- A Special Camp for Kids with ADHD
On the surface, it's just like every other camp: bright green grass covers the ground, laughter from the pool fills the air and kids run through the fields with smiles from ear to ear. Peer a little deeper into this scene, however, you will find that this is no ordinary camp.
Located in Riverdale, NY, the New York University Summer Program for Kids (SPK) is dedicated to helping children ages 7 to 11 with attention deficit hyperactivity disorder (ADHD) grow and develop in a safe, supportive environment. Here, specially trained counselors help children work on social, academic and athletic skills, and, most importantly, build self esteem and pride.
"We're considered to be a 'therapeutic day program,'" says Dr. Karen Fleiss, child psychologist and camp director. "But we're here to help each kid work on what he needs to work on."
Encouraging Growth
Throughout the eight-week session, counselors at SPK assess each child individually and develop a list of skills each needs to improve upon. For example, a child who needs to work on reading directions more carefully spends 90 minutes each morning working on academics in a classroom. Meanwhile, on the field, goals may be set to enforce teamwork or participating with the group. The camp is structured solely to help, not hinder, these children in achieving success.
For example, sports-time for many other camps means letting the kids run into the field with a baseball and bat. In this situation, most children with ADHD would soon find themselves confused and frustrated.
"Kids with ADHD often do poorly in team sports. They don't like the give and take; they lose patience with waiting for their turn," says Fleiss who explains that part of the problem is that these children just don't understand the rules of the game.
So, at SPK, counselors emphasize learning one new rule every day. With a lot of positive reinforcement, each child has the opportunity to learn the rule and feel good about even the simple parts of sports, like waiting their turn and cheering on their teammates.
But the lessons go much further than the sports field.
Learning How to Be a Friend
One of the most important tools used by counselors is a camp-wide point system. Points are awarded to each child for every positive thing they do over the course of the day. These points serve as an incentive system, as the children receive rewards and special privileges when they reach different milestones.
Points are given to a child when they do something simple, like participate in a group discussion, or they can be used to reinforce the most important skills taught each day. For instance, if the day's theme is 'validation,' the counselors will discuss with each child ways they can offer validation to their friends. Points are then awarded when a child compliments another on her art project or cheers for the boy who scored a goal in soccer.
The foundation of all lessons at SPK is improving social skills. "Kids with ADHD have trouble making and keeping friends," explains Fleiss, which is why these kids so often find themselves singled out by their peers in school. Here, because every child at this camp has something to work on, the bullying and teasing that so often occurs at regular camps is kept mostly at bay.
"Kids don't feel ostracized or that they're under the microscope," says Fleiss, "Because it's a kind environment, they will take risks and try things they wouldn't normally do."
Lingering Lessons
But it's not just the kids who are taught lessons at SPK. Parents also attend classes throughout the summer to learn the techniques used by the counselors so they can be implemented in the home and ensure that the skills developed in the summer don't go to waste.
Ultimately, everyone wins.
"This was sort of a last ditch hope for us," says one parent, who enrolled her son, Teddy, in the camp after he found so many other camps to be more frustration than fun.
At first, the program didn't seem to click for Teddy either, but two weeks in, "little by little we started to see all these miraculous little improvements," she adds. "Before when I would ask Teddy to do something he'd complain, but now its 'OK mom, be ready in a minute.'"
And even the kids realize how much they have achieved.
"I think that I learned more than I ever learned, and I want to come back," says one as another chimes in, "I had a spectacular summer."
- Tonsil Removal and ADHD: Connected?
Can a fairly routine problem, enlarged tonsils, be causing attention deficit disorder (ADHD) in your child? Not quite, says a new study, but tonsil problems may be partially to blame for some of your child's behavior problems.
While the cause-and-effect relationship is not entirely understood, researchers from the University of Michigan suspect that there is a relationship between enlarged tonsils and sleep-related breathing problems. Taking the relationship one step further, they also suspect that sleep problems may underlie some cases of behavioral problems in children, including ADHD.
"An undiagnosed sleep disorder is not the solution for all children with ADHD. But it could be something worth looking into for a substantial minority," said Dr. Ronald Chervin, study author and director of the University of Michigan Sleep Disorders Center.
Chervin and his colleagues assessed 105 children, 78 of whom were scheduled for a routine tonsil and adenoid removal. Tonsils and adenoids are in the back of the throat, and if infected or enlarged, they may affect one's ability to breathe at night. In fact, most of the children in the study who were having their tonsils removed had also been diagnosed with symptoms of obstructive sleep apnea, a sleep problem caused by frequent awakenings at night because of trouble breathing.
After evaluating the cognitive and behavioral abilities of all children, the researchers determined that 22 of the children scheduled for a tonsil and adenoid removal also had ADHD, while only two children from the 27 not scheduled for the surgery had this behavioral problem.
A year later, the children who had their tonsils removed to treat sleep apnea showed a significant improvement of their symptoms. Also, 11 of these children who were previously diagnosed with ADHD no longer met the criteria for diagnosis. The results of the study were published in Pediatrics.
"The findings help support the idea that sleep-disordered breathing is actually helping to cause behavioral problems in children," said Chervin.
The reason why obstructive sleep apnea may affect a child's behavior is not at all clear. While poor rest and general grogginess may contribute to behavior problems, a few children in the study developed new ADHD a year after the surgery, suggesting that sleep-disordered breathing may cause damage that is not seen until years later.
The take home message of the study, according to the authors, is that children who snore or seem to have other difficulty breathing while they sleep, should see a doctor for treatment. If the child also has behavioral problems and those dissipate as a result of the treatment, so much the better.
