failure, promiscuity, delinquent behavior, increased aches and pains, suicidal thoughts or attempts, may look more like adult depression

Sometimes ADHD and depression are confused with each other. Many children have both.

Is it contagious?

Depression in parents and caregivers can worsen depression in children, and vice versa.

How long does depression last?

The symptoms of depression usually develop over several days or weeks. Without treatment, the depression usually lasts between six months and a year. About 90% of cases will resolve – some without treatment. However, about 40 to 80% of these children will often become depressed more than once.

How is depression diagnosed?

Whenever there is concern that a child might be depressed, an evaluation is important. This might include rating scales or structured interviews. Sometimes blood tests or EEGs are used to support the diagnosis.

How is depression treated?

Depression in children may be treated with antidepressant medication and/or therapy, such as cognitive behavioral therapy. The response to treatment in children can be quite good.

How can depression be prevented?

Parents taking care of their own needs can help prevent depression in their children. In addition, nurturing attention, exploration and activity, good sleep, and good nutrition can be helpful. Some kids will become depressed, though, even in an ideal situation.

Related A-to-Z Information:

Attention Deficit Hyperactivity Disorder (ADHD), Breath Holding, Head Banging, Headache, Lead Poisoning, Nightmares, Sexual Curiosity in Young Children, Sleep Apnea, Stuttering, Thumb-sucking, Tourette’s Syndrome

Related concepts:

Pallid breath-holding spells, Cyanotic breath-holding spells, Pseudo-seizures

Introduction to breath holding:

Breath-holding spells shine a brilliant spotlight on one of the biggest challenges of parenting. We do not like to disappoint the little children that we love so much. Moreover, we don’t want to get into yet another battle with our children — in the short run it is always easier to give in to a tantrum than to do what we instinctively feel is best. For parents of breath-holding children, this crucial struggle of parenthood is powerfully amplified.

What is breath holding?

Breath-holding spells are perhaps the most frightening of the common, benign behaviors of childhood. Desperate parents often want to splash cold water on the child’s face, start mouth-to-mouth resuscitation, or even begin CPR.
These spells are usually triggered by the child’s not getting her own way. They can be an attempt to exert control on the circumstances around her.  In these cases, the child typically turns blue or purple during a crying episode.
There is another, far less common, type of breath-holding spell, where the child turns deathly pale instead of blue or purple. These pallid spells are involuntary and unpredictable. They are brought on by a sudden startle, such as falling and striking the head.
There is an even less common type of breath-holding spell associated with a rare genetic condition called familial dysautonomia; these involuntary spells occur in children who are already acting seriously ill.

Who gets breath holding?

Breath-holding spells occur in about 1 in 20 children.
The spells occur sporadically, but when they do occur, it is not uncommon for there to be several spells within a single day. Once parents have witnessed one breath-holding spell, they can often predict when another one is about to happen.

What are the symptoms of breath holding?

This is a typical scene: A little child is playing happily, something upsets her, she exhales forcefully with a brief, shrill cry — but she doesn’t take another breath. You wait, but she still doesn’t breathe. She looks as if she’s crying, but no sound emerges. She begins to turn blue, her face strained, and still she is not breathing. Now she is unconscious, unresponsive, limp, and limp; the sight of her lifeless body is terrifying. Now her back arches and her blue arms and legs begin to jerk uncontrollably. Your heart is pounding, frantic…
Thankfully, breath-holding spells resolve spontaneously soon after the child passes out, and unless the fall hurts the child, she will be fine afterwards. The spell usually resolves within 30 to 60 seconds, with the child catching her breath and starting to cry or scream. Sometimes children will have real seizures as part of breath-holding spells, but these brief seizures are not harmful and there is no increased risk of the child’s developing a seizure disorder.
In pallid breath-holding spells, the child stops breathing, goes limp, passes out, and rapidly drains of color. Pallid breath-holding spells also resolve spontaneously.

Is breath holding contagious?

No

How long does breath holding last?

