Copyright ⌐ 1995 by Susan Setley. All rights reserved.
ABOUT THE BOOK:
TAMING THE DRAGONS: REAL HELP FOR REAL SCHOOL PROBLEMS by Susan Setley, M.Sp.E. (covers educational issues onlyùnot behavioral ones).
This book was written specifically for the parents of children with learning disabilities or attention deficit disorders.
The first third covers how children learn and what kinds of things interfere with learning, including heavy emphasis on the problems ADD can bring. The other two thirds cover simple, specific things parents can do with their childrenùall of them both fun and effectiveùto help them master a variety of skills including reading, spelling, math, written expression, other subjects, study skills and organzization. It will be most useful for students who perform at a kindergarten - eighth grade level.
All the suggestions have been both parent-tested and researched for educational soundness, and the publisher offers a money-back guarantee.
ABOUT THE AUTHOR:
Susan Setley, M.Sp.E., is an educator and a parent who has sat on both sides of the tableùas a teacher telling parents about their child's difficulties; as a parent listening while the specialists told her about her children's learning and attentional problems.
Mrs. Setley has taught children and adults with behavior, learning and/or attentional problems since 1970. In 1973 she earned her master's degree in special education from Southern Illinois University. Since then she's continued her education with seminars and post-graduate courses.
Mrs. Setley began work on Taming the Dragons after writing out simple instructions for the parents of her learning disabled students to use at home. Those instructions eventually evolved into the book.
Her unique background both as an educator and as a parent of children who have faced difficulties has given her a special perspective of the problems parents face as they cope with their children's learning problems. She has been married since 1978 to Frank Clark, and they have two daughters.
In addition to Taming the Dragons, Mrs. Setley's writing has appeared in newspapers and magazines. Mrs. Setley can be contacted online through America On Line¬ as SusanS29, and via the INTERNET at SusanS29@AOL.com.
You'll find instructions for ordering the book at the end of this file.
CHAPTER SEVEN
LOST IN THE CROWD: ATTENTION DEFICIT DISORDER
Opening quote:
"I tried so very hard. Don't say I didn't try hard enough. Harder never would have been enough."
Chris G., an adult diagnosed with ADD when he was 49, talking about his
school experiences
IMPORTANT NOTE TO READERS:
This book does not provide a complete overview of Attention Deficit Disorder; it emphasizes educational issues. For more complete information on ADD see the list of books at the end of the chapter.
Comments about therapeutic approaches and medications reflect the author's bias. In no way should parents substitute these views for medical guidance. Parents are urged to seek professional help if they suspect their child has a significant attentional or hyperactivity problem.
This chapter can supplement but cannot substitute for medical treatment, educational interventions, family or individual counseling, psychotherapy, or other appropriate treatment plans for the problems discussed. Parents should look to their child's physician for medical guidance, not to this book. The purpose of this chapter is to provide enough background information that parents can intelligently evaluate the educational advice offered in this book.
Carla's mother, Lucy, found this note on her pillow one day in 1981:
"Dere Mom
I love you
you ARe mY Mome
I lov you
Love
Carla"
Although the note brought a smile, Lucy sighed with discouragement. Carla was in third grade and should have been able to write much better than that. Her child had mixed upper and lower case and ignored punctuation. The content of the note was extremely simplistic. Lucy thought the note was more like what a young first-grader would write.
"Why can't Carla write any better than that?" Lucy asked Carla's resource teacher.
Carla's special teacher was baffled. Carla could write better than that, but unless prodded, would do all her work in just such a superficial and apparently careless manner. When supervised, Carla wrote longer sentences and expressed more complex thoughts. The teacher knew Carla could spell every word in the note.
In 1981 Carla's resource teacher had never heard of Attention Deficit Disorder, often shortened to ADD (see footnote 1). The problem was called "hyperactivity" then, and since Carla wasn't hyperactive the label didn't seem to suit her.
We've learned a lot about diagnosis of children with ADD (AD/HD when the child shows hyperactivity) since Carla wrote her mother that note. In 1981 ADD was under-diagnosed, especially when the clue of hyperactivity was absent. Hyperactivity was considered a behavioral problem, not an educational one; all discussion focused on behavior; and we didn't expect to see the problem in girls.
Many experts believe that ADD still goes undiagnosed quite frequently today and that the same diagnostic mistakes persist: ADD without hyperactivity, and in girls, gets overlooked. By contrast some other specialists are convinced that too many children have been diagnosed already. That view is understandable when we see claims that up to 20% of our student population has ADD. One wonders if anything found in 20% of the population can fairly be called a disorder. Some of these critics believe the whole problem of ADD is overblown out of excessive need to have students conform to rigid behavioral expectations.
Somewhere among all the views lies the truth, and most reasonable estimates suggest that between 3% and 5% of all children show the signs of ADD. This range allows for children who haven't been diagnosedùmost often girls (see footnote 2) but also boys whose attentional difficulties don't trigger behavior problems as well. ADD can cause tremendous amounts of frustration and even grief for the people who have to cope with it. The problem goes well beyond "normal variation," and if left untreated ADD can be a devastating educational problem.
