No-Fault

Brain Disorders Each of the chapters in Part Three addresses a different brain disorder, focusing on the symptoms, the diagnosis, the recommended course of treatment, the prognosis, and the effects of a disorder on a child's personality and on his relationships with others. I also talk about the special parenting concerns a.s.sociated with each disorder.

CHAPTER 7.

Attention Deficit Hyperactivity Disorder.

Nicholas, nearly three, still slept in the crib he used when he was a baby. His parents hoped that the high sides of the crib would discourage him from getting up in the middle of the night and wandering around the house. When that didn't work, and when he took to going downstairs to the kitchen and playing with the stove, his mother and father tied a cowbell to his door. When he opened the door, the bell would ring and wake his parents. During the day Nicholas was fidgety, unable to sit for even the shortest time. He had no interest in the TV shows most children like; he watched only the commercials. A lovely, lovable little boy with a keen sense of humor and a real zest for living, Nicholas was like an engine that wouldn't stop running. Everywhere he went, accidents happened, and little things got broken. His grandparents, who doted on Nicholas, nicknamed him "Sweet Destructo."

"He's been difficult since the day he was born." That's what Theo's mother said about her 11-year-old son the day we first met. He'd been a very demanding infant, with lots of sleep problems. He walked at eight months and was a whirlwind of activity from the start. When Theo was two, he and his mother were politely asked to leave a "Mommy and Me" program at the local YMCA; Theo just took up too much room. Theo never did get along with the other children. He was always grabbing their toys, pulling their hair, and cutting ahead of them in line. Even now, at 11, Theo pokes at his younger brothers during meals. In a restaurant he plays with the sugar and knocks over the water gla.s.s. He's been going to the same sleepaway camp for three years, and he hasn't made a single friend. This year complaints from his school have been coming almost daily. The teachers say that Theo fidgets constantly, rips papers, shouts out comments in cla.s.s, and gets up every ten minutes to walk around the room. The parents are frankly embarra.s.sed to take Theo anywhere. In a private moment Theo's father confesses to me: "I just don't like him."

When Peter's parents brought their 10-year-old son to my office, he fought them every inch of the way. Two appointments had already been canceled. Peter didn't think he had a problem, although everyone who came into contact with him strongly disagreed. He was getting bad grades in school, and his teachers said he was constantly missing a.s.signments and losing papers. He was always looking for trouble with the other kids in school. He had a fight with a boy in his neighborhood that was so bad, he had been socially ostracized by his cla.s.smates ever since. None of the other kids wanted to play with him. His father, who was the coach of Peter's soccer team, told me that his son was always ending up in the wrong place on the soccer field. Peter was a terrific athlete otherwise, but he kept getting lost out there.

THE TERRIBLE TWOS,.

THREES, FOURS, FIVES, SIXES, ETC.

If the statistics are to be believed, there's one in every crowd-a child who's different from all the others. He's more accident-p.r.o.ne and more difficult to manage. In all likelihood he ran as soon as he started to walk. In a playground he refuses to leave the jungle gym when it's time to go home. While all the other toddlers are sitting still on Mom's lap during "Mommy and Me," he's squirming or running around. He needs more supervision than all the other kids put together as he shouts out answers and fights with his cla.s.smates. When the rest of the moms leave their kids to enjoy their hour or two of fun and games at a birthday party, his mother is asked to stay on to make sure he doesn't tear the place apart.

The disorder I'm describing is attention deficit hyperactivity disorder-ADHD-the most common of all the childhood psychiatric illnesses. More than a million children in this country have ADHD. According to the most conservative estimate, 3 to 5 percent of all children have the disorder, and some estimates put it as high as 9 percent. The overwhelming majority of kids with ADHD are boys. The male-female ratio is anywhere from 4-1 to 9-1, depending on the study. As we become more aware of the symptoms in girls, that balance will shift.

ADHD is a behavioral disorder with three major symptoms: inattention, impulsitivity, and hyperactivity. Like all disorders, ADHD can be mild, moderate, or severe. Some children are somewhat fidgety (in fact, we expect all toddlers and preschoolers to be a little little fidgety), while others can't sit still for even a minute. There are kids who are terrors in large groups but do fine when the interactions are one-on-one. The children with the most severe ADHD have problems constantly and in all settings: at home, at school, and at play. fidgety), while others can't sit still for even a minute. There are kids who are terrors in large groups but do fine when the interactions are one-on-one. The children with the most severe ADHD have problems constantly and in all settings: at home, at school, and at play.

Although signs of this disorder are often evident during toddlerhood or even earlier, most children who have ADHD make their way to the office of a mental health professional a little later, most often when they start school. Parents and other loved ones may be willing and able to cope with or even ignore the behavior a.s.sociated with ADHD, like the grandparents who indulge their "Sweet Destructo," but teachers cannot and will not put up with it.

ADHD is a chronic, not an episodic, illness; the inattention, impulsivity, and hyperactivity don't come and go as a result of circ.u.mstances. Normal children may have any or all of the ADHD symptoms temporarily as a result of something that happens in their lives-if their parents divorce, for instance-but that behavior will disappear after a short time. The symptoms of true ADHD won't make a sudden appearance after a child is in school. The disorder usually starts early and gets worse over time.

Over the last few years ADHD has developed a high profile, and many misconceptions connected with ADHD have surfaced. The most widely held, and the most alarming, is the belief that children will outgrow the disorder. For example, if a child is physically aggressive at the age of two, a well-meaning pediatrician might tell his parents, "He's just being negative and oppositional because he's going through the terrible twos." A year later, when that same child is even more badly behaved-more aggressive, more unpleasant, more active and inattentive-the pediatrician may well stick to his original interpretation: "He's immature," he might say. "It's the terrible twos at three. He'll outgrow it." Three years later the child is six and in first grade, unable to stay in his seat and driving everyone crazy with his antics. Not only has he not outgrown his symptoms; things have gotten a lot worse.