Breath-holding is quite rare before 6 months of age. It peaks as children enter the twos, and disappears finally by about age five.

How is breath holding diagnosed?

The first time a spell occurs, the parents should have the child examined by a doctor. Because breath-holding spells do share several features in common with seizure disorders, the two are often confused. In epileptic seizures, a child may turn blue, but it will be during or after the seizure, not before.
If your doctor confirms that the event was indeed a breath-holding spell, it is a good idea to check for anemia.

How is breath holding treated?

Treating the anemia, if present, will often decrease the frequency of passing out.
The parents’ most important job, however, is to not reinforce the breath-holding behavior. A parent reinforces this behavior by bending to the child’s will or by paying more attention to her when she has these spells.
Instead, if you are certain she hasn’t choked on something, place her in a safe spot (without giving in to whatever she held her breath to achieve) and ignore her behavior.
Some breath-holding spells are also treated with medications.

How can breath holding be prevented?

If the spells are frequent or severe, preventive medications may be prescribed for some types of breath holding.
Most would expect that a breath-holding spell would be difficult. Most are surprised, however, to find that in many ways, the biggest challenge is life between spells. Parents become timid about setting limits or disappointing their children because of the very real possibility of provoking another spell. For all of us, love consists of having the courage to act in spite of our fear.

Related A-to-Z Information:

Anemia (Low hemoglobin), Attention Deficit Hyperactivity Disorder (ADHD), Concussion, Febrile seizures, Head Banging, Night Terrors, Separation Anxiety, Tantrums

Related concepts:

Attention Deficit Disorder, ADD, Hyperactivity

Introduction to ADHD:

Over-diagnosed? Under-diagnosed? Probably both – and certainly real. ADHD affects children’s school performance and their relationships with others. Parents who are wondering if their children have ADHD are often exhausted and frustrated.

What is ADHD?

ADHD is a problem with inattentiveness, over-activity, impulsivity, or some combination of these. Scientific studies, using advanced neuroimaging techniques of brain structure and function, show that the brains of children with ADHD are different from those of other children. These children handle neurotransmitters (including dopamine, serotonin, and/or adrenalin) differently from their peers.

While we still don’t know exactly what causes ADHD, it appears that it is often genetic. Whatever the specific cause may be, it seems to be set in motion very early in life as the brain is developing. Other problems, such as depression, sleep deprivation, specific learning disabilities, tic disorders, and oppositional/aggressive behavior problems, may be confused with or appear along with ADHD. Every child suspected of having ADHD deserves a careful evaluation to sort out exactly what is contributing to his concerning behaviors.

Who gets ADHD?

There is a lot of controversy surrounding the actual number of children with ADHD. The Diagnostic and Statistical Manual (DSM-IV) suggests that it occurs in 3 to 5 percent of all children. Other estimates are far higher or lower. It is diagnosed much more often in boys than in girls.

Most children with ADHD also have at least one other developmental or behavioral problem.

What are the symptoms of ADHD?

The Diagnostic and Statistical Manual (DSM-IV) divides the symptoms of ADHD into those of inattentiveness and those of hyperactivity/impulsivity.

Inattention

1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
2. Often has difficulty sustaining attention in tasks or play activities
3. Often does not seem to listen when spoken to directly
4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
5. Often has difficulty organizing tasks and activities
6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
7. Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
8. Is often easily distracted by extraneous stimuli
9. Is often forgetful in daily activities

Hyperactivity

1. Often fidgets with hands or feet or squirms in seat
2. Often leaves seat in classroom or in other situations in which remaining seated is expected
3. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
4. Often has difficulty playing or engaging in leisure activities quietly
5. Is often “on the go” or often acts as if “driven by a motor”.
6. Often talks excessively.

Impulsivity

1. Often blurts out answers before questions have been completed
2. Often has difficulty awaiting turn
3. Often interrupts or intrudes on others (e.g., butts into conversations or games)

Is ADHD contagious?

No

How long does ADHD last?

