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Attention Deficit Hyperactivity Disorder Pt.8

The Medication Debate

As useful as these drugs are, Ritalin and the other stimulants have sparked a great deal of controversy. Most doctors feel the potential side effects should be carefully weighed against the benefits before prescribing the drugs. While on these medications, some children may lose weight, have less appetite, and temporarily grow more slowly. Others may have problems falling asleep. Some doctors believe that stimulants may also make the symptoms of Tourette's syndrome worse, although recent research suggests this may not be true. Other doctors say if they carefully watch the child's height, weight, and overall development, the benefits of medication far outweigh the potential side effects. Side effects that do occur can often be handled by reducing the dosage.

It's natural for parents to be concerned about whether taking a medicine is in their child's best interests. Parents need to be clear about the benefits and potential risks of using these drugs. The child's pediatrician or psychiatrist can provide advice and answer questions.

Another debate is whether Ritalin and other stimulant drugs are prescribed unnecessarily for too many children. Remember that many things, including anxiety, depression, allergies, seizures, or problems with the home or school environment can make children seem overactive, impulsive, or inattentive. Critics argue that many children who do not have a true attention disorder are medicated as a way to control their disruptive behaviors.

Medication and Self-Esteem

When a child's schoolwork and behavior improve soon after starting medication, the child, parents, and teachers tend to applaud the drug for causing the sudden change. But these changes are actually the child's own strengths and natural abilities coming out from behind a cloud. Giving credit to the medication can make the child feel incompetent. The medication only makes these changes possible. The child must supply the effort and ability. To help children feel good about themselves, parents and teachers need to praise the child, not the drug.

It's also important to help children and teenagers feel comfortable about a medication they must take every day. They may feel that because they take medicine they are different from their classmates or that there's something seriously wrong with them. CH.A.D.D. (which stands for Children and Adults with Attention Deficit Disorders), a leading organization for people with attention disorders, suggests several ways that parents and teachers can help children view the medication in a positive way:

Compare the pills to eyeglasses, braces, and allergy medications used by other children in their class. Explain that their medicine is simply a tool to help them focus and pay attention.
Point out that they're lucky their problem can be helped. Encourage them to identify ways the medicine makes it easier to do things that are important to them, like make friends, succeed at school, and play.

Myths About Stimulant Medication

Myth: Stimulants can lead to drug addiction later in life.
Fact: Stimulants help many children focus and be more successful at school, home, and play. Avoiding negative experiences now may actually help prevent addictions and other emotional problems later.

Myth: Responding well to a stimulant drug proves a person has ADHD.
Fact: Stimulants allow many people to focus and pay better attention, whether or not they have ADHD. The improvement is just more noticeable in people with ADHD.

Myth: Medication should be stopped when the child reaches adolescence.
Fact: Not so! About 80 percent of those who needed medication as children still need it as teenagers. Fifty percent need medication as adults.

Treatments To Help People With ADHD and Their Families Learn To Cope

Life can be hard for children with ADHD. They're the ones who are so often in trouble at school, can't finish a game, and lose friends. They may spend agonizing hours each night struggling to keep their mind on their homework, then forget to bring it to school.

It's not easy coping with these frustrations day after day. Some children release their frustration by acting contrary, starting fights, or destroying property. Some turn the frustration into body ailments, like the child who gets a stomachache each day before school. Others hold their needs and fears inside, so that no one sees how badly they feel.

It's also difficult having a sister, brother, or classmate who gets angry, grabs your toys, and loses your things. Children who live with or share a classroom with a child who has ADHD get frustrated, too. They may feel neglected as their parents or teachers try to cope with the hyperactive child. They may resent their brother or sister never finishing chores, or being pushed around by a classmate. They want to love their sibling and get along with their classmate, but sometimes it's so hard!

