Friday, May 23, 2008

Definition: ADHD

Okay. Maybe we will get into should you drug your kid or not?

Attention-Deficit/Hyperactivity Disorder
There are different types: Predominantly Inattentive, Predominantly Hyperactive-Impulsive, and Combined Type. It's either a 314.01 or a 314.00.

We'll not split hairs on diagnosis, though. Not today.

Did I ever tell you this story? (Let's change all the details, so even if it seems like it's you, no, it's definitely not you).

The story goes back to the early eighties when I was a young therapy doc. No idea what I was doing. That's how it feels all the time when you're a young therapy doc.

A couple of alcoholic parents come in with two little boys, ages 6 and 8, wild and crazy. Seemed to me, happy. The parents say, "The school insists we put our boys on medication. At least J, the older one. They'll wait on H."

J is eight and he has been a problem for as long as they can remember. Born on the move. These days he probably wouldn't have survived first grade without a drug to slow him down.

"But," the parents tell me, "We're alcoholics (in recovery for ten years) and we don't want to use any medication. We want to teach our kids how to behave and how not to behave. Can you help us? We'll work with you a hundred percent."

Well, sure. Glad to help.

(I quake, Uh, how should I know if I can help you?)

Meanwhile, the kids are literally climbing the walls of my office, swinging from the rafters. This is how I assess ADHD with hyperactivy. If they're climbing walls, standing on top of your desk, jumping on the sofa, then MAYBE there's a hyperactivity problem here.

We go to work on it. Both parents enforce the behavior modification program, my first, developed on the spot. Been using it for years, I say. (At this stage of my career, I have been using it for years. One day I'll make a video* demonstrating how it's done. You'll see me. I'll be the one talking to you in a ski mask.)

The teacher worked with us.

The grandparents had us covered.

The babysitter came to the therapy.

And it didn't take all that long for them to become new kids. Unrecognizable, nice kids. Productive, good students.

It's surely what someone used to say It takes a village stuff. She's totally right. But this isn't a political endorsement of any kind. It's an ecosystem endorsement.

Find your people and use them. Is that always possible? Aren't there other variables? What if people in the family, parents, especially, don't get along or have mental illnesses, personality disorders? What if? What if? What if?

Most likely that's the case, right? Everyone needs therapy. The specifics are what we call the big confounders. They make therapy more difficult. But not impossible.

All I'd like to suggest in this post, really, is that before the physician prescribes even the newer, better medications, that a good psycho-social history is in order.

More than once in the past few years I've seen an overweight adolescent girl who says she just developed what she is sure is ADHD.

She wants me to tell her pri-care to prescribe Ritalin or another drug to help her focus in school. A good student, a girl like this now has a boyfriend problem, or parent problems, and oh, definitely a weight problem. And trouble in school, a new problem. But if I get to know her (we talk girl talk) it's the weight that's freaking her out. I get it. She wants drugs to kill her appetite, slim down. Good drugs.

There's all kinds of prescription medication abuse going on out there.

Should we give children speed for obesity? Medicate children for carrying the emotional intensity of their family systems? It can be hard to differentiate hyperactivity from anxiety. But it's not my call. I'm not an MD. And neither are teachers calling for the med-evals, insisting, sometimes.

Maybe for some kids it is genetic and there is a need for medication. I don't know.

But I humbly suggest that a family assessment is in order before a doctor writes a scrip, and that parents look hard into other strategies of behavioral change.

Hyperactive kids can be nervous, angry kids, too. Treat them. Treat their parents. Get it all done the first time around. Shop for good therapists.

Parents should address all of the problems in the family, and all of the problems in the eco-system (school, church, etc.) that might be contributing to symptoms in their children.

It only makes sense. Of course, medication is so much easier, right?

therapydoc
* blee neder no promises

28 comments:

Anonymous said...

Wow, my step-daughter is giving all three of her boys medication. They are 9, 8 and 7 years old. Her and her husband fight constantly and he refuses to get a job. My guess is the boys are reacting to their environment and aren't necessarily hyperactive. Nice post, thanks alot. I love reading your blog.

therextras said...

My hearty compliments also.

In my most recent post I state: The medical model is a failure for children and parents who have these problems. I agree with the need for an ecological evaluation - something that includes the lifestyle the child lives, the people who have power to control that lifestyle.

Wish I could refer people to you - at best, I have just linked your blog to mine, under the list: For My Mental Health.

Alice said...

Am I right in thinking that you blog from the USA? America needs a national health service. Badly!

Joylene Green said...

Great post! I hardily agree.

Christina Shaver said...

At the same time, when medication is necessary, medication is necessary.

Maybe I'm hyper-sensitive to this topic because my four year old takes multiple medications for ADHD and anxiety -- in addition to three hours of psychotherapy A DAY, an hour of occupational therapy a week, and, starting in the very near future, an hour of vision therapy a week.