- The Ritalin Generation Goes To College
One graduate student at New York University first tried it in the windowless office of her college newspaper. She was on the third day of no sleep and began snorting the white lines to get through the exhaustion. Another student tried it after receiving the pill as a birthday present from a friend. The gift helped her zip through the last paper of the semester without any distraction.
A cup of coffee is no longer the vice of choice for pulling an all-nighter. Even over-the-counter caffeine pills don’t cut it anymore.
Vitamin R, Bennies, Jollies: slang names for the drugs students are now using to help them outline one more chapter or polish off that last paper, without disrupting their social lives.
What are these drugs? Medications meant to focus the over-active brain caused by attention deficit hyperactivity disorder (ADHD). While intended for one use, drugs like Ritalin and Adderall are being abused by students faced with increasing constraints on their time.
Experts on student behavior are just beginning to catch up with the latest college trend.
"While much is known about the college study use of alcohol, cigarettes, marijuana and other illicit drugs, we’ve not had a handle of the abuse of prescription drugs." says Dr. Henry Wechsler, professor in the Department of Society, Human Development and Health at the Harvard School of Public Health.
The Need to Achieve?
The use of illicit substances on campus is no surprise. The widespread use of alcohol and marijuana among college-aged kids is well known and documented. And generally, students use these substances to help them relax and forget about their schoolwork. Those who take prescription stimulants, however, have a different goal in mind. They want to be able to sit down, focus and plow through their work.
Some students only turn to these drugs as a last resort, using them get through the worst part of the semester.
"I was writing my last paper for school one semester and having trouble concentrating." said one female student from New York University, who, like most of the students interviewed, wished to remain anonymous. "I decided to just take it, and about an hour and a half later, I was finished. It definitely worked."
Others use the drugs more frequently to help them stay up through the night.
"If I have an exam to study for, I can stay up the whole night and read all the chapters I need to. The next day, I don’t feel tired at all for the exam, even though I haven’t slept for over 24 hours." said Lauren, an undergraduate from Syracuse University who says she uses Adderall about four or five times a semester.
As more and more students come clean about their use of stimulant drugs for non-medical purposes, the picture of a typical user comes into focus.
White, Male and Well Focused
According to a January 2005 survey of over 10,000 students from 119 four-year colleges, the use of prescription drugs for non-medical use has increased almost three percent in the last year. Interestingly, the study showed that prescription stimulants are most commonly abused in the highly-competitive colleges of the northeastern United States. Combine that with the fact that students with an average of B or lower are more than twice as likely to take these drugs, and one may quickly assume that abuse of ADHD drugs is tied to the need to achieve.
But study author Christian Teter, professor of pharmacy practice at Northeastern University, says that the reasons students use prescription stimulants may be more complex. "It could be that they are turning to [these drugs] for the academic advantage." he says. "But it may be they have better health care, so they can get a prescription easier."
In fact, previous studies have shown that members of fraternities and sororities—who tend to come from a wealthier background than their peers—are more likely to abuse both legal and illegal drugs than their classmates. With greater access to illicit and legal substances, it was not so surprising to Teter that his recent study also found that prescription stimulants are most commonly used by white, male fraternity members; women in sororities also represent the highest number of female users.
Increasing Access
So how do college kids get their hands on ADHD drugs? Many of the students interviewed reported getting their doses of Adderall—the stimulant of choice for its long-lasting effects—from other students who have been diagnosed with ADHD and have a prescription for the drug. Prices for one pill can go as high as five dollars, but friends often just pass them along for free.
With more than 1.5 million adults and 2.5 children currently taking drugs for ADHD, the supply on campus is only going to increase.
Some schools even report that students are making appointments with campus medical centers in hopes of scoring a personal supply.
Teter warns parents and school officials that while these drugs may not be as dangerous as other prescription drugs and illicit stimulants, like Oxycontin or cocaine, they can be deadly to someone with an unknown heart condition. More importantly, use of these drugs is tied to other risky behavior across the board. In fact, Teter’s study showed that students who use prescription stimulants are more likely to engage in binge drinking, drunk driving and the use of illegal drugs.
But some students think that even with all the warnings and risks, abuse of Ritalin and Adderall is only going to rise.
"It’s only natural that people are going to take advantage of these things to try to get a leg up." said one student.
- Quiet Riot: Girls with ADHD Sit in Silence
The image of a boy running chaotically around a playground is what most parents expect to see with attention deficit hyperactivity disorder (ADHD). But that quiet girl daydreaming her way through class may also have the same problem, and the subtlety may cause it to go undiagnosed for years longer than her male counterpart.
The difference in how girls and boys with ADHD act causes a lot of confusion for parents trying to help their child achieve their best. So what should moms and dads be looking for if they suspect their little girl has ADHD?
Dr. Martin T. Stein, professor of pediatrics and director of Developmental Behavioral Pediatrics at the University of California, San Diego, describes how girls with ADHD typically act and the best ways teachers and parents can help them succeed.
Is ADHD more common in boys than girls?
By the criteria we use for the diagnosis of ADHD, for every girl with the diagnosis, at least three or four boys are also diagnosed. So, it's about a 3:1 or 4:1 ratio of boys to girls.
However, if you look at the ratio in those who are referred to a doctor by an outside group, like from a school or a church, the ratio is as high as 9:1 boy to girl. This difference is because the only children who are diagnosed in these environments have associated problems, such as conduct disorder, severe depression, anxiety or oppositional behavior. And, as you will see, boys with ADHD tend to have more of these associated problems.
Why do boys with ADHD tend to be noticed more often?
There are three subtypes of ADHD. One type is primarily identified by hyperactive impulsive behaviors. A second type is primarily identified by inattentive behaviors. Finally, the third type combines both groups: hyperactive impulsive and inattentive.