ADHD is a long-term, chronic condition. About half of the children with ADHD will continue to have troublesome symptoms of inattention or impulsivity as adults. However, for many children, the symptoms of ADHD may improve with time.

How is ADHD diagnosed?

Too often, difficult children are incorrectly labeled with ADHD. On the other hand, many children who do have ADHD remain undiagnosed. In either case, related learning disabilities or mood problems are often missed. The American Academy of Pediatrics (AAP) has issued guidelines to bring more clarity to this issue.

The diagnosis is based on very specific symptoms, which must be present in more than one setting (including at school). Every evaluation should include a search for possible additional conditions including conduct disorder, oppositional defiant disorder, mood disorders/depression, anxiety, and learning disabilities.

To be diagnosed with ADHD, children should have at least 6 of the attention symptoms or 6 of the activity/impulsivity symptoms listed in the DSM-IV. They must display these to a degree beyond what would be expected for children their age.

The symptoms must be present for at least 6 months, observable in 2 or more settings, and not caused by another problem. The symptoms must be severe enough to cause significant difficulties. Some defining symptoms must be present before age 7.

Older children who still have symptoms but no longer meet the full definition have ADHD in partial remission.

Some children with ADHD primarily have the Inattentive Type, some the Hyperactive-Impulsive Type, and some the Combined Type. Those with the Inattentive type are less disruptive and are easier to miss being diagnosed with ADHD.

How is ADHD treated?

The American Academy of Pediatrics (AAP) has developed evidence-based guidelines for the treatment of ADHD:

• ADHD is a chronic condition and must be treated as such.
• It is important to set specific, appropriate target goals to guide therapy.
• Medication and/or behavior therapy should be started.
• When treatment has not met the target goals, it is important to evaluate the original diagnosis, the possible presence of other conditions, how well the treatment plan has been implemented, and the use of all appropriate treatments.
• Systematic follow-up for the child with ADHD is important to regularly reassess target goals, results, and any adverse effects of medications. Information should be gathered from parents, teachers, and the child.

ADHD is a frustrating problem. A number of alternative remedies have become quite popular, including herbs and supplements, chiropractic manipulation, and dietary changes. While there is evidence suggesting the value of a healthy, varied diet, with plenty of fiber and other basic nutrients (the diet that would be best for most children), there is little or no solid evidence for many remedies that are marketed to parents. The most promising specific nutritional actions include getting adequate iron and omega 3 fats in the diet, and possibly avoiding certain artificial dyes and chemical preservatives. Adequate sleep has been proven to help ADHD symptoms.

Children who receive both behavioral treatment and medication often do the best. Medications should not be used just to make life easier for the parents or the school. There are now several different classes of ADHD medications that may be used alone or in combination.

How can ADHD be prevented?

New links are being discovered between ADHD and environmental triggers. Avoiding prenatal tobacco, lead, or organophosphate pesticide exposure, for instance, has been linked with lower rates of ADHD. Minimizing unnecessary exposure to known neurotoxins and maximizing healthy food and sleep may prevent ADHD, but this has yet to be proven.

Early identification and treatment can prevent many of the problems associated with ADHD.

Related A-to-Z Information:

Depression, Enuresis (Bed-wetting), Sleep Apnea, Tourette’s Syndrome, Tonsillitis

Related concepts:

Temper tantrums, Emotional storms

Introduction to tantrums:

When your child kicks and screams at not getting his way, the outburst often seems to come at the least opportune times: during grocery shopping, when you’re on the phone, when you’re trying to get out the door, trying to make dinner, or at a family gathering.

What are tantrums?