The name of the disorder doesn't describe the difficulty accurately, however. A child with ADD shows too much attention. He notices too many things but often on a superficial level. His attention jumps from place to place and from idea to idea, accompanied by diminished ability to focus selectively or to sustain concentration when needed. Better titles for the problem might be Attention Focusing Disorder, Attention Fluctuation Disorder or even Attention Surplus Disorder, since these children seem to attend to everything around them instead of pulling out important features from all the surrounding clutter.
Children with ADD typically have difficulty choosing what to focus on, and they have difficulty maintaining that focus. The level of difficulty people with attention deficits experience ranges from mild to incapacitating. In addition, an individual's difficulty may vary from hour to hour, day to day, or week to week. The only thing consistent about ADD is its inconsistency.
This inconsistency leads some teachers to assume a child really can perform better than he typically does. The teacher has seen the child at his best and mistakenly believes he can deliver top performance all the time.
Many factors affect how severely an attentional problem interferes. A student with ADD will be able to concentrate better in subjects he's stronger in than subjects he's weaker in. If his mind wanders while working through his strengths he'll return to task and get re-focused more efficiently and reliably. This is true of all of us, but attentional problems magnify the tendency to the point that it stands out.
This explains how some children with attentional problems can learn the words to hit songs and yet struggle over math facts. Remembering words to songs takes place in a different area of the brain than learning math facts does, and a child really could be much better at the one function than the other.
Lack of sleep aggravates attentional difficulties for most people with ADD, as does any kind of strong emotion or stress.
Recent research on attention problems points to a biochemical disorder of the brain as its root cause.
With Attention Deficit Disorder we suspect two problems with the neurotransmitters implicated. Perhaps the person's brain doesn't produce enough of them, or maybe the levels swing wildly from adequate to low. Either problem would prevent the person's brain from functioning in a predictable, organized way.
ADD AND EDUCATION
Most children with ADD have a remarkably hard time focusing and sustaining their attention on their schoolwork. Although perhaps not hyperactive in the usual sense, they may fidget a lot, act impulsively and have a hard time controlling where their attention roams.
About 60% of children with attentional problems show hyperactivity as wellùeither by marked physical impulsivity or by talking a great deal (often not saying much of anything). With or without hyperactivity, most if not all have difficulty maintaining impulse control and with considering the consequences of actions before acting. Their impulsiveness also shows in their schoolwork, where they are likely to put down any answerùeven though they really know the right answer. They just don't stop to think first.
Students with ADD frequently show difficulty using their memory well. They don't separate out the important details from the unimportant details, and remember both equally well. The renowned specialist in childhood learning problems Dr. Mel Levine calls the tendency to remember trivial or unimportant facts "impaired forgetting." The things they should forget clutter up their minds while important facts remain unlearned.
Since these students typically focus only superficially on their work, they don't concentrate well enough to get information into permanent memory with any consistency. Many students with ADD perform poorly in subjects that rely heavily on memory skills, such as foreign languages. Often in "content area" subjects such as biology and history they will grasp the basic concepts but fail to retain names, dates, or technical terminology well.
Finally, their scattered and disorganized approach leads to forgotten textbooks, papers, assignments and other routine school expectations.
A significant number of these students have serious problems getting along with other children. Some, but not all, have behavior problems as well.
TRIGGER POINTS
Some circumstances strongly affect the school work of a child with attentional problems. These factors affect all students, but they affect children with ADD much more than they do the typical child.
The difficulty of the task for that child. The more difficult the task, the more likely he is to have trouble concentrating on it.
How well the task matches the child's emotional needs of the moment. If he urgently wants to talk with his friends, it won't take much to derail him from what he's supposed to be doing. If, on the other hand, the assigned work is a subject he enjoys, uses a method he finds engaging or involves a project that has captured his imagination, his attention may be much better.
Who's in charge. If he likes and respects the adult in charge, and if he feels he is getting positive attention from this person, he'll work harder. A positive bond with the teacher enhances a child's ability to pay attention.
How interesting he finds the task. Children with ADD are easily bored and cope quite badly with boredom. This does not mean such a child is being willful, defiant or controlling, however. If the task is not too hard for him, innate interest in the task helps him marshal his unpredictable focusing abilities to get the most out of the lesson.
Whether the setting encourages him to stay focused. In a noisy classroom where the teacher possesses few skills for maintaining control of her students a child with ADD will display many more problems than he would in an orderly, predictable classroom. We also know that children with ADD learn new, complex material better when working one-on-one or in small groups than in large group settings.
The effects of these factors vary widely from child to child and lead to the need for carefully chosen workùwork truly on his instructional level. It shouldn't be too easy, which leads to boredom, or too hard, which results in quick frustration.
No one description fits all students with attentional problems. There isn't any one way to describe children with ADD except that all have the same internal communication disorder: a brain that doesn't communicate within itself reliably, efficiently, or consistently.
DIAGNOSIS
The purpose of an educational diagnosis is to turn a child who struggles into a child who learns. Many kinds of practitioners possess the legal right to diagnose (or rule out) attentional problems in children. The difficulty parents face is that these professionals, although they all mean well, vary greatly in their skills and knowledge of the problem. Specialists who diagnose ADD or AD/HD include pediatricians, pediatric neurologists, child psychologists, child psychiatrists, and school diagnostic teams. Some diagnosticians do excellent jobs, but some aren't really up to the task. Inexperienced or inadequately trained diagnosticians frequently confuse ADD or AD/HD with other childhood problems. They may mistake ADD for some other difficulty, or they may diagnose ADD when some other, serious problem actually accounted for the child's difficulties.