Most boys have a combined type of ADHD, where they have both hyperactive impulsive and inattentive symptoms. Additionally, they tend to have these symptoms for enough time to cause a functional impairment that leads to an easy diagnosis of ADHD. Many girls, on the other hand, are more likely to just have the inattentive form of ADHD.
So, do girls simply have a different set of symptoms than boys?
Boys have what people generally think of as ADHD. They're overactive. They're getting up all the time in class. They're fidgety. They're inattentive. Some of these behaviors, like touching and talking to other kids, create behavioral problems or disorder in the classroom. So, they're more likely to come to the attention of teachers and parents earlier on.
When a child has the inattentive type of ADHD, however, they are easily distracted. They daydream. They're disorganized. They are unfocused and have trouble with concentration, particularly during learning situations. Although, in some cases, this also occurs during social interactions. In a classroom, this type can be more subtle because kids with the primarily inattentive type don't have behavior problems. These kids can be very quiet. And it tends to go unnoticed even more if the child has at least average intelligence, and they're doing reasonably well early on, when there are no huge academic challenges.
When do people tend to recognize the symptoms of ADHD in girls?
It is said that girls with ADHD who primarily have the inattentive type are likely to have a diagnosis several years later than boys. It could be as early as the third or fourth grade, when academic material increases in its level of difficulty. But in some cases, particularly when the child is a little brighter and has some strategies to get around it, girls are not diagnosed until junior high. Here, the levels of organization and classes that require greater sequencing, memory and organizational skills come into play, so that's when all these inattentive symptoms make learning—at least in traditional classroom settings—very difficult for many of the girls with inattentive ADHD.
Is it more likely that a girl with ADHD will go undiagnosed?
Yes. And if the child is underachieving, and a teacher or parent doesn't recognize the symptoms of inattention or ADHD, they might think it's a learning disability, but more commonly, they get a label of laziness.
How do these labels affect a young girl?
There are many potential outcomes to it. At the worst end, she goes through school and it's not diagnosed or attended to. The interesting thing is that these girls with inattentive ADHD will do well on standardized tests in some cases. So, parents and teachers recognize their ability, but since they're still underachieving in the classroom, they are called lazy, and it can affect self-esteem.
But these inattentive symptoms can also affect social interactions. Think about somebody who can't concentrate on social interchange and is less focused, not organized and barely getting to places on time. This can affect social interaction as well.
What should teachers be looking for if they suspect a girl has ADHD?
There are very specific symptoms for ADHD, which include poor concentration, easy distractibility, difficulty focusing on material, disorganization and forgetfulness. An example of this in school would be a girl who does the homework for class, but forgets to turn it in. At home, difficulty in organizing can be seen as a very disorganized room or it can be seen in school as not keeping a record of when assignments are due. All of these symptoms should be red flags to a teacher.
How would treatment differ in a girl with the inattentive type of ADHD?
There are really three treatment approaches to ADHD: education, behavioral management and medication.
First, a very clear education is important in helping the parent and the child understand what ADHD is. Here, we would talk about the myths of ADHD and remove misconceptions to give the family a clear understanding that this is a biological condition.
The next treatment strategy would be behavior management, where we make some environmental accommodations for the child. For the inattentive form, treatment probably consists of accommodations more than anything else.
What accommodations can be made in school and at home?
In the classroom, we may suggest that the child sit up front, closer to the teacher. Then, the teacher can keep the child on task, tap her shoulder periodically, make more eye contact, remind the child to write assignments down and make sure she hands in the homework. Also, giving assignments in smaller parcels is sometimes helpful. And it helps if parents go over the assignments when they are completed.
At home, these girls shouldn't be doing homework in a room with a lot of distraction: Led Zeppelin should not be on the stereo, the television shouldn't be on and computer games shouldn't be played. It should be quiet, fairly boring and without visual or auditory distractions. They shouldn't be doing homework in the kitchen or dining room when there are other kids around.
How do reward systems fit into behavioral management?
The basic behavioral management with ADHD is no different than with any behavioral condition in children and adults. The principles are rewarding good behavior, giving a lot of strokes and commendations when good behavior is occurring. Good behavior could mean just turning in your homework or getting a better grade than you did last week, completing assignments or getting a star from the teacher for that day or that week. But it is important to give lots of positive feedback when it's deserved.
It is important to not make a lot of negative feedback, especially for minor things. In other words, choose your areas of concern. Don't constantly be putting the child down.
It helps to set up some kind of a token economy, where you give rewards for good behavior or, in some cases, remove privileges for negative behaviors. But these all have to be very carefully organized so the child understands the contract, and so they can be used both in school and at home.
The Academy of Pediatrics recently published a very good book for parents on ADHD: ADHD: A Complete and Authoritative Guide. There are a couple of chapters there on suggestions for parents and teachers on behavior modification techniques.
Is the role of medications different for girls?
So far, there isn't strong evidence to support different practices for medications between boys and girls. Some individual clinicians feel that some medicines work better in girls than boys, but the scientific studies have not yet shown strong differences either in response to the medications or with regard to side effects.
Would you recommend trying behavioral therapies first before resorting to the medications or do you think they work best together?
Ideally, one or both treatment methods are used. I emphasize that both medications and behavior management have a strong evidence base to their effectiveness. Even if a parent chooses medication, I always encourage and teach the behavior modification.
Now, the behavioral management requires a lot of effort and learning on the part of the parents and teachers, so often someone to do this teaching is not available. Pediatricians, who see most of the children with ADHD, often don't have the time or training to really do very specific planning with behavior modification. We try to do some, but a child requires some real guidance and several sessions to set up an effective system. It takes a lot of time and most insurance companies will not pay for that.
