Debbie Walhof, M.D.
You are clearly in a very difficult position. You are dealing with your own issues and you are trying to be supportive of your daughter who is not yet on a path to success. As a physician, I need to say that you have limited influence over her decisions, given her adult status. As a parent, my suggestion is to be supportive and available when she comes to you for help. If she is not interested in talking and problem solving with you, leave information on the kitchen table for her to discover. You absolutely should recommend to her that she seek out an MD who specializes in adult ADHD. And perhaps try to enlist someone whom she knows and trusts (not you, not an "authority figure") to talk with her about her goals, her medication issues, and how she can improve her situation in school.

Another thought is, what about LD? Might she also have a learning disability that is lurking and not yet discovered or understood? An evaluation might be in order. If paying for an evaluation is a problem, she should explore access to free or low cost evaluation services through the college disabilities services office, a university-based clinic, or even a local office of the State Office of Vocational Rehabilitation.

Debbie Walhof, M.D.
Keep looking! The internet is filled with great resources about LD and the NCLD website, LD. org is a conduit for high quality information about all things LD. Visit the site and sign up for free newsletters, use their free online Resource Locator and more.

Other suggestions:

• Contact your local Parent Training and Information Center (PTI) as they can field questions and offer support, connects to other parents, resources, agencies, etc. (look for listings on the Resource Locator
• Ask other parents where they get their information.
• Scout out some books about LD; they often have lots of great resources.
• Look in your local library for resources such as the Learning Disabilities Directory, published by Grey House.

Debbie Walhof, M.D.
Let me begin by saying that pediatricians may not be the best persons to provide advice about your options here. They are, for the most part, simply not going to know! But they should be ready to be supportive, talk to people in the school and help you as you discover what is right for your child and make it happen. As a pediatrician (and also having been through this process myself) I first needed to discover my son's rights and only then could I work with school personnel to ensure that these rights were protected.

Let me also suggest that parents can play an important role in helping schools meet their obligations. Here are a few resources that spell out parents' rights and schools obligations when it comes to private vs. public school placements.

• Ed.gov's Q and A: Questions and Answers On Serving Children With Disabilities Placed by Their Parents at Private Schools
• IDEA Parent Guide (see page 53)

Debbie Walhof, M.D.
My first recommendation is to go back to the physician who is prescribing your daughters medicine and share your concerns. Whether it’s Focalin or any other medication, you need to work closely with the practitioner who prescribed the medicine to identify whether the drug is working and to evaluate the specific side effects your daughter is experiencing. There may be a need to change the dosage or dosing interval. It’s also possible that a change in medications might be in order or that non-medication options need to be explored.

Whatever you do, do NOT make medicine-related decisions by yourself! Any changes in drug regimen must be made in conjunction with your child’s health care provider.

On a personal note, in my opinion, medication for kids with ADHD is always a last resort: "Tweak the environment before you tweak the child." Make sure to consider such things as sleep, nutrition and stressors at home, in school and in your child’s community of peers. And for many children, a combination of medication and therapy (e.g., counseling, relaxation/meditation, guided play) yields the best outcomes. If you are interested in knowing more about non-medication approached to treating ADHD, one book for you to look at is titled ADHD Without Drugs by Sanford Newmark, MD and published by Nurtured Heart Publications 2009.

Debbie Walhof, M.D.
Absolutely! Both family history and your child’s past medical history are critical pieces of the puzzle that constitute the health of your child.

According to one study of children in the USA, the risk that a child will have a reading problem is increased from 4 to 13 times if one of the parents has a similar problem. The tendency for dyslexia to "run in families" has been confirmed by numerous studies. So in this case, family history is very important and can lead to earlier diagnosis if everyone involved is paying attention to early warning signs. In addition, family history of food allergies or other chronic illness are important pieces of information to relay to your doctor.

