Children: Diagnosis,
"Treatment" and Alternatives
Children are most often
referred for a diagnosis by the school system. In some cases, schools actually give
parent ultimatums: Medicate your child or he will be expelled. If you are in a
situation where you do not believe your child has a disorder and feel pressured by the
school, please contact your state Board of Education and tell them about your experience.
Some states have begun taking action. The Colorado Board of Ed passed a
non-binding resolution in 1999 to prevent teachers and school administrators from
recommending Ritalin and other psychotropic drugs. This is not to say that all
schools push Ritalin, because there are schools where none of the kids are taking meds.
If your child ONLY has
problems in school, then, by definition, your child does not meet the DSM IV diagnostic
criteria for ADD. A child must exhibit ADD behavior in two or more situations to a
degree that is "maladaptive" in order to be diagnosed ADD.
If you feel your child is
not disordered, but school personnel are pressuring you, then I suggest you get the book
"Nurture
By Nature" and determine your child's MBTI temperament type. Chances are very
high that the very behavior problems or inattention that the school is complaining about
will be noted in the description of your child's temperament type. These are
considered NORMAL behaviors by temperament experts and are tradeoffs for other talents.
Show the description to the school administrators. This book also provides
strategies for dealing with each type of child. If your child is very bright and
creative, then I also recommend The Edison
Trait. I've heard back from one reader who said the book made the difference
between failure and achievement at school.
Getting a Diagnosis
I
f you decide to have your child assessed for ADD, do NOT use any
school personnel or anyone connected with the school system because they are biased.
Unfortunately, the public school system is rewarded by having difficult children labeled
ADD in three ways. First, the medicated child is easier to handle and less
disruptive. Second, the school receives money for each child thus labeled if special ed services are requested (that's why
you probably can't get special services like tutoring unless your child is officially
diagnosed with a learning disability). And third, medicated children may do better on
standardized test exams, making the school administrators and teachers look better.
Long-term studies, however, show that medicated children do not actually learn more in the
long run, even though they get better grades. So while it is in the school's self
interest to have your child diagnosed ADD and medicated, it may not be in your child's
best interest. Parents should ultimately make this decision, not the school or even
the doctors.
In some school districts up
to 20% of white 5th grade boys are taking meds in school, while in others NONE are taking
meds. If the school has suggested ADD, you might ask the school nurse how many of
the kids are taking meds in your school. If the number is high, then be very
suspicious. The suburbs tend to have the highest rates of diagnosis. I personally
think this information should be made public so that people can compare school districts.
How many people would want to move to a school district where 20% of the grade
school boys were on meds? What does that tell you about the school's ability (or
lack thereof) to really engage the student?
Do not use a pediatrician.
As a group, pediatricians know less about ADD and are more inclined to simply
prescribe medications without really doing a proper diagnosis.
Psychiatrists
can prescribe medication and many do so VERY quickly. Most seem to be really
enamored with the idea of how absolutely wonderful meds are for as many people as
possible. They have a high tendency to view all behavior as just a symptom of a
chemical imbalance that can be fixed with the right drug. I think I know what
some of these people were doing in the sixties!
Neurologists
are highly inclined to see brain abnormalities because that is their training and
background.
Psychologists
are not medical doctors and cannot prescribe medication, but if necessary will write a
letter recommending medication to your pediatrician. I personally would start with a
psychologist because their focus is more holistic than medical doctors. A good
psychologist is more likely to consider issues like giftedness, temperament, family
problems, peer problems, discipline strategies, and other issues which can affect behavior
and concentration.
Before you take your child
in for a diagnosis, make sure you have a clear understanding of what ADD is and are
familiar with the diagnostic criteria. Some practitioners are not doing diligent
assessments. See my pages on What is ADD? and A Closer Look at the DSM IV Diagnostic Criteria. I highly
recommend getting a few books as well (my recommendations are described on my page on ADD books).
Before you make the
appointment, ask what an ADD assessment entails. You want one that is thorough and will
include IQ tests and preferably the Torrence test for creativity (since many ADHD children
are actually creative-gifted). My assessment took four hours.
Be aware that an assessment
for ADHD is extremely subjective. If your child is diagnosed ADD and you don't feel
comfortable with that, then get a second and third opinion.
"Treatment"
Options and Alternatives
You have several options for
how to handle the child who acts like an ADHD child. Physicians usually want you to
medicate immediately. I advise against moving that fast. Here's a checklist of items
for you to research first in order to rule out things like nutritional deficiencies or
food sensitivities. After all, if your child is simply reacting to a food, wouldn't
it be better to remove the food than to give your child a mind-altering substance?