What overall message do you have for parents concerned about ADHD?
I think many parents still feel that ADHD is primarily a condition of boys, because they see it as a disorder where there's a lot of hyperactivity and aggressive behavior. And it certainly does occur in girls, so I think the more teachers and parents are attuned to this, the more attention kids will get in treatment.
These kids are not bad people. They have lots of ability and talent, but they have this problem with inattention that's getting in the way of learning and social experiences.
- Determining a Better ADHD Drug Proves Elusive
Just after the Centers for Disease Control reported that 2.5 million children and 1.5 million adults are currently taking myriad medications for attention deficit disorder (ADHD), a drug first approved for narcolepsy could be the latest addition.
While one might question the connection between treating a sleep disorder and an attention problem, this newest finding highlights the confusion over how to determine which of the many options is the best choice for treating ADHD.
"Few studies pit one stimulant against another in a head-to-head comparison." said Dr. Marian McDonagh from the Oregon Evidence-based Practice Center at the Oregon Health and Science University.
The Newest in a List of Drugs for ADHD
This problem can be seen with the most recent study confirming the positive effects Provigil (modafinil) has on kids with ADHD. Provigil, is approved as a "wake-promoting agent" for those sluggish from a lack of sleep, specifically for shift workers. Logically, it seems to follow that the same drug would also help those who have trouble staying attentive during the day.
After early studies showed that Provigil helped adult patients with ADHD, Cephalon, the company that manufactures the drug, created a pediatric version to be tested for widespread use.
During a nine-week-long study, which was presented at the 2005 Annual Meeting of the American Psychiatric Association (APA), the pediatric version of Provigil was shown to improve children’s scores on a standardized test.
"This study not only shows that this medication is effective and rapid in onset for the treatment of pediatric ADHD." said lead researcher Dr. Joseph Biederman, chief of pediatric neuropsychopharmachology at Massachusetts General Hospital, "It also gives the clear signal that we have a medication that can be used…to treat ADHD in children who cannot tolerate amphetamines."
Even if Provigil did have a positive effect, in the study it was only compared to a placebo, not to Ritalin nor any other drug for that matter.
"Short-term trials do not provide clear evidence that any one stimulant is any more tolerable than another." said McDonagh.
Comparing the Options
With almost 20 drugs being used for the treatment of ADHD, ranging from stimulants to antidepressants, things can get confusing. Most doctors simply prescribe the popular stimulants Ritalin, Concerta or Adderall. But if the patient doesn’t respond to these drugs or if the side effects are intolerable, as is the case 60 to 80 percent of the time, an alternative method needs to be tried.
The problem is finding an option that seems to work best.
Of the 2,287 papers that McDonagh reviewed for her analysis, published in September 2005 by the Drug Effectiveness Review Project, the only drug ever used in comparison studies is Ritalin, the drug recommended by the American Academy of Pediatrics as a first-line against ADHD.
But even in those studies, the vast majority were short-term with limited numbers of mostly Caucasian participants, leaving almost none that looked at the long-term effectiveness, side effects or possible ethnic differences to show if one treatment truly worked better than another.
"The bottom line is that [choosing a drug for treatment] is trial and error." says Dr. John Santa, medical director of the Drug Effectiveness Review Project, a program dedicated to analyzing the data on various types of drugs to determine the safest and most helpful option.
Shaping the Future of ADHD Treatment
For people looking for good ADHD treatment, the key is, says Santa, finding a reputable doctor. Patients should also be sure to let the doctor know if cost is a problem, as some brand-name drugs can be quite pricey. "If money is an issue, there are some alternatives that are just as good." says Santa.
Santa and his colleagues were astounded by the gaping holes in the understanding of ADHD treatment and large number of studies that did not produce any new data. It seems that many more studies will be necessary to first determine the true pros and cons of the traditional mediations before even beginning to determine whether Provigil, or any new drug for ADHD, is truly better or worse than another.
"We are drowning in information, starved for knowledge." he says.
Looking towards the future, the biggest problem, according to Santa, is that the medical community doesn’t require head-to-head trials before a drug goes to market.
"We need to look within ourselves because we don’t require or reward comparison studies." said Santa.
- A Lack of Sleep or ADHD?
At a busy pediatric clinic in Rhode Island, Dr. Judith Owens sees a fair share of hyperactive children. They come in bouncing off the walls. Some may have trouble focusing in school or lash out at others for no apparent reason.
Could this type of behavior, the parents wonder, mean that their child has something as serious as attention deficit hyperactivity disorder (ADHD)? Before she answers, Owens is quick to ask them a question she fears too few are posing: "How well is your child sleeping?"
In fact, the same symptoms that characterize ADHD often overlap with the type of problems that result from a lack of sleep, according to various studies. Although doctors can usually separate the two, Owens warns that mood and behavioral changes caused by sleepless nights might sometimes be mistaken for ADHD.
"In the back of everyone’s mind should be whether these symptoms are related to sleep problems." says Owens, a pediatrician at Rhode Island Hospital in Providence.
How to Spot a Sleep Disorder
A thorough look at your child’s sleep behavior can help determine whether the problem is simply a lack of rest. Excessive daytime sleepiness is often the clearest indication.
Snoring is another key warning sign. In a recent study, researchers at the University of Michigan found that loud snoring helped predict which children would end up hyperactive several years later.
"Snoring is a major symptom of a sleep apnea." says Owens, referring to one of the main sleep disorders that children face. After several restless nights, children may demonstrate the same hyperactivity that kids with ADHD show.
Still, trying to distinguish sleep disorders from attention deficit ones can prove complicated. Not only are the symptoms very close, there is the chance that ADHD may interfere with sleep as well.