It's especially hard being the parent of a child who is full of uncontrolled activity, leaves messes, throws tantrums, and doesn't listen or follow instructions. Parents often feel powerless and at a loss. The usual methods of discipline, like reasoning and scolding, don't work with this child, because the child doesn't really choose to act in these ways. It's just that their self-control comes and goes. Out of sheer frustration, parents sometimes find themselves spanking, ridiculing, or screaming at the child, even though they know it's not appropriate. Their response leaves everyone more upset than before. Then they blame themselves for not being better parents. Once children are diagnosed and receiving treatment, some of the emotional upset within the family may fade.

Medication can help to control some of the behavior problems that may have lead to family turmoil. But more often, there are other aspects of the problem that medication can't touch. Even though ADHD primarily affects a person's behavior, having the disorder has broad emotional repercussions. For some children, being scolded is the only attention they ever get. They have few experiences that build their sense of worth and competence. If they're hyperactive, they're often told they're bad and punished for being disruptive. If they are too disorganized and unfocused to complete tasks, others may call them lazy. If they impulsively grab toys, butt in, or shove classmates, they may lose friends. And if they have a related conduct disorder, they may get in trouble at school or with the law. Facing the daily frustrations that can come with having ADHD can make people fear that they are strange, abnormal, or stupid.

Often, the cycle of frustration, blame, and anger has gone on so long that it will take some time to undo. Both parents and their children may need special help to develop techniques for managing the patterns of behavior. In such cases, mental health professionals can counsel the child and the family, helping them to develop new skills, attitudes, and ways of relating to each other. In individual counseling, the therapist helps children or adults with ADHD learn to feel better about themselves. They learn to recognize that having a disability does not reflect who they are as a person. The therapist can also help people with ADHD identify and build on their strengths, cope with daily problems, and control their attention and aggression. In group counseling, people learn that they are not alone in their frustration and that others want to help. Sometimes only the individual with ADHD needs counseling support. But in many cases, because the problem affects the family as well as the person with ADHD, the entire family may need help. The therapist assists the family in finding better ways to handle the disruptive behaviors and promote change. If the child is young, most of the therapist's work is with the parents, teaching them techniques for coping with and improving their child's behavior.

Several intervention approaches are available and different therapists tend to prefer one approach or another. Knowing something about the various types of interventions makes it easier for families to choose a therapist that is right for their needs.

Psychotherapy works to help people with ADHD to like and accept themselves despite their disorder. In psychotherapy, patients talk with the therapist about upsetting thoughts and feelings, explore self-defeating patterns of behavior, and learn alternative ways to handle their emotions. As they talk, the therapist tries to help them understand how they can change. However, people dealing with ADHD usually want to gain control of their symptomatic behaviors more directly. If so, more direct kinds of intervention are needed.

Cognitive-behavioral therapy helps people work on immediate issues. Rather than helping people understand their feelings and actions, it supports them directly in changing their behavior. The support might be practical assistance, like helping Henry learn to think through tasks and organize his work. Or the support might be to encourage new behaviors by giving praise or rewards each time the person acts in the desired way. A cognitive-behavioral therapist might use such techniques to help a belligerent child like Mark learn to control his fighting, or an impulsive teenager like Lisa to think before she speaks.

Social skills training can also help children learn new behaviors. In social skills training, the therapist discusses and models appropriate behaviors like waiting for a turn, sharing toys, asking for help, or responding to teasing, then gives children a chance to practice. For example, a child might learn to "read" other people's facial expression and tone of voice, in order to respond more appropriately. Social skills training helped Lisa learn to join in group activities, make appropriate comments, and ask for help. A child like Mark might learn to see how his behavior affects others and develop new ways to respond when angry or pushed.

Support groups connect people who have common concerns. Many adults with ADHD and parents of children with ADHD find it useful to join a local or national support group. Many groups deal with issues of children's disorders, and even ADHD specifically. The national associations listed at the back of this booklet can explain how to contact a local chapter. Members of support groups share frustrations and successes, referrals to qualified specialists, and information about what works, as well as their hopes for themselves and their children. There is strength in numbers--and sharing experiences with others who have similar problems helps people know that they aren't alone.

