Does how we look at it matter?
I was a teacher for over 16 years in public schools. Many children I taught had attention problems. There really wasn’t an ADHD label at the time I started teaching; we labeled them with Minimal Brain Dysfunction. We had no idea why they seemed so easily distracted. However, we did know they drove us crazy.
Even with a graduate degree, I realized I had neither the knowledge nor resources to help these students whether they were adults or children. I went back to university to ask my professors what to do. They were somewhat puzzled too. Most hadn’t been in a classroom in over 30 years. So I attempted the good old standbys: moved the student closer to my desk, developed and individualized education plan (IEP), a behavioral plan, a rewards program, and communication with the parent. These are typically the accommodations still used today. Essentially, we modify environment. We do not retrain the child or adult. In other words, we don’t teach coping skills or cognitive skills, we just try to make their environment easier to muddle through.
Approximately 60% to 70% of all ADHD children will carry their problems into adulthood. As adults, research tells us they have higher rates of substance abuse, obesity, incarceration, traffic accidents, divorce, and commonly make less money than their peers. This is a truly sad commentary on our educational system and our treatment of ADHD medically and as a society. What we currently do is not working.
The next rational question is, “Why is this system a failure?”
Teachers are on the front line with the students and they are often responsible for the initial diagnosis. While they cannot legally make a diagnosis, they often recommend parents to take their child to a pediatrician for diagnosis. Frequently, with a 20 minute evaluation, a diagnosis is made.
Sometimes the pediatrician will be wise enough to send rating scales home and to the teacher. These checklists (often the Conners or the Vanderbilt scales) are assessed to determine symptom frequency and severity. These are sometimes evaluated pre and post, but commonly just post medication to determine medication’s effects to adjust the dosage accordingly.
The salient question seldom addressed: Why are we are treating symptoms and not the underlying cause? If I go to my doctor and tell him my leg hurts, he doesn’t just let me walk away with pain medication. Instead, he asks me what I’ve been doing. “Have you been running? Exercising on that leg?”
I tell him I’ve just started skipping rope regularly for aerobic exercise. He feels my leg.
“I’d like to take an X-ray to check for other problems as I can’t feel anything,” he says.
The X-ray shows I have a stress fracture in my shin bone. “We can see a stress fracture in your shin. That’s the cause of your pain. You’re going to have to cease the rope skipping for a while.”
Pediatricians and parents are asking the wrong question: “How do we control the symptoms?” This is tantamount to the doctor hearing about soreness in my leg and prescribing a couple of aspirin a day. It gets nowhere near the root of the problem.
The question needs to be: “What is causing the problems we’re seeing in this child?”
Are you in the middle of a divorce? Does your child get enough exercise? Has he/she had a full physical to rule out hearing, vision, or other health problems? Either parent suffering from depression? Is there a history of abuse in the family? Has a family member died in the recent past? Do we see any sensory processing problems? So many good questions can be asked to get to the root of the problem, they would be impossible to list here, and these rating scales don’t ask about family history or life stressors. Unfortunately, the current standard of care makes it possible to diagnose and treat ADHD without ever learning about any essential history.
As a society, and even medically, we have a propensity to disregard these questions because we have a notion that ADHD is caused, in part, by genetic factors. Research tells us that genes may play a role, but it’s still unproven. Irrespective of genetic involvement, should this be a rationale upon which we ignore vitally important questions? The answer it a resounding NO!
Genes are not the beginning and end all of our existence. I’ll give you a good example. The number two tennis player in the world (he was number one for quite a while) is Rafael Nadal. Genetically born right handed, his uncle Tony switched him to play left handed as a youngster. Lefties offer a greater challenge to most right handed tennis players which provides an advantage. Through deliberate practice, ‘Rafa’ beats virtually every other player in the world holding a racquet in his non-dominant left hand. Did he alter his genetic predisposition? Yes.
Before I elicit many negative responses from parents categorically denying any problems at home, I can say that over the last 20 years of educational experience, about 5% of the children I taught had true ADHD without family or environmental stressors. This included both symptoms and a family history of attention problems verified by their psychologist or pediatrician. Regardless, the next rational question is: “What can we do to help this child gain self-control and improve?”
The current answer is to remove control from the family to medication. Sometimes a therapist will be involved, but given current economic conditions and that the majority of diagnoses are given to minority children and children of low socio-economic means, therapists are usually not part of the equation.
Parents often believe that cannot make a significant change since they’ve been told ADHD is likely a genetic trait. Other excuses are:
“I don’t have enough time.”
“I don’t know what to do.”
“We already fight all the time. I need something else to help like medication.”
“His father doesn’t think he has a problem. Of course, he’s not here when I try to do homework with our son.”
Family is an undeniably important component to making significant change for a child struggling with self-control/regulation. The British have adopted this as the first line of treatment. Medication is only prescribed when all else fails.
In the US, once a child is placed on medication, short-term improvement is common and the motivation to address the cause and difficult cognitive and behavioral aspects is lost.
The answer to “What can we do to help this child gain self-control and improve?”
1) First and foremost, search for a cause. Correct it. Seek help if necessary.
2) In your search, be certain to include an evaluation from a qualified healthcare provider. But, don’t begin with an ADHD evaluation. Maslow said [paraphrased], “If the only tool in your toolbox is a hammer, all your problems look like nails.” Tell your healthcare provider about behavioral problems that concern you and get a full physical to rule out physical problems, sleep problems, diet, etc.
3) Schedule at least a minimum of two hour long visits for an evaluation that uses a variety of instruments or tests.
4) Be certain the initial evaluation details family history, social history, and environmental stressors.
5) It’s often a good idea for both parents to make the first visit with without their child as it’s less stressful and can often provide more insight into the problem.
4) Since most of the problems associated with ADHD are cognitive or behavioral, find out if these can be corrected through training.
5) Medication may be considered for an older child if he is struggling in an academic environment or function in a social environment without it. As the British suggest, preliminarily, attention should be given to cognitive and behavioral interventions. This is often difficult as immediate change is expected and pressured in great part by the school.
Don’t fold under such pressure.
We are discussing the life of your child. We know that if we don’t address the root cause, medication will work short-term or for years with adjustment, but it teaches nothing. Remember 60% to 70% will carry their problems into adulthood. Should we wait until something bad happens? Academic failure? Car accident? Impulsive criminal behavior? Substance abuse? As I’ve said previously, the current standard of care for ADHD is not working. And with the new diagnostic manual out, diagnosis is extended down to age 4. A revolution needs to happen, and no one is going to do it except those concerned. I’m greatly concerned.