Hesitations in Medicating for ADHD
Posted by FamilyFirst Psychological Services
Parents who have children diagnosed with ADHD often feel apprehensive about following through with a physician recommendation for medication in order to manage symptoms. Reasons for apprehension range from concerns about the specific side effects (e.g., disturbance in appetite) to a blanket fear that not all side effects of the medication are discoverable. Research has shown that a combination of medication and therapy provide the best outcome for symptom management of ADHD. Given this information, psychologists are often in the position of helping parents to address the ambivalence associated with the decision to provide medication to ensure that parents make sound decisions based on facts versus fears or misunderstandings. While caution about prescribing medication to young, developing bodies is warranted, it should be tempered with the following considerations:
~The biological basis for ADHD is a neurotransmitter dysfunction. Nerve cells in the brain release neurotransmitters from the end of one nerve cell into a synaptic gap or space. There, they are absorbed by the dendrites of a neighboring nerve cell. Dysfunctions related to brain-based disorders, such as ADHD, involve problems with release or absorption of neurotransmitters. Medication helps to regulate disturbances in neurotransmitter release/absorption.
~Is there a bias that all problems arising from the brain should be controlled with a “mind over matter” mentality simply because thoughts originate in the brain? In other words, would the same hesitations exist if you were faced with a recommendation for medication to treat another organ (kidney, liver) with a disturbance in function or is there a bias with the brain?
~What are the socio-emotional side effects of a decision to not medicate? Recognition of the obvious gain of not having to worry about side-effects or stigma of medication should be tempered with an awareness of what is lost by allowing the neurotransmitter dysregulation to persist. Important costs to consider are:
1. What are the effects of adult reactions to the symptoms (parental yelling, teacher frustrations) on the child?
2. How is the child’s identity compromised when s/he receives messages that s/he is failing (to be organized, to follow through, to remember)?
3. What is the effect of poor peer relations brought about by symptoms (impulsivity)?
These effects are not life threatening in the physical realm, but do challenge processes critical for development of confidence and social-connectedness. In summary, it is important to examine hesitations to medicate to ensure that the biological need for an organ to be regulated is acknowledged. Further, the psychological effects of not medicating should not be overlooked as concerns about medicating are thoroughly addressed.
Virginia DeRoma, Ph.D.
Licensed Clinical Psychologist
Researching the Research: How to Understand and Evaluate Psychological Studies
Posted by FamilyFirst Psychological Services
Given my work as a clinical psychologist, I try my best to stay up on the latest research across several areas, so that I can help parents make well-informed decisions regarding their children’s treatment. Recently, I was tuned in to NPR and was intrigued to hear a Dutch researcher being interviewed with regard to a study about the role of diet in Attention Deficit/Hyperactivity Disorder in children. I turned up the volume and listened carefully, hoping to hear something that would prove interesting and useful for my clients. The statement that the researcher went on to say astounded me. In no uncertain terms, the researcher concluded that a majority of children with ADHD symptoms were exhibiting those symptoms as a result of dietary sensitivities. I waited for the typical caveats that researchers are obligated to provide regarding limitations of their results. I waited for the interviewer to ask some pointed questions regarding the nature of the research that led to these conclusions. However, neither was forthcoming. ( If you are curious, you can read the transcript of the interview on NPR – the study was discussed on All Things Considered on March 12, 2011. A response evaluating the conclusions to this study, put out by CHADD, can be found here:www.chaddleadershipblog.blogspot.com/2011/03/elimination-diets-for-adhd-not-ready.html
Given the age we live in, parents have access to an astounding amount of information, which is both extremely helpful and also potentially enormously overwhelming. It can be very difficult to sort through claims that are made and posted on the internet or via other news media regarding a particular disorder and/or treatment. Here are a few guidelines to help parents and other concerned individuals to be informed consumers of psychological research:
1. How was the sample selected for the study? How representative was this sample of the population that was intended as the focus of research? For example, studying children who have AD/HD – Combined Type may not yield results that are applicable to children with other forms of AD/HD.
2. How were variables defined and measured? For example, if the researchers report “improvement” in symptoms, what constituted improvement and where did this information come from? Studies that rely on reports from individuals that know that the individuals are participating in a treatment study, and that know what type of treatment was given, are considered less reliable. These reports may be inadvertently biased by beliefs that the treatment is working. Studies that include reports from raters that are “blind” to the conditions of the study are more reliable.