Some children do leave the symptoms of ADHD behind once they reach p.u.b.erty, but that fact doesn't mean that this serious disorder should go untreated for ten years. If ADHD is ignored, a child may well end up going through p.u.b.erty with rotten grades, no friends, and a terrible att.i.tude. Studies have shown that more than half of all kids with ADHD will continue to have difficulties a.s.sociated with the disorder as they get older. The most common problems are continued inattention, impulsivity, restlessness, learning difficulties, poor social relationships, and low self-esteem. The high school dropout rate for kids with ADHD is more than 12 times that found among high school students without ADHD. Further findings suggest that youngsters with ADHD who are aggressive in childhood are more likely to show antisocial behavior during adolescence and adulthood.

As far as I'm concerned, whether a child outgrows ADHD is beside the point. The point is that every child should be given the chance to enjoy school, to be liked by his parents, and to go to his friends' birthday parties-without his mother or father. Children who can't pay attention to their studies, who spend their childhood being yelled at and considered stupid, lazy, or just plain bad by family, friends, and teachers are not getting the start in life that they need and deserve.

THE SYMPTOMS.

There are three different types of ADHD. The first type, and the least common, features behavior that is predominantly hyperactive and impulsive, characterized by fidgetiness and restlessness. (Theo, back at the beginning of this chapter, has this type of ADHD.) The kids in this category are the ones who can't wait in line, have trouble remaining seated, and are likely to blurt out answers in cla.s.s.

The children with the second type are predominantly inattentive, distractable, and disorganized-ADHD without the H H, hyperactivity. Children with ADD make a lot of mistakes, often forget or lose their possessions, daydream, procrastinate, and fail to complete their work. (Peter, the boy who's always getting lost on the soccer field, falls into this category.) They may be impulsive, but they're not as active as the first type, so ADD is somewhat more difficult to diagnose than ADHD. Children and especially adolescents with ADD (no hyperactivity) may be perceived as lazy, willful, frustrated, and academically limited. Parents often describe children with ADD as charming in two-way conversations with friends and family but "a little off" in large groups. These kids aren't disruptive, but they miss social cues and often seem out of step with the rest of the world. These kids may get by in elementary school, but the increased demands of junior high usually bring about their downfall.

The third type of this disorder-and the most common form-combines the symptoms of the first two, hyperactivity and inattention. Nicholas, alias "Sweet Destructo," falls into this category.

One mother of two children has two types of ADHD in her own family: a son, Carl, who's 11; and Amy, a daughter who recently turned eight. Both kids are in treatment now, but their mother, a schoolteacher accustomed to observing and reporting on the behavior of children, remembers very well what it was like in the bad old days. Here's how she describes the differences in their behavior before they started their treatment: "You'd never know they have the same disorder. It manifested itself so differently. Carl was impulsive but not hyperactive. If he saw something he wanted, he would just get up and help himself to it, without any thought for the consequences. With other children, if you say 'don't,' they don't. If I said 'don't' to Carl, he did anyway. It was almost as if he didn't even hear me. He was always getting himself into awful situations. He was easily distractable, but periodically he could get it together and seem fine. Amy was much more hyperactive. Even when she was really small, she went nonstop. If I didn't bolt the front door, she'd fly outside and into the street. When she was two years old, she climbed up the drawers of the dresser to reach something. Of course, the dresser came over on top of her, and she ended up in the hospital. Carl was afraid of a lot of things, so he was usually safe, but for a while my husband and I lived in terror because we just couldn't seem to keep Amy safe. If we didn't watch her every second, she'd run out into traffic. I'll never forget the day a photographer asked me if Amy, who's a pale blonde and very pretty, would be available to do some modeling. I had to laugh. I said, 'Go ahead if you want, but I doubt you can get her to stand still long enough to take a picture.'"

Carl and Amy's mom is right: ADHD doesn't look the same on everyone. It's the cla.s.s bully who punches the other kids, grabs their books, and steals their cookies at lunchtime. It's also the "nerdy" kid who always seems out of it, the one who forgets to do his homework or loses it on the way to school and never even realizes that his shirt isn't tucked in. It's the little girl who can't swim but keeps jumping into the pool anyhow and the pre-kindergartner who shouts profanities at his teacher. It's the child at the carnival who gets so stimulated that he moves from one ride to another without ever settling on anything.

Generally speaking, no matter how ADHD is manifested, all of these children are difficult and demanding, to say the least. One mother summed it up this way: "He wants what he wants when he wants it, and that means now. now. And everything has the same intensity. When he wants something, there's no difference between a candy bar and a bicycle." And everything has the same intensity. When he wants something, there's no difference between a candy bar and a bicycle."

THE DIAGNOSIS.

We make a diagnosis of ADHD the old-fashioned way, by talking to the parents, the teachers, and the child himself. We learn as much as we can about the child's functioning since birth, paying special attention to his development, his activity level, and especially his interactions with others. (We know that children with ADHD have more trouble in groups than they do in one-to-one situations.) We compare the level, frequency, and intensity of their symptoms with those of normal children of the same age. Along the way we look for the crucial telltale signs of any disorder: distress and dysfunction.

ADHD is tricky in this regard because children with this disorder don't always recognize that they're in distress. Kids with behavioral disorders, as opposed to anxiety disorders, tend to be unreliable historians. As far as many of these kids are concerned, they're fine; it's their parents or their teachers who have the real problem. "There's nothing wrong with me. I'm great," they tell me, and often they really mean it. One of the best ways we have of persuading a child to acknowledge that something might be wrong is to ask one of the standard child and adolescent psychiatrist's questions: if you could have three wishes, what would they be? Most kids with ADHD will offer a variation on these three themes: "I wish I didn't have to go to school."

"I wish I had more friends."

"I wish my parents would stop yelling at me."