Sometimes a parent can work carefully through the checklist and still find medication
necessary. On the other hand, many parents have had miraculous results. You
will never know unless you try. Your goal should NOT be a perfectly obedient,
compliant child who focuses well on things he or she finds boring. It is normal from some
children to be difficult and to daydream. But a child should not be failing out of school
and totally friendless, either. And even if you do use meds, you may find the meds work
better in conjunction with some of the following:
1. Does your
child have a fatty acid deficiency? Studies have linked fatty acid
deficiencies to ADD, behavior problems and learning disorders, and I have heard from quite
a few parents who found that fatty acid supplements dramatically affected their child's
behavior. Test: Try a supplement of Effalex, a good blend of fatty acids, for
3 months. If you can't find Effalex, try DHA or fish oil (for omega-3 fatty acids)
AND primrose oil (contains GLA Omega-6 fatty acids). You should be giving about 1
gram of DHA each day for the first 3 months. If this works, then try switching to
flax oil, which doesn't contain the environmental contaminants often found in fish oil.
Side note: Japanese parents have been giving their kids DHA supplements for years so they
get better grades. See my page on fatty acids for more
information, also Nutrition for ADD Kids.
2. Is your child
sensitive to certain foods or food additives? The Center For Science in the Public Interest reviewed 25
years of scientific studies and concluded that some kids react to foods and food additives
in a way that causes behavior problems or problems concentrating. This reaction can
be severe. It is most likely in children who: 1) have allergies, eczema, ear
infections, or asthma; 2) have sleep disturbances; 3) seem unhappy, irritable and
generally not well; 4) have bizarre swings in mood not related to what is going on around
them. Food colors such as Tartrazine (yellow #5) cause problems in such
children, especially sleep disturbances. I personally have banned all the processed foods
from my house which contain colors and lots of additives. Stick to food that is
REAL. You should also see a pediatric allergist if your child has
allergies. Through testing, I found that my son is allergic to soy, an otherwise
healthy ingredient in many packaged foods, including Spaghettios and tuna fish. Some
parents discover their children's allergies by reducing their diet to a few non-allergenic
foods and gradually increasing the variety while they keep a careful diary of food vs.
behavior. This is a lot of work but many payoff well. By the way, sugar does not normally
make kids hyper, except in a few instances when the child is allergic to a certain type of
sugar. If your kid reacts to junk food it's probably the colors, not the sugar. Read my
page Can Allergies Cause Behavior Problems? Other Resources: "Is This Your
Child? Discovering and Treating Unrecognized Allergies in Children and Adults" by
Doris Rapp, M.D.; Why Can't My
Child Behave? The Feingold Diet updated for today's busy families; The Feingold Association website; and the online report
Diet, ADHD & Behavior - A
Quarter Century Review by the Center For Science in the Public Interest.
3. Is your child
gifted and bored in school? Gifted children who are bored can display lots
of negative behavior AND get low grades in school. They don't pay attention and can
cause lots of mischief. They'll argue with teachers and may have peer problems. In
fact, lists of "gifted" behavior are similar to the diagnostic checklist for
ADHD. If this is your child, then please change the environment, not the child!
If your child acts out because of boredom, then find a way to stop boring your
child. Would you give a gifted child Valium in order to tolerate a boring class?
Then why give him or her Ritalin for the same reason? I personally do NOT
like official "gifted" assessments because they are somewhat arbitrary and can
give a child a complex, but if you do go for one be sure to have them include the Torrence
test for creativity. A child can be gifted even if his or her IQ is less than 130 if the
creativity score is high. If your school cannot accommodate your child's needs, then
try homeschooling or a private school. See my page on Alternatives
in Education. And never tell your child he or she is smart, because it gives
these kids a complex. Always give praise on the basis of hard work and effort.
See Potential Negative Creative Traits and Praise Children for Effort, Not Intelligence.
4. Is your child a
"visual" learner? Many kids labeled ADD are visual thinkers.
Average kids are verbal thinkers, as are the teachers. Bright kids who have problems
with reading, spelling or handwriting are usually extremely visual thinkers. Get the book
"Left-Brained
Children in a Right-Brained World." It describes how visual thinkers learn
differently and gives practical tips.