The people who diagnose childhood problems take on a complex task. No one test exists that will prove with 100% confidence that your child does or does not have ADD. Inattentiveness, hyperactivity and distractibilityùthe benchmarks of ADD and AD/HDùare superficial signs of several other childhood problems as well. These problems include temporary anxiety from family upheavalùsuch as recent divorce or long-term chaotic home life.
Severe family dysfunction, such as when the parents are severely alcoholic or when the child suffers physical, psychological or sexual abuse, can mimic ADD at first look. Furthermore, significant family dysfunction of all kinds occurs more frequently when one or both parents have attentional problems. So, because ADD tends to be passed genetically from one generation to the next, many children in troubled families also have ADD. Finding serious problems within the family doesn't rule out ADD but makes it more difficult for the specialists to make a good diagnosis. In addition some medications can aggravate ADD or mimic its symptoms as a side effect, especially some medications for asthma, some cold/allergy medications and some anti-convulsants.
Another diagnostic complication has its basis in the nature of children with ADD. They behave differently in different settings. Sometimes, captivated by all the intriguing sights, sounds and smells of a medical office, they appear fully in control. They ask what the equipment is used for and engage the doctor in interesting conversation. The doctor gets the impression of a bright, curious child, not a flighty and unfocused one.
That doctor might get a wholly different impression if he ignored the child's questions, took control of the conversation and asked the child to do some math problems.
Parents' best protection from diagnosticians who aren't "up to speed" on ADD is to read everything they can get their hands on about the problem before taking their child to be tested. Then they can ask intelligent questions, and they'll be more likely to know whether they're getting accurate and detailed answers or not.
Some questions to ask might be:
How many children have ADD?
How many of the children who come to you end up diagnosed with the problem?
What ∞ do you use for diagnosis?
What else looks like ADD on the surface, and how do you make sure the child has ADD and not some other problem?
What treatments do you feel are most effective?
How would you describe your success rate?
Another problem in diagnosis turns on issues mentioned earlier in this chapter. Some diagnosticians see ADD under every rock; others think the problem quite rare. Neither view is accurate. One way to sort this problem out is to ask the examiner how many children, in his or her opinion, have ADD or AD/HD. If the examiner reports that 10% or even 20% of children have ADD, this person may have a too-strong bias toward diagnosis.
But you must also avoid bias against diagnosis as well. Whether the specialist sees ADD where it doesn't exist or overlooks the problem when it's present, it's your child who runs the risk of an inaccurate diagnosis. If the specialist says something like "3%╨5%, but we're not absolutely certain because we know some children go undiagnosed..." this person has a good perspective on how common the problem is.
DIAGNOSTIC CRITERIA FOR ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
(see footnote 3)
According to new guidelines contained in the Diagnostic and Statistical Manual (DSM-IV), the child must meet the criteria under either (1) or (2) below:
(1) Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
Inattention
(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
(b) often has difficulty sustaining attention in tasks or play activities
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
(e) often has difficulty organizing tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
(g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities
(2) Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
Hyperactivity
(a) often fidgets with hands or feet or squirms in seat
(b) often leaves seat in classroom or in other situations in which remaining seated is expected
(c) often runs about or climbs excessively in situations in which it is in appropriate (in adolescents and adults, may be limited to subjective feelings of restlessness)
(d) often has difficulty engaging in leisure activities quietly
(e) often is "on the go" or often acts as if "driven by a motor"
(f) often talks excessively
Impulsivity
(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g., butts into conversations or games)
Some of the symptoms that caused the difficulties must have been present before the age of 7 years. In addition the impairment must be observed in more than one setting, such as home and school. There must also be clear evidence that the child is actually impaired significantly either socially or academically (in people old enough to hold a job impairment at work would be considered significant as well). Finally, for a valid diagnosis of Attention Deficit Disorder the difficulties cannot be caused exclusively by a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The person's difficulties can't be explained better by some other mental disorder, such as Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder.
GETTING TO YES OR NO
In Chapter Five we saw that diagnosis is the process of confirming some hunches while ruling out others. This is as true of ADD as it is for learning disabilities. Just as we do when looking for learning disabilities, we gather information from a variety of sources. Teachers and parents fill out questionnaires about the child's behavior and characteristics. A physician rules out medical causes for the child's difficulties, such as seizure disorders, side-effects of other medication the child has to take, or other physical conditions that can affect attention span.
The examiner interviews child and parents, and a really good evaluation includes observations of the child in school. Individual testing determines overall intellectual potential and detects any other learning problems that might be present. Other specialists may be called in if needed. The author prefers to see the child's learning style as well as attentional abilities explored. Diagnosis is made by combining information from all these sources.
MYTHS ABOUT ADD
Diagnostic myths:
Myth: Your child's teacher can tell if he has ADD or not.
Reality: Teachers spot struggling children very well. They aren't as good at judging what the cause of the problem is. For this reason, teachers should not advise parents to place their child on medication. However, encouraging them to seek an evaluation is entirely appropriate.
Myth: Your pediatrician is always the best person to determine whether your child has ADD or not.