On the other hand, parents make excellent historians when it comes to children's behavioral disorders. When we ask mothers and fathers about the actions of a child with ADHD, the facts come pouring out: the child has terrible grades; he's always losing things; he gets into fights with the other kids; teachers complain about him nearly every day. Things usually aren't too rosy at home either. A child with ADHD rarely has a good, well-rounded relationship with his parents. The relationship often consists in large part of constant criticism of a child's behavior. Furthermore, the tension created by the disorder in the household may lead to disharmony between Mom and Dad. It's not easy keeping romance alive when everyone is shouting and upset all the time.

Parents are not always infallible in their observations, of course. Many first-time parents don't recognize that their youngster is more inattentive or hyperactive than the average child; after all, this is their only child. Other parents think that their child's inattention is more willful than chemical. "He pays attention just fine when he's watching television or playing video games, but somehow he just can't focus on his homework" is something I hear often from cranky, frustrated parents, and what they say is true as far as it goes. What those parents don't realize is that the type of attention needed for watching TV and playing Nintendo is actually different from the type required for doing homework. Everyone has an easier time paying attention when he is directly engaged. That explains why many children with ADHD are much more responsive when they interact one-on-one than when they are in groups. If an activity doesn't engage a child or if the setting is distracting, he'll find it nearly impossible to focus. Willfulness has nothing to do with it.

We look to a child's teachers for an a.s.sessment of his behavior as well. Teachers can be excellent sources of significant facts about how a child is functioning and how his behavior compares with that of others; teachers have a lot lot of experience with normal children. When we suspect that a youngster has ADHD, we ask teachers to provide information about the child's academic performance, his behavior in cla.s.s, and his social interactions. We also ask teachers to fill out standardized rating scales designed to elicit information that's relevant to this disorder. The form most often used is the of experience with normal children. When we suspect that a youngster has ADHD, we ask teachers to provide information about the child's academic performance, his behavior in cla.s.s, and his social interactions. We also ask teachers to fill out standardized rating scales designed to elicit information that's relevant to this disorder. The form most often used is the Conners Teacher Questionnaire Conners Teacher Questionnaire, which helps a teacher to evaluate a child's hyperactivity, pa.s.sivity/inattention, and conduct problems. The 28 questions in the form I use ask teachers to a.s.sess a child's behavior, learning ability, and social skills in the cla.s.sroom. Is he restless? Does he make inappropriate noises? Does he insist that his demands be met immediately? Does he daydream, pout, or disturb the other children? Does he deny his mistakes or blame others for them? Does he make excessive demands on the teacher? Does he fail to finish what he starts? And so on. Because the Conners questionnaire has been used for thousands of normal children as well as those suspected of ADHD, the Conners score provides yet another piece of useful evidence in the diagnostic process. Once a child diagnosed with ADHD is on medication, Conners forms are sent regularly to teachers and used to help monitor the effects of the medicine.

It's also important to review and interpret correctly any tests given by schools, psychologists, or independent testing services, such as IQ tests, standardized achievement tests, and tests for learning disabilities. Far too often my colleagues and I hear the sad tales of parents who have been misled by faulty test results. One couple in particular got the runaround for several years before their child finally got the help she needed. Here's the story they tell: "We had an inkling that something was wrong with Carrie well before she was two years old. She was slow to walk and slow to talk compared with her peers and her older brother. And she was difficult. When she started nursery school, we began what we now understand is a typical adventure. First we were told she was okay. Then we were told she had some serious problems. Then we were told she was okay but we we had some problems-namely, we were overprotective and neurotic. We had her tested by two different, very reputable places, and they gave us totally different results. One said she was normal, and the other said she had speech delays and learning disabilities. When she started kindergarten, the teacher said she was a perfectly normal kid, but by the end of the year she was saying that Carrie was immature. It took us another two years before we got the right diagnosis and the right treatment. Carrie definitely has ADD." had some problems-namely, we were overprotective and neurotic. We had her tested by two different, very reputable places, and they gave us totally different results. One said she was normal, and the other said she had speech delays and learning disabilities. When she started kindergarten, the teacher said she was a perfectly normal kid, but by the end of the year she was saying that Carrie was immature. It took us another two years before we got the right diagnosis and the right treatment. Carrie definitely has ADD."

Early identification of ADHD and early intervention are extremely important. There's a huge difference between diagnosing a child early, when all he has is a little impulsivity and inattention, and seeing him later, when his parents are angry at him, his teachers are fed up with him, and his every encounter since early childhood has been negative. It's not unusual to see kids of 12 or 13 with ADHD who don't want to be in school anymore. It's also not difficult to understand why they feel that way. If I were being picked on and berated at the office every day, I'd want to quit my job too. Studies have shown that teachers are not only more short-tempered with kids who have ADHD; they're less patient with everyone in the cla.s.s.

THE BRAIN CHEMISTRY.

Too much sugar and too little discipline: those are just two of the things that do not not cause ADHD, no matter what Uncle Frank says he thinks he read in last week's cause ADHD, no matter what Uncle Frank says he thinks he read in last week's Parade Parade magazine or what the well-meaning but ill-informed math teacher announced at the last parent-teacher conference. I've never met parents of a child with ADHD who haven't been told, somewhere along the line, that their child wouldn't be acting this way if he just got a little discipline at home. magazine or what the well-meaning but ill-informed math teacher announced at the last parent-teacher conference. I've never met parents of a child with ADHD who haven't been told, somewhere along the line, that their child wouldn't be acting this way if he just got a little discipline at home.

ADHD has nothing to do with diet or with parenting. It's also not caused by chronic exposure to lead, another theory that has been proposed but not substantiated. ADHD is a disorder of the brain. Children are born with a vulnerability to the disorder.

There is a great deal of evidence to suggest that ADHD is genetic. For one thing, parents of children with ADHD tended to show symptoms a.s.sociated with the disorder when they themselves were kids. For another, ADHD is more prevalent among the siblings of kids with ADHD than in the general population. And finally, there is a higher rate of hyperactivity and restlessness between identical twins than between fraternal twins.