Parenting skills training, offered by therapists or in special classes, gives parents tools and techniques for managing their child's behavior. One such technique is the use of "time out" when the child becomes too unruly or out of control. During time outs, the child is removed from the agitating situation and sits alone quietly for a short time to calm down. Parents may also be taught to give the child "quality time" each day, in which they share a pleasurable or relaxed activity. During this time together, the parent looks for opportunities to notice and point out what the child does well, and praise his or her strengths and abilities.

An effective way to modify a child's behavior is through a system of rewards and penalties. The parents (or teacher) identify a few desirable behaviors that they want to encourage in the child--such as asking for a toy instead of grabbing it, or completing a simple task. The child is told exactly what is expected in order to earn the reward. The child receives the reward when he performs the desired behavior and a mild penalty when he doesn't. A reward can be small, perhaps a token that can be exchanged for special privileges, but it should be something the child wants and is eager to earn. The penalty might be removal of a token or a brief "time out." The goal, over time, is to help children learn to control their own behavior and to choose the more desired behavior. The technique works well with all children, although children with ADHD may need more frequent rewards.

In addition, parents may learn to structure situations in ways that will allow their child to succeed. This may include allowing only one or two playmates at a time, so that their child doesn't get overstimulated. Or if their child has trouble completing tasks, they may learn to help the child divide a large task into small steps, then praise the child as each step is completed.

Parents may also learn to use stress management methods, such as meditation, relaxation techniques, and exercise to increase their own tolerance for frustration, so that they can respond more calmly to their child's behavior.

Controversial Treatments

Understandably, parents who are eager to help their children want to explore every possible option. Many newly touted treatments sound reasonable. Many even come with glowing reports. A few are pure quackery. Some are even developed by reputable doctors or specialists--but when tested scientifically, cannot be proven to help.

Here are a few types of treatment that have not been scientifically shown to be effective in treating the majority of children or adults with ADHD:

biofeedback
restricted diets
allergy treatments
medicines to correct problems in the inner ear
megavitamins
chiropractic adjustment and bone re-alignment
treatment for yeast infection
eye training
special colored glasses

A few success stories can't substitute for scientific evidence. Until sound, scientific testing shows a treatment to be effective, families risk spending time, money, and hope on fads and false promises.

Sustaining Hope

Mark

Today, at age 14, Mark is doing much better in school. He channels his energy into sports and is a star player on the intramural football team.

Although he still gets into fights now and then, a child psychologist is helping him learn to control his tantrums and frustration, and he is able to make and keep friends. His grandparents point to him with pride and say, "We knew he'd turn out just fine!"

Lisa

Lisa is about to graduate from high school. She's better able to focus her attention and concentrate on her work, so that now her grades are quite good. Overcoming her depression and learning to like herself have also given her more confidence to develop friendships and try new things.

Lately, she has been working with the school guidance counselor to identify the right kind of job to look for after graduation. She hopes to find a career that will bypass her attention problems and make the best use of her assets and skills. She is more alert and focused and is considering trying college in a year or two. Her counselor reminds her that she's certainly smart enough.

Henry

These days, Henry is successful and happy in his job as a shoe salesman. The work allows him to move around throughout the day, and the appearance of new customers provides the variety he needs to help him stay focused. He recently completed a course in time management, and now keeps lists, organizes his work, and schedules his day. Now that he has harnessed his energy, his ability to think about several things at once allows him to be creative and productive.

He is proud that he and his wife have developed important parenting skills for working with their son, so that he, too, is doing better at home and at school. Henry is also pleased with his new ability to follow through on projects. In Fact, he just finished making his son a beautiful wooden toy chest for his birthday.

Can ADHD Be Outgrown or Cured?

Even though most people don't outgrow ADHD, people do learn to adapt and live fulfilling lives. Mark, Lisa, and Henry are making good lives for themselves--not by being cured, but by developing their personal strengths. With effective combinations of medicine, new skills, and emotional support, people with ADHD can develop ways to control their attention and minimize their disruptive behaviors. Like Henry, they may find that by structuring tasks and controlling their environment, they can achieve personal goals. Like Mark, they may learn to channel their excess energy into sports and other high energy activities. And like Lisa, they can identify career options that build on their strengths and abilities.