Reality: Some pediatricians have made a point to learn all they can about ADD, but others have not. If you follow the advice given earlier to educate yourself about ADD, you'll be in a better position to judge what your child's doctor knows about it. ADD is more than a medical problem and often brings educational and social problems with it as well. The doctor may be able to treat ADD medically, but you will probably need help and guidance from other specialists.
Myth: Highly intelligent children cannot have ADD.
Reality: Attentional problems have nothing to do with a person's intelligence. Extremely bright childrenùeven those we might call true geniusesùcan have severe attentional problems. Retarded children can have ADD as well, although their difficulties have to be compared to their mental age and not their chronological age.
Myths parents often believe:
Myth: This child can't have ADD. He can concentrate for 30 minutes at a timeùor moreùwhen he wants to. He watches TV for hours if we let him.
Reality: Many people believe that if a child has attentional problems it means he can never concentrate. A child's ability to sustain his focus depends on several things, including how interesting he finds the task and whether it taps into his strengths.
TV-watching makes a particularly poor indicator of attention span. The content of a TV show changes every few seconds and sometimes even faster. In addition, all we really know is that the child's body is pointed at the TV. We don't know what's going on in his mind.
Myth: He doesn't have ADD. He's just spontaneous (bright, imaginative, creative...).
Reality: Children with ADD are typically described as bright, imaginative, spontaneous or creative. In fact, ADD may enhance those characteristics. However, there's an important difference between "spontaneous" and "impulsive." When we say "impulsive" we mean the person shows diminished ability to act in a planned and controlled way. Impulsive people have lessened control over their spontaneity.
Myth: A lot of so-called ADD is nothing more than a clash of personalities between child and teacher. Put him with a different (or better) teacher and his problems will evaporate.
Reality: Matching the personality of the child to the teacher may help tremendously, but it won't make true ADD go away.
School-related myths:
Myth: He's just lazy. He could do it if he tried.
Reality: Children innately want to learn. If a child doesn't learn, or doesn't learn as well as he should be able to, there has to be a reason, and we owe it to the child to find out what that reason is. Calling a child names ("lazy," "unmotivated," "underachiever") solves nothing and stops the search for a real explanation of his difficulties.
Myth: He can't have ADD. He isn't hyperactive. He's not a behavior problem.
Reality: Not all children with ADD are hyperactive; not all show behavior problems; and those without hyperactivity can still have quite serious educational and social problems. Those problems must be dealt with if the child is to grow up healthy and whole.
Myths about outcome:
Myth: ADD never goes away.
Reality: About 20% - 35% of all children with ADD will either outgrow it after puberty or see their symptoms lessen so much that it's not much of a problem for them anymore. Some people with ADD, however, don't get diagnosed until middle/junior high, senior high, or college, and some struggle through school but are diagnosed during adulthood.
Myth: ADD is all bad.
Reality: People with attentional problems show some remarkable strengths that non-ADD people often don't have. They may include:
╨ a refreshingly new view of the world;
╨ the ability to make connections between facts or events that non-ADD people might have overlooked;
╨ an ability to focus on the present without worrying too much about the past or the future (a tremendous asset in a sales career);
╨ the ability to make the person they are talking to feel like the only other important person in the world.
When adults with ADD learn to capitalize on their strengths and compensate for their weaknesses they can make the ADD work for them instead of against them.
TREATMENT
The goal of treatment is to increase the child's level of success in all things important to him: learning, behavior, socialization, and development of recreational skills. The interventions most likely to meet this goal are medication combined with these others as necessary: behavior modification, individual and/or family counseling, group counseling, educational support, and training the parents in behavior management skills. Not every child will need every kind of help.
MEDICATION
We've listed medication first because so many children with ADD benefit from its intelligent and careful use. The other interventions mentioned all work better when combined with medication.
WHAT DOES MEDICATION DO?
Drugs used to treat ADD act at the chemical level in the brain. Evidence strongly suggests that low or fluctuating levels of neuro-transmitters are at the heart of ADD, (see footnote 4) and medications partly correct this problem. Increased levels of neuro-transmitters (and we know of no way to do this except with medication) allow people with ADD to focus their attention better on one thing rather than jumping from thing to thing to thing to thing. A favorite story among parents of children with ADD is that they think like this: "Ready... fire!!! OOPS!--Aim!" Medication increases the likelihood that they will "aim"ùthat is, thinkùfirst, before "firing" off an answer or an action.
What medication for ADD actually does is improve communication between nerve cells within the child's brain, allowing the child to distinguish the important features of what he is doing and hold his focus on them.
WHY ARE SOME PEOPLE SO OPPOSED TO MEDICATION?
There are several reasons. First, for many years medication, particularly Ritalin, was presented erroneously as a "magic bullet," a total cure. Some schools got extremely aggressive with parents, sometimes pushing hard for a child to take medication even when no diagnosis had been made.(see footnote 5)
This situation was aggravated when a prominent newspaper got its facts wrong and reported that up to 10% of all students in one community took medication "to control their behavior." Actually the school had said that 10% of their students had learning disabilities. The school wasn't even talking about either hyperactivity (as it was called then) or medication.
One special interest group in particular latched on to this report and began a campaign of disinformation. They succeeded because the diagnostic process for ADD hadn't been refined to the level it is at today, and Ritalin was used inappropriately sometimes. The media was already full of suggestions that Ritalin was being over-used. It has been remarkably easy for this special-interest group to keep the disinformation going to suit their own purposes.