3. Who was compared in the study? Was there an experimental group and a control group? Was there a “placebo control”? Often individuals participating in a treatment study improve by virtue of being involved in a study, and not due to the treatment itself. Thus, it is very important to compare a treatment to other comparable types of interventions, not just to no treatment.
When in doubt, consult nationally known organizations for the latest information regarding a given treatment. Examples of reliable websites include the American Psychological Association website (www.apa.org), the NIMH website (www.nih.nimh.gov) and for AD/HD, the CHADD website (www. chadd.org ).
Kathleen Boykin McElhaney, Ph.D Posted by FamilyFirst Psychological Services Attention-deficit/hyperactivity disorder (ADHD) affects not only the child who experiences the symptoms but also the child’s family system and social networks. Each family system must make accommodations to the diagnosed child in order to maintain the family’s stability. Typically, the necessary accommodations by the family are often extensive and affect all family members and roles. Families with a child or children diagnosed with ADHD face increased daily stress and frustration. Research indicates that members of a family with a child diagnosed with ADHD are at a greater risk for developing their own psychological distress than are family members of a child without this disorder. Below you will find brief descriptions of family challenges typically encountered in families with a child diagnosed with ADHD. Impact on Parents. Parents of children with ADHD experience greater stress that goes beyond that found in normal child development. The more problematic the behaviors presented by the diagnosed child, the greater the stress experienced by the parents. Most parents with a child suffering from ADHD display more negative reactions around their children’s behaviors, have lower self-esteem, and feel their child has negatively impacted multiple areas of their lives. The ongoing struggles that parents with children diagnosed with ADHD encounter lead to great frustration as they attempt to manage school and home behaviors. These difficulties take away their attention from other children in the family as well as their own marriage. Eventually, these struggles become the focus of parental communication. Frustrated parents tend to report feelings of inadequacy around parenting abilities. Parents often experience great concern about their child’s difficulties, but also experience high level of guilt and blame. At times, such feelings may promote reactive responses by parents toward the diagnosed child that may lead to ineffective and negative parenting responses. Such responses may include blaming the child for his/her difficulties, becoming overly-protective and overly-involved in the child’s life, or display unhealthy communication patterns. Impact on the Marriage. Stresses of raising a child with ADHD tend to spread into the marriage, which results in higher levels of marital dissatisfaction and conflict. These parents typically report that their conversations and interactions, even when alone, are centered on the child’s problems. Poor co-parenting skills further exacerbate the couple’s struggles. Often parents report lost intimacy and feeling disconnected from one another. Impact on Siblings. Each sibling within the family system will likely respond differently to the child with ADHD. Siblings may distance themselves from the child because of embarrassment. Some studies indicate high rates of sibling aggressive interactions between the child with ADHD and his/her siblings. Siblings may also express feelings of anger and frustration toward their diagnosed sibling because they feel somewhat left out or rejected since the parents are often pre-occupied with the diagnosed child. Younger siblings especially cannot understand why their parents give so much attention to the “disruptive” sibling. Older siblings sometimes admit feeling sorry for the struggles that their parents face. In summary, the behaviors displayed by children with ADHD influence parent-child relationships, spousal relationships, parental child rearing skills, child-sibling relationship, and the emotional state of the entire family system. As such, it is important to utilize an integrated family-oriented approach when treating childhood ADHD. Maria Kanakos, Psy.D. Posted by FamilyFirst Psychological Services Symptoms of ADHD (hyperactivity, impulsivity, and/or inattention) often lead to under-achievement in school for the child. Below you will find a list of common learning problems experienced by most children diagnosed with ADHD. Keep in mind that every child is unique and may have some, but not all of these challenges. Impulsivity: Includes rushing through work (e.g., careless errors), does not read directions, difficulty waiting, and lack of thinking before acting. Language-related Problems: Problems include slow information processing (e.g., cognitive processing speed), slow retrieval of information, reading comprehension weaknesses, oral expression problems, and written language difficulties (e.g., getting thoughts down on paper). Poor Organizational Skills: Includes losing homework, difficulty getting started on assignments, problems with multi-step problems (e.g., what goes first), problems organizing thoughts, and inability to plan ahead. Poor Concept of Time: Includes lack of awareness for the passage of time, often late, problems anticipating how long assignments will take, difficulty planning ahead, does not manage time well, and homework takes forever.