Temper tantrums are expressions of intense, immediate frustration. They occur most frequently at an age when children’s verbal skills are inadequate to express their roiling emotions.
Gradually, after a child has mastered walking, an irresistible urge to make his own choices begins to well up inside him. This is an exciting development, but to make an independent choice he must disagree with you in order for the choice to be his own. Now, when you ask him to do something, part of him wants to please you, but part of him wants to refuse.
Many people call this important phase of development the “Terrible Twos.” I prefer to call it “The First Adolescence.” This period begins long before age two and actually continues long afterwards, but in the majority of children, it is most intensely focused around the period from one-and-a-half to three years of age.
The hallmark of this stage is oppositional behavior. Our wonderful children instinctively want to do exactly the opposite of what we want. We have nice, reasonable expectations and they say “NO!” or they simply dissolve into tears. Suppose you have some place to get to in a hurry. Your son has been in a great mood all day until you say, “I need you to get into the car right now.” He will, of course, want to do anything but get into the car.
As if this weren’t enough, children in this phase of development have a great deal of difficulty making the choices they so desperately want to make. You ask your child what he would like for dinner and he says macaroni. You lovingly prepare it for him and then as soon as it’s made he says, “I don’t want that!” It is perfectly normal for him to reverse a decision as soon as he has made it, because at this stage, he even disagrees with himself.
This phase is difficult for parents but it’s also hard for children. When children take a stand that opposes their parents, they experience intense emotions. Although they are driven to become their own unique persons, they also long to please their parents. Even now, when I do something that my parents disagree with, I feel very conflicted. I am an adult, living in a different city, with well-thought-out choices, and it is still quite difficult. For a child who is tentatively learning to make choices, who is dependent on his parents for food, shelter, and emotional support, it’s even more intense. Dissolving into tears is an appropriate expression of the inner turmoil that is so real for children who are in the midst of this process.
This season of emotional outbursts in children is reminiscent of labor – a series of intense spasms that ushers in a whole new phase of life.

Who gets tantrums?

Children going through this volatile developmental stage are most likely to get frustrated and have a tantrum when the intensity of the immediate situation increases. The excess stimulation may be visual, auditory, tactile, or a combination. It often includes being confronted with a bewildering array of choices, or being unable to get the attention or the desired, chosen outcome.
Let’s look at the example of the grocery store. As an adult, you can choose whether or not you want to go to the grocery store, when to go, what products you are going to buy, and which products you will not purchase. When you are in the middle of shopping in the grocery store, your child will see things he wants. To make the supermarket situation worse, there are cleverly designed packages up and down the aisles that scream, “Buy me! Buy me! Buy me!” We are largely able to tune that out, although it affects us much more than we think. For a small child who is just learning to make choices, it’s like going to a deafening rock concert. They are visually overwhelmed by high-decibel choices. They are compelled to start wanting multiple attractive items. When they can’t have what they want, they dissolve into tears and worse — deafening screams. Of course everybody in the store turns and looks at your child and (shudder) at you!
Almost all healthy children will have a number of temper tantrums but will eventually discard them as they find better strategies.
Those with ongoing tantrums often have reason for ongoing frustration or they have discovered that tantrums work! If children get the desired attention or outcome from their tantrums, they can become a powerful habit. Often these tantrums only occur when the parents are present.

What are the symptoms of tantrums?

A child may be acting ‘out of sorts’ before the tantrum begins. Then he asks for something he can’t have, can’t make up his mind, or tries to do something, but fails. Crying, perhaps screaming, will result. Some kids flail the arms and kick the legs. Some throw themselves on the ground. Some cry hard enough to vomit (making their parents desperately want to give in). Others will hold their breath – even to the point of passing out.

Are tantrums contagious?

Tantrums are not contagious, although the behavior of those around a tantrum can play into it.

How long does tantrums last?

Most children outgrow frequent tantrums by the time their language is mostly understandable to strangers.

How are tantrums diagnosed?

Tantrums are not a diagnosis. They are a normal phase of development, though they may be more prolonged, more frequent, or more intense in some children.

How are tantrums treated?