5. Is your child's
natural temperament a factor? Is there a temperament clash between you
(spouse, teachers, etc.) and your child? Usually the answer to this question
is "yes." For example, a quiet and reserved adult is far more likely to
see a "disorder" in a high-energy extraverted child, even when the child's
behavior is normal for his or her type. And an adult that focuses naturally on what
is concrete and "real" is more likely to view a daydreaming child as having
attention problems. In each case, the adult is likely to give off vibes that
he or she does not like the child, and the child may act out or get depressed and
anxious. Please find out what your child's natural temperament preferences
are, as well as your own, and learn about temperament biases. There are no
right or wrong preferences: each preference has positive and negative aspects. In
"real life" I frequently see high-energy extraverted kids being medicated by
quiet, reserved mothers or fathers who are overwhelmed by their child's energy level.
I have a lot of information about MBTI temperament types on this website (see Temperament). I also highly recommend the book Nurture by
Nature which lets you understand better how your child's mind works and how best to
interact with him or her.
6. Is your child
over- or under-stimulated? I have found this factor to be absolutely
critical on a day-to-day basis at our house. Some kids act out when they are bored
(understimulated), but also become easily overstimulated if there is too much going on
around them. Lack of sleep constitutes overstimulation.
Our rule at home is that a string of bad behavior means my son goes to bed early on the
grounds that he is probably tired, and this usually works well. Extreme
extraverts (like my son) have a strong tendency to become really wound up and spin out of
control after they are around other people for too long (they are "energized" by
being around people). Conversely, introverts can become overwhelmed and shut down if
they are in a busy classroom all day. My friends' daughter, a bright introvert,
covers her ears when people clap and says "Mom, tell them to stop making so much
noise!" The girls' teacher has noted that she sometimes doesn't pay
attention. When her Mother informed the teacher that there was probably too much
noise in the class, the teacher said "I never thought of that."
7. Try
Alternative Discipline Strategies: For kids with behavior problems, try
some alternative discipline strategies. These kids don't respond to
punishment the way average kids do. Instead, they usually respond in an equal and
opposite fashion, so the more you punish them the more they act out. I have found such
strategies to be absolutely critical. See my section on Teaching
Self Discipline. Also extremely important is to designate a specific amount of
time each day for giving your child positive attention. In
one study reported in Science News, 37 ADHD children were taken off of medications while
their parents received special training. After one year all the children were still off of
their medications - a success rate of 100% without any side effects or damage to the
child's self esteem. You will hear of studies that show medications are more
effective, which is true. Drugs can turn a spirited, wild child into a robotic,
compliant child, but should that be the goal?
8. Is this all about
grades? Do you have a child getting Cs and D's and you want your child to get A's
and B's and THATs why you're looking at an ADHD assessment? Medications can work
wonders in achieving higher gradepoint averages. But why bother? There is no
correlation between grades and later success in life. So what's the point?
Your child will still be able to get into a college, maybe not Harvard, but he or she will
certainly be able to get into some college. Success will depend on job performance,
not grades in school. I have never once regretted my average performance in school,
including college.
9. Is your child
socially clueless? This is actually pretty normal for some temperament types.
Very logical children, for example, are mystified by the idea that they should
consider people's feelings. They have to be TAUGHT. Very extraverted children will
often interrupt other children and talk too loud and too much. An extraverted
logical type will want to be in charge and may be very bossy. The answer to these
problems is simply to teach, teach and teach some more. You have to explain social
rules over and over to them. An effective trick is to camcorder your child with
other children. Later, when the child is away from other children, play the tape
back and critique your child's social skills together with your child.
10. Does your child
need to move? Extraverted kids in particular need to move in order to think. See
if the teacher will allow your child to have two desks and let your child get up at will
and move from desk to desk. And make sure your child has lots of opportunity to get
up and move around throughout the day. This type of child may have trouble doing
homework in a quiet corner. Believe it or not, the kitchen table may be best. Extraverts
need lots of activity to stay alert. Turn on the radio!
11. Do distractions
keep your child from getting ready for school, eating, or cleaning his or her room?
This is normal for kids with a strong preference for divergent thinking.
Think of it not as lack of focus, but as an alertness to new information. Follow-through
is critical on your part. Create some simple rules and stick to them. If your child is not
ready for school at a certain time, then he or she must go to bed early that night.
If he can't clean his room, then there are too many toys: box a bunch of them up and put
them in the attic until he shows he can handle cleaning them up. Your child must
learn consequences, or he will never learn to overcome his natural tendency to
procrastinate (and he CAN learn!). Especially useful is a timer and an effective
ultimatum. "I'm going to set the timer for 10 minutes. If you are not in
your pajamas with your teeth brushed when it goes off I'm going to take your new Pokedex
away for one day." The timer and ultimatum keep him focused so he can complete the
assignment. As an adult, this type of person often works best in a crisis
atmosphere.