> Forgetful: Includes forgets what is for homework, does not take appropriate books and study materials home to complete homework, forgets to turn in completed homework, forgets long-term projects, and forgets teacher and parent requests. Problems with Working Memory and Recall: Includes difficulty holding facts in mind while manipulating information (e.g., doing complex math problems in their head), and problems following multi-step instructions. Working memory skills are essential for anticipating what will happen next, avoiding repetition of mistakes, and planning for the future. Poor Fine Motor Skills/Coordination: Includes poor handwriting, writes slowly or avoids writing in general, prefers to print rather than write cursive, and in terms of coordination can be clumsy. Low Frustration Tolerance: Includes difficulty controlling emotions, loses temper easily, quick to give up in the face of challenging tasks or ones that take more effort, blurt out things that they do not mean to say, can be argumentative with others or talk back, transitions are often problematic, and changes in routine are difficult. In closing, it is important to keep in mind that difficulties in school may be caused by a combination of several learning problems. Early identification of learning challenges is critical for the implementation of appropriate accommodations in the classroom setting. Keep in mind that educational accommodations are a necessity for children with ADHD. They do not behave in challenging ways deliberately; instead they struggle to function smoothly on a day to day basis without assistance. Maria Kanakos, Psy.D. Posted by FamilyFirst Psychological Services When a child is diagnosed with Attention-Deficit/Hyperactivity Disorder it is important to understand that this disorder influences the entire family. Parents of children with ADHD often report elevated stress levels and frustrations around parenting. It is important to keep in mind that “traditional” parenting techniques are ineffective when trying to manage the behavioral problems associated with ADHD. Below is a list of tips to help you begin creating an ADHD friendly environment within your home. Provide structure and daily routine. Children with ADHD are much more successful in environments that are predictable and structured. It is important to establish morning and evening routines in your household (e.g., homework, dinner, and bed time routines). To avoid behavioral pitfalls and allow children to transition more smoothly, provide ample warning when something in the schedule or routine changes. Establish concrete, clearly defined house rules. Make a list of the most important rules you would like your child to follow and define these clearly. For example, when asking a child to “be good” or “be respectful”, a parent needs to be mindful that these are broad terms and are left to a child’s interpretation if not defined more specifically. In these instances, listing what constitutes good and respectful behavior is important for success (e.g., use nice words, wait your turn, etc.) Build an incentive system for following house rules. Behavioral incentive charts are an efficient way to keep track of a child’s successes and promote motivation. The charts should target a few behaviors that the child is trying to improve. Rewards that were established ahead of time should be provided for following the behavioral expectations. For example, if the two or three household rules are followed for the day, the child can earn extra playtime or a special treat that day. Daily reward systems are best when first starting any behavioral plan. Eventually, you can reward the child after longer increments of time have passed, such as the end of the week. It is noteworthy, for behavioral plans to be successful keep in mind the following: Provide daily praise. It is easy to catch the negative behaviors and point them out, but seeing the good seems to take more effort. Catch your child doing what he/she is supposed to be doing and let them know it. Organize the household. A disorganized household inhibits the child with ADHD from learning how to organize him/herself. Reduce clutter and use a system where every item has its place. You can help your child be more organized by promoting the use of a “launching pad” where he/she puts out all the things needed for school (backpack, shoes, jacket, completed homework, etc.) in one place near the doorway. Additionally, encouraging the use of labeled bins for items in the child’s room is useful for finding things and un-clutters the environment. Set up a system for homework. Establish a daily homework time in a designated homework spot. The homework area should be clutter-free and away from noise and distractions. For younger children, it is best that the homework place be located at a place where you can see the child and access him/her as needed for help, redirection, and motivational praise. Other things to keep in mind that will help reduce homework battles include, The ability to implement the above tips successfully in your household relies on establishing a supportive and strong co-parenting team. Additionally, the quality of the parent-child relationship also influences the success of any home-based interventions. As such, foster positive relations between you and your child by focusing on his/her effort, catching him/her being good, providing empathy for his/her struggles, and scheduling routine “special time” weekly. Maria Kanakos, Psy.D. Posted by FamilyFirst Psychological Services When your child receives a clinical diagnosis of ADHD, many