Attention-Deficit / Hyperactivity Disorder

(A question from a listener:)

 I run a children's theater group. One day, four sets of parents advised me that their kids had ADHD  (Attention Deficit/ Hyperactivity Disorder). I noticed that some of these "wild kids" were able to stay in control when they wanted to.  I sat the children down and asked them what would be acceptable  behavior for rehearsals. The children came up with the following:

  1. They need to show up for every rehearsal…….on time.
  2. There is to be no disruptive behavior during the rehearsal.
  3. The focus is on working together, not trying to undermine one another.

I wrote these points down in a contract. Each child's signature on the contract meant that he or she understood and would adhere to the rules. Three violations of the contract and they were out of the play. If they kept the conditions of the contract, they were welcome to stay. If they chose not to keep to these rules, they would have chosen not to stay. They opted to sign the contract and I have  had no problems with these ADHD kids! Is there anything to ADHD?

Answer: Come back with me to my son's birthday party. He was about 7 years old. He invited several buddies to sleep over. All would have gone smoothly, except for Joey. Joey could not sit still for one minute. He saw a couch and full speed ahead, dashed towards the cushions and somehow landed on the backside of the couch – multiple times. He raced around rooms touching whatever he pleased at lightening speed. While my son's focus was on his party, my focus was on Joey. He was fidgety, he was excessively noisy; he looked as though he were driven by a jet engine. He would interrupt me. I tried the time out technique; it served only as a temporary commercial break from his high-speed activity.  I pitied his mom.  But that night, I pitied me! His mother came over the next morning (after my husband and I had a frantic night monitoring Joey) and said,  "I hope he wasn't much trouble. I forgot to give him his  Ritalin. I didn't want to drive back."  I was ready to lambaste her!  How dare she know how disruptive he is and not bring his medicine back.  After this experience and after experience  with young children in therapy, I think there is some merit to the ADHD diagnosis.

ADHD has gone through several name changes including "minimal brain dysfunction" and "hyperkinetic reaction of childhood".  The current name, Attention-Deficit/Hyperactivity Disorder, denotes a developmental disorder with several of the following symptoms for at least 6 months in a  manner that is developmentally inconsistent and maladaptive:

Inattention symptoms:

  • fails to attend to details
  • has difficulty sustaining attention in  tasks or play activities
  • doesn't listen when spoken to
  • has difficulty organizing activities
  • has difficulty following instructions (e.g., chores, homework)
  • is easily distracted
  • is often forgetful

Hyperactivity – Impulsivity symptoms:

  • fidgets, squirms, leaves seat in classroom  when expected to sit still
  • restlessly runs about or climbs excessively
  • has difficulty engaging in quiet play
  • acts as if driven by a motor
  • talks excessively
  • blurts out answers before questions have been completed
  • has difficulty awaiting his turn
  • interrupts or intrudes on others

(Source: DSM-IVTM)

One doctor commented that some of these symptoms describe Tom Sawyer and Huck Finn. So is there any merit to this diagnosis? Here is the problem. One cause of such behavior may be biological.   "My sister is impulsive and uncontrollable…she never listens. Ritalin is a lifesaver. She's wonderful company when she's medicated. Her uncontrollable behavior does not seem intentional. It seems like a biological mishap."

Another cause of such behavior may be psychological. I worked with many seriously abused and traumatized children. I observed that several of the most "ADHD" looking children had major sexual abuse or traumatic experiences in their backgrounds. Such children would ricochet off my office walls.  Over time, as they disclosed the abuse, their behavior became less impulsive and less agitated; their ability to focus improved.  Someone had heard them; someone had understood them and  would help them. They no longer had to silently struggle with the abuse. Why did such children have difficulty focusing in school? When asked, many said that they were so worried about going home at night that they would spend their time at school thinking up ways to avoid the anticipated physical or sexual abuse.  Most of their mental focus was siphoned off to survival tactics rather than to the less important material, math or spelling.

Another cause of ADHD behavior may relate to less life-threatening family issues. Sometimes children are trying to cope with their parents'  marital tension, or their father's drinking, or their mother's rageful reactions, or their parent's pushy behavior. Children may be rebelling against their parents' irrational, controlling or neglectful  style. Their level of restlessness and hyperactivity may be the way they express their anxiety and frustration with family problems.  It may be a cry for help.  Their parents may be unwilling to face the family problems openly. They might resort to scapegoating a child. For example, when there is hidden marital conflict and one child speaks out bluntly, naming the issue, the parents might label such a child as "the problem". Since the parents refuse to face their own conflict, they prefer to blame a child for family troubles. They have a vested interest in giving the child a label (such as ADHD) to  whitewash themselves and to shift the blame to the "problem child".

