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The Complex World of ADHD

Melany Bartholow describes her son’s early childhood behavior as “painful.” When he was diagnosed with ADHD in the first grade, Bartholow’s search for answers and remedies began — a search that has only continued to evolve as her son grows.

“He was always lashing out emotionally over small things like shoes being tight, uncomfortable T-shirts or not getting along with kids at school. The teachers didn’t know how to handle it. They just put more pressure on his behavior with charts, demerits and punishment, thereby making him feel like a ‘bad’ kid,” recalls the Dallas mom. With his self-esteem plunging, my patience suffering and his peer group of friends shrinking, I knew I had to do something.”

If you’re the parent of an ADHD child, this sense of desperation is all too familiar. Dealing with Attention Deficit Hyperactivity Disorder or ADHD — and its many alternative treatments — is a challenge that’s complex, often controversial and constantly evolving.

And, as science continues to probe new frontiers with studies, research and therapies, it can be overwhelming to stay informed, and correctly interpret and understand the implications of new discoveries — where fresh answers most often lead to deeper questions.

Recently, two landmark studies published independently have sparked hope about whether kids can in fact outgrow ADHD. Could it change the way scientists, educators, doctors and parents understand and manage disruptive children? We went straight to the source for our own answers: moms next door and local experts who know what’s working and what’s not in navigating the enigmatic world of ADHD.

New Thinking Revives Old Questions
In a study of more than 16,000 children in kindergarten through elementary school, international researchers, led by Greg J. Duncan of Northwestern University, found that math skills are the strongest predictors of future academic achievement. Traditional thinking has placed a much greater emphasis on reading — where ADHD students tend to falter. This study, on the other hand, suggests that a knack for math offers a better indicator of learning readiness. Published in the Developmental Psychology journal, the “School Readiness and Later Achievement” report also minimizes the importance of socio-emotional factors as predictors of future success, noting that disruptive behaviors in kindergarten did not influence academic results at the end of elementary school.

Could it be that we are expecting too much too soon?

Enter the second (unrelated) study focused on brain imaging. Conducted by researchers from the National Institute of Mental Health (NIMH) and McGill University, this research reveals that in ADHD children, the brain’s frontal cortex (the area responsible for controlling thinking, attention and planning) matures in a normal pattern, yet exhibits a three-year delay. According to Dr. Philip Shaw, lead researcher at the NIMH Child Psychiatry Branch, “This could help explain why many youth eventually seem to grow out of the disorder.” But do they really outgrow it? Or do they just overcome the symptoms? Does that mean we should take a wait-and-see approach and hope it’s a phase?

ADHD is the No. 1 psychiatric diagnosis given to disruptive young children. In fact, it affects 3 percent to 5 percent of school-age children. Experts have long sparred over whether the condition is a result of a brain deficit or a delay in development.

No Correlation Between IQ and ADHD
Dr. Ray Levy, LSSP, a Harvard-trained Dallas clinical psychologist who specializes in working with families and schools in handling ADHD and other disorders, says he believes that while studies such as these are very interesting, they really make no difference in dealing with the behavioral issues common to ADHD. “Regardless of the cause, the object of addressing these issues is to get the brain working together,” Levy says. “The old adage is ‘what fires together wires together’ and so as we practice desired behaviors over and over, they get better.”

Levy prefers to concentrate on parent training as opposed to individual or group therapies for ADHD children. This shift in focus is gaining popularity, Levy reveals. Providing parents with specific tools for retraining these behaviors is getting significantly better results.
He attributes the success of these strategies to working around what he laughingly calls “the garlic disorder.” “When you eat garlic it is not as much a problem for you as it is for others around you,” he explains. “Most of these ADHD kids just don’t see themselves as a problem, so they are not motivated to change. They may learn something in a group or individual situation, but they reject it because they don’t think it applies to them.”

One particularly effective parent-led strategy involves helping a child build rituals of organization that, according to Dr. Syed Quadri, psychiatrist and medical director of an area adolescent behavioral medicine program, is the key to minimizing the affects of ADHD symptoms.

Quadri says that both parents and schools should make a special effort to put specific organizational rituals in place.
“You cannot tell them ‘go clean your room,’ he explains. “They simply can’t do it. You have to break it into very small pieces and do it one step at a time.”

