The article that was featured in the English Update two weeks ago titled, “The Silent Struggle − Adult women with ADD” generated a lot of interest and feedback. Judging by the phone calls and emails that I received, many people read the article and identified with the struggles depicted, or felt that one of their children may be suffering from ADD/ADHD and wanted to know what the next step is. This piece will outline some ideas about how to get a proper diagnosis and build a comprehensive treatment plan that can help adults or children
The process of getting a diagnosis differs depending on the age of the individual. For the sake of clarity I have divided this section according to age groups.
Children up to age 6
It is highly unusual for a child to be diagnosed with ADD before entering grade school. Preschoolers may show signs of inattentiveness, poor concentration and high activity level, which may need some attention, yet often children this young will respond well to small classrooms or playgroups, outdoor activities, and healthy diet. If, as parents, you feel that the behavior is outside the norm for that age range, consult a professional; occupational therapy or behavioral therapy may be helpful.
Children ages 6 to 9
When children enter first grade, schools expect much more of them. They must sit at their desks for longer periods of time, be responsible for homework and school supplies, and be able to concentrate well enough to learn reading and writing skills. This is the age range when many children are diagnosed with ADD/ADHD. In Israel, children up to age nine are eligible to receive a comprehensive assessment and diagnosis through Machon Lehitpatchut HaYeled, but some parents may choose to go to a pediatric psychiatrist or neurologist either through Kupat Cholim or privately. A proper assessment will include:
Screening for dyslexia and other learning disabilities − A child who is having trouble sitting in her seat in class may be uncomfortable because she is not able to read, and not because she is suffering from ADD.
Cognitive assessment − What are the child’s cognitive abilities? Could the limitation be cognitive and not a concentration problem?
An assessment of emotional and social wellbeing − Is someone bullying him at school? Is he anxious or depressed about something that is going on in his family? Does he feel that the teacher dislikes him? Is he suffering from fears or nightmares?
Medical issues − Does she need glasses or have a hearing problem? Is she suffering from lice or worms and is so uncomfortable that it is affecting her concentration? Is she receiving the nutrition that her body needs for her mind to function optimally? Is she suffering from a vitamin or mineral deficiency? Is she underweight and complaining often of stomach pain? Could she be suffering from celiac? What other medical issues has the child dealt with? Is she getting enough sleep?
Family assessment − What else is going on in the family? What is the nature of the child’s relationship with each of the parents? With siblings? Extended family? Are there other stressors in the family life, such as Aliya adjustment, marital discord, or serious illness?
Sensory issues- Does the child seem to be unusually sensitive to noise, light or touch? Does he often complain that clothing doesn’t feel right or seem overwhelmed or frustrated by levels of stimulus that don’t bother other children? At the other end of the spectrum, does he seem to have minimal or no response to external stimuli? Sensory Processing Disorder often is misdiagnosed as ADHD. Children with Sensory Processing Disorder should be treated by an occupational therapist who specializes in sensory integration and not medicated with Ritalin.
Getting a proper assessment and diagnosis is crucial. Don’t let the rest of your child’s life be affected by the declaration of a “doctor” who spoke to you and your child for only ten minutes.
Children ages 10-18
From the age of ten, children are no longer eligible for an assessment through Machon LeHitpatchut HaYeled; they can get proper assessment and diagnosis from a pediatric psychiatrist or neurologist. All of the points mentioned above should be included in the assessment process. If a child begins to exhibit symptoms of ADHD after age ten, it is crucial to understand what changed. Has something in the family, school or the child’s environment changed significantly? Are there any new stressors? Has she experienced some sort of trauma? Has the inattentiveness or hyperactivity set in around the age of puberty?
Diagnosis in adults
It is unusual for ADD/ADHD symptoms to begin only in adulthood. If the symptoms have existed for years and the man or woman only realized as an adult that there is a name for what they have been experiencing, the process of finally getting diagnosed and treated can be transformative. (This was discussed at length in the previous article.)
The ADHD Spectrum
There seems to be a range of experiences among people with ADD. Most people have some symptoms of ADD, but in a manageable range − none of us have computers for brains. Sometimes the root of the issue seems to be more neurologically based, and sometimes it seems to be more environmentally based. In either case, taking a careful look at the environment can be beneficial.
Consider a ten-year-old child, “David,” who has been diagnosed with ADHD based on his hyperactivity, inattentiveness in school, and difficulty following directions and completing tasks. His parents often argue at home, and have different opinions on how to deal with David. His father is strict and thinks that David should be punished for jumping up from the Shabbos table or getting poor grades. David’s mother thinks that Dad is too strict and that David is just a kid who will grow up just fine if Dad gets off his case. David’s older brother’s emotional and behavioral problems often determine the atmosphere at home and his needs frequently overshadow the needs of the younger children. David has never liked vegetables, and mom has given up on fighting with him about it. David’s bedtime is eight thirty, but he often gets distracted and doesn’t fall asleep until 10PM or later.
Clearly, a doctor who prescribes Ritalin without looking at the whole system is doing David and his family a huge disservice.
A comprehensive treatment plan would include assessing David’s family dynamics, nutritional needs, emotional needs, and structure of activities. David could benefit from some behavioral therapy, and his family would benefit from family therapy. David’s therapist would be in touch with his teachers and principal, and together with the parents, a consistent set of rules and positive and negative consequences would be put in place.