And I must say, that with my personal experience raising a son with ADHD, this is a neurological disorder. There is no amount of behavioral therapy in his "village" that will miraculously turn him around without medical intervention, though I pray it were the case.

Which makes me wonder if the two young boys you described in your post really did have ADHD or just lived in a misguided household.

therextras said...

To Alice: Not.

What say you, therapydoc? - after sabbath, of course.

therapydoc said...

Right-o, Christina. But the boys in the post met almost every criterion for ADHD.

What presents as symptoms and behaviors (how we diagnose) will look the same in most cases. What's going on inside, however, is more of a mystery, and probably varies greatly child to child.

One day soon, it's possible that much of psychiatric intervention will be hands on, lasers to the brain, electronic waves, or some kind of bio-technology.

For all we know, meds will be out.

Alice said...

Not in the US?

Or not a believer in a) the right to universal health care and/or b) the wisdom of separating clinical decisions from financial ones as far as is practicable?

My thinking was that I'd rather these decisions were not skewed by people's desire to medicate to make money from selling their medication.

therapydoc said...

Important issue, Alice.

therextras said...

Myth: Physicians are exhorbitantly compensated for prescribing pharmaceuticals. Most providers struggle to be compensated for any services.

Controlling the flow of money between physicians and pharmaceutical companies has not improved the medical care in countries where it is done, or in the government controlled systems here in the US.

How does universal health care address the issue of prescribing medication for children ADHD?

therapydoc chooses not to continue a discussion on "the system" of healthcare relative to ADHD. Probably a wise choice, and she gets to choose, nonetheless. With the next post, these comments get pushed (down and less visibly) into cyberspace.

Still think this was an exceptionally good post on the topic, on par with all your posts. Thanks.

Leora said...

One argument against universal health care: we need big business to make enough money to pay for medical research. True, the big business will be skewed by what makes money (that's why good alternative medicine doesn't get studied properly). But Canada basically piggybacks off our medical research.

Fallen said...

First of all, I always love reading your blog. Haven't had as much time lately so here I am catching up.

Really, I love the line, "Of course, medication is so much easier, right?" Not to say that there aren't cases where medication isn't warranted. But it really is so much easier to simply control the behavior rather then change it. Any type of therapy takes work and it takes time. Medication is often a quick fix.

In too many situations I think we have gotten away from asking, "Why?" Why are they doing x? Look at the underlying causes and then work from there. It's not even about alternative medicines... It's about having a more balanced approach where your treatment might involve your doctor, a therapist, maybe even a chiropractor, etc. Or perhaps that's asking a little too much.

Midwife with a Knife said...

I will say that I read not too terribly long ago that there's some evidence that therapy makes durable changes in brain function (on one of those fMRI type of studies).

What I'm wondering is what kind of behavioral intervention you make for ADHD?

therapydoc said...

not intervention, interventions. I'll demonstrate one approach on YouTube, it doesn't translate as well unless you see it. I could try to script it for you here, but can't promise.

estee said...

Interesting and insightful post, as usual.

I would request that you be more sensitive to the subtleties of parenting a child with behavioral problems. Your opening line "Should you drug your kid?" is brutal. As you state, some children really do need medication. And many of those parents have tried anything and everything before "drugging" their kid. In fact, it is often those parents who are most "in tune" with their child who will hesitate and postpone medication because they feel guilty or distrust their health care providers because people look at them with horror and say "You DRUG your kid????" So no one gets the help they need. Not good for either parents or children.

Education is important. Sensationalizing is not educating. Education with sensitivity and without doing harm to parents who are trying their very best to help kids in trouble is worth the extra effort, don't you think?

therapydoc said...

Estee, you're totally right. I humbly apologize for the tone and if I offended any of you reading this, really hope you'll forgive me.

The post is aimed at people who insist that a child be on meds. "If you don't put him on something, I can't educate him, is the message."

This is, unfortunately, a situation that I've encountered many, many times. The popularity of meds for ADHD and behavior disorders is growing.

Parents get it. I rarely meet a parent who wants to use medication for the mental or behavioral disorders of children.

Systems therapists don't blame anyone, as you know, but we do intervene in as many ways as we can, try to hedge our bets for change.

I've avoided this topic for two years, you should know, because it is hard to seem open to both sides of the issue. But I am open. Whatever works, works.

Just have a good assessment, too.

Thanks for the sensitivity poke.

Rob at Kintropy said...

Very good post, Therapy Doc. Engaging in a family, environmental, and detailed analysis takes time, but may actually address some root causes, particularly if the those causes are not physically or chemically "hard wired." Medication really just addresses symptoms (even when it's necessary).