12. Is caffeine a
problem? Some people don't realize that some orange soda and root beer
contain caffeine, as well as colas. It's possible that a few kids are simply being
drowned in caffeine and that's why they are hyper. This may be especially true of
teens who stay up late and then can't wake up the next morning. Caffeine metabolism
varies considerable from one individual to another, and it can take up to 12 hours from
caffeine to leave the body. Caffeine can cause anxiety as well as irritability as it wears
off.
13. Is there a problem
with a specific teacher? Challenging kids can be hypersensitive to whether
or not their teacher seems to like them. Outgoing, cheerful and non-judgmental
teachers seem to do the best with high-energy kids. If there's a problem in the
classroom, try and find out how the teacher interacts with your child. Does the
teacher take challenging behavior in stride or does she act annoyed with your child?
Are the teacher's expectations reasonable, or is she setting your child up for
failure by expecting him to sit perfectly quiet? Does the teacher LIKE your child?
Does she have a sense of humor? If not, you child will know it right away and will
probably act out. You may not be able to get a different teacher (kids need to learn
to deal with teachers they don't like anyway) but it's good to know if this is a factor.
This is especially important if this particular teacher happens to be telling you
your child needs Ritalin. A child who is trouble for one teacher can be an angel for
another.
Medications:
Stimulant medications are
extremely effective in most (but not all) children. Ritalin is the most common and
the most powerful, but it also has the worst side effects. I tried it out and though
it allowed me to organize my son's toys for 5 hours straight, I definitely felt like I was
"on" something. And as it started to wear off I got a splitting headache
and became highly irritable and emotional. This is called the "rebound"
effect. I hate to think of kids going through this, and yet they do. Parents
complain about how impossible their child is to deal with during the rebound. I can
see why. When I complained to the doctor about it, he switched me to a much higher dose in
an extended release form (that's a psychiatrist for you). This made me sick within a
few days and I even missed a day of work because I felt so terrible. I also
developed an annoying eye twitch. I threw out the Ritalin. The eye twitch
stayed for six months afterwards, until I stopped drinking my two cups of coffee each
day. I know now that Ritalin induced an anxiety reaction in me, which is something
any stimulant can do. The anxiety reaction included a complete inability to concentrate,
forgetfulness, fogginess, muscle stiffness, the jitters and problems sleeping. The
reaction did NOT end as soon as I stopped taking the Ritalin. Someone can take
stimulants (including caffeine) for decades without a serious problem and all at once
develop an anxiety disorder because of it. Many people write to me and say their
medication worked wonderfully for years but all the sudden they cannot concentrate or
remember anything, and I wonder if they are developing an anxiety reaction like the one I
had.
Many people have told me
they prefer Adderall because it is "smoother" with less of a rebound effect.
Ritalin is prescribed most often primarily out of habit. I suggest that if
your doctor recommends Ritalin you ask about Adderall. There are other stimulant
medications, but these two are the ones I hear about most frequently. Wellbutrin is
classified as an antidepressant but is really more of a stimulant. I tried it and
couldn't sleep for four days.
The website Rx List - The Internet Drug Index has a lot of specific
information about medications, including a message boards for some medications such as
Ritalin. Because there is already a good source of this info online, I'm not going
to repeat it here.
Don't try using herbal
remedies on kids. Herbs are drugs. They have not been tested and you don't
have any idea what they might do to your kid in the long run. And there's no quality
control, so fillers might include toxic ingredients like lead. Don't use a homeopath
or naturopath. They'll give your child herbs or other substances that have not been
tested for safety. One mother I spoke to was giving her child "arsenica album,
tarantula, and a calming herb" per the homeopath she was using. That's arsenic,
spider venom and an unknown sedative. I'm surprised she didn't throw in some rat
poison as well. A possible exception is pine bark extract (or "Phycogenital"),
which is said to contain natural bioflavinoids that act as antioxidants. If
so, it's closer to a nutrient than a medication. I've heard from a couple of people who
had a good experience, and one reader has suggested that it may work best with inattentive
types rather than hyperactive types. It's also supposed to act as a natural
antihistamine. Herbal information is listed at Rx List - The Internet Drug Index. (Note that the
following are nutritional rather than herbal supplements: essential fatty acids from flax
oil, Effalex, fish oil or primrose oil; and vitamins and minerals like calcium and
magnesium. All people should make sure they get enough of these nutrients.)
