attention deficit disorder Archives

Whose Prescription Is It, Anyway?

by Author Howard Markel, MD, PhD – ICPA.org:

Attention Deficit Disorder and Ritalin

The boy is 14 years old and has one of the most severe cases of attention deficit disorder (ADD) that I have seen as a pediatrician. He fidgets; there are nonstop hand gestures, leg swinging and tapping. More troubling, he simply will not pay attention to any adult attempting to engage him in conversation, placing him in great jeopardy of flunking out of school.

During his first office visit, the boy explained his predicament to me: “It’s like I’m in a room with 20 big screen HDTVs blaring away in surround-sound. And on them are all the newest videos from MTV. The problem is that I can’t decide which one to watch, so I try to watch them all.”

His mother is less focused on her son’s perpetual motion than on his angry outbursts and what she sees as his refusal to listen to her. The day we met, she had already decided what she wanted to do. I was being told to write a prescription for Ritalin.

As every pediatrician knows, stimulant drugs like methylphenidate (Ritalin) cause most people to speed up their actions and thoughts. But for those with ADD (with or without hyperactivity), these drugs can slow them down, reduce overactivity, increase attention span, and can even improve relationships between a child and parents or other family members. There are, however, some nagging problems: none of us is exactly certain how these drugs work or what their long-term benefits and risks might be. Sometimes, they cause intolerable side effects such as tics and sleep disturbances.

The young man was clearly unhappy with his mother’s decision and let it be known with a slew of scowls and outcries of “Shut up!!” I asked him why he would prefer not being able to pay attention to his schoolwork, to which he replied: “You just don’t get it. I’m a lot more fun when I don’t take Ritalin. I crack great jokes in class and my friends think I am really cool. But when I take that stuff, I’m zoned out. I’m like a log. Ritalin ruins my life.”

This description went a long way in explaining why many teachers (and not a few parents) of kids with ADD prefer their charges to be medicated and why many children resist such attempts. Left untreated, however, many of these kids create problems with disruptive behaviors and can destroy the normal dynamics of a classroom and at home.

Here was my dilemma: The boy’s mother, and not the young man, wanted the prescription. The law defines a 14-year-old as a minor, but given that his condition was hardly fatal and essentially a behavioral issue, to whom should I have listened? The mother, who wants a more controllable child, or the boy, who simply wants to be what he perceives to be his true self? After all, the essence of adolescence is finding out who you are and figuring out who you want to be. As a pediatrician, I am supposed to be assisting youngsters in this difficult process.

That day, I listened to the parent and wrote the standard prescription for 40 mg of Ritalin a day. Like millions of youngsters with ADD, he takes 20 mg before going to school in the morning and another 20 mg at lunch.

Every month, I see the boy to renew his prescription for Ritalin and to make sure that there are no serious side effects. At each visit, he greets me with a deep-rooted but quiet anger. His fidgeting and outbursts seem to have diminished, but there has been little improvement in his schoolwork. Last year, he barely passed the eighth grade and his mother admitted that 2 of his teachers simply elected to pass him to avoid a repeat year with him. Nevertheless, she is delighted with the results.

When the boy is on vacation from school, I have noticed a definite change in his demeanor. Typically, when school is out, pediatricians give children with ADD a “drug holiday.” When he does not take his medication, his fidgeting and inattention are back in full force but he beams with joy, at least when I see him, and tells me that without Ritalin he can again enjoy cutting up in front of his friends.

But in his mother’s defense, I don’t live with him and have no real idea how disruptive his ADD behaviors can be at home. In cases like these, I have to listen to the parent that does live with him. I remain terribly conflicted about pharmacologically altering this young man against his will. Using potent pills to treat a disorder we do not completely understand flies in the face of prudent medical practice, and yet we pediatricians do this all the time with our ADD patients. More than a century ago, the great physician Sir William Osler observed that “the desire to take medicine is one feature which distinguishes man, the animal, from the rest of his fellow creatures.” In the practice of pediatrics, we are often compelled to include the parent’s desire in that rubric.

But still, I wonder, am I doing the right thing?

Article originally posted at ICPA.org.