There's a strong suspicion that brain chemistry, and specifically the level of the neurotransmitters dopamine and norepinephrine, is an important determining factor for ADHD. All of the medications that have been effective in the treatment of ADHD affect the regulation of one or both of these chemicals. Neuroimaging techniques-especially magnetic resonance imaging (MRI), positron emission topography (PET) scans, and single photon emission computer topography (SPECT)-have demonstrated that children with ADHD have brains that are different from the brains of kids who don't have it-specifically, dysfunction in the areas of the brain that have high concentrations of dopamine. PET scans performed on adults with ADHD have shown some evidence that a particular area of the brain is undermetabolizing or underutilizing energy. When those adults were treated with Ritalin, a dopamine-increasing stimulant discussed in detail later in this chapter, the PET scan returned to normal. This result indicates-indirectly, to be sure-that dopamine plays a part in ADHD.

THE TREATMENT.

The good news is that ADHD is relatively easy to treat. There are more than 200 studies showing that a stimulant called Ritalin (generic name: methylphenidate) works wonders for children with ADHD. Stimulants have been used in the treatment of ADHD for more than 90 years. Adults feel more focused and alert after a cup of coffee in the morning. That's roughly how Ritalin works on children. Ritalin and other stimulants increase the alertness of the brain and nervous system, stimulating it to produce more dopamine and norepinephrine. The medication increases the child's attention and reduces excess fidgetiness and hyperactivity, allowing him to focus on his work. Children with ADHD who take Ritalin make fewer errors on a variety of tasks than untreated children do. They are less impulsive and more attentive, both in the cla.s.sroom and in social situations. They're better able to control themselves. Kids with ADHD taking Ritalin receive more praise and less criticism from parents and teachers, and they get along a lot better with the other kids. Their grades go up, they become more popular, and they feel better about themselves.

A myth surrounding the treatment of ADHD is the "paradoxical calming effect" of stimulants such as Ritalin. It is a commonly held misconception that if a stimulant calms a child, then he must have ADHD; if he didn't have the disorder, the thinking goes, the medication wouldn't have any effect. That is categorically not true. Stimulants increase attention span in normal children as well as those with ADHD.

The recommended dosage of Ritalin varies widely. I've seen kids who respond to as little as 10 milligrams of the medicine and others who require 80 milligrams. Most children I see take from 30 to 70 milligrams of Ritalin; we start with the low doses and build up if necessary, taking into account the decrease in symptoms and the occurrence of side effects. Children nearly always take their Ritalin twice or three times a day: first thing in the morning, at lunchtime, and right after school. (This third dose helps kids to focus as they do their homework.) A dose of Ritalin lasts about four hours.

A child should have had a complete physical examination within the last year before a stimulant is prescribed. (We want a baseline of a child's physical condition before the medication begins, so that we won't mistakenly conclude that the stimulant is causing adverse effects.) Ritalin usually decreases appet.i.te and may affect a child's growth, so we pay special attention to a child's height and weight, checking both every four to six months to monitor his growth rate. Most kids take ADHD medication for a minimum of nine to twelve months.

A decrease in a child's rate of growth is a possible side effect of Ritalin, but that doesn't happen very often. Most youngsters experience minimal negative side effects or none at all. The most common side effects are reduction in appet.i.te, delay in falling asleep, headaches, and tearfulness. These side effects almost always disappear over time or with an adjustment in either the timing or the dosage of medication. Stimulants have been known, rarely, to cause tics, usually in children whose families have a history of tics. When a child is genetically vulnerable to tic disorders, particularly Tourette syndrome (described in Chapter 13 Chapter 13), we look to other medications for treatment.

Ritalin is unquestionably the medication of choice-the first line of attack-with ADHD; but when Ritalin doesn't get results or when the negative side effects are such that it must be discontinued, several other medications are routinely prescribed. The other stimulants that have proven to be effective are Dexedrine, Adderal, and Cylert. Dexedrine lasts longer than Ritalin and has similar, more frequent side effects: decrease in rate of growth, decrease in appet.i.te, and delay in onset of sleep. Both Ritalin and Dexedrine are available in sustained release (SR) pills, which have the advantage of not requiring a school nurse to give the lunchtime dose. Frequently children taking Ritalin SR will also need to take regular Ritalin with their morning dose and an additional dose of regular Ritalin after school. Adderal is long-acting and similar to Dexedrine spansules. It lasts for about six hours, and since it comes in tablet form, it is easy to adjust the dose. Cylert lasts about ten hours, so it can be given once a day. Unlike the other stimulants, which work very quickly, Cylert may require two weeks before the full effects are felt. Cylert's side effects are a little different from the others; appet.i.te, sleep patterns, blood pressure, and heart are less often affected, but inflammation of the liver may occur in a small number of children. The manufacturer of Cylert recently reported on a series of youngsters who developed liver failure while on Cylert. At this time, it is not clear if this is a side effect of the medicine or a coincidental finding; however, given the serious nature of this side effect, Cylert should be used only for youngsters who have been nonresponsive to other medications.

Wellbutrin, a new antidepressant, has proven to be effective in children with ADHD who have had a poor response to stimulants. The side effects are similar but less frequent than those a.s.sociated with the stimulants. There are three tricyclic antidepressants (TCAs) that psychiatrists turn to in treating ADHD, especially when the child being treated is vulnerable to tics: Norpramin, Pamelor, and Tofranil. These antidepressants have their own side effects, of course. They may cause tiredness, dry mouth, and constipation. More important, they may have an effect on heart rate; a child taking any of these medications must have an electrocardiogram before starting the medicine and before the dose is increased. Until recently Norpramin was the TCA used most frequently because it has fewer of the bothersome side effects, but over the last year or so several sudden deaths have been reported in children taking this medicine. Although there is not sufficient evidence to link those deaths with the Norpramin, it is rarely prescribed; Pamelor and Tofranil are now the medications of choice. The doses of Pamelor and Tofranil that are prescribed for children with ADHD are lower than those prescribed in the treatment of depression, and they need from one to four weeks to take effect. Because the medicine lasts a long time, it is taken in the morning and at bedtime.