While it may not seem apparent to parents and others (teachers, other care providers), a child’s medical history holds many answers if it is thoroughly known and reviewed. Prematurity and any trauma associated with birth or multiple acute illnesses or hospitalizations as well as any chronic illness need to be shared and reviewed with your child’s physician. I know it might sound like a cliché, but the world of medical care to day is very different than it was even a few years ago, and not just in the knowledge we have about diagnosis and treatment. Rather than having a long-term relationship with a single medical provider, patients of all ages often end up being treated by a number of different medical practitioners. The consequences of having your child switch practitioners can be serious, especially if the new provider does not have a relaxed and trusting relationship with you and your child. Every time you switch to a different practitioner it is important to relay all previous medical records to your new doctor and make a specific appointment to review them together, particularly if your child has ongoing or significant medical issues.

Debbie Walhof, M.D.
Thanks for asking this very important question. Some children, and especially adolescents, show signs of worry and low self-esteem at some point I time and these may be part of their "normal developmental path." Or not! Watch for symptoms of depression, school avoidance issues and nondescript recurrent medical symptoms that may point to school avoidance, and don't wait to share these with your child's school and pediatrician.

Depression is a condition characterized by:

• extreme feelings of sadness
• lack of interest or pleasure in most or all activities
• significant weight gain or loss
  
• sleeping too little or too much
• restlessness or exhaustion
• low energy
• feeling worthless
• difficulty concentrating, and
• thoughts of suicide

However, as a parent, you need to stay in regular contact with your child's school and ask several important questions:

• Is my child making academic progress, performing about the same, or doing worse?
• Is my child interacting positively with others or is he withdrawing?
• Does my child appear to be happy during school or sad?
• Does my child appear tired or seem to have adequate energy?
• Does my child seem to have a positive or negative attitude toward school?

A combination of answers to these questions that she is doing worse academically, withdrawn, sad, tired and has a negative attitude are red flags that you should consider having your child evaluated for depression by a licensed clinician.

Debbie Walhof, M.D.
That is a great question. The first question I ask parents is whether their child has chronic abdominal pain or persistent headache on the weekends. Simple as it may sound, this is often a good way to ferret out if the medical complaint is part of school avoidance or is indeed some physical manifestation of disease. I don’t know of a medical condition that only occurs on school days that is solely physical in origin. Keeping a symptom diary is a great way for you to work with your child’s physician to discover the root of your child’s problem. By the way, although school may be at the root of the issue does not mean that the child is not experiencing true physical symptoms.

Debbie Walhof, M.D.
It saddens me to see how many kids are evaluated for ADHD by pediatricians or other medical practitioners and started on medication without the benefit of a more comprehensive evaluation.

First and foremost, in my opinion, one needs to make sure a child does not have a learning disability that appears like ADHD behavior to the teacher and parents in the school and home environment. Trust me when I say, most physicians are not trained in recognizing learning disabilities. Studies vary in reporting how many children have LD, ADHD or both. Some studies suggest that 25-50%of children with ADHD have a concurrent learning disability. Others state that 15-35% of children with a learning disability also have ADHD.

To effectively treat ADHD, a comprehensive evaluation to rule out a learning disability is a must. And a word of caution to parents whose children have been diagnosed with ADHD: Don’t assume that because ADHD is the focus of your child’s IEP or 504 plan, a learning disability is also not part of the equation. The criteria used by schools to determine whether a child meets criteria for a learning disability often acknowledges only those children who fall in the moderate to severe range of impairment. Those with milder manifestations of learning disabilities may be able to get by in school, especially in the early grades. It is not uncommon for a child with ADHD (and undiagnosed LD) who did fine in elementary school to really struggle academically in middle and high school. More than just sharing information with the physician, educators, psychologists, speech-language pathologists, behavioral pediatricians--a diverse team of professionals schooled in learning disability evaluations--need to be part of the evaluation process.