Interestingly, in preparing this article I spoke to a number of health practitioners: a practitioner of Chinese Medicine, a pediatrician, a nutritionist, a chiropractor, two psychiatrists and a family therapist. Each one had a different approach to treating ADHD, but all agreed on one thing: a client must be treated as a complete human being, and not as a short list of symptoms.
Batya Prebor, a Chinese Medicine practitioner explained, “Chinese medicine has its own methodology for diagnosing and treating based on a completely different paradigm from conventional medicine - where we look at and treat the whole person and not just a list of symptoms. So while ADD/ADHD is a label given to a child exhibiting specific behaviors, in Chinese medicine we analyze each child's specific behaviors in the context of his greater physical and emotional constitution. Using the paradigm of Chinese medicine we can diagnose specific organ disharmonies and treat them using the tools of Chinese medicine which include acupuncture, herbal therapy and dietary recommendations. Treatment is obviously individualized and tailored to each person."
Zev Ganz, M.S.W., a family therapist in Jerusalem and Ramat Beit Shemesh, also emphasizes that addressing the family issues is an essential part of treatment when working with ADD/ADHD families. How does the family communicate? What are the rules and how are they enforced? What other stresses is the family facing? How does the child interact with the various family members? How do family members relate to the symptoms and problematic behaviors that the child is presenting with? What is their response to this behavior? Family therapy will not make the ADD/ADHD disappear, but it can greatly improve the child’s and the family's ability to manage it effectively.
Ya’akov Wieder, who treats children with ADHD using homeopathy, five element acupuncture and cranio-sacral therapy has found that there are patients who exhibit ADD/ADHD like behaviors which are aggravated by trauma or family issues. His work can release the stress and trauma trapped in the body and can bring significant improvement. When parents see that their child is improving from the treatments they may become open to getting some treatments themselves. Parents with lower stress levels manage better in family interactions, improving the home environment which helps the child even more.
The Role of the School
Partnership with the teachers and the school is fundimental for proper ADD/ADHD treatment. In fact, some family therapists will make a school visit an essential part of the treatment. It is important for the teachers and administration to see the child as a whole person, with strengths and challenges; focusing on building the child’s strengths is just as important as addressing the child’s weaknesses. Sometimes an intervention as simple as moving the child’s seat in the classroom, allowing her to get up and walk around every half hour, or giving her a stress ball or rubber bands to keep her hands busy during classes can make a big difference.
During the elementary school years, children are learning many skills, a lot about the world, and an understanding of human interactions. They are also developing their sense of self. If a child is in a school or a family that emphasizes academic achievement above all else, and he continues to struggle academically, his self-esteem will be affected. Each time he tries his hardest and still fails, he will learn that he is a failure, and that others do not recognize his best efforts. A child with ADD who is struggling academically even with treatment and support should not be ridiculed for his challenges, and should be encouraged to find other areas where he can achieve greater success. Maybe he is good at sports, has a musical talent, or enjoys caring for his younger siblings. A healthy school environment will be happy to cooperate with the parents and therapist and be an integral part of the treatment plan. If that is not the case, look for a different school.
It is important to keep in mind that while a child’s symptomatic behaviors affect those around him, the child is also affected by the reactions of others to his behaviors. The long-term emotional impact of a negative feedback loop can be very detrimental to a child’s self-esteem and wellbeing. The goal of the treatment team is to help the child manage well in his environment, and to create a positive feedback loop that will benefit the child by reinforcing his successes and building a positive sense of self.
Having ADD/ADHD is a challenge that a child will face for life. If the right attitude is modeled by those around him, he will accept his challenges and invest in his strengths. If not, the challenge of ADD will be compounded by the shame, guilt and frustration of feeling like a failure. Dr. Edward Hollowell, author of Driven to Distraction, and himself a successful adult with ADHD, compares the ADHD mind to a racecar, and explains to children that the reason they are having a hard time in school is that they have a racecar mind with bicycle brakes. He compares treatment for ADHD to installing racecar brakes. This type of metaphor allows children to accept that while they may be different from some of their peers, they are not less than their peers. It is essential for ADHD children to learn to accept their challenges, build their “brakes” and capitalize on their strengths.
The Ritalin Debate
Any discussion about giving medications to children will be a heated debate with very vehement opinions on both sides. Deciding what the place of medication will be in a treatment plan is a case-by-case decision for parents and physicians to explore together. Many studies have shown Ritalin to be a safe and effective treatment, but many parents do not want their child to grow up dependent on a substance, or are concerned about potential side effects.
Under-treating ADHD may sometimes be more dangerous than over-treating, as it may put the child at risk of feeling like a failure and developing emotional issues that can affect the child for life. Treating ADHD with alternative means is expensive and time consuming. Not all parents have the various sorts of resources needed in order to go an alternative route, and Ritalin can make the difference between a positive experience in school and positive self-esteem − which will create a positive self image − and a negative feedback loop. When medication is given as part of the treatment, it should be presented to the child in a way that does not jeopardize his self-esteem. The child shouldn’t feel that he is sick or “messed up” and needs pills, but rather that the medication will help him to build his racecar brakes so that he can use all his skills and talents to succeed.
It must be made clear that Ritalin alone is not enough to effectively treat ADHD. A comprehensive treatment plan will enable a child to learn skills that will help him to compensate for his ADHD; family issues, school issues and other factors must also be addressed.
The bottom line is that a person with ADD/ADHD is a person and not a diagnosis. Successful treatment lies in seeing the person as a complete being and addressing all the various facets of life.