It's crucial for parents to check the sources of information they read, especially when the claims are alarmist in nature. It's fairly easy to spot inaccurate but scary claims: through distortions and outright fabrications the reports grossly exaggerate the occasional mild side effects, especially targeting Ritalin. Almost always these wild claims include the wholly erroneous notion that medications used for ADD somehow "drug the child into submission" (the words used to say it may vary) and that the children will be more likely to experiment with drugs later. Neither claim has any merit.
WHY DO SO MANY PEOPLE SEEM TO BELIEVE THESE INACCURATE CLAIMS?
Two reasons. First, doctors invite criticism any time they recommend medication casually or in the absence of the other interventions so often necessary.
Second, the most commonly used medicationùRitalinùworks quickly and leaves the child's body quickly. Often doctors prescribe it during the school day only, with the result that the parents don't observe their child while the medication is active.
Parents should ask the doctor to let the child take it during a couple of weekends if their child takes medication only during school hours. That way they can see exactly how the medication does and does not affect their child. A parent's best protection against overlooking other equally necessary therapies and relying too heavily on medication is to get a multidisciplinary evaluation, one involving doctor, child psychologist, learning specialist and others.
We've mentioned Ritalin (methylphenidate). Although highly effective for many children, other medications also help achieve the goal of a child more able to control himself. They include Dexedrine (dextroamphetamine), Cylert (pemoline), some antidepressants, such as forms of desipramine, and even some medications originally designed to treat high blood pressure, such as Catapress (Clonidine).
Sometimes a variety of medications must be tried before the right one is found for any one individual, and occasionally a combination is used.
Once in a while doctors prescribe a "double-blind" study (see footnote 6) to make absolutely certain the medication is working as everyone thinks it is. In a double-blind study, the child takes capsules for four weeks. For two of those weeks he actually takes the medication, but for the other two weeks he takes a placebo, or fake pill with no medication in it. Only the pharmacist knows which weeks the child is really taking medication. Then the doctor compares behavior reports from home and school to see if the reported improvements, if any, occurred when the child was actually getting the medication. This may be a good option for parents who have reservations about medication and want to be certain it's really helping.
COMMON QUESTIONS
WHAT CAN MEDICATION DO FOR MY CHILD?
Enable him to benefit more from other interventions, such as academic support and behavior modification;
enable him to stay on task more;
decrease purposeless physical activity (what we call "hyperactivity");
enhance his ability to get along with classmates and teachers (and family, if he takes it at home as well);
increase his tendency to cooperate with others;
decrease tendencies toward aggressive behavior (unless the aggression was purposeful, not impulsive);
may enhance academic performance, but that will depend on what else interferes with learning.
These improvements may not be immediate, and they aren't guaranteed. They happen often enough to make medication a powerful tool in the management of ADD.
WHAT CAN'T MEDICATION DO BY ITSELF?
By itself, fix any accompanying learning problems;
guarantee long-term academic success;
solve all behavior problems;
olve all social problems.
Medication increases the odds that the additional methods used to solve those problems will be successful, however.
Medication myths
Myth: Medication is given for the convenience of parents or teachers.
Reality: Although parents and teachers may benefit from a child who is easier to deal with, that happens because the child functions better. The real benefit, and the important one, is to the child.
Myth: Medication "drugs children into submission."
Reality: Medications for ADD, with rare exceptions, stimulate. They don't sedate, and they don't mask symptoms. They can't force a child to meet someone's arbitrary behavior standards. Medications that help ADD allow the child to make better choices about his actions.
Myth: Medication makes the child more "manageable," but does not address the cause of the problem.
Reality: The cause of the problem does seem to be decreased brain activity (see footnote 7), so increasing brain activity with medication works directly at the cause of the problem.
Myth: Ritalin is prescribed casually.
Reality: This was a valid criticism twenty years ago and may still be valid in some isolated areas. Parents should not accept a prescription to treat ADD unless they're convinced the child has the problem. When that is the case, medication is not being prescribed casually. The parents' best protection against frivolous drug therapy is to get the best evaluation for their child they can find.
Myth: Ritalin is dangerous because it is highly addictive.
Reality: The author did extensive research prepared to accept any findings. She didn't find a single case of youth with ADD addicted to Ritalin. The concern is theoretical. In reality Ritalin isn't prescribed in addictive doses.
Myth: Medication can make attentional problems go away.
Reality: Medication often eases symptoms but rarely eliminates them.
Myth: Medication always works.
Reality: Ritalin helps about 70 - 85% of the children with ADD. For the remaining children, other medications can be tried, but there is a small group of children who do seem to have ADD but for whom the doctor can find no suitable and effective medication.
Myth: Ritalin is always the medication to use.
Reality: Some children should not take Ritalin for medical reasons. If your child has some secondary difficulty, such as anxiety or depression, your doctor may choose a different medication. Your doctor may also choose a different medication for reasons not listed here. If you don't understand your doctor's recommendations, ask questions.
Myth: Stimulant medication works differently in children with ADD than in other children.
Reality: This is the so-called "paradoxical effect." People noticed that stimulants appeared to calm over-active children, the opposite of what stimulants were supposed to do. They reasoned that stimulants must work in these children in some unusual, or paradoxical, way.
