Re-Thinking the Care and Treatment of ADHD

Re-Thinking the Care and Treatment of ADHD

Sam Goldstein, Ph.D.
This is a SamGoldstein.com Monthly Article - August, 2000
Copyright ? 2000 Dr. Sam Goldstein - All Rights Reserved

Professionals working with children increasingly acknowledge the effect of genetics and environment on how children develop cognitively -- that is, how children learn awareness, perception, reasoning, and judgment.

Combine genetics and family-school environments with the rapid pace of a complex technological society and it is not surprising that researchers find psychiatric problems increasing among children. Some experts conclude that as we try to keep up with the rest of the world, we may be hurrying our children. In our best efforts to help them, we expose youngsters to situations that may be beyond their emotional, behavioral, or cognitive capacities. We may be preparing them for a technically focused life at a very dear cost psychologically.

In such a world, life can be a challenge for children without disabilities. For those with learning, emotional, or behavioral disabilities, however, meeting the demands and expectations of adults around them is even more difficult.

As they consider the situation, behavioral scientists are beginning to realize that the childhood disorder defined as Attention Deficit Hyperactivity Disorder (ADHD) does not, in fact, represent faulty attention, but rather a problem of modulation and self-regulation (self-discipline). Children with ADHD, when interested or sufficiently motivated to pay attention, do as well or nearly as well as others. When their assignments are repetitive, complicated, uninteresting, or not their choice, the children may have difficulty remaining focused and on task. They experience greater frustration than their peers when consequences, either rewards or punishments, are delayed, infrequent, unpredictable, or inconsistent.

Problems with self-regulation cause difficulty in managing emotion. Children with the problem tend to over react to small events. It is also difficult for them to develop habits. From brushing teeth to completing homework, negotiating the demands of everyday life requires efficient self-regulation to develop habits necessary for success. It takes more attempts over longer time for children with ADHD to learn to do routine tasks without reminders or consequences -- developing a habit.

It is not surprising then that children with ADHD often have difficulty coping with the demands in their lives, and they may be poorly prepared to enter adulthood. In clinic populations, two-thirds of children with ADHD experience other disruptive disorders such as conduct or oppositional problems; one-fourth have some type of depression; one-fifth exhibit some type of anxiety; and one-third have a specific learning disability.

Psychosocial and medical treatments for ADHD are quite effective in relieving symptoms, but thus far have been found to contribute only minimally to overall success in life. Thus, relieving the symptoms does not necessarily mean positive long-term function. Experts increasingly recognize that multiple developmental pathways (the way a child develops in specific areas) mingle with the pathway of ADHD to determine resulting behavior and accomplishments for each person with the disability. Therefore, home, school, and community environments in which interventions for ADHD are implemented play an equal, if not more powerful, role in predicting life success than therapy or medication.

With this new understanding, treatment for ADHD and, for that matter, all childhood developmental, emotional, and behavioral problems is taking on an increasing dual role. For ADHD, interventions such as behavior management and medication are effective in reducing immediate symptoms and increasing efficient daily functioning. In addition to these treatments, however, it is critical to use another set of interventions focused on providing positive learning experiences, support, and daily successes. They must be provided for all children, but at an even higher dose for children with disorders such as ADHD.

With this new understanding comes hope. Combining treatment with interventions that build protective, supportive environments increases the odds for success for children with ADHD and, for that matter, children with any childhood disorder.

Not long ago as I addressed a group of parents someone asked, "What are the five or ten most important things you have learned about ADHD?" I decided to not limit the list to scientific facts and proven hypotheses but to also include common sense and experiential things I have learned along my professional journey. With patience and a black magic marker, I have distilled this list into the ten most important things I have learned in twenty-five years in the field of hyperactivity/ADHD. I apply these daily. They are important to me. I hope they are helpful to you.

