The real question is: Who’s the real child—the unhappy, sluggish one swathed in sweaters or the carefree, gleeful one running around in his shirtsleeves? As far as I’m concerned, there’s no contest; the one without the sweater is the child as he is meant to be. He’s the one who’s functioning properly. He pays attention in school, interacts well with his friends, and, like the new Allen, has a fruitful, fulfilling, loving relationship with his parents. He’s the one with a real chance for a happy, healthy life.
Once in a while parents give undue credit to their child’s medicine. That was certainly the case with the mother and father of 12-year-old Libby. “I remember the first year we sent Libby to camp after she started taking her medication,” her father told me. “When we went to see her for Parents Day, she seemed very subdued. All the other kids were running around, but she was quiet. I said to my wife, ‘It’s the medicine that’s making her like this. What are we doing to our child?’ My wife looked at me with a funny expression on her face and said, ‘She didn’t take the medicine today. She knew we were coming, so she didn’t take it.’”
THE SIDE EFFECTS
“What will this medicine do to my kid?” is almost always the first question that passes any parent’s lips, and it’s a good one. If a child with a fever takes too much Tylenol, it may cause inflammation of the kidneys. The ampicillin that cures a child’s ear infection often causes diarrhea. All medicines, including those prescribed for children’s brain disorders, have side effects, and parents should know in advance what to expect. (Specific medications and specific side effects are described in Part Three, which covers individual disorders, and summarized in Appendix 3, Psychopharmacology at a Glance.)
However, parents should also be mindful that the adverse effects of not taking a drug are often far more unpleasant than the possible side effects of taking it. The long-term effects of an untreated brain disorder—distress, low self-esteem, dropping out of school, unsatisfying interpersonal relationships, and many others—can be truly devastating.
Little Billy, a seven-year-old child with a brain disorder—attention deficit hyperactivity disorder—comes to me in severe distress and obvious dysfunction. He’s inattentive, hyperactive, agitated. He can’t focus on anything in school, and he drives everyone crazy with his obnoxious behavior. His teacher doesn’t like him; the other kids don’t want to play with him; even his parents find his behavior intolerable. He’s the only one in the class who doesn’t get invited to the birthday parties. He’s not learning anything, and he’s not having any fun. With the correct dose of a stimulant he can focus in school and follow the lessons. He can play with his friends and go places with his parents.
To be sure, the stimulant may cause a decrease in little Billy’s appetite, alter his sleep patterns slightly, or cause an occasional headache. But without the stimulant this child is heading for trouble that’s a lot more serious than a headache. To me the choice seems clear: the child needs the medication.
THE BOTTOM LINE
A colleague of mine says that the most important task that children have is to choose the right parents. Carefully chosen parents not only accept their children’s assets and deficits; they also do whatever is necessary to make sure that their kids have plenty of opportunities to use their assets and are given whatever help they need to compensate for those deficits. That’s what parenting is all about.
A child’s brain disorder is not a parent’s fault, but finding the right treatment for the disorder is a parent’s responsibility. If a son is diagnosed with diabetes, it is a parent’s job to give the child his medication, work out a proper diet, and give him the moral support he needs to keep himself well. If a daughter has an allergy, a parent should make sure she takes her shots, keep the house allergen-free, and offer moral support. The same rules apply to a brain disorder. A parent’s job is to find the right treatment, work with the doctor and the child to implement it, build the child’s self-confidence, and make the child’s life easier along the way. Often the right treatment will include medication.
There are hundreds of thousands of success stories associated with pediatric psychopharmacology. “We got our life back” and “We finally could think about having another child” and “It was a miracle” are the kinds of comments heard every day from parents whose children’s lives have been turned around by medication. Like Adam’s parents, who took their child to a therapist 750 times before deciding to give medicine a try, they probably don’t like the idea of giving a child medicine, but they like it a lot more than the alternative. The story that Margaret’s parents tell, which describes a journey from despair to optimism, sums it all up.
“Our daughter Margaret was always different, not like the other kids. When she was six—that’s seven years ago now—we had her independently tested, and we got this 28-page report telling us that she had terrible problems and needed full-day special education. At this point Margaret was completely miserable. She didn’t have any friends, and everything she did was wrong. Her self-esteem was incredibly low. I remember asking the psychologist who tested her what class or activity we could sign Margaret up for that she would be most likely to succeed at. We wanted to make her feel good about herself. I’ll never forget his answer: ‘Don’t sign her up for anything. She will never succeed at anything.’ Those were his exact words. We were completely devastated.