Studies suggest that children with attention deficit disorders are naturally sleepier than healthy kids, possibly due to overactive minds that keep them stirring at night. This could partly explain why some become hyperactive—such behavior is the body’s way of adapting to a lack of sleep, Owen explains.
Catching Some Zzz’s
Regardless of the ultimate cause, sleep problems can lead to irritability, a lack of focus and trouble in school. And if it turns out that your child does have ADHD, the wide use of stimulant medications may create its own sleep problems.
Owens says that newer drugs, such as Strattera, are less likely to interfere with sleep than Ritalin and the rest. But some children still complain of tiredness and irritability after taking Strattera, according to the Food and Drug Administration.
Whether a child’s lack of sleep is from ADHD, medications or sleep apnea, getting a good night’s rest is crucial. A lack of sleep can either exacerbate ADHD symptoms or cause problems that seem just as bad.
The first step, Owen says, is for parents and doctors to discuss a child’s sleep behavior. If your child is waking often in the night or having trouble going to sleep, there are simple steps you can take.
Owens recommends the basics:
- A regular bed time
- No caffeine or running around shortly before bed
- A relaxing bedtime environment, meaning no television
"Kids who have television sets in their rooms have more trouble going to sleep." says Owens. Reading a bedtime story instead, she adds, can prove better for the child and for mom and dad as well.
"Insomnia in children frequently affects parents’ sleep and stress." says Owens.
- A Safer Way to Treat ADHD?
For parents worried about over-medicating children who have attention problems, behavioral therapy may be a welcome addition to treatment. This type of therapy helps someone with attention deficit hyperactivity disorder, or ADHD, alter their behavior and thought patterns to learn how to relate to others and succeed.
In one of the more recent studies, published this May in Experimental and Clinical Psychopharmacology, researchers from the University of Buffalo looked at the benefits of behavioral therapy on 27 children with ADHD between the ages of 6 and 12. They found that behavioral therapy could cut the need for stimulant drugs by up to two-thirds. Moreover, when drugs and behavioral therapy were combined, the two treatments were more effective in controlling ADHD than either used alone.
How does behavioral therapy work? Dr. J. Russell Ramsay, assistant director of the ADHD Research and Treatment Program at the University of Pennsylvania, answers some common questions about this treatment option.
What is behavioral therapy?
Behavioral therapy is a form of psychotherapy that involves an individual or a family sitting in a room with a counselor to talk about the problems that have led the individual to seek help. Unlike traditional forms of therapy, the focus is on the behaviors of the person and what contributes to these behavioral patterns.
How is behavioral therapy used to help somebody with ADHD?
There are a couple different ways that behavioral therapy can work. We know that ADHD shows up differently across the lifespan, therefore, behavioral therapies are used differently for individuals of different age groups.
For example, behavioral therapy for children with ADHD focuses on parent and teacher training, and how they can better understand and manage behaviors. We teach parents and teachers how to guide behaviors. We also work with the family to develop more structured household routines. That way, we can make sure that the patterns used at home are most effective for the ADHD symptoms.
With adolescents, we look at maintaining constructive communication, helping the parents think through the rules of the household. We establish the bedrock rules that the family really wants to establish, and what rules might be a little more negotiable. Some teens may also benefit from additional therapy to address how they think about their emerging identity and the role ADHD plays in that.
Therapy is quite different for adults. Most of the time, an adult's difficulties may have gone undiagnosed earlier in life, so very often we're dealing with an individual who is trying to make sense of a lifetime's worth of frustration. Understandably, these frustrations may have created a negative belief system about how the individual defines himself, his prospects for the future and general attitude about the world. So we have to try to change these negative thoughts, as well as deal with behavioral issues.
What should somebody look for in a therapist?
The term therapist is a wide-ranging term. You could find a psychiatrist, a psychologist, educational psychologist or licensed clinical social worker that has experience in these techniques. First off, be sure that you trust the therapist. Make sure somebody has received adequate training in conducting therapy for people with ADHD.
There are many good professional organizations to help in your search: the Association for the Advancement of Behavioral Therapies (AABT) and the Academy of Cognitive Therapy. They keep a referral base of people trained in cognitive behavioral therapy.
What should a family expect to happen during a therapy session?
Assuming a therapist already confirmed the ADHD diagnosis, they would first look at what the family, child and teachers view as some of the problematic situations. After that, we get down to what we are going to do about it.
For example, if the student is having trouble sitting still, we define the problem and try to describe what happens to cause the problem. We try to flesh out the scene so we can understand what can be modified to get the behavior moving in the right direction. For example, if the teacher likes to have students sit in alphabetical order in the classroom, perhaps a child with ADHD would do better sitting near the teacher's desk. So, even though the child's last name might have required him or her to sit towards the back of the class, we can tweak these rules based on the child's situation.
Why does a family need to get the teacher involved?
Behavioral therapists recognize that only so much happens in a weekly, hour-long session, and that they can't be present for the remaining 167 hours in that week. So, if there is collaboration among all interested parties things can be more productive. The therapist might consult with the teacher and work on what can be changed in the classroom to accommodate the child.
How is therapy monitored?
Unlike traditional therapies, behavioral therapies monitor whether the plan is working in concrete ways. We use a behavioral criteria, like the number of times the child gets out of his seat during class, to measure the success of the plan. If the plan works we can then work to maintain the positive results. If something's not working about the plan, we look to see if there were any unanticipated problems. Perhaps it wasn't a realistic plan, and we have to move on to plan B.
Does any of the responsibility to change fall on the child?
Progressively, more responsibility is taken on by the child as he or she gets older. But even younger children can help keep track of things, and the therapist often works with the child to come up with a reminder system about how to handle certain situations.