One more recommendation: An evaluation by your medical practitioner for food allergies or other chronic medical conditions is also very important. If your child doesn’t feel well, they are aren’t going to pay attention in school. The home environment is also critical to evaluate, including such things as amount of sleep time, type of nutrition and type of learning environment. The bottom line is that just having ADHD questionnaires filled out by the teachers and parents and scored by a pediatrician in a 15 minute appointment will end up being a disservice to all involved. In my opinion, first evaluate thoroughly in all venues, then tweak the environmental conditions and only if all else fails consider medicating a child. And for parents who are interested in exploring integrative medical practices, some websites to visit are the Arizona Center for Integrative Medicine and Dr. Sears Official Web site.

Debbie Walhof, M.D.
Diet is a critical foundation of health for everyone but especially for a growing child trying to learn.

Many studies have shown that children learn better when they are fed whole fresh foods and stay away from processed foods with additives and dyes and synthetic sweetening products. I recommend a fresh whole food diet, and balance in food choices. I do recommend organic when possible but also recognize the increased cost. For a list of those products which are the most and least important to eat organic, go to the Organic Consumers Assocation's Web site. No food is inherently evil if eaten in moderation. I do think that each child is unique and if certain foods result in a change of behavior or seem to have a negative impact on your child's ability to learn, it only makes sense to then avoid those foods as much as possible.

As far as nutritional supplements are concerned, I believe most kids (and many adults!) do not meet all of their daily dietary needs from diet alone. My strong recommendation is that children have some protein for breakfast, and that they eat low glycemic load foods throughout the day. I recommend a probiotic daily (live cultured yogurt) or a probiotic supplement. (A 1000 mg dose of an omega 3 DHA/EPA blend is ideal, and I personally like Nordic naturals but there are many good brands on the market.). I also recommend a good children’s multivitamin daily.

I also recommend that families eat at least one meal together daily. A great study was done by the National Center on Addiction and Substance Abuse (CASA) at Columbia University and sponsored by TV Land and Nick at Nite’s Family Table. The report, The Importance of Family Dinners III, also reveals that, compared to teens who have five or more family dinners per week, those who have two or fewer are:

• More than twice as likely to have tried cigarettes;
• One and a half times likelier to have tried alcohol;
• Twice as likely to have tried marijuana; and
• More than twice as likely to say future drug use is very or somewhat likely.

Another important finding of the CASA study was the correlation between family dinners and academic performance. It was reported that teens who have frequent family dinners are more likely to get better grades in school, and it is well known that higher academic performance is associated with lower risk for substance abuse. Teens who have dinner with their families five or more times a week were more likely to report grades of all A’s or mostly A’s and B’s in school that teens who have dinner with their families fewer than three times a week (63 percent vs. 49 percent).

Debbie Walhof, M.D.
No. There is no specific blood test for a learning disability.

There is research that has shown small differences in newborn hearing in children who later on develop dyslexia. There is research that suggests genetic markers or brain PET scan differences with some children with learning disabilities and these types of testing are used exclusively for research purposes. No standard medical testing that point to learning disabilities is available at this time.

I do recommend a few blood tests when I am evaluating children for learning disabilities and/or ADHD. I check for anemia with both a hemoglobin and ferritin level. Low ferritin has been shown to correlate with inattention and hyperactivity in some studies. A Vitamin D level is also important to check. A surprisingly large number of children have low vitamin D levels. If a child has any issues with inattention or hyperactivity or a suggestive family history I might also check for food allergies.

Debbie Walhof, M.D.
I think you are right to ask about vision training before making up your mind whether it is right for your child. Some parents have wondered aloud that their child was evaluated by a behavioral optometrist, engaged in many weeks of vision therapy without any apparent benefit. Others parents have been neutral about the benefit (not sure, but it didn’t do any harm) and many others say that it made a huge difference. My advice about vision therapy can be applied to pretty much every type of "specialty" approach to treatment. Be an informed consumer and do your homework!