Nutritional Considerations for ADHD

by Pathways Magazine – ICPA.org:

Early Use of ADHD Drug Alters Brain

Ritalin use in preteen children may lead to depression later in life. Ritalin and cocaine have different effects on humans. But their effects on the brain are very similar. When given to preteen rats, both drugs cause long-term changes in behavior.

One of the changes seems good. Early exposure to Ritalin makes rats less responsive to the rewarding effects of cocaine. But that’s not all good. It might mean that the drug short-circuits the brain’s reward system. That would make it difficult to experience pleasure—a “hallmark symptom of depression,” Carlezon and colleagues note.

The other change seems all bad. Early exposure to Ritalin increases rats’ depressive-like responses in a stress test. “These experiments suggest that preadolescent exposure to [Ritalin] in rats causes numerous complex behavioral adaptations, each of which endures into adulthood,” Carlezon and colleagues conclude. “This work highlights the importance of a more thorough understanding of the enduring neurobiological effects of juvenile exposure to psychotropic drugs.”

my.webmd.com/content/article/78/95700.htm?lastselectedguid={5FE84E90 -BC77-4056-A91C-9531713CA348}

Consider Fish Oil Over Ritalin

Children with attention-deficit hyperactivity disorder (ADHD) have problems paying attention, listening to instructions, and completing tasks; they also fidget and squirm, are hyperactive, blurt out answers, and interrupt others.

It is conservatively estimated that 3-5% of the schoolage population has ADHD. Although drugs, such as Ritalin, are frequently used to treat ADHD, they are fraught with complications. Disadvantages include possible side effects, including decreased appetite and growth, insomnia, increased irritability, and rebound hyperactivity when the drug wears off.

One would not expect to find that a single cause or even a handful of factors could explain why ADHD appears to be so rampant in our society. Because it is accepted that both genetic and environmental factors play a role in ADHD, many other factors—both intrinsic and extrinsic— could influence an individual’s fatty acid status.

Inefficient Conversion of ALA (Flax Oil) To EPA And DHA

A possible cause for the low fish oil status of the ADHD children may be impaired conversion of the fatty acid precursors LA and ALA to their longer and more highly unsaturated products, such as EPA and DHA (fish oil fats).

It appears that children with ADHD just are not able to chemically convert the plant omega-3, ALA to fish oil very well. The problem is further worsened when omega-6 fats are consumed and the ideal omega-6:3 ratio of 1:1, progresses to the typical standard American ratio of 15:1. Many of these children have ratios which are even worse and can be as high as 50:1.

This study provides the research evidence supporting the use of the omega-3 fats found in fish oils to effectively address the underlying deficiency that is present in most of these children and appears to be contributing to the ADHD.

Two books worth having for your lending libraries:

Smart Fats: How Dietary Fats and Oils Affect Mental, Physical and Emotional Intelligence
by Michael A. Schmidt

Omega 3 Connection
by Dr. Stoll

Article originally posted at ICPA.org.

ADHD and Non-Medical Care

by Pathways Magazine – ICPA.org:

Parents seeking treatment for their child with ADHD (attention deficit hyperactivity disorder) often pursue alternative treatments to those offered by conventional medicine. A study conducted in Australia investigated how many parents with ADHD children did seek some form of alternative to stimulant medication. This study published in the January 2005 issue of the Journal of Paediatric Child Health revealed that over two-thirds of families with an ADHD child sought alternative care. Families of 50 children out of 75 respondents attending the Royal Children’s Hospital in Victoria reported using at least one form of alternative treatment for ADHD.

Diet modification was the most common form of alternative treatment pursued by these parents (66 percent of those who tried alternatives). Other treatments that parents had tried included vitamins and minerals (32 percent), aromatherapy (24 percent), dietary supplements (24 percent), chiropractic (20 percent), naturopathic therapy (16 percent), herbal therapy (14 percent), and neurofeedback and behavioral optometry (10 percent each).

Parents were also asked their goals in seeking alternative treatment, and 89 percent wanted to minimize their child’s symptoms. Avoiding side effects of prescribed medications was rated as important by 67 percent of families.

Most importantly, nearly 60 percent of families rated at least one type of alternative treatment helpful for their child.