For example, kids with ADD might forget to raise their hand in class, so perhaps the therapist talks with the child about what might be a helpful reminder. Perhaps there's a little picture of a child raising his or her hand that can be taped to the child's desk as a reminder. A therapist may engage the child to find ways to keep track of when homework assignments are due. There's a lot of ways children with ADHD can be empowered to gain control over their behavior. The key is not to ask too little and risk having the child become overly dependent on other people, and not to ask too much and risk having them overwhelmed by the responsibility. So, this is where the behavioral therapies are very collaborative, checking in with each other about the process to see how things are progressing.
What is behavior modification?
Behavior modification is one aspect of behavioral therapy. It looks at different ways of shaping behaviors by introducing a positive reinforcement for a desired behavior. For example, every time the child has spent 30 minutes doing his or her homework, they get a point. Over time, the points add up and the child will receive a prize.
Behavior modification can also work by matching a less-desirable behavior with a desirable one. A child may work with a friend on a more difficult topic that the child would typically avoid. This way it becomes less negative, and the child can learn mastery on the task.
What is the role of medications with behavioral therapy?
The issue of medications is often a very personal one. Sometimes people might be reluctant to take them for a host of different reasons: maybe they don't identify as somebody who's really a medication taker, and they're skeptical of the effects. In that case, there might be certain incorrect beliefs about the medications that a therapist can work on with the individual.
Other times, we'll hear beliefs like, "If I take the medications while I'm doing my work, I don't know if it's really me doing it. How much is me, and how much is the medications?" Even though behavioral therapy is very outcome focused, we don't turn a blind eye to some of these identity issues. We can look to see if there are ways that misinformation is affecting this person's choice about their medication compliance.
We certainly respect the right of self-determination and some people do make an informed decision to not take medication. So, in this case, we could have a discussion on their willingness to engage in therapy to make changes.
Can behavioral therapy serve as a substitute for medication?
That's not really been well researched. One study looked at medications alone and medications combined with behavior therapy and showed about equal effectiveness.
However, some people choose to augment the medication therapy with behavioral therapy, particularly if they feel that certain issues have not been addressed by medication alone. I have worked with some people with relatively mild or low ADHD who did not want to take medications. They tried cognitive behavioral therapy first and felt like they had a successful therapy experience under those conditions.
How long does it take behavioral therapy to start working?
It's very individualized, because some people may come in as an adult newly diagnosed and are ready for change. Other people might be more ambivalent about the prospect of change. But that's part of the treatment. We personalize this behavioral model to each person, taking a look at individual difficulties.
What is the ultimate goal of behavioral therapy?
The end goal of behavior therapy or cognitive behavioral therapy is to make the therapist obsolete by imparting coping skills and helping the individual become better versed in why they do what they do. This way, the individual, the family and the teacher can together take control of the management of ADHD in the long run.
- Best Treatment for ADHD: Good Parenting
With her oldest daughter already diagnosed with having mild attention problems, it was at least easier for Roxanne Salazar to notice that her son’s behavior went beyond normal. At the age of five, he was kicked out of kindergarten for biting another child and spent his time at home "dancing off the walls." Salazar says. This behavior was later found to be the result of attention deficit hyperactivity disorder (ADHD).
Salazar was reluctant to treat her son with anything stronger than soda and candy. But after these alternate stimulants failed, along with vitamins and just about everything else she could try, Salazar heeded her doctor’s advice and put him on a prescription stimulant medication. The difference, she says, is like night and day.
"His teacher says he’s at the top of his class." Salazar adds, beaming.
Salazar’s own life, however, is not about to return to normal anytime soon. Even with successful treatment, children with ADHD require almost constant attention. Salazar must juggle the special needs of her son with a full time job and a growing family. Her fourth child is due in December.
If she could offer one bit of advice to busy parents struggling with their own child who has ADHD, it would be this: "Have a lot of patience." she says.
The Scope of ADHD
As many as six percent of all American kids may suffer from severe attention problems, which can put extra strain on the already difficult work of raising a family. Children with ADHD develop more slowly in school, typically have fewer friends and may require special care even after they leave for college.
"Raising a child with ADHD is exponentially more difficult." says Dr. Arthur Robin, a professor of psychiatry and behavioral neurosciences at the Wayne State University School of Medicine in Michigan.
The pressure is compounded by the controversial nature of ADHD. As the diagnosis and treatment of this disorder continues to rise, pediatrician groups increasingly square off with critics who feel that ADHD has become a catch-all for hard to control but otherwise healthy kids.
Left in the middle are concerned parents, who must balance the needs of their child against the debate over ADHD. Few issues are more perplexing than the use of stimulant medications.
Drugs like Ritalin, Adderall and Concerta are low-dose versions of powerful amphetamines. This sets off alarm bells with parents, but Robin says that they are currently the most effective option for controlling problem behavior.
"It’s the only thing that can directly change the way the mind is functioning." he says.
Robin is quick to add that children should also try other steps besides stimulant medications, such as behavioral therapy. As a psychologist, Robin teaches kids how to compensate in areas where they have trouble. When used together, drug and behavioral interventions help more than either alone, studies show.
Parents Need Help to Help Their Kids
Still, putting your own child on any medication is not an easy choice. Salazar told her doctor that she wanted to try her way first before allowing her son to take a stimulant. "I hate the idea of drugs." Salazar says, adding that she herself flinches at the use of antibiotics. Although the treatment has proven successful for her son, she can’t help but think she did something wrong.
"You feel you’ve failed as a parent." she says.
Indeed, the stress and effort of raising a child with ADHD is enough to make parents need their own form of help. During her spare time, if it could be called that, Salazar runs an online discussion group for ADHD families who share their concerns and advice. Hospitals and medical organizations also hold local support groups for those who want to talk face-to-face.