Two antihypertensives, Catapres and Tenex, have been used when children have tics as well as ADHD. (An antihypertensive is frequently given in combination with a stimulant.) The medicine lasts a short time, so children must take it three or even four times a day. Catapres is available in a skin patch, which eliminates the necessity for the multiple doses. Side effects of Catapres and Tenex are minimal-sedation, headaches, nausea, dry mouth, and constipation-and they usually disappear with time. Antihypertensives don't have the same cardiac effects on children as they do on adults, who take the medicine for high blood pressure, but an electrocardiogram is necessary before the medication is started. The child's blood pressure and heart rate should be checked on each visit.

BuSpar, an antianxiety medicine, is currently being studied for use in children who have Attention Deficit Disorder and symptoms of anxiety. Some antipsychotic medications, especially Haldol, Thorazine, and Mellaril, reduce the symptoms of ADHD, but their side effects are such that they're not ordinarily prescribed for this disorder.

We prescribe "drug holidays" for children who take stimulants, suggesting that parents discontinue the medication for at least four weeks each year. There are two reasons for a drug holiday: first, it allows kids whose rate of growth or weight has been affected to catch up; and second, it lets us know if the medicine is no longer necessary. (Some children with ADHD do get better.) Most parents are inclined to declare the drug holiday in the summer, when a child's school work won't suffer, but it's harder to a.s.sess a child's progress in the summertime, because there is relatively little pressure on him to perform when school is not in session.

No matter when the drug holiday comes, most parents dread dread it. "I have a very hard time with drug holidays," said one mother of a 10-year-old boy being treated for ADHD. "My whole life turns upside down, and the rest of the family goes a little crazy too. He is so different off the medicine, and by it. "I have a very hard time with drug holidays," said one mother of a 10-year-old boy being treated for ADHD. "My whole life turns upside down, and the rest of the family goes a little crazy too. He is so different off the medicine, and by different different I don't mean I don't mean better. better. July is the longest month of the year." July is the longest month of the year."

Another mother wanted to give her son the summer off between fifth and sixth grade, but the child's baseball coach pleaded with her to put him back on. The medication made a critical difference in his performance. Since playing the game well also made a critical difference in the child's happiness and self-esteem, the mother gave him back his Ritalin after two weeks.

I've known parents who flat-out refuse to give their children a drug holiday. "We just couldn't take drug holidays," said one such mother, whose 11-year-old daughter has been taking Dexedrine for five years. "It's not just that she's incredibly unpleasant. We could deal with that. It's that she's so reckless. She gets into terrible trouble. She can't make rational decisions and get on with her life without the medication. We worry about her too much to take her off it for any length of time."

Then there are the parents of children with ADHD who say that their kids seem to take a drug holiday every day, when the lunchtime dose of Ritalin wears off. (Some children taking stimulants experience behavioral rebound: behavioral rebound: several hours after the last dose of the stimulant taken, there's a dramatic increase in hyperactivity, hypertalkativeness, and irritability.) I've often talked to parents who disagree about their child's diagnosis depending on the time of day they're most likely to interact with him. For example, a mother says her son needs an extra dose of Ritalin. At the moment he takes it twice a day: in the morning and at lunch. Mom tells me that her son has trouble following directions after school; he has temper tantrums at home; he doesn't always behave on the bus in the afternoon; he loses his focus when he's doing his homework. Dad says that the twice-a-day regimen is just fine. "He's great at Little League, and he's fun to be with. We wrestle together and have a terrific time. My wife is making too big a deal out of this," says the father. The explanation for their difference of opinion is quite simple: the father nearly always spends time with his son on weekend mornings, when he's on Ritalin. By the time Dad gets home from work every day, and the medication has worn off, the child is in bed asleep. Mom is there when the little boy gets off the school bus, already a little out of control. She was right about the extra after-school dose of Ritalin. several hours after the last dose of the stimulant taken, there's a dramatic increase in hyperactivity, hypertalkativeness, and irritability.) I've often talked to parents who disagree about their child's diagnosis depending on the time of day they're most likely to interact with him. For example, a mother says her son needs an extra dose of Ritalin. At the moment he takes it twice a day: in the morning and at lunch. Mom tells me that her son has trouble following directions after school; he has temper tantrums at home; he doesn't always behave on the bus in the afternoon; he loses his focus when he's doing his homework. Dad says that the twice-a-day regimen is just fine. "He's great at Little League, and he's fun to be with. We wrestle together and have a terrific time. My wife is making too big a deal out of this," says the father. The explanation for their difference of opinion is quite simple: the father nearly always spends time with his son on weekend mornings, when he's on Ritalin. By the time Dad gets home from work every day, and the medication has worn off, the child is in bed asleep. Mom is there when the little boy gets off the school bus, already a little out of control. She was right about the extra after-school dose of Ritalin.

Stimulants and the other medications used for ADHD have many miraculous powers, but they cannot and do not solve all the problems a.s.sociated with ADHD. Stimulants help a child to pay attention, but they don't automatically make him more organized. However, they do make him more able to benefit from other interventions. A child with ADHD may need to work on improving his organizational skills and study habits, ideally with a tutor who specializes in psychoeducational tutoring. Parents can help with this too, of course, by working with the child and the tutor to come up with new strategies for behavior and then reinforcing the new behavior with a system of rewards. For instance, parents may tell a child: "If you come home, have a snack, and then settle down to do your homework right away, you get a star. If you don't have a fight with your brothers and sisters today, you get a star. For every day your teacher says you worked quietly without interrupting in cla.s.s, you get a star. For every three stars you earn, you get to play a half-hour of video games at the arcade." The reward will be different for every child, of course, but the principle stays the same.