Despite intervention or strategy, Quadri asserts that it is especially important for parents and teachers to understand that there is absolutely no correlation between IQ and ADHD or behavior.
“I have parents come to me all the time saying, ‘My kid is getting straight A’s in school, yet has all these ADD symptoms.’ So I tell them, ‘Your son is brilliant, but that has no correlation to his behavior,’” Quadri says.

He adds that although it is very common to find ADHD children with average or above average IQs doing well academically in elementary school, by the time they reach middle school it becomes tougher and tougher for them to stay at peer level due to poor organizational skills and what he calls “executive dysfunction.”

So will a bright child be able to catch up once his or her brain matures? Not necessarily, Quadri offers, because the symptoms of ADHD can cause a child to miss important developmental milestones that are difficult, if not impossible, to make up later.

“These kids will never regain what they lost in these areas while their brains were catching up. If a child has a delay in speech, you are not going to ignore it because he will eventually catch up,” he adds. “You put them in speech therapy so they will catch up and stay up with their peers.” He bases this opinion on the results of a 30-year study done by nationally renowned ADHD expert Russell Barkley, Ph.D. Barkley emphasizes the importance of early intervention and advocates for accommodations in the school systems.

At the Center for Advanced ADHD Research, Treatment and Education (CAARTE) at UT Southwestern Medical Center in Dallas, scientists are investigating non-medication interventions for ADHD, including parent training and attention training. “We have a research program for children ages 3 to 12 and are showing that parenting interventions are a necessity … particularly when applied early in the child’s life,” says Leanne Tamm, Ph.D., assistant professor of psychiatry. “Early results from our clinical research show that the children and families are benefiting, ADHD symptoms are improving and executive functioning skills are improving.”

Based on these results, Tamm advises caution in interpreting these studies — and not to mistakenly conclude that we don’t need to intervene if the child is struggling.

Although the brain imaging findings of the NIMH study are particularly compelling, results may not directly impact the way we manage ADHD now, though it can help direct future investigations. “I believe that these studies will have a stronger influence on science/research than on clinical care in the immediate,” Tamm asserts. “And the long-term goal is for science to lead to better biological interventions and possibly prevention.”

“Each new bit of knowledge just adds to what we previously knew,” agrees Beth Lusby, Ph.D., of the Metroplex’s Cornerstone Assessment & Guidance Center, LP. She agrees that although these research findings offer promise, no single study should serve as the basis for an entire course of intervention.

Lusby says she finds the School Readiness study appealing because for a long time reading research has been far ahead of math research. “I was impressed with the idea that they’re now saying it is really important to focus on all those things, and not just the hot topic of the moment,” she says. “This goes back to practical, good old-fashioned parenting — help your child learn skills in a variety of areas.”

It seems that on one point everyone agrees: Time is of the essence. Those first years offer a precious window of opportunity for brain, social and self-esteem development. “Sometimes parents panic and think that they have to do everything at once or it won’t be fixable at a later date,” Lusby cautions, but adds: “Early child development is an opportunity to make impacts that you can, so you pick your battles and you help these children in the areas they need the most help.”

The Learning Curve
From stories of children pushed aside because teachers simply don’t know what to do with them, to those mislabeled as difficult, lazy or unmotivated, to still others mistakenly considered mentally challenged, one thing is clear. Parents are their children’s best — and sometimes only — advocates, and it requires us to stay informed, keep active and combine common sense with intuition and tenacity to find solutions that work.

“From my point of view as a parent of an ADHD child, there is nothing wrong with my daughter. She simply, like others, processes information differently,” says Shannon Williams, mom of an eighth-grade daughter.

“Why does something have to be wrong with her brain? Could it be the brains of children with ADHD are perfect but different? In some ways they are superior. They can brainstorm quicker than non-ADHD brains. They process information quickly. They can be very creative. My daughter, for example, can retain information she’s heard or read verbatim if it’s something she’s interested in. How is her brain defective? In my opinion, it simply does not fit in certain structured school environments.”

This, agrees Quadri, is often the crux of the problem, as many, if not most, schools still lag behind current knowledge in working with these kids and their families. “The schools need to step up and help these children,” he says. “Teachers are reluctant to offer modifications — and they often point only to intelligence and need for discipline. And worse, when they see a kid struggling in certain areas, they refuse to help because he or she has a high IQ.”