This study shows the frustration and general dissatisfaction among parents with the pharmaceutical approach to children’s attention problems. Parents are seeking a holistic approach to these children’s problems, and this study shows the perceived benefit that parents experience from these holistic methods of treatment.

Article originally posted at ICPA.org.

The Myth of Attention Deficit Disorder

by Thomas Armstrong, PHD – ICPA.org:

Over the past thirty years, attention deficit disorder (ADD), or attention deficit hyperactivity disorder (ADHD), has emerged from the relative obscurity of cognitive psychologists’ research laboratories to become the “disease du jour” of America’s schoolchildren. Accompanying this popularity has been a virtually complete acceptance of the validity of this “disorder” by scientists, physicians, psychologists, educators, parents, and others. On closer critical scrutiny, however, there is much to be troubled about concerning ADD/ADHD as a real medical diagnosis.

There is no definitive objective set of criteria to determine who has ADD/ADHD and who does not. Rather, there are a loose set of behaviors (hyperactivity, distractibility, and impulsivity) that combine in different ways to give rise to the “disorder.” These behaviors are highly context-dependent. A child may be hyperactive while seated at a desk doing a boring worksheet, but not necessarily while singing in a school musical. These behaviors are also very general in nature and give no clue as to their real origins. A child can be hyperactive because he’s bored, depressed, anxious, allergic to milk, creative, a hands-on learner, or has a difficult temperament, is stressed out, is driven by a media-mad culture, or any number of other possible causes.

The tests that have been used to determine if someone has ADD/ADHD are either artificially objective and remote from the lives of real children (in one test, a child is asked to press a button every time he sees a 1 followed by a 9 on a computer screen), or hopelessly subjective (many rating scales ask parents and teachers to score a child’s behavior on a scale from 1 to 5: these scores depend upon the subjective attitudes more than the actual behaviors of the children involved).

The treatments used for this supposed “disorder” are also problematic. Ritalin use is up 500% over the past six years. Yet, Ritalin does not cure the problem; it only masks symptoms. In addition, there are several disadvantages to Ritalin: children don’t like taking it, children use it as an “excuse” for their behavior (“I hit Ed because I forgot to take my pill.”), and there are some indications it may be related to later substance abuse of drugs like cocaine. Behavior modification programs used for kids labeled ADD/ADHD work, but they don’t help kids become better learners. In fact, they may interfere with the development of a child’s intrinsic love of learning (kids behave simply to get more rewards), they may frustrate some kids (when they don’t get expected rewards), and they can also impair creativity and stifle cooperation.

ADD/ADHD is a popular diagnosis because it serves as a tidy way to explain away the complexities of turn-of-the-millennium life in America. Over the past few decades, our families have broken up, respect for authority has eroded, mass media has created a “short-attention-span culture,” and stress levels have skyrocketed. When our children start to act out under the strain, it’s convenient to create a scientific-sounding term to label them with, an effective drug to stifle their “symptoms,” and a whole program of ADD/ADHD workbooks, videos, and instructional materials to use to fit them in a box that relieves parents and teachers of any worry that it might be due to their own failure (or the failure of the broader culture) to nurture or teach effectively. Mainly, the ADD/ADHD label is a tragic decoy that takes the focus off of where it’s needed most: the real life of each unique child. Instead of seeing each child for who he or she is (strengths, limitations, interests, temperaments, learning styles etc.) and addressing his or her specific needs, the child is reduced to an “ADD child,” where the potential to see the best in him or her is severely eroded (since ADD/ADHD puts all the emphasis on the deficits, not the strengths), and where the number of potential solutions to help them is highly limited to a few child-controlling interventions.

Instead of this deficit-based ADD/ADH paradigm, I’d like to suggest a wellness-based holistic paradigm that sees each child in terms of his or her ultimate worth, and addresses each child’s unique needs. To do this, we need to provide a wide range of options for parents or teachers.

Article originally posted at ICPA.org.

To Empower! Not Control! A Holistic Approach to ADHD

by Thomas Armstrong, PHD – ICPA.org:

Thousands of studies tell us what children with ADHD can’t do, but few tell us what they can do. This article presents holistic strategies for helping children with ADHD succeed at home and in school by building on their interests, learning styles, and many talents.