Most children with ADHD will need some social skills training as well. Unlike children with social phobia (see Chapter 10 Chapter 10), who must be encouraged to take part in the events around them and learn how to do more more in the way of socializing, kids with ADHD have to learn to do in the way of socializing, kids with ADHD have to learn to do less. less. In all probability they've been accustomed to leaping before they look; they have to learn that their social actions have consequences. ("Stop. Listen. Look. Think. Act." That's the cognitive behavioral mantra taught to children with ADHD.) Being in control takes practice; most of these kids don't even know what it feels like. A child psychologist who specializes in behavioral therapy or a social worker with a specialty in social skills training can be of great help to a child just learning how to behave in social situations. As strange as it may seem, some children don't know the first thing about how to act at a birthday party. Professionals can show them the way. In all probability they've been accustomed to leaping before they look; they have to learn that their social actions have consequences. ("Stop. Listen. Look. Think. Act." That's the cognitive behavioral mantra taught to children with ADHD.) Being in control takes practice; most of these kids don't even know what it feels like. A child psychologist who specializes in behavioral therapy or a social worker with a specialty in social skills training can be of great help to a child just learning how to behave in social situations. As strange as it may seem, some children don't know the first thing about how to act at a birthday party. Professionals can show them the way.

A psychologist can help with parent training and counseling too. A child with ADHD on medication is more attentive, less hyperactive, and less impulsive, but he still has to be managed, and the job of child management falls primarily to the parents. Parents have to learn to exercise control over their children without losing control themselves. The message a parent must convey to children who misbehave is: "This is unacceptable behavior. It will not be tolerated. It keeps you from functioning in the world."

When that doesn't work-and everyone knows that it sometimes doesn't-parents have to know when and how to go to the next level: "Look, I just gave you a warning. You didn't listen to me. Now you've lost 15 minutes of television for tonight. Please get up and go to your room now. You've already lost 15 minutes. The next time I tell you to leave, it'll be 30 minutes. Are you leaving? No? Okay, you just lost 30 minutes." The parents' request and the consequences for noncompliance are both clear. The parent is calm and in control, and the punishment is meted out without rancor or malice.

If and when the battle escalates, a parent moves to level three: "Now you need a time-out. Your behavior is intolerable. I won't put up with that kind of talk. You know you're not allowed to bang on the furniture." By now the parent is taking the child by the arm and walking him to his room. "You have to stay in your room for five minutes." The older the child, the longer the time period should be. At the end of the time period the child is asked, "Are you ready to come out and join us?" If the child is still not in control, he goes back for another five minutes.

When the child comes out of the room, the punishment still stands, of course. He still loses 30 minutes of television. The final message from Mom and Dad should reinforce all the others. "We still love you. We still want to hug you and give you a kiss. Life will go on. But tonight it will go on without television."

These kinds of parenting skills don't come naturally; they have to be learned and practiced. Children with ADHD need an immediate response from their parents. "If you do that one more time, you'll be punished" doesn't work with them. Parents have to be ready to respond to any and all situations. With normal children parents can get away with, "I'm not sure yet what your punishment is going to be, but it's going to be a whopper." With these children parents have to be ready with specifics. Parents of children with ADHD also have to be absolutely consistent. Kids who have ADHD need structure, because it helps them to learn rules and establish limits.

Another aspect of ADHD that therapy can address is the youngster's self-esteem. There's no empirical evidence at the moment that being liked by parents and teachers is good for a child, but we don't need statistics to know that being yelled at and put down on a regular basis doesn't make a child feel good about himself. Unfortunately there is no medicine that works on a child's self-esteem. Some of these kids become so accustomed to failure that it's hard for them to acknowledge anything else.

I was reminded of this fact when Teddy, a seven-year-old boy I was treating for ADHD, came to my office for a checkup after three months of Dexedrine. He was responding beautifully; his parents and teachers were delighted with his behavior. I asked Teddy how he was feeling. He told me that he felt the same as always. Then came the kicker: "Since I started taking medicine, my teacher and my parents are much nicer," he told me.

PARENTING AND ADHD.

"I wasn't prepared for this," said the mother of Cheryl, a five-year-old girl with severe ADHD. This was before her daughter started taking medication. "My idea of having kids used to be dressing them up in cute little outfits. Then I thought we'd all do things together as a big happy family. I never knew so many things could go wrong. We went to Disney World for vacation, and it was a nightmare. Cheryl was impossible. She didn't want to wait in line. She didn't want to sit still when we got on one of the rides. When we went to the gift shop, she couldn't make a decision; she wanted everything, and she didn't want anything. Sometimes my husband and I play a game called 'Normal Family.' We take the kids out to dinner, sit down at the table, and pretend that we're totally relaxed, not at all worried that Cheryl is going to pick up the b.u.t.ter dish and throw it across the room. We always wonder if people can tell how much work it takes just to keep her in her seat."

Being the parent of a child with ADHD is is a lot of work, perhaps more demanding and more challenging in terms of time and attention than any of the other disorders. When the kids are little, finding children for them to play with can be a full-time job; they tend not to be on anyone's "A" list. As they get older, helping them with their schoolwork is usually extraordinarily time-and energy-consuming. The hard work usually pays off, though. The mother of one 13-year-old girl I've treated works closely with her daughter on her homework every night and helps her to prepare for tests, and the results have been spectacular. Last report card the girl came home with straight As. Her mother says that if any of the kids in the cla.s.s have a question about the homework a.s.signment, they always call Kelly. "Everybody knows that Kelly is the most organized child in her cla.s.s," she says. That's because they work long and hard at it. Some nights after Kelly's medication wears off, her mother sits in a chair next to Kelly and rubs her back while she studies. It's the only thing that helps the girl concentrate. a lot of work, perhaps more demanding and more challenging in terms of time and attention than any of the other disorders. When the kids are little, finding children for them to play with can be a full-time job; they tend not to be on anyone's "A" list. As they get older, helping them with their schoolwork is usually extraordinarily time-and energy-consuming. The hard work usually pays off, though. The mother of one 13-year-old girl I've treated works closely with her daughter on her homework every night and helps her to prepare for tests, and the results have been spectacular. Last report card the girl came home with straight As. Her mother says that if any of the kids in the cla.s.s have a question about the homework a.s.signment, they always call Kelly. "Everybody knows that Kelly is the most organized child in her cla.s.s," she says. That's because they work long and hard at it. Some nights after Kelly's medication wears off, her mother sits in a chair next to Kelly and rubs her back while she studies. It's the only thing that helps the girl concentrate.