Think of the fable of the two blind men who approach an elephant from different directions. The one who discovers the trunk describes the animal very differently than the one who finds the tail, than the one who finds the leg, the tusk, etc. None of them “see” that what they found is just one part of the same, bigger animal.

I believe that all learning disabilities are multifaceted and that LD manifests itself in unique ways in each individual. I don’t believe one approach or practitioner holds all the answers. With regard to vision therapy, I have seen some amazing results in some children, and minimal in others. I believe, for some children, it is a modality worth exploring with a skilled practitioner.

If you decide to explore any multifaceted, multi-modality approach for your child, be very clear about the goals of treatment and pay careful attention to the unique characteristics of your child. How can you know whether vision therapy is right for your child? I believe that the answer lies in the workup. Starting vision therapy without a full workup or comprehensive consultation is an invitation for poor success. Everyone chooses their tests for evaluation based on the information they want to gather, which is usually based on the comprehensiveness of their treatment. It all has to do with the evaluation and preparation for therapy. You must have other testing that dives deeper into the reason for the convergence insufficiency or tracking issue. Any office that wants to start VT without a workup, consult or both is asking for a low success rate. You want to work with a Behavioral Optometrist who is experienced and skilled in Vision Therapy.

Even within Behavioral Optometrists' offices there are differences here. I think the best way to know if it’s right is to ask about success rates and compliance rates. How does the program work? How do you measure success? Is it goal-based or number of sessions-based? Talk with former patients who have completed their program. It’s very important to think of the VT as a specialty service. It’s not primary care, and it warrants some research.

Debbie Walhof, M.D.
Thanks for asking this question. Lots of parents are unnerved when they hear about alternative modalities, just like other parents are rattled by more mainstream and conventional approaches to treating disorders. In treating my patients, I look at many different modalities and approaches and try to help parents evaluate the specific benefits of each for their child.

Each child is unique, and there is no single approach to treatment that holds all the answers for all people. There are many pieces of a child's physical and developmental profile that make up the larger picture and that need to be considered when offering advice and treatment.

For example, certain homeopathic products such as Attend (by Vaxa) are helpful to some children. Like with all products, consult with your child's physician before providing supplements, especially if your child is routinely taking medicine. This product is actually a homeopathic/botanical blend.

I also recommend a full consult with an experienced Homeopath for some of many of my points.

I certainly recommend that modalities such as targeted tutoring, speech-language therapy, occupation therapy and behavioral counseling be considered as front-line approaches to helping children overcome specific weakness associated with LD. I have also worked in partnership with health care professionals such as Naturopathic doctors, Cranio-Sacral therapists and Acupuncturists who also offer effective treatments that can have a positive effect on the well-being of the child.

As an Integrative Pediatrician I place a strong emphasis on a child's nutritional environment as well as on home and school environment. When I treat a child I look at the whole child and that is never modality specific but it is child specific. Modalities are tools and different modalities work for children with similar issues.

A final thought: Music therapy is another modality that can be of benefit to children. For information about music therapy, visit sites like the Brain Sync Web site. Bottom line: It is important to work with an integrative practitioner who understands many different modalities and can customize and prioritize a treatment plan with you and other skilled practitioners for your child's specific needs.

Debbie Walhof, M.D.
This is a great question. Most pediatricians are not able to attend IEP meetings due to time and practice limitations. Most however, are willing to have a phone conversation with teachers, the school psychologist or other personnel. Absolutely feel free to ask your child's pediatrician to write a letter to the IEP team outlining his/her concerns and opinions and recommendations about your child's situation. But as I said earlier, most pediatricians are not well versed in the nuances of learning disabilities. If your child has been evaluated by a specialist, a behavioral pediatrician or an outside learning specialist, make sure you share copies of those consult notes with the IEP team. Some specialists are able to attend IEP meetings. In my opinion, it never hurts to ask.

Debbie Walhof, M.D.
Great question. NCLD just published a very informative article about Executive Function called Executive Skills and Your Child with Learning Disabilities that is a wonderful resource to look at.