My role is an informant
My role is to try to use data to inform patients and their parents, and not to assert anything. When I talk to families about medication, I don’t see my job as trying to sell them on medication. My job is to inform them about what the data say and what’s available to them. They can use me to help them work that out, or use behavioral therapies and come back later if that doesn’t work and see us, or whatever they want– it’s our job to inform them.
Leonard Rappaport, MD, MS, Director, Developmental Medicine Center
Concerns Kids Have
Concerns that kids have depend on the age of the kids. When they’re younger, I think they’re mostly concerned about why they are getting in so much trouble, or they’re denying that they are getting in trouble, or they are blaming it on someone else. And it almost is like they are blameless, because it’s not within their control to contain their actions. At that age, they also want to know if there is something that can help them with the problems they’ve been having, because they’ve tried everything they can do.
As they get older, there is a need for everyone to feel like he or she is not different from everyone else. Being able to prescribe long acting medications allowed us to get kids out of the nurse’s office because they no longer had to take a mid day medication, which I think made medication much more acceptable to kids. I think it was highly embarrassing for them before these long acting medications existed for them to have to go to the nurse to get their medication during the school day and be identified as being different.
Almost every adolescent at some point goes through a period where he or she doesn’t want to take his or her medication anymore. There are multiple reasons for this. First, they want to be the same as everyone else– it’s common for kids to refuse to take their medication for almost everything when they are adolescents– their diabetes medicine, asthma medicine, seizure medicine, all things. Also, I think they become much more aware of how they feel physically, and they may not like some of the side effects from medication that they may have not even noticed having before, and these may be real or perceived side effects. Finally, they’re taking generally more control over their lives and trying to be a little more assertive, and it sometimes can these efforts get played out by not taking their medication.
Leonard Rappaport, MD, MS, Director, Developmental Medicine Center
Problem solving
With children nine years of age or older, we work on particular types of self-control strategies to reduce their impulsivity around their symptoms. We work to develop social problem solving strategies– for example, how would this child go about negotiating with a peer whose turn it should be to play a game or what the rules for the game are? Or, if the child is playing a game, what happens if the two of players both want to be the leader? For example, if they are playing pirates, should there be two captains of the ship or one captain of the ship? We talk about how to negotiate, which is a critical developmental skill.
Eugene D’Angelo, PhD, Chief, Division of Psychology
Treating from all angles
The literature indicates that no one single treatment is usually effective. Depending on the severity of symptoms and impairment of functioning in multiple areas, treatment may entail psychopharmacology, parent training, and a behavioral plan at home to increase praise and set up some sort of structure, as well as some individual group psychotherapy depending on their social skills or if there are other co morbid disorders such as depression or anxiety. So there may be an individual psychotherapy component as well. It really depends on a number of factors; in most cases there is not one level of treatment, but multiple levels of treatment.
Marcus Cherry, PhD, Child and Pediatric Psychologist
Realizing something is wrong
I think the thing to understand about awareness is to understand the cognitive development of the child. I think by age 7 they are starting to understand that something is a little different than their peers. They will say, “I can’t sit still like my buddies, I’m always getting in trouble unlike my buddies, I’m always getting in fights or having some sort of conflict with a peer.” They are aware of those things. They may not be aware of ADHD per say, but they are aware that their behavior is different than that of their peers and at that age they don’t want to be different from their peers. They are also aware that adults are very concerned about them, teachers are calling home, and parents are continuously upset, frustrated, and angry.
Marcus Cherry, PhD, Child and Pediatric Psychologist
Concerns of kids as they get older
For the kids who are much more self-aware, and this may also be a developmental phenomenon so that the older you are the more self-aware you typically are about situations, their worries tend to be about the immediate situation– for example, whether or not they can actually complete the schoolwork they are trying to do and do it relatively well so they are competitive for higher education experiences such as college. They worry how different they are from other children who are their age and if they are different, what that means for them. In terms of thinking about longer term planning: whether they will have attention deficit disorder forever and if so what does that mean for them?
Eugene D’Angelo, PhD, Chief, Division of Psychology
Symptoms may lessen with time
As children with ADHD get older, their symptoms, both in terms of their intensity and the way they are organized, may shift. Even if one has Attention Deficit Hyperactivity Disorder the normal developmental process continues and there may be some neurodevelopmental or cognitive shifts, particularly as the person enters the high school years, that help him/her have better control over some of the symptoms. Talking to an eight year old about the difficulties they have with ADHD is sometimes different than talking with an adolescent.
Eugene D’Angelo, PhD, Chief, Division of Psychology
Helping kids with disorganization
Someone once said, “Kids with ADHD can be a lot of fun to play with, but you don’t want to lend them your bike because it may never come back.” It’s not that this child stole it, it’s just that it got lost. Therefore, we try to get children with ADHD to be aware that when something has been misplaced or lost, or when something is disorganized that it this is part of this attentional problem that they need to work on. We also try to have them be aware of their different feelings. By way of example, a child who has diabetes needs to be aware of how they are feeling before their blood sugar is so low that they are in danger. It’s similar for ADHD; having these children be aware and self-monitor increases the self-control. You have to be aware that you are having difficulty before you can correct it.
Eugene D’Angelo, PhD, Chief, Division of Psychology
Tutors can be helpful
I’ve done consultations with organizations that have people who go to the home and help provide the structure, organization and planning to help children with ADHD complete homework. This method is especially useful for adolescents; sometimes older kids who struggle with homework respond better to having someone who is not a parent who can help guide the adolescent through the homework, help them focus, and also teach them skills in organization. That can be very successful.
Marcus Cherry, PhD, Child and Pediatric Psychologist
Maladaptive coping strategies
I explain to my patients what ADHD is and that a lot of kids have it, that it isn’t their fault that they have it. Sometimes kids have tried to deal with it beforehand and it hasn’t always been very successful. They have used maladaptive coping strategies that haven’t worked and so they get into difficulty. It depends on the age group too. If an adolescent hasn’t been treated there can be a whole host of problems, including using street drugs to manage. Often there have been poor grades in school, they feel badly, they push and whine and no one wants to choose them when it comes to picking teams. There are all kinds of problems because they don’t know really how to manage their symptoms.
Frances Johnson, Advanced Practice Nurse
Treatment is a team effort
The clinician treating ADHD in a child needs to have a good alliance with the parent or guardian, the school, and with the patient, especially as the patient gets older. Medication treatment should be part of the treatment for almost all kids with ADHD. The motivation for changing behavior can sometimes be instilled in the child with a behavioral plan that rewards good behavior. In school the child with ADHD may need more structure, smaller classes, preferential seating in front of the class. If there are relationship problems present those can often be helped with psychotherapy. The parents, the teachers, and the child need a lot of education about ADHD and how it impacts a child so that they can make good decisions.
Joseph Gonzalez Heydrich, MD, Senior Associate in Psychiatry, Child and Adolescent Psychiatrist
The importance of consistency
The treatment effects of ADHD often don’t continue if the treatment is stopped. So the medications for ADHD work only while the medications are on board. When the medications are gone, the effect of the medication is gone. It is the same thing for the psychosocial treatments for ADHD: they tend not to generalize outside of the setting, so it is important to keep in mind what the troubling situations are and target them. It is also important to teach the child, the parents, and the teachers how to maintain gains that have been made, for instance by continuing medication, or continuing a behavioral plan.
Joseph Gonzalez Heydrich, MD, Senior Associate in Psychiatry, Child and Adolescent Psychiatrist