Kelly's parents think that they have the school situation pretty much under control, but as their daughter reaches p.u.b.erty, they're starting to have serious worries of a different kind. So far Kelly is not allowed to date, but they know that the day will come. "We're a little nervous about her with boys," her father told me. "She really needs her medicine. She's the kind of kid who has terrible judgment and no impulse control without it. If somebody offered her a drink or a some marijuana, I could see her accepting if she hadn't taken her medicine. She would think it was 'neat.' If some guy says, 'Let's go for a ride' or 'Let me put my hand there,' I'm afraid she'll do it. She knows the rules, but rules don't really work for her if she's not on her medicine."

Parents of children with ADHD often drastically rearrange their lives, sometimes without even acknowledging that they're doing it. "We don't mind not eating together as a family," one mother of a nine-year-old told me. "If we try to have dinner together, he just knocks everything over. It's better for everyone if I just stand and watch while he has his dinner."

Before the parents of five-year-old Gary started their son on Ritalin, they had stopped taking him anywhere-no movies, no restaurants, nothing. Two weeks into the Ritalin treatment they took him to a puppet show at the local college, and he sat through the whole thing. "I had forgotten that these family outings could be fun," Gary's father told me.

Parents should understand that when they change their lives to suit the symptoms of their child's disorder, they are not doing the child any favors. A kid who lives in a world in which everyone accommodates him is in for an extremely rude awakening. Parents can't and shouldn't shelter their kids forever. The sooner they teach their children to follow the rules of polite society, the better off everyone, especially the child, will be.

This disorder is tough on everyone in the family, including the other siblings. First of all, mothers and fathers of children with ADHD tend to be more short-tempered with all all their kids, not just the one with the irritating symptoms. Second, kids with ADHD require and demand so much attention that there's not always enough to go around for the others. their kids, not just the one with the irritating symptoms. Second, kids with ADHD require and demand so much attention that there's not always enough to go around for the others.

"Seth is so well behaved that I take him for granted," a mother says about her son who doesn't doesn't have ADHD. "When he does misbehave, I know I'm too hard on him. I count on him not to give me any trouble." have ADHD. "When he does misbehave, I know I'm too hard on him. I count on him not to give me any trouble."

Another mother feels similarly guilty about her ADHD-free son, who is a couple of years older than the child with ADHD. "The other day they both came home with grades. Casey got 100 percent on his test-which he always does-and Ben got 80. I'm sure I made much more of a fuss about Ben's 80. Casey never complains. In fact, he's a wonderful, caring older brother, and he really helps Ben. But I'm sure he feels slighted sometimes." Family therapy can help a family deal with the child's disorder and its impact on the whole family.

One of the biggest problems that parents of children with ADHD face is that the kids get labeled by the rest of the world. "Troublemaker" is the usual epithet they're given, and it doesn't take long for the word to spread. Fortunately a bad reputation is relatively easy to shake, at least as far as teachers are concerned. Kids who get treated for ADHD are almost always regarded as "new and improved" by their teachers, with no hard feelings. Cla.s.smates tend to be less forgiving, however, and there are instances in which a kid with ADHD alienates his peers beyond redemption. When that is the case, it may be necessary to ask the school to place the child in a different cla.s.s for the next academic year. A fresh start may be just the ticket for a child being treated for ADHD.

Teachers and other school officials, who should be part of a strong support system for these troubled children, sometimes make this problem worse. Kids with ADHD are disorganized and easily distracted, so remembering to take their medicine every day at school can be tricky. One of the children I treated set his watch so that it would beep, reminding him to take his medication at noon. The teacher complained that the beeper disrupted the cla.s.s and wouldn't let him use it. Another teacher routinely made fun of the fact that one of his students needed Ritalin. If the boy did anything out of the ordinary in cla.s.s, the teacher would say, "I bet you forgot your medicine today, Tommy. Look how you're acting." I've encountered nurses who give a child his medicine if he remembers to come to their office but refuse to track him down to make sure he gets there.

Most schools will listen to reason, especially if parents enlist the help of the child's psychiatrist, psychologist, or social worker to get their attention. High school guidance counselors are looking more favorably on the idea of untimed SAT tests-allowing kids with ADHD to complete the tests at their own speed-and many colleges feature special resource centers for their students with ADHD. The U.S. Office of Education has started a major campaign to inform school personnel about ADHD, including its identification, its treatment, and the special needs of children who have it. As more school systems become enlightened about this no-fault brain disorder, the same kinds of accommodations will be made for these kids as are made for children with any medical disorder.

The Age of Enlightenment may already be underway in the schools. I came to that conclusion when, quite recently, I evaluated a child with ADHD and faxed a letter to the school with instructions on how the medication was to be given. I was floored when, the very same day, the school nurse called to ask me how often I wanted the Conners questionnaire to be filled out by the child's teacher. I told her that I'd like the form filled out every two weeks and that I would send her some forms. "No, don't bother," she told me. "We have our own supply right here."

For sound practical advice about coping with ADHD many parents turn to ADHD support groups. The best known of them is CH.A.D.D.-Children and Adults with Attention Deficit Disorder-the largest organization of its kind in the country. The members of CH.A.D.D. have helped to identify ADHD as a real disability, forcing school districts and insurance companies, among others, to acknowledge its existence. They have enormous resources and can be helpful to parents who come up against teachers, camp counselors, or other authorities who are reluctant to cooperate with the treatment of a child with ADHD.