 I have had parents bring a child into therapy and tell me "He (or she) is the problem in the family. If  only he would obey us and never question us, we would have a lovely family. But he never obeys. We punish him firmly too.  He is the whole problem in our family. Get him to listen and obey us. That's  all I want."
     What's your gut reaction to such a parent? It makes me feel as though they are hiring me to teach their son or daughter boot-camp etiquette. My gut reaction is  that I want to learn a lot more about the family. I encourage family therapy and I try to give the parents better parenting skills.

Another cause for ADHD type behavior may be boredom. If you force a child to spend day after day in a classroom with a dull, boring teacher, he may be "driven to distraction".  I recall sitting with my husband and a physician at a lecture that  was approximately 75 minutes long. The lecture was the most painfully boring lecture I have ever attended. I was trapped. We sat front row center so there was no escape. I felt very fidgety and anxious. When we were finally released from the prison of excruciating boredom, all three of us went outdoors and had the same reaction – we were jumping up and down, giddy, hysterically laughing and looking rather revved up.  ADHD behavior? To onlookers it could certainly look that way. Imagine being a bright, ambitious and energetic student and having to sit day in and day out for a full year with a boring teacher.  If you suspect your child is ADHD, unobtrusively find out what his days at school are like. Volunteer at the school for an event, or for a class field trip. Listen to what your child's friends  or their parents say about the teacher.

How can you tell whether your son's or daughter's problem is biological or psychological or some combo of the two? The answer given most frequently is "we don't know".  We know that the mind can affect the body (e.g., we can consciously decide to relax). We know that the body can affect the mind (e.g., my mental clarity is dimmed when I  have the flu).  We don't even know whether ADHD is a single condition, a broad range of problems or a misdiagnosis of a bright, spirited, energetic kid; it's an ill-defined diagnosis.

So with the ADHD diagnosis, buyer beware!  If you have a child who has been labeled ADHD, run through some checkpoints:

  1. Is your child disruptive in all situations or only in a specific situation (home, school)?
  2. Is your child disruptive with all people or only with particular individuals?
  3. Are there marital or other family issues that could be  causing distress in your child?
  4. Does your child have the capacity to focus well in some activities (e.g., video games, softball) but not in others (e.g., school)? If so, what might account for this  difference?
  5. Is your child's schoolwork motivating, challenging, creative and bringing out the best in him?
  6. Do you have the sense that your child's behavior is not a "cry for help" for wider  family problems but truly beyond your child's control? If so, medication may be the best cure. Structured interventions to help your child focus and attend better may be in order. One book that offers some advice to teachers is Attention without Tension by Edna Copeland and Valerie Love.

You may be lucky and discover that your child doesn't have ADHD.  He just needs a more stimulating teacher.  Or you may realize that it's to your benefit and to the whole family's benefit to address other pressing but previously ignored areas of family dysfunction. It's very anxiety-provoking for a  child to hold in family secrets. If you know this to be the case, do yourself a favor and get the whole family in to see a good family therapist. In any case, beware of the recent trend to give the ADHD  diagnosis too freely.

Many parents lapse into focusing on the functional aspects of childrearing (e.g., clean clothes, clean room, meals). My mom was terrific. She was a fabulous listener. I would tell her all about my day and she was my friend, not my critical judge. To become a close friend with your child is a once-in-a-lifetime opportunity. What are his strengths?  Let him  know that you notice them.  Enjoy special time with your child. Ask him to tell you about school. What does your child enjoy at school? What does he dislike? Are there any problems – with kids? With teachers?  What feels fair? What feels unfair? What suggestions does he have to improve things? What does your child enjoy at home? What works well? What feels unfair? What would he suggest to solve the problem?

This is the method that the questioner used with her four ADHD theater students. These students identified rules of conduct that would be reasonably  expected of them as a basis for participation in the play. They voluntarily agreed to adhere to these conditions, and they succeeded.  The questioner had a wonderful directing experience in what might have otherwise been a disaster.

And remember to always medicate your ADHD kids before dropping them off at a pajama sleepover birthday party.