One reason for regarding ADD as a distinct disorder with a biological origin is the immediate and striking relief from some of its symptoms provided by the stimulant drugs methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and magnesium pemoline (Cylert). These drugs are helpful for about 75% of children and adults with ADD. They become less irritable and restless, and their attention and motor coordination improve; others begin to like them better, and they begin to think better of themselves. The drugs have no direct effect on learning disabilities, but may make special education and tutoring easier.
There is little danger of drug abuse or addiction, because users do not feel euphoria or develop tolerance or craving. They become dependent on stimulant drugs, it has been said, only in the same sense that a person with diabetes is dependent on insulin or a nearsighted person on eyeglasses. The main side effects – appetite loss, stomach aches, nervousness, and insomnia – usually subside within a week or can be eliminated by lowering the dose. A child’s rate of growth may be slowed for a few years while he is taking a stimulant, but it returns to normal in adolescence. There is no evidence of long-term deleterious effects.
Methylphenidate and dextroamphetamine are short-acting drugs, but they are now available in time-release capsules that prolong the effects to eight or ten hours. Pemoline is longer-acting. These drugs are started at a low dose that is gradually increased if necessary; parents can make adjustments according to their child’s level of activity. If the symptoms do not improve after two weeks at the highest acceptable dose, drugs will probably never be useful. Some doctors recommend that children take stimulants only during school hours and not on weekends or vacations. Most believe that drug treatment should be discontinued for several weeks once every six months or once a year to see whether it is still needed.
Not a panacea
The long-term benefits of drug treatment are uncertain. It is difficult to predict which children will be helped and how long the drugs will be needed. Anxiety, depression, learning disabilities, and conduct disorders are not directly affected by the drugs. Although children may calm down, concentrate better, and behave less disruptively while taking a stimulant, there is no guarantee that their schoolwork will improve in the long run or that the adult outcome is affected. The original symptoms usually return in full force when a child stops taking the drug.
Adolescents with ADD are often reluctant to take their medications at all. They may be embarrassed about having to see a school nurse at noon to take a pill and humiliated by the implication that they cannot control their own behavior. Adolescents dislike the feeling of being different, defective, or dependent.
Pediatricians and family doctors who consider prescribing stimulants should be sure that the problem is really ADD. Children should not be given drugs just because they are noisy or unruly, and other treatable conditions should be ruled out. Even if drugs are necessary, they should not be used to the exclusion of other treatments or as an excuse for not trying to find and eliminate the causes of specific symptoms in specific circumstances. ADD is not a simple problem with a single solution. Drugs cannot give people skills they have never developed or fully relieve the resulting frustration and shame. Possibly the most important use of drugs is to create a space for other treatments to work.
Part of the solution is simply acknowledging that the symptoms constitute a recognized psychiatric disorder. That is often reassuring for children and parents who have found the situation mystifying and maddening. Psychotherapy may help patients to identify and deflect the feelings that cause impulsive and aggressive reactions. Since children with ADD often have difficulty following social rules and understanding social situations, therapy must be didactic; for example, they may have to learn how to look at others who talk to them, listen to what they say, and wait their turn before answering.
Children and adults with ADD need structure and routine. They should be helped to make schedules and break assignments down into small tasks to be performed one at a time. Especially when young, children with ADD often respond well to strict application of clear and consistent rules. In school, they may be helped by close monitoring, quiet study areas, short study periods broken by activity (including permission to leave the classroom occasionally), and brief directions often repeated. They can be taught how to use flashcards, outlines, and underlining. Timed tests should be avoided as much as possible.
In a sense, establishing structure and routine is a form of behavior therapy – consistent schedules with rewards for acceptable behavior. Behavior therapy in a more formal sense is also useful in preventing a particular kind of aggressive or disruptive behavior that occurs in a few specific circumstances, especially in adults, but applying it to all the situations in which symptoms of ADD appear would be impractical – too time-consuming and demanding for anyone’s patience and skill.
Family conflict is one of the most troublesome consequences of ADD. Especially when the symptoms have not yet been recognized and the diagnosis made, parents blame themselves, one another, and the child. As they become angrier and impose more punishment, the child becomes more defiant and alienated, and the parents still less willing to accept their child’s excuses or promises. A father or mother with adult ADD sometimes compounds the problem.
Constantly compared unfavorably with his brothers and sisters, the child with ADD may become the family scapegoat, blamed for everything that goes wrong. When ADD is diagnosed, parents may feel guilty about not understanding the situation sooner, while other children in the family may reject the diagnosis as an excuse for attention-getting misbehavior.
To avoid constant family warfare, parents must learn to distinguish behavior with a biological origin from reactions to the primary symptoms or responses to the reactions of others. They should become familiar with signs indicating imminent loss of self-control by a child with ADD. A routine with consistent rules must be established; these rules can be imposed on young children but must be negotiated with older ones and with adolescents. The family should have a clear division of responsibility, and the parents should present a united front. It often helps to write out complaints and to praise good behavior immediately. Family therapy or counseling, parent groups, and child management training are often useful.
Most of the principles used in treating children with ADD also apply to the treatment of adults. They respond almost as well as children to stimulant drugs (according to one study, even cocaine abusers with ADD can be effectively treated with methylphenidate or dextroamphetamine). Like children, they must often learn how to schedule, organize, and take time to reflect before talking or acting. They may need specialists in learning disabilities or psychotherapists to help them with chronic anger, alcohol and drug abuse, or low self-esteem. Self-help support groups can also be useful. Many suggestions for coping with parent-child conflict apply to conflict between husbands and wives. They have to avoid a pattern in which the person with ADD, constantly criticized and nagged, increasingly ignores or distances his or her partner.
based on The Harvard Mental Health Letter
Dr. Gnap is a family practice physician and behavioral medicine specialist in suburban Chicago. Dr. Gnap developed the Inner Control™ Program in 1970 and has worked with thousands of people to improve and correct medical, emotional, behavioral and learning problems including performance. He started the Inner Control program because so many patients asked, “what more can be done along with traditional treatment methods?”