We now know Ritalin affects all people in the same way, whether young or old, with or without ADD. We see the dramatic improvement in children with ADD because there's so much space for improvement. Some children with ADD reveal the disorganization in their brain by disorganized, impulsive and purposeless movements, which we see as "hyperactivity." Improved brain function translates into more organized movement.
Myth: Good alternatives to medication exist but are not commonly known for some reason.
Reality: Everyone would love to find an alternative to medication, but research presently doesn't support most non-traditional therapies. The things we know helpùlearning compensating strategies, academic support, counseling to aid specific difficulties (not to counsel the ADD away), and behavior modificationùall work better when combined with the skilled use of medication.
Drug therapy may require many adjustments in both medication and dosage. Your child is an individual unlike any other child on Earth with or without attentional problems. ADD traits show themselves within the personality of the child and the world (home and school) he lives in. Just as each child is unique, each solution will be unique as well. Attention-focusing problems have a strong medical component. Medication can be an important part of the overall plan but cannot and should not be viewed as the whole solution, and will not be suitable for all children with ADD.
WHAT ELSE WORKS?
BEHAVIOR MODIFICATION
Behavior modification is a collection of techniques used to increase desired behaviors and decrease undesired behaviors. It works on the principle that if we're rewarded for doing something we're more likely to do it again, and if we're not rewarded for doing something we're less likely to do it again. Although that sounds simple, designing a behavior modification program that works for your child can be a complicated matter.
To keep a behavior modification system going requires a considerable investment of time by the parents. To use it effectively, everyone involved with the child must agree to focus on one or two target behaviors. The rewards should be ones chosen by the child, not just things the adults assume the child will welcome. It's best to involve the child when planning the behavior modification. That way he is less likely to feel "bossed around."
Well done, behavior modification can, and often does, improve a child's ability to get along in the world. Badly done it can, and often does, blow up in the parent's or teacher's face.
The most common mistake made with behavior modification is that people end it too soon. The temptation is to stop the program before the child has internalized the behavior changesùthat is, has made it a part of his personality so completely that rewards are no longer necessary. In addition, the parents must respond to inappropriate behavior in a truly neutral way, because positive and neutral responses work much better than negative or punishing ones. One of the toughest things for parents to learn how to do is how to remain neutral in the face of repeated provocative behavior by their child.
Sometimes the behavior improvements wear off rapidly in spite of the most careful efforts, and some children don't seem to respond well to behavior modification no matter how skillfully it is used.
In spite of this, behavior modification can be a powerful tool, especially when part of an overall treatment plan. Because it is such a complex technique, most parents will be better off to use it under the guidance of a therapist or counselor. That way, when they have difficulties with the techniqueùand they willùthey'll be able to call someone for advice. All behavior modification systems have to be fine-tuned occasionally to keep them working well.
Those opposed to use of medication often trot out behavior modification as an example of an easily-used alternative. In reality behavior modification by itself is unlikely to solve all the problems that come with ADD. The only effective way to use behavior modification is to target one or two behaviors at a time. While the parents might be able to keep such a long-term plan in mind, it might not be best for the child, who might need more rapid help than that.
For excellent descriptions of behavior modification, see the bibliography at the end of the chapter.
ACADEMIC SUPPORT
Many children with ADD struggle with one or more school subjects. By the time they are diagnosed they may be seriously behind. Or, they may fall behind later on. As they advance through school and expectations increase, most have considerable difficulty keeping homework, textbooks, materials and assignments organized. Parents should monitor their child's school progress carefully and be ready to step in sooner rather than later. Sometimes the only help needed is an occasional tutor, but any child who has difficulty with schoolwork because of ADD is entitled to support and help to convert frustration into success. For a list of interventions known to work with attention-deficient children, see the Chapter Seven Appendix starting on page 227.
Forty percent or more of all children with ADD also have learning disabilities. If your child struggles with his schoolwork, get him an educational evaluation (see Chapter Five).
FAMILY COUNSELING
Raising a child with ADD requires turbo-charged parenting skills, so many families find short-term family counseling invaluable. The parents learn it's not their fault their child has this problem. They master specialized techniques for dealing with what can be a difficult child, and they have an expert they can call on for advice when new problems emerge. The brothers and sisters of children with problems often harbor resentment and frustration, and family counseling can get these feelings out into the open where they can be dealt with.
Short-term family counseling can provide new tools to solve many problems. When your child is grown, you'll know you did everything you could to help him cope with the problem. Don't be afraid to try several therapists until you find one you're all comfortable with.
INDIVIDUAL AND GROUP COUNSELING
Traditional psychotherapy concentrates on working through the presumed underlying psychological causes of problems. Since ADD has a biochemical cause, talk therapy won't make the ADD go away. However, a therapist who understands ADD can help a child cope with numerous frustrations or secondary problems. Psychological support can also help the child understand himself and accept his weaknesses while recognizing and taking pride in his strengths. Group therapy targeted at social skills often helps children who have difficulty making and keeping friends.
Researchers make remarkable discoveries every day that affect the treatment of children with ADD. By the time most books (including this one) have gone to print, some of their information will be out of date. Specifically, the areas of diagnosis, drug therapy and other effective treatments continue to be researched aggressively. However, it can be difficult to get accurate and up-to-date information.
