It's Nobody's Fault

by Harold Koplewicz

  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: 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 associated 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 class, 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), who must be encouraged to take part in the events around them and learn how to do more in the way of socializing, kids with ADHD have to learn to do 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.

  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 butter 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 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 w
ork 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 class have a question about the homework assignment, they always call Kelly. “Everybody knows that Kelly is the most organized child in her class,” 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 puberty, 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 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 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. Classmates 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 class 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 class 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 class, 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 tr
eated 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 repetitive actions, things he did on a regular basis. He also tied his shoelaces repeatedly, checked his eyeglasses 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.