Ultimately, being a strong parent is what kids most need to overcome attention problems. In one study published in 2002, researchers found that a firm and encouraging parenting style had a significant moderating effect on a child’s behavior at home. Approaches that include clear, concise instructions and nurturing a child’s talents can help improve behavior, studies suggest.
Kids are largely on their own at school, however, so parents should consistently check in with teachers to ensure that their child is up-to-speed and behaving well.
Stay Positive
Despite the frustration some parents may feel, children with ADHD require more coaxing than typical kids. Robins says moms and dads should take great care in making sure that they emphasize the positive over the negative.
"You need to be a cheerleader for your kid." says Robins. In addition, he says parents should give more immediate feedback, use incentives before punishment and enforce agreed-upon consequences for kids who fail to behave.
Salazar uses the five minute rule when her son gets out of hand. After two polite warnings to stop what he is doing wrong, a third warning signals that he has to remain still and silent for the next five minutes.
"What kid wants quiet time?" she asks. "It really works."
Yet, even with all the advice and research on how to be a better parent, there are times that Salazar feels at a breaking point. She takes a deep breath and composes herself.
"No matter what happens, stay strong." she says.
- Get Out! Popular Dance Video Game Helps Kids with ADHD
The same video game that endlessly distracts kids from schoolwork may improve concentration and memory, according to a study on a small group of children with attention deficit disorder. Researchers found that playing Dance Dance Revolution, the arcade hit from Japan where dancers try to match the steps of a gyrating computer animation, led to an intriguing boost in reading comprehension.
"We’re still in the beginning stages." cautioned Tammy McGraw, an education specialist with the Appalachian Educational Laboratory and lead author of the study. "But if we can demonstrate that video games help, we can find solutions that do not require us to medicate children as much."
The game McGraw and her colleagues tested is a far cry from the gang violence found in Grand Theft Auto or the bloody martial arts action of Mortal Kombat. There isn’t even any bumping or grinding. Available for such popular home gaming systems as Sony’s PlayStation II and Microsoft’s Xbox, Dance Dance Revolution involves stomping on four large buttons to a danceable beat in what educators describe as a mix between Twister and Simon Says.
McGraw, who presented her findings at a recent Digital Games Research Association conference in Vancouver, Canada, said that she first got the idea to study the game after seeing a long line outside a mall. Following the endless convoy of adolescents, McGraw was surprised to find what everyone was waiting for: a chance to shake it against a virtual dancer.
McGraw had recently read about research suggesting visual and rhythmic stimulation could improve reading and attention. Perhaps, she thought, this emerging theory about learning could be matched with the latest video game craze.
"There are a lot of ways to help kids read better." said McGraw, adding that few children find them interesting. "Kids naturally gravitate toward video games."
As part of the study, McGraw and colleagues recruited 62 sixth graders who suffered from attention deficit hyperactivity disorder (ADHD). First, the children were given a series of reading tests. Half the kids were then instructed to play Dance Dance Revolution for about an hour a week. The other children continued with their normal routine.
Just to ensure that no parent was taken aback by the unusual educational aid, McGraw said they chose the Disney version of the game, which includes a dancing Mickey Mouse and songs by Chubby Checker.
Three months later, the kids took the same reading tests again. The scores were largely the same for both groups, but those who played Dance Dance Revolution did slightly better with so-called receptive coding skills, the ability to immediately recall a word or series of numbers. This type of testing indicates greater focus and attention, a key issue for children with ADHD. The more times the kids played the game, the better they did.
"This was the real hot spot." said McGraw. By quickly matching their movements to visuals and music, children who play Dance Dance Revolution seem to strengthen the areas of the brain that are necessary for better memorization, McGraw explained. Since the game is exciting, these skills are more easily improved.
McGraw hopes to press ahead with her research to find a broader educational role for Dance Dance Revolution, as well as other video games.
"Everyone is playing them." she said, "And it’s something schools can afford."
- Terms of Impairment: Underperformer or Adult ADHD?
It’s not that hard to identify attention deficit hyperactivity disorder (ADHD) in a kid who is jumping up and down on the school desk or flitting from one activity to another. But ADHD can be harder to pick up in adults, who have figured out ways to cope with many of their symptoms but are often still struggling to juggle the responsibilities of modern life.
Even though the condition will persist into adulthood for about 60 percent of kids with ADHD, many people still think of ADHD as a childhood disorder. According to a recent study by the Harvard School of Public Health, ADHD affects 4 percent of the U.S. adult population, or 8 million adults. Yet, 80 percent of those 8 million don’t know they have ADHD and aren’t treated.
"Most primary care physicians haven’t been trained to see it in adults." says Leonard Adler, MD, director of the Adult ADHD Program at the New York University (NYU) School of Medicine. "The impairments from the disorder are clear in terms of their impact on the workplace, the family and society." Below, Dr. Adler talks about how to recognize ADHD in adults and explains how treatment can help people with ADHD hold their jobs and families together.
What is ADHD?
ADHD is attention deficit hyperactivity disorder, which is a term we use to encompass all attention deficit disorders. It’s a very common impairing neuro-psychiatric disorder that affects individuals throughout the lifespan.
How is ADHD diagnosed?
For a diagnosis of ADHD, you have to be experiencing either inattentive symptoms (and if you have those, then you’re the inattentive subtype) or hyperactive/impulsive symptoms (and those would be the hyperactive/impulsive subtype). You may have both and have the combined subtype, which is the most common.
The second thing is that the symptoms must cause trouble. The impairment must occur in at least two settings, be that at school or work, at home or in social settings.