Parents need to know: except for people doing scientific research, people write because they hold an opinion. Whether you read it in a book or magazine the possibility of bias exists. The first thing publishers (book or magazine) want to know from an author is "What's your slant?" Newspapers try to avoid bias but because of their short deadlines, don't always get all their facts right, and frequently cover issues incompletely.
The way to handle this dilemma is to read everything you can find, but always remain alert for potential bias. Was the publication put out by a drug company? If so, was their purpose to promote the use of their medication, or conversely, to protect themselves from liability? Either slant will affect the contents profoundly. If it's a magazine article, examine the magazine. Does it have a clear bias? Many magazines do. If you're reading the newspaper, consider the source the paper got its information from. Think about whether the article really covered the issue in depth or not.
Ask your child's doctor to do a search of the medical literature once a year for any new information, but allow your doctor to interpret the results. Details such as the number of participants in a study and how they were selected can have tremendous effect on whether decisions should be based on the results or not.
But most of all, take to heart Elizabeth Weiss' statement when she says to "...hold in suspicion the idea that all children must excel in the same way."(see footnote 8) Help your child find his strengths, and then rejoice in them with him. There's no such thing as a child without strengths.
FOOTNOTES:
1) ADD is also called AD/HD (Attention Deficit/Hyperactivity Disorder).
Occasionally we see ADDH used. Experts have used many labels over the years, and in all likelihood the name used by experts will change again. Readers should realize that the traits and difficulties discussed are also common in children diagnosed as "hyperactive." The author will use Attention Deficit Disorder, shortened to ADD, throughout the book, because it's the attentional problems that interfere with learning.
For a selected list of books talking about the behavior difficulties of students with ADD or AD/HD, see the end of the chapter.
2) Bain, Lisa J. A Parent's Guide to Attention Deficit Disorders. 1991, Doubleday Dell, p. 48.
3) American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, pp. 89-90. American Psychiatric Association, Washington, D.C., 1994.
4) For detailed information about current thought on the biology of ADD, see Hallowell and Ratey's book listed at the end of the chapter.
5) Teachers should not recommend medication. They also should avoid discouraging its use when it's needed (although as trained observers of children they should report any problems they observe to the child's parents and doctor). Educators do not have the background needed to evaluate medical treatment.
6) Double-blind studies don't work with all medications, only fast-acting ones such as Ritalin. Other medications, such as Cylert and Tofranil, build up effectiveness in the child's body over time. Double-blind studies won't work well with those medications.
7) Zametkin, A. J. et al., "Cerebral Glucose Metabolism in Adults with Hyperactivity of Childhood Onset," New England Journal of Medicine,323 (1990): 1361╨66.
8) Weiss, Elizabeth. Mothers Talk About Learning Disabilities: Personal Feelings, Practical Advice. 1989, Prentice-Hall.
For further reading:
Bain, Lisa J. A Parent's Guide to Attention Deficit Disorder. 1991, Bantam Doubleday Dell Publishing Group, Inc.
See this book in particular for an excellent explanation of behavior modification and other support therapies for ADD.
Fowler, Mary, in collaboration with others. CH.A.D.D. Educators Manual: An In-Depth Look at Attention Deficit Disorders from an Educational Perspective. 1992, CH.A.D.D: 499 N.W. 70th Ave., Plantation, FL 33317.
This booklet explains everything youùand your child's schoolùneed to know about the educational needs and rights of children with ADD. Buy two copies of this manual. Read yours carefully, and then make a gift of the second one for your child's teacher.
Garber, Stephen, Marianne Garber, and Robin Spizman. If Your Child is Hyperactive, Inattentive, Impulsive, Distractible... . 1990, Villard.
This book may be out of print by the time Taming the Dragons has gone to press. However, its excellence makes it worth the trouble to find it at a library if bookstores no longer carry it.
Hallowell, Edward M., M.D. and John J. Ratey, M.D. Driven to Distraction:
Recognizing and Coping with Attention Deficit Disorder from Childhood through Adulthood. 1994, Pantheon. ISBN: 0-679-42177-7.
Driven to Distraction provides a broad and detailed discussion of ADD and may give parents some insight into the question they're sometimes afraid to ask:
"What about when he's grown?" We strongly recommend this book.
Hartman, Thom. Attention Deficit Disorder: A Different Perception. (This book is known informally as the "hunter in a farmer's world" book.) Publisher:
Mythical Intelligence, Inc., distributed by Publishers Group West. ISBN:
0-88733-156-4.
Hartmann wrote and published this book himself because of the depth of his convictions. Hartmann explains the strengths adults with ADD may possess particularly well.
Ingersoll, Barbara. Your Hyperactive Child. 1991, Doubleday.
This book provides an excellent overview of attentional problems in childhood and a particularly good explanation of the strengths and weaknesses of behavior modification.
Ingersoll, Barbara, and Sam Goldstein. Attention Deficit Disorder and Learning Disabilities: Realities, Myths and Controversial Treatments. 1993, Doubleday. ISBN 0-385-46931-4.
We recommend that any parent read this book before considering a nontraditional treatment for either attentional or learning problems.
Organizations
ADDA
(Attention Deficit Disorder Association)
P.O. Box 972
Mentor, OH 44061
800-487-2282
CH.A.D.D.
(Children and Adults with Attention Deficit Disorders)
499 NW 70th Avenue, Suite 308
Plantation, FL 33317
305-587-3700
Fax: 305-587-4599
Newsletters
ADD-ONS: A Paper "Support Group" for Those Living with ADD.