Realize that tantrums are an expression of acute frustration. They deserve a medium amount of attention (children should not feel that they get more of your attention by throwing a fit). Parents may be tempted to be loud or angry, but tantrums are a time to be calm.
First, take a deep breath. I’ve been in a grocery store with my children having temper tantrums, as a pediatrician, with my patients in the checkout line. The first thing you feel is, “I just wish I could drop into the floor so nobody would see me.” Many people won’t understand. They will look at you and think your child is spoiled or that you are a bad parent. The truth of the matter is that you probably have a normal child and are a good parent.
People who don’t have kids may not understand, yet. That is their problem, though. Try to be patient with them.
When I see a parent whose child is having a tantrum in a store, I am reminded of labor. When I look at a mom in labor, I see something that is heroic, triumphant, and beautiful. Tears come to my eyes when I am privileged to be a part of a birth. So, the next time this painful situation happens to you, take a deep breath and remember: if Dr. Greene were here, he would see something heroic and beautiful.
Next, while you are taking a deep breath, consciously relax. Kids play off your emotions. It’s so hard to relax in this situation, but just let your muscles go. The more uptight you are, the more energy is available for their tantrums. Kids thrive on attention, even negative attention.
Where you go from here depends on your child. Some children will calm down if you pick them up and hold them. My first son was like that. His storm would dissolve if you just gave him a big hug and told him it would be all right. If you picked up my second son during a storm, he would hit you — there were different ways to get him to calm down. Each child is unique.
One thing that often works very well is to try to voice to the child what he is going through. “You must really want to get this, don’t you?” Then he may melt and say, “Uh huh.”
Handle tantrums with a light touch. Seasoning the interaction with understanding, humor, and distractions can save the day.
You will have to experiment with your child to see what it is that can help him understand that everything is okay, these bad feelings will pass, and that it’s all a normal part of growing up.
Whatever you do, if your child had a temper tantrum to try to get something, don’t give it to him, even if you would have ordinarily done so. Giving in to tantrums is what spoils a child. Giving in is the easiest, quickest solution in the short run, but it damages your child, prolongs this phase, and ultimately creates far more discomfort for you. Choosing your son’s long-term gain over such dramatic short-term relief is part of what makes properly handling temper tantrums so heroic.

How can tantrums be prevented?

Children are most susceptible to storms when they are tired, hungry, uncomfortable, bored, or over-stimulated.
Be creative at orchestrating life to minimize tantrum weather. You may want a toy basket that only comes out when you are on the phone or online. Dinner preparation is a great time for your child to watch an entertaining video.
When possible, plan shopping for times when your child is rested, fed, and healthy. Interact with your son throughout shopping and/or bring along stimulating toys or books.
Remember the situation from your child’s perspective. You are going along making choice, after choice, after choice, but when he tries to make a choice, he doesn’t get what he wants. You can see how frustrating this would be. It’s often helpful to let your child pick out one or two things when at the store. A good way to do this is when a child asks for something, instead of saying, “No,” (which will immediately make him or her say, “Yes!”) say, “Let’s write that down.” Then write it down. When your child asks for something else, write that down, too. Then when you are all done, read back a few of the things on the list that you think would be good choices, and let him pick one or two of the things on the list. If children can make some choices, they will learn more and feel better.
Another worthwhile technique is for you to make a list before you go to the store. That way it won’t look so arbitrary when you pick what you want off the shelf while your child doesn’t get his choice. As you shop, whenever you put something in your basket, check it off your list. Even if it is not on your list, check it off. The list is to teach that each item has a purpose, not that you had thought of it previously.
His task during this time is to gain skill at making appropriate choices. To help him accomplish this, offer your son limited choices at every opportunity. He will be demonstratively frustrated when he is given direct commands with no options. He will decompensate if he has too many alternatives. Two or three options generally work best.
Make sure the choices you offer fall within an appropriate agenda. Your son still needs the security of knowing that he’s not calling all the shots. When it’s time to eat, say something like, “Would you rather have a slice of apple or a banana?” He feels both the reassuring limits that you set and the freedom to exercise his power within those limits. If there are two things he needs to do, let him decide which to do first, when appropriate.

Related A-to-Z Information:

Attention Deficit Hyperactivity Disorder (ADHD), Breath Holding, Head Banging, Nightmares, Separation Anxiety