questions/concerns go through your mind. Most parents say “Does my child have to take medication?” or “What other treatment options do we have?” In the past, ADHD was treated primarily with stimulant medications. The ongoing Multimodal Treatment Study of Children with ADHD (MTA Study) has consistently noted that the best treatment is a comprehensive one that includes a combination of medication, behavioral/social interventions, and educational accommodations. The decision to medicate your child is not an easy one. Further, when you do decide to move forward with medication, the road is not so easy. Some children go through several trials of different medications and doses before finding the most effective one. Still, others do not respond to them or may experience uncomfortable side effects. Yes, the road to treating ADHD is frustrating and truly is an art, not a science. Not all children with ADHD are the same. The treatment method that works for one child may not work for another. The good news is that research continues to seek innovative/alternative ADHD treatments. Most recently, parents are asking about Neurofeedback Therapy and Cogmed Training. Neurofeedback has not yet been proven to help children with ADHD. However, it is being used with some reported success. Neurofeedback uses brain exercises to reduce impulsivity and increase attentiveness. Cogmed training is an evidence-based, computer program for helping children improve attention by training their working memory. This treatment can be done using a PC at home and does not require office visits. The goal of this training is to increase functions of the prefrontal cortex of the brain including starting tasks, following through, remembering things, and being more organized. As evidence of benefits for both neurofeedback and cogmed training accumulates, parents may consider whether it is worth trying. However, these methods are expensive and many parents have trouble justifying the benefits of such investment, especially since the body of evidence supporting their use is still growing. Many parents also frequently ask about treating ADHD with better nutrition and diet. Hyperactivity has long been associated with sugary foods such as sodas and candy. Certainly, reducing these types of foods and eating a balanced diet may prevent swings in behavior caused by hunger, vitamin deficiency, and changes in blood/sugar levels. The whole nutrition/dietary approach to treating ADHD, while introduced a long time ago, is a gray area. Indeed, you will find “good” studies that have been done, but again they are not empirically validated, evidence based and most importantly can NOT conclude that many of the children with ADHD benefit from these approaches consistently. Because results vary from study to study, nobody knows how many kids are affected by changes in diet and there is no evidence that claims there is one particular diet that is effective for treating all children with ADHD. How frustrating indeed! Still, that does not mean that families avoid this alternative way of treating the disorder. My recommendation is that you consult with an allergist or dietician/nutritionist who can speak more about this approach to treatment. In sum, recent research trends are moving towards alternative ADHD treatments. This presents hope to addressing ADHD in children that do not respond favorably to medication for one reason or another. As a clinician I encourage parents to think about two questions when considering treatment options; 1) How is ADHD impacting my child’s daily functioning?, and 2) How do we (the parents) measure success? Maria Kanakos, Psy.D
Licensed Clinical Psychologist
How Does Childhood ADHD Affect the Family?
Licensed Clinical Psychologist
Common School Problems Faced By Children With ADHD
Poor Concentration: Includes difficulty with listening in class, daydreaming, lack of attention to detail, missing content of lesson, highly distractible, and inability to finish tasks.
Licensed Clinical Psychologist
Posted 10-25-10
Creating An ADHD Friendly Home
1) Be consistent; both parents need to operate under the same house rules and use the same rewards;
2) Define the behavioral expectations in positive terms (e.g., “use your words” versus “no hitting”);
3) Charts should be presented in visual formats and easily understood by the child;
4) Develop a list of rewards in advance for display of desired behaviors;
5) Be patient and set up realistic expectations when first starting the charts;
6) Have the child check off or place a sticker next to the behavior he/she has accomplished at the end of the day; and
7) Help start the day on a positive note by reminding the child of the behaviors he/she is working on and what rewards follow.
1) Break homework into smaller increments and provide short breaks after each part is finished;
2) Use timers to help keep the child on track;
3) If the child is on medication for ADHD, plan homework during his/her optimal performance window and not too late in the day when the medication is wearing off;
4) Utilize incentive/reward systems as needed for homework completion;
5) If the child is spending too much time on homework despite good effort and focus, contact the teacher to see if accommodations such as reducing his/her workload is warranted; and
6) Do not engage in parent-child homework battles. Preserve your relationship with your child and hire a tutor if necessary.
Licensed Clinical Psychologist
September 28, 2010
The Tomorrow of Treating Childhood ADHD: Beyond Medication
Licensed Clinical Psychologist
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