Eight-year-old Billy, in the front row, will have nothing to do with my demonstration on new techniques for teaching spelling. During my visit to his elementary school classroom in upstate New York, Billy is out of his seat during most of the lesson. When I ask the children to visualize their spelling words, however, I am amazed to see Billy return to his seat and remain perfectly still. Covering his eyes, Billy “looks” intently at his imaginary words—fascinated with the images in his mind!

Later on, I realize that something more important than a spelling lesson went on that afternoon: Billy was able to transform his external physical hyperactivity into internal mental motion and, by internalizing his outer activity level, was able to gain control over it. This incident occurred some time ago but remains memorable to me. Why? Because it suggests that internal empowerment, rather than external control, is often the best way to help kids diagnosed with ADHD.

A Decidedly Unholistic Approach

Much of the current work in the field of ADHD looks at the issue from an external control perspective. The two interventions touted in almost all books and programs about ADHD are medication and behavior modification. While these approaches are often dramatically effective in young people with ADHD, both have troubling features that often receive scant attention. Some researchers suggest that when children receive medication, they may attribute their improved behaviors to the pills rather than to their own inner resources (Whalen & Henker, 1990). Others may expect the medication to do all the work and thus neglect underlying issues that may be the true causes of a child’s attention and/or behavior difficulties.

Behavior modification programs, which abound, seek to control children’s behaviors through some combination of rewards, punishments, or response costs (the taking away of rewards). Some programs rely on token economy systems, while others use behavior charts, stickers, and even machines. For example, the Attention Training System sits on a child’s desk and automatically awards a point every 60 seconds for on-task behavior. The teacher can also deduct points for bad behavior using a remote control. Students trade points for prizes and privileges. Although behavior modification programs may influence children to change their behavior, they do it for the wrong reason: to get rewards. Such programs can discourage risk-taking, blunt creativity, decrease levels of intrinsic motivation, and even impair academic performance (Kohn, 1993).

Looking at the Whole Child

Most ADHD researchers and practitioners see children labeled with ADHD in terms of their deficits. Thousands of studies tell us what these kids can’t do, but few tell us what they can do and who they really are. Two exceptions are Crammond (1994) and Hartmann (1993). Where are the studies that tell us what these kids are interested in, what kinds of positive teaming styles or combinations of intelligences they use successfully in the classroom? What sorts of artistic, mechanical, scientific, dramatic, or personal contributions can they make to their schools and communities?

A new vision of educational interventions is needed to reflect a deeper appreciation for the whole child based on a wellness paradigm, rather than a deficit perspective rooted in a medical or disease-based model. We need to initiate a new field of study to help children with behavior and attention difficulties—one based on discovering their strengths rather than fixing their faults. Parents and teachers tell me about cases of ADHD-labeled kids who are talented dancers, musicians, sculptors, and dramatists. The ADHD community needs to conduct research on the positive qualities of these children and what their abilities could mean in contributing to their success in the classroom and in life.

Such research could develop assessment strategies geared toward identifying their inner capabilities. Gardner’s theory of multiple intelligences (1983) is one possible framework for developing appropriate assessment instruments to help identify such abilities—a refreshing change from the behavior rating scales and artificial performance tests currently used to assess ADHD in children. We must develop individualized educational plans (IEP) that give more than lip service to a child’s strengths and have goals and objectives that solidly reflect a desire to help children achieve success, rather than to “overcome their problems.”

While the ADHD worldview tacitly approves of a teacher centered, worksheet- and textbook-driven model of education (almost all of its educational suggestions are based on this kind of classroom), current research suggests that all students benefit from project-based environments in which they actively construct new meanings based on their existing knowledge of a subject. Some research suggests that students with ADHD do better in environments that are active, self-paced, and hands-on (McGuinness, 1985). Video games and computers are powerful teaming tools for many of these children. In fact, their high-speed behavior and thinking lend themselves quite well to such cutting-edge technologies as hypertext and multimedia (Armstrong, 1995).

Finally, interventions need to go beyond strategies such as smiley faces, points, and medications, and reflect a full sense of the child’s true nature.