I said earlier in this chapter that ADHD is relatively easy to treat. I wish I could say that it's easy to live with. Still, with active treatment and a lot of hard work, a child with ADHD can have a well-rounded, happy, productive life even if his symptoms never disappear entirely. He'll probably have to make some allowances; he'll do best to choose a profession that lets him move quickly from task to task rather than one requiring long periods of concentrating and sitting still. Theater critic is probably out, but he'd probably make a terrific stockbroker or salesman. I know one young man with ADHD who's a physician. His specialty? Ears, nose, and throat. He told me he needed a practice with lots of action and quick results.

One mother whose child I've been treating for seven years is cautiously optimistic about the prospects of her 12-year-old son, more so than she ever thought possible. "When Max was first diagnosed with ADHD, I spent a month crying," she told me. "I would drive to school with the tears rolling down my face, wondering what in the world we were all going to do. I just kept thinking that I wanted him to be like all the other kids. I wanted him to be treated like everyone else. It hasn't been easy, but I think he really is is treated like the others. He does all the things that the other kids do. It just takes a lot more effort." treated like the others. He does all the things that the other kids do. It just takes a lot more effort."

CHAPTER 8.

Obsessive Compulsive Disorder James was 12 years old when he came to see me. Earlier that week he and his family had been on vacation, skiing in Colorado. One evening just before dinner James bolted out of the bathroom wrapped in a towel. Still wet from his shower, he stood in the middle of his parents' bedroom and moved his head methodically from side to side, touching his chin to each shoulder over and over again. He said he couldn't stop. The family, who'd never witnessed anything like this before, watched helplessly as he kept moving his head back and forth, sobbing. Soon the parents were crying too. Finally James's older brother grabbed the bedspread off the hotel bed, wrapped his brother in it, and rocked him until he calmed down. A half-hour later they all went down to dinner, and James refused to talk about what had happened. During my first meeting with James I discovered that the chin-to-shoulder motion was only one of his inexplicable repet.i.tive actions, things he did on a regular basis. He also tied his shoelaces repeatedly, checked his eyegla.s.ses for cleanliness dozens of times a day, and kept on bending his fingers back, one by one, until he felt exactly the right amount of tension in each.

Five-year-old Mary likes to tear things. If the pictures she draws aren't absolutely perfect-and they never are-she rips them into dozens of pieces. She also tears her clothing, particularly her underwear. If her parents don't monitor her carefully, she'll go to nursery school literally in rags. In the bathroom she constantly touches the walls and tightens the faucets. The barrettes in her hair have to be equally tight on each side. When her parents take her out to a restaurant, she checks for gum under the table 20 or more times during a meal. Her parents say she's been doing some of these things since she was two years old.

STEP ON A CRACK,.

BREAK YOUR MOTHER'S BACK When I was in junior high school, a boy from my homeroom used to fascinate me in the school cafeteria every day. Like the rest of us, Norman would stand in line, fill his tray with food, and carry it back to the table. That's when it got interesting. I would stare, mesmerized, as Norman proceeded to eat his lunch one quadrant at a time. He was incredibly precise about it; first he'd eat what was directly in front of him. Then he'd carefully rotate the plate 90 degrees and eat the contents of the second quarter. He went on like this until his plate was clean. Kids teased him about it, of course, but during the time I knew him he didn't change his eating habits. Back then I thought Norman was weird. Today I'm reasonably sure that he had obsessive compulsive disorder, or OCD.

Childhood rituals and superst.i.tions are perfectly normal. At about two and a half years of age children begin to follow and indeed expect a regular routine, especially at mealtimes or in preparation for bed. "Before I go to bed, I brush my teeth. Then Daddy reads me a story, and Mommy rubs my back," a child might recite. Another kid says: "When I take a bath, I have six toys in the tub with me. Daddy sings Rubber Ducky' while he washes my hair." Any change in routine can create discomfort in a small child. Between five and six children develop group rituals, during which they play games. These games nearly always have rules, and most kids are as strict as Marine drill sergeants about them. Anyone who tries to circ.u.mvent or break the rules will face an extremely irate kindergartner. As children get older-from seven to 11 or so-they begin to take up hobbies and start collections: stamps, coins, baseball cards, dolls, and so on. They often appear overly preoccupied with their hobbies, but that too is normal. Obsessiveness is part of any hobby or collection.

Ritualized behavior helps to relieve anxiety and eases socialization in children as well as in adults. Anyone who has ever worn a "lucky shirt" to watch the World Series on television or knocked on wood to ward off bad luck knows about the stability that pointless rituals can bring. At any age we derive comfort from following a routine, waking up, going to school or work, eating meals, going to bed for the night. Some people are more obsessive-compulsive about their actions than others, like the man who checks his keys half a dozen times or the woman who has to lock the front door exactly three times before she can leave the house. "Checking" is a common behavior: locks, lights, ovens, faucets. It often verges on obsessive-compulsive, but if it doesn't interfere with functioning, it isn't considered a symptom of the disorder. When obsessive thoughts and compulsive acts become so frequent or so intense that they cause distress or dysfunction, a diagnosis of obsessive compulsive disorder is made.

Two eight-year-old girls are skipping down the street, and bystanders can hear their familiar refrain: "Step on a crack, break your mother's back." Both are avoiding the cracks in the sidewalk, but one little girl loses interest after covering less than a block. The other keeps going, refuses to stop. When the second little girl is asked why, she seems distressed. "I can't stop because I haven't done it enough times," she says, and keeps on skipping. There's nothing carefree or cheerful about her actions. She's an eight-year-old with a mission. The first little girl is playing a simple fantasy game. The second child has OCD.

THE SYMPTOMS.