My six year old son has tons of energy and is incredibly social all the time. We haven't had the Serious Teacher/Principal discussion yet, but I dread the possibility of it a bit. I'm convinced my son's active imagination and social skills are assets, particularly as he learns to control them and use them appropriately.

therextras said...

And I thought this discussion was fizzled....well, I have been wrong before. I heartily recommend the book: An Elephant in the Playroom by Denise Brody. Out of the mouths of parents, this book is honest and thorough and thoughtful.

Psychiatry101 said...

ADHD is such a tricky diagnosis.Is the rumor true that lots of television watching is a factor?

therapydoc said...

Good question. No idea. I think it depends upon the kid, what the kid watches, and in general, how others respond when the child copies what he sees.

After all. That's the big problem with television, the modeling thing.

therextras said...

The key word is "factor" or contributor. Suggesting a cause-and-effect relationship is inaccurate. Agreed, good, and a well-worded question.

Looking through my lense....In the case of excessive (lots) of tv viewing, the young brain is laying down firm pathways for receiving fast, interesting, potentially emotionally stimulating (love, comfort, shame, guilt) and adrenaline producing (threat, fear, violence, aggression) visual images. Once there are firm (not physiologically correct term - but conveys the concept) brain pathways and the visual input is taken away, what kind of response would you expect from the child?

I think it's a reasonable recommendation to tell parents to limit tv watching, but not effective if you do not help them figure how to that within their particular lifestyle. I'd be willing to bet that part of therapydoc's effective treatment intervention was to reduce tv viewing. Would I win the bet, therapydoc?

therapydoc said...

You bet. And increase time with those bound paper things with words printed on them. but if the motor's always running, I send them off to the park, have 'rents teach them to play hard, physically, to run more, skip more, jump more.

Not that it ALWAYS works. This is not about never using meds, it's about using them appropriately.

estee said...

Thanks for your response, TD.

As you know, I love the eco-approach. The conundrum of the eco-approach with a young kid is that the ones who are responsible for getting the kid into treatment (of any kind) are usually the same folks who are part of the eco-mess that is generating the problem. I am seriously allergic to "blaming" the parents -- I only want to point out how difficult it might be for parents to see their kid's issues as a reflection of their own issues. Case in point: Talking with a parent recently about a VERY bright child who has some severe social/behavioral problems. The family is in therapy. The parent was complaining that the therapist spends most of the time trying to resolve issues between the parents -- instead of addressing the child's behavioral issues. I pointed out to the parent that perhaps the therapist IS trying to address the child's behavioral issues AS A RESPONSE to the "mixed messages" she is getting from her parents. There was stunned silence.

As for meds, as long as we look at them as a "last resort", parents will continue to feel that there is a stigma to meds and many will feel guilty about putting a kid on meds. That HAS to stop. In the same way that you've advocated elsewhere on this blog for de-stigmatizing mental health issues, I hope that you will take a strong position to de-stigmatize meds-when-appropriate for kids. The "when appropriate" is key -- but that is NOT for neighbors, other parents, or other kids to decide. It's even difficult for health professionals - which is why every parent should be encouraged to have a thorough work-up by a qualified developmental expert -- NOT your local pediatrician, or even your local social worker. It is tragic to see a kid go untreated because the parents have been told that "Meds are BAD" or because they are afraid that their child will be stigmatized.

therapydoc said...

The local social worker, armed with an MSW, might do a really good job. Working alone is just silly, and many mental health professionals have no problem doing that. You always need a team and that includes teachers. Especially valuable is the family doctor. Thanks Estee.

Spirophita said...

This is a fantastic post. My little adopted brother is believed to have ADHD with Hyperactivity disorder. But our family is extremely controlled, very focused, probably overly structured, and my mother is a family therapist with her MA in social work. So far, my little brother has:
-Oppositional defiance disorder
-ADHD
-Hyperactivity

And a string of other "issues." I see his issues largely as an outcropping of his family situation and struggles in being an adopted child. The answer is medicating him to a great degree.

What do you do when an entire family should go to therapy but doesn't because one of the members is in the psychological wellness field?

Helene said...

Great post. Medication should be a last result if used at all. Many behavioral disorders affecting school work will disappear when the environment is changed. For example, many of these problems disappear when the child is homeschooled.

What scares me most is when a child must be on multiple medications because the side effects of one drug must be mitigated by a second or even 3rd drug. I have seen people badly messed up after taking a cocktail of different drugs for psychiatric discorders.

Deb said...

Great post. I work with many kids and adults with ADHD and agree with so much of what you wrote.

Wonder Woman! said...

This is such a great illustration... wow. :) I have seen the effects of many kids medicated and brutally over medicated. I wonder what damage we do to these developing brains when we pour these foreign chemicals in. I believe that if everyone pulls together we can make a community. Thanks for writing this! :D