The third thing is that symptoms have to begin in childhood. That doesn’t mean that you have to have the diagnosis as a child, all of the symptoms, nor the level of impairment that you see as an adult. Many bright individuals have symptoms that start in childhood, but in childhood, we have structure provided by our parents and school. As we get older, we go from being managed by others to managing ourselves or managing others.
The fourth thing is that the symptoms have to be from ADHD and not another disorder.
Why do people think of ADHD as a childhood disorder?
One reason may be that the criteria that are in the Diagnostic and Statistical Manual of Mental Disorders uses childhood symptoms, so if you don’t think about how the symptoms may change throughout life, you won’t know that an adult has ADHD. For example, inattentive symptoms become much more prominent for adults as compared to the hyperactive-impulsive symptoms. Adults know that it’s not appropriate to climb on top of their desk and "runs about and climbs" is one of the childhood symptoms. No adult does that because that would be very stigmatizing.
How do people tend to cope with symptoms at work?
Adults have had a lifetime of coping with their symptoms and it’s important to look at how they’re coping. They may select jobs that allow them to deal with some of their symptoms better. For example, if you have a lot of symptoms of restlessness and you pick a job that allows you to be physically active, that will be much more in line with your symptoms than if you have a nine-to-five, buttoned-down job sitting at a desk all day. People will tend to find jobs that allow them to move from one activity to another.
You not only want to look at coping strategies but you want to look at impairment. Impairment can be relative. You may look at an individual with ADHD and say, "How in the world can this individual have ADHD? They’re an executive." The reality is that they can’t function without their executive assistant. They have to be organized by someone to function.
They may be working very, very long hours and everything is going up until the last minute. That’s relative impairment, which can be quite costly to the individual, because if they’re working long hours, there’s not a lot of time left for themselves or their family. It can spill over to difficulties in family life.
How does ADHD affect other aspects of life?
Untreated adults with ADHD are more likely to underperform academically. They’re more likely to change jobs, underperform on the job and more likely be fired. They’re about twice as likely to smoke cigarettes. If untreated, they’re more likely to use substances.
In terms of the family, they’re more likely to be divorced or separated. A number of patients who have come to our center have been in a family crisis. The spouse will complain that the individual who’s being considered for ADHD isn’t listening and is not following through on tasks. They may be seen as unreliable. There have been a number of marriages that have been on the precipice that have been pulled back with one of the two parties getting treated for ADHD.
Do symptoms tend to be different in men and women?
Women and girls tend to have more of the inattentive symptoms, which, in part, have led to some of the under-recognition. Historically, if you were behaviorally disruptive and in and out of your chair in childhood, you were more likely to be identified as having ADHD than if you were, let’s say, daydreaming and not attending to the task. This, in part, led to girls not being identified, though they are a little bit more likely to be recognized as having ADHD as adults. If you look at the gender split in childhood and adulthood, it’s four boys to every one girl and about two men to every one woman.
Are parents with ADHD likely to pass it on to their kids?
This is a familially transmitted disorder. If there’s a child in the family with ADHD, there’s about a 40 percent chance that one of the two parents will have ADHD and there’s about a 25 percent chance that a first-degree relative, such as a sibling, will have it.
One of the most common ways adults will present with ADHD is that they have a child who has been diagnosed and they’ve realized that they had the symptoms themselves in childhood. Their spouse will sort of nudge them and say, "Honey, you have them now, too."
What conditions are sometimes confused with ADHD?
There are a number of disorders that can appear ADHD-like. It’s important to remember that we’re looking at symptoms throughout the course of one’s life. That’s one way to establish what may be ADHD and what may be a mood disorder, such as depression. There are many disorders that co-travel with ADHD, like depressive disorders, bipolar disorder, anxiety disorders and learning disabilities. But it’s important to remember that mood disorders tend to come and go, whereas with ADHD, the symptoms are more or less present all the time.
These generally co-traveling disorders tend to present in families of people with ADHD, too. But for some, the anxiety disorders and maybe the chronic depression arise when the ADHD is not getting treated.
How is ADHD treated?
For adults and for children, medications play a role in treating the ADHD. The medications are the tools. The cognitive behavioral therapy or coaching will help individuals on medication to implement change. There have been a number of studies that have shown that either stimulants or non-stimulant medications can be quite effective in treating adults with ADHD. There is about a 70 percent chance of getting better with the first medicine you take, pretty good numbers in medicine.
We tend to use the longer-acting versions of the stimulants. The only stimulant that’s approved for ADHD in adults is Adderall XR, which is an amphetamine preparation. Ritalin-type stimulants, such as Ritalin LA, Metadate CD and Concerta, are also used. The non-stimulant medication that’s approved for ADHD in both kids and adults is Strattera.
People will stay on their medication long term. That doesn’t always mean forever. We evaluate the need for medications on an ongoing basis.
If you think you or a loved one has ADHD, what are the signs you should look for?
You want to look for the inattentive symptoms: trouble paying attention, distractibility, organizational difficulties, misplacing things, trouble with time management, restlessness, difficulty waiting, interrupting others when talking. You want to see if those symptoms cause trouble for the individual and also whether there’s some sense that the symptoms go back to childhood.
There is a screening tool copyrighted by the World Health Organization, that has the six symptoms that are most predictive for adults of having the disorder. It’s on the NYU website. If you have at least four of the six symptoms, you should be evaluated by your doctor to see if you have it. This is a screening tool that’s meant to identify individuals at risk for ADHD. It’s not meant to provide a formal diagnosis.
This is a disorder that’s clearly common. This is a disorder that can be diagnosed by sitting down with your doctor and going over your history. We have good screening tools. We also have good treatments and people can get better.