As they grow up, with appropriate help from parents and clinicians, children with ADHD become better able to suppress their hyperactivity and to channel it into more socially acceptable behaviors, like physical exercise or fidgeting. And although we know that half of all children with ADHD will still show signs of the problem into adulthood, we also know that the medications and therapy that help children also work for adults.

All people with ADHD have natural talents and abilities that they can draw on to create fine lives and careers for themselves. In Fact, many people with ADHD even feel that their patterns of behavior give them unique, often unrecognized, advantages. People with ADHD tend to be outgoing and ready for action. Because of their drive for excitement and stimulation, many become successful in business, sports, construction, and public speaking. Because of their ability to think about many things at once, many have won acclaim as artists and inventors. Many choose work that gives them freedom to move around and release excess energy. But some find ways to be effective in quieter, more sedentary careers. Sally, a computer programmer, found that she thinks best when she wears headphones to reduce distracting noises. Like Henry, some people strive to increase their organizational skills. Others who own their own business find it useful to hire support staff to provide day-to-day management.

What Hope Does Research Offer?

Although no immediate cure is in sight, a new understanding of ADHD may be just over the horizon. Using a variety of research tools and methods, scientists are beginning to uncover new information on the role of the brain in ADHD and effective treatments for the disorder Such research will ultimately result in improving the personal fulfillment and productivity of people with ADHD.

For example, the use of new techniques like brain imaging to observe how the brain actually works is already providing new insights into the causes of ADHD. Other research is seeking to identify conditions of pregnancy and early childhood that may cause or contribute to these differences in the brain. As the body of knowledge grows, scientists may someday learn how to prevent these differences or at least how to treat them.

NIMH and the U.S. Department of Education are cosponsoring a large national study--the first of its kind--to see which combinations of ADHD treatment work best for different types of children. During this 5-year study, scientists at research clinics across the country will work together in gathering data to answer such questions as: Is combining stimulant medication with behavior modification more effective than either alone? Do boys and girls respond differently to treatment? How do family stresses, income, and environment affect the severity of ADHD and long-term outcomes? How does needing medicine affect children's sense of competence, self-control, and self-esteem? As a result of such research, doctors and mental health specialists may someday know who benefits most from different types of treatment and be able to intervene more effectively.

With further study, researchers may find that ADHD actually covers a number of different disorders, each with its own cluster of symptoms and treatment requirements. For example, scientists are exploring whether there are any critical differences between children with ADHD who also have anxiety, depression, or conduct disorders and those who do not. Other researchers are studying slight physical differences that might distinguish one type of ADHD from another. If clusters of differences can be found, scientists can begin to distinguish the treatment each type needs.

How do children with ADHD turn out, compared to brothers and sisters without the disorder? As adults, how do they handle their own children? Still other studies seek to better understand ADHD in adults. Such studies give insights into what types of treatment or services make a difference in helping an ADHD child grow into a caring parent and a well-functioning adult.

Animal studies are also adding to our knowledge of ADHD in humans. Animal subjects make it possible to study some of the possible causes of ADHD in ways that can't be studied in people. In addition, animal research allows the safety and effectiveness of experimental new drugs to be tested long before they can be given to humans. One team of scientists is studying dogs to learn how new stimulant drugs that are similar to Ritalin act on the brain.

Piece by piece, through studies of humans and animals, scientists are beginning to understand the biological nature of attention disorders. New research is allowing us to better understand the inner workings of the brain as we continue to develop new medications and assess new forms of treatment.

As we learn more about what actually happens inside the brain, we approach a future where we can prevent certain brain and mental disorders, make valid diagnoses, and treat each effectively. This is the hope, mission, and vision of the National Institute of Mental Health.

Source:
National Institute for Mental Health
http://www.nimh.nih.gov