Sometimes doctors prescribe
a stimulant along with an antidepressent, such as a Ritalin/Prozac combination. In
some cases the anti-depressant is given to counteract the anxiety reaction that the
stimulant is causing, which makes me wonder what they give to counter the side effects of
the anti-depressant. Be aware that both drugs act on the brain's neurotransmitter
system and these drugs have not been tested together for safety. I bring this up
because of the Phen-Fen fiasco, an "ultra safe" drug combination for dieters
that was later found to cause heart valve problems. Each drug is very safe when
taken separately. One theory for the problem is that each drug works on the
serotonin system, and people were effectively getting a double dose. DRUG
COMBINATIONS HAVE NOT USUALLY BEEN TESTED TOGETHER FOR SAFETY. If a doctor wants your
child to take two or more medications simultaneously to treat ADD, your child is being
used as a guinea pig. I've also heard of doctors prescribing sleeping pills to
children who could no longer sleep because of the Ritalin they were taking. I strongly
advise parents to get a second opinion if it seems that medications are being prescribed
flippantly.
Safety:
Medical people say Ritalin and similar meds are safe. Ritalin has been used for
decades. For people who really truly need meds, I wouldn't worry too much about the
safety issue. There are risks with all medications, but if you really get a lot of
benefit from a medication, then the benefits usually outweigh the risk.
However, there ARE safety
concerns as well as serious potential side effects, so if your child does not absolutely
NEED medication, then don't give it to him. Deaths HAVE occurred, as well as other
serious problems. The makers of Ritalin are currently being sued by a parent whose
child died from an irregular heart beat brought on by Ritalin. Another child died
recently from cardiac arrhythmia because the pharmacist misread the prescription dosage
for imipramine1. Before you give your child any medication, do a very thorough
search on the potential side effects so you know what they are. There have been NO
long term studies for safety. It is now believed that most people do not outgrow ADD
and may very well need medication all their life, and no one knows what taking Ritalin for
70 years will do to the brain and body. It is not known whether the brain somehow adjusts
to the presence of Ritalin, so that once the Ritalin is stopped the child is more ADD than
they were before. Sometimes Ritalin (or other meds) suddenly stop working,
requiring a switch to a less effective drug. Again, no one knows why.
And consider carefully the
medical community's idea of "safe." A 1998 study estimated that 2,000,000
Americans a year are seriously injured and about 100,000 die from properly prescribed and
administered medications taken at their recommended dose2. So their
definition of "safe" may differ from your definition of "safe."
Again, if your child really needs the meds, then don't worry too much. But if your
child doesn't absolutely need them, then don't let anyone give you the impression that
Ritalin or other meds are as safe as candy.
Stimulants were
NOT approved for flippant use, but only as a last resort. Read this section from the
Internet Mental Health article on
Methylphenidate (Ritalin):
"Drug treatment is not indicated for
all children with this syndrome. Stimulants are not intended for use in the
child who exhibits symptoms secondary to environmental factors....Appropriate educational
placement is essential and psychosocial intervention is generally necessary. When remedial
measures alone are insufficient, the decision to prescribe stimulant medication will
depend upon the physician's assessment...Long term effects of methylphenidate in children
have not been well established."
Ritalin: I've taken the following
information from "Prescription and NonPrescription Medications For Children" by
Max Van Gilder, M.D. and Shelagh Ryan Masline.
The initial dose is 5 mg two or three times a day, which
can be increased by 5 mg per dose every three or four days until it becomes effective but
without too many side effects. Note that very often doctors prescribe too high a
dose. Every child responds differently so the dosage MUST be tailored to the
individual. The dosage should be reduced or stopped if your child becomes
"withdrawn, tearful or suspicious." The most common side effects are loss of
appetite, followed by a hearty appetite when the drug wears off, dizziness, headache,
rash, heart palpitations, changes in pulse rate and blood pressure, and nausea. In
addition toxic psychosis has been reported, and depression, anxiety or mood disorder may
also occur. Ritalin is not recommended for children who "exhibit extreme
anxiety, tension, or agitation, as it may aggravate these conditions."
Ritalin as a Street Drug: Some kids are
selling their Ritalin to classmates who crush the tablet and then either snort or inject
it. Street names include "speed" and "west coast". When
snorted or injected it may cause paranoia, hallucinations, delusions, tremors, fevers,
convulsions and other problems. (Source: "Growing up Drug-Free: A Parent's
Guide to Prevention" by Partnership For a Drug-Free America, a booklet the school
sent home with my son). I'm curious as to why so many ADHD kids are selling their
Ritalin.
Other Sources:
1. "Faulty Warning Labels Adds to Risk
in Prescription Drugs" New York Times, June 4, 1999.
2. Consumer Reports article "Are you
taking too much medicine?" March 2000. I'm looking for the original source of
the 1998 study regarding serious injuries and death from taking meds as directed.
The study was well publicized but I can't remember where it was published. If you
know, please drop me a note.