ADD-ONS, Ltd.
P.O. Box 675
Frankfurt, IL 60423
CH.A.D.D.ER
CH.A.D.D.
499 NW 70th Avenue, Suite 308
Plantation, FL 33317
305-587-3700
(This newsletter is included with membership in CH.A.D.D.)
* * * * * * * * * *
CHAPTER 7 APPENDIX
THINGS THAT HELP CHILDREN WITH ADD COPE IN THE CLASSROOM
(Note: this doesn't mean your child is entitled to all of these modifications. It might not even be a good idea. What you want to do is to give your child enough help that he can grow but not so much that growth is stifled. Be prepared; you and the classroom teacher may disagree often on just that issue.)
LOW-LEVEL INTERVENTIONS:
Use untimed tests (including standardized tests). One easy way to do this is to allow the child to start the test before school.
Provide preferential seating (near the front, away from distractions such as classroom pets, aquariums and open doors).
Provide testing in a quiet place.
Allow breaks during testing.
Allow the child to begin an assignment (say, do the first three problems in math) and then come to the teacher for confirmation that he's doing it right and to get a pat on the back.
Allow the child to repeat directions back to the teacher.
Set up a non-verbal "return to task, please" signalùcatching his eye, touching him on the shoulder, etc.
Allow the child to time how long it takes him to complete each segment of an assignment and write it down on the paper (watch out for impulsive answers just to improve his time).
Give any needed reprimands in private.
Actively seek opportunities to praise the child (the teacher can keep a 3 x 5 card taped to her desk as a reminder, and put a check mark for each positive comment). Children with ADD can't hear too much appropriate praise. If you doubt that, think of all the times they hear criticism.
Allow the child to review directions with the teacher before he begins.
Provide an extra set of textbooks to be kept permanently at home.
Encourage the child to tape-record lectures to provide another method for review.
Provide the amount of support and structure the child needs to succeed, not the amount of support and structure traditional for that grade level or that classroom.
Allow adequate time for students to answer questions to allow the student to form a thoughtful answer.
Have a study carrel in the room that students can choose to use if they feel particularly distracted.
Provide a few minutes at the end of the day for students to get their homework materials together (discourage visiting and other distractions during this time).
Write assignments on the board as they are given.
Make sure the duplicated materials are clear, dark and easy to read.
MORE SUPPORTIVE INTERVENTIONS:
Encourage use of a note-taker (done simply by providing a good note-taker with carbonized paper. The student with ADD should take notes as well to the best of his ability.)
Divide assignments into three or four segments and allow the child to check in with the teacher after each segment is completed.
Allow use of a calculator to check accuracy of math completed with pencil and paper.
PROVIDE SUPPORT WHILE ENCOURAGING GROWTH WITH THESE STRATEGIES:
For children with strong computer skills, encourage use of word processing programs for all writing assignments.
Encourage use of computer spell-checkers, thesaurus and grammar checkers.
Allow a reduced course load.
Provide extended time to complete courses of study.
Provide photocopies of overlays, lecture notes, etc.
For children who work slowly, reduce the size of required assignments.
Invite an older student to come in and help the child get organized for the day (work this out with another teacher in the building who has a student needing a self-esteem builder). This will require some supervision and coaching at first. The child with ADD should have the same helper every day.
Encourage "study buddies." The child with ADD checks with his study buddy to make sure he has assignments written down correctly, is taking home everything he needs, etc.
When you give several assignments or multiple-step instructions, allow the child to write them down. Then provide him with a written list so he can double-check what you said.
Allow the use of a calculator to get math facts not yet memorized.
As you talk, write key words on the board to aid in note-taking.
Help students with ADD plan how they will break larger assignments into smaller, more manageable tasks. They should create a checklist to keep track of their progress on the project.
STRONG INTERVENTIONS; SHOULD BE USED ONLY WHEN OTHER METHODS HAVE FAILED:
Use modified test formats (such as multiple-choice instead of essay). The older the child, the more potential this intervention this has to hold your child back. It's more serious when a tenth grader can't write an essay answer than when a third grader can't.
Waive any foreign language requirement.
Allow use of a calculator for all math under all circumstances.
RECOMMEND THESE BOOKS TO YOUR CHILD'S SCHOOL:
CH.A.D.D. Educator's Manual. CH.A.D.D., 499 NW 70th Ave., Suite 109, Plantation, FL 33317. $10.00 plus shipping/handling.
Hawthorne Educational Services Inc. The Attention Deficit Disorders Intervention Manual. For information, call 314-874-1710. For orders only, call 1-800-542-1673.
Rief, Sandra F. How to Reach and Teach ADD/ADHD Children: Practical Techniques, Strategies, and interventions for Helping Children with Attention Problems and Hyperactivity. 1993, The Center for Applied Research in Education. ISBN: 0-87628-413-6.
How to order TAMING THE DRAGONS: REAL HELP FOR REAL SCHOOL PROBLEMS by Susan Setley, M.Sp. E:
Publisher:
Starfish Publishing Company
6510 Page Avenue, Suite 103
St. Louis, MO 63133
(314) 725-0054
Your local bookstore can also order it for you through Baker & Taylor, a major book distributor. The retail price of the book is $23.