1. Common sense rules. Common sense is a great ally. Although some phenomenon of science may not initially make sense, I have learned to start with common sense. It is a quality and a way of thinking that we share with the families with whom we work. When all else fails, I urge parents and teachers to think about a problem in a common sense way and not be burdened by what others think or what may be right or wrong. In my diagnosis and treatment protocols, in my work with residents and interns, I too attempt to apply this rule as my initial means of evaluation. ADHD as a set of human qualities exists. It does not require the large volume of studies we have generated to prove this phenomenon, to believe it. Rather it requires the willingness to consider the data from a common sense perspective.
2. Listen to caregivers (they are usually right). The most ecologically valid means of understanding a child is to live with him. As clinicians and educators, we rarely, if ever, have that luxury, except with our children. The second most valid way is to obtain a thorough history from parents or caregivers. Although these individuals may not possess our diagnostic or clinical framework for data analysis, history is our best ally for initial case formulation and the generation of diagnostic hypotheses.
3. Life is complicated. As eminent, child psychiatrist, Dr. John Werry, has said, "biology is not destiny." I would like to add, however, that it does affect probability. Thus, although biology may set and define the boundaries of each individual's playing field of life, experience and the unique ways each of us thinks are a powerful phenomenon in affecting life outcome. The work of Emmy Werner and others has very powerfully demonstrated this fact. ADHD may predispose individuals to behave in certain ways, however, it does not guarantee that they will or will not turn out in certain ways as adults. Although we learn much as scientists by comparing different groups of children, as the applied behavioral analysts remind us, each individual is unique and each individual must comprise their own experiment.
4. Symptoms of ADHD are catalytic. I believe that in and of themselves symptoms of ADHD are neither good nor bad. Their value is determined by the environment we design for our children and the expectations we hold. A large literature teaches us that children with ADHD, placed in high risk environments, fare far worse into their adult years than children with ADHD who are raised in environments providing protective factors. Although yet to be scientifically demonstrated, the corollary may also be true, that symptoms of ADHD in a uniquely nurturing environment may in fact represent an asset for specific individuals. Thus, we must help families understand that ADHD may place individuals at greater risk in certain circumstances to develop problems but they are not destined to have those problems.
5. Relieving symptoms is desirous, but it may not change long-term outcome. The majority of research and clinical practice has demonstrated that we have become particularly efficient through medical and psychosocial interventions at relieving symptoms of ADHD. However, symptom relief has not been demonstrated as synonymous with affecting long-term outcome. Not a single study has been published suggesting that if children take their Ritalin they will turn out to be better adults. Yet there are well over 500 studies suggesting that if they take their Ritalin today there is a reduced likelihood their mothers and teachers will respond to them in angry, frustrated ways. Although we choose to believe that if each day of a life is better, future life outcome will be better, we have yet to demonstrate this in populations of children with ADHD. Thus, families must be helped to understand that treatments for ADHD are directed at relieving symptoms. However, factors powerful in predicting good life outcome for all children are critically important for children at risk such as those with ADHD. Such factors include strong family attachments, good educational experiences, developing appropriate social relations and locating activities in life to experience success and develop a sense of efficacy.
6. Make life interesting. Individuals with ADHD appear to struggle most when tasks are repetitive, effortful, uninteresting and not of their choosing. Their performance improves as these variables become less of a factor. Our ability to make what appear to be mundane tasks interesting or meaningful for individuals with ADHD or for that matter, something they voluntarily choose to do, improves their daily functioning.
7. Make consequences valuable. Once again, a large body of research has demonstrated that as motivation increases problems caused by symptoms of ADHD decrease. This phenomenon has even been demonstrated with the computerized tasks currently used as part of many clinicians' ADHD evaluation. The implication of the axiom "make life interesting and payoffs valuable", suggests that we need to work harder to better match our educational system with children experiencing ADHD. Fortunately, making life interesting and payoffs valuable is beneficial for everyone. Thus, what is good for individuals with ADHD is likely good for all children.
8. Loss is a powerful motivator. We have demonstrated that reward in the absence of negative consequences is an inefficient means of modifying and shaping the behavior of children with ADHD. Response cost, that is a give and take system in which what is earned can be lost, is suggested by a modest research literature as being the most efficient means of managing any type of consequence for children and adolescents with ADHD. We have yet to demonstrate whether this pattern can be applied effectively to adults with ADHD.
9. Sometimes the solution is worse than the illness. In our efforts to support and help children with ADHD, we appear to place our hot breath on their necks significantly more than other children. This pattern results in children with ADHD frequently complying not to earn good consequences but in a negatively reinforcing model to avoid aversive consequences. A model of negative reinforcement can be applied very effectively at an elementary school level. However, by the junior high school years parents and teachers cannot offer a sufficiently omnipresent, aversive presence to make negative reinforcement work. In our efforts to help children with ADHD we may actually further shape their behavior to work only to avoid negative consequences. What appears to work well under age ten may actually be shaping children with ADHD in a way to make the adolescent and perhaps even adult years that much more difficult.
10. Love, acceptance, respect and empathy are most important. Not long ago, a late elementary school age child with ADHD and a number of other problems responded to my question about whom he would like to be for a day with "my dad." When I questioned his reason he explained, "you just have to know my dad - he loves me." An increasing body of research on children's ability to cope with adversity suggests that the emotional ties they have with parents, the quality of parental relationships, the availability of parents, their acceptance, support and ability to be proud, patient and persistent when advocating for their child are likely the best predictors of positive adult outcome for all children. This is not to suggest that parents should feel guilty if their children are struggling but rather that they understand and accept the responsibility they have for structuring their lives in ways that protect and insulate not just children with ADHD but all children.

I suspect each of you has at least four or five additional items which you have learned on your life's journey about ADHD. I urge you to take the time to generate your own list and I welcome your observations about mine.

This Fact Sheet was authored by Sam Goldstein, Ph.D. Dr. Goldstein is a member of the faculty at the University of Utah and in practice at the Neurology, Learning and Behavior Center.