A distraught Bartholow decided to take matters into her own hands after her son’s first-grade ADHD diagnosis. She first hired an educational consultant who evaluated the situation and recommended a professional psycho-educational examination. “It was worth it to finally know what was so ‘different’ about our bright, handsome son,” Bartholow adds.

But even with a combination of medication, counseling and tutors, Bartholow says that she knew her son that was still struggling both socially and academically. After interviewing several schools that specialized in learning differences, she chose The Winston School because of its ADHD specific curriculum and understanding of these students’ needs.

“I totally agreed with the idea that my son was very bright, but he did learn differently and needed to be challenged while also being understood if he acted out. He finally felt ‘safe’ enough to learn.” Today, Bartholow’s son is a straight-A student who just received the Lower School Service Award for best behavior, helpfulness to teachers, helpfulness to other students and an overall good attitude.
In addition to the right educational environment, Bartholow credits parent-training strategies with turning things around at home.

To Medicate or Not to Medicate
Quadri says parents and children are often resistant to medication. “And you should be cautious,” he adds. “Medication is not always necessary, but in some cases it makes all the difference.”
Williams agrees with Quadri’s assessment. Her daughter, who has been on medication for ADHD since the first grade, sometimes pretended to take her pills (and instead threw them away). “On those days,” the McKinney mom relates, “I always received e-mails from her teachers about her behavior.”

Although drugs have proven to be the right answer for Williams’ daughter during the school year, the family does not medicate her during school breaks. Instead, Williams says that they work on building coping skills with realistic expectations and small tasks that will help her daughter learn to work with the ADHD instead of against it.

Still, Williams stresses that she recognizes the importance of medication. “Her necessity for meds has not lessened at all,” she says. “However, it’s only in the structured school environment that she needs meds.”

While medication can be helpful — even crucial — to getting ADHD symptoms under control, Quadri advises that building rituals, improving organization and developing coping skills are the keys to lifelong management of ADHD.

And, although people may grow out of some of the ADHD symptoms (hyperactivity, impulsivity, inattention, and disorganization), contrary to the study’s findings, he believes that ADHD is something that stays with you for life.

“Impulsivity fades as you get older and wiser and learn from mistakes,” he explains. “You are still impulsive, but you have learned to be more careful. Hyperactivity is most definitely gone by middle school or high school, although sometimes people remain somewhat fidgety either internally or externally. Attention problems stay for life, but adults learn to work with it by choosing jobs and fields that allow for multitasking and constant stimulation.”

“You only need treatment if these symptoms are adversely affecting two or more areas of your life, but I don’t think you ever grow out of it,” Quadri explains.

As a parent, Bartholow echoes Quadri’s skepticism of the idea of outgrowing ADHD. “I think my son will mature and will outgrow some of the traits,” she says. “But ADHD is part of who he is, and managing it will be a lifelong thing for him. I feel good knowing that I’ve done my homework and have done everything I can to make sure he has the coping tools he needs.”

Effectively parenting an ADHD child means seeking appropriate treatment, being an active advocate and using discernment. And all this requires a parent to stay informed. Lusby encourages her patients to read and research on their own. “You can actually look many of these studies up and read what the researchers said,” she adds. “And many of these studies have discussion sections at the end where researchers specifically point out what they think the results mean.”

However, the amount of research out there is staggering, even for professionals, Lusby stresses. It can be difficult, confusing and downright overwhelming to slog through the extensive research available in this complex and often controversial topic (A simple Google search for “ADHD” turned up 33,800,000 results). That’s not to mention determining the quality of and interpreting the information you are reading.

“When you read about a study you think may be significant for your child, consider talking with your child’s treating professional,” Lusby advises. “Ask them if they would review the article in the context of what else is being done and tell you what their thoughts are about how or whether it relates to your child specifically.”

When it comes right down to it, Lusby says that she usually tends to fall back on good old common sense. “Research findings may not be all that consistent,” she explains. “And when it comes to raising your child, you can’t wait for research to specifically address what you’re interested in. And opinions change. You may read one study that says you don’t need to address something, and then a little while later another comes out that says you do. It can be very difficult for parents to know what is the right intervention and what research to listen to.”