“That was in January. By April we had seen a psychiatrist who put Margaret on Ritalin, and after two days on the medicine she was able to focus for the first time. The change in her was so dramatic that we called her the new Margaret. It was as if she rose from the dead. By the end of the school year she was getting perfect scores on all her tests and having sleepover dates with her classmates. Today, seven years later, she makes straight As in school, plays French horn in the band, and has plenty of friends. She still takes Ritalin three times a day for her ADHD. I can’t say we like giving her the medicine, but we know she needs it. We can’t imagine her life without it.”
PART THREE
No-Fault
Brain Disorders
Each of the chapters in Part Three addresses a different brain disorder, focusing on the symptoms, the diagnosis, the recommended course of treatment, the prognosis, and the effects of a disorder on a child’s personality and on his relationships with others. I also talk about the special parenting concerns associated with each disorder.
CHAPTER 7
Attention Deficit Hyperactivity Disorder
Nicholas, nearly three, still slept in the crib he used when he was a baby. His parents hoped that the high sides of the crib would discourage him from getting up in the middle of the night and wandering around the house. When that didn’t work, and when he took to going downstairs to the kitchen and playing with the stove, his mother and father tied a cowbell to his door. When he opened the door, the bell would ring and wake his parents. During the day Nicholas was fidgety, unable to sit for even the shortest time. He had no interest in the TV shows most children like; he watched only the commercials. A lovely, lovable little boy with a keen sense of humor and a real zest for living, Nicholas was like an engine that wouldn’t stop running. Everywhere he went, accidents happened, and little things got broken. His grandparents, who doted on Nicholas, nicknamed him “Sweet Destructo.”
“He’s been difficult since the day he was born.” That’s what Theo’s mother said about her 11-year-old son the day we first met. He’d been a very demanding infant, with lots of sleep problems. He walked at eight months and was a whirlwind of activity from the start. When Theo was two, he and his mother were politely asked to leave a “Mommy and Me” program at the local YMCA; Theo just took up too much room. Theo never did get along with the other children. He was always grabbing their toys, pulling their hair, and cutting ahead of them in line. Even now, at 11, Theo pokes at his younger brothers during meals. In a restaurant he plays with the sugar and knocks over the water glass. He’s been going to the same sleepaway camp for three years, and he h
asn’t made a single friend. This year complaints from his school have been coming almost daily. The teachers say that Theo fidgets constantly, rips papers, shouts out comments in class, and gets up every ten minutes to walk around the room. The parents are frankly embarrassed to take Theo anywhere. In a private moment Theo’s father confesses to me: “I just don’t like him.”
When Peter’s parents brought their 10-year-old son to my office, he fought them every inch of the way. Two appointments had already been canceled. Peter didn’t think he had a problem, although everyone who came into contact with him strongly disagreed. He was getting bad grades in school, and his teachers said he was constantly missing assignments and losing papers. He was always looking for trouble with the other kids in school. He had a fight with a boy in his neighborhood that was so bad, he had been socially ostracized by his classmates ever since. None of the other kids wanted to play with him. His father, who was the coach of Peter’s soccer team, told me that his son was always ending up in the wrong place on the soccer field. Peter was a terrific athlete otherwise, but he kept getting lost out there.
THE TERRIBLE TWOS,
THREES, FOURS, FIVES, SIXES, ETC.
If the statistics are to be believed, there’s one in every crowd—a child who’s different from all the others. He’s more accident-prone and more difficult to manage. In all likelihood he ran as soon as he started to walk. In a playground he refuses to leave the jungle gym when it’s time to go home. While all the other toddlers are sitting still on Mom’s lap during “Mommy and Me,” he’s squirming or running around. He needs more supervision than all the other kids put together as he shouts out answers and fights with his classmates. When the rest of the moms leave their kids to enjoy their hour or two of fun and games at a birthday party, his mother is asked to stay on to make sure he doesn’t tear the place apart.
The disorder I’m describing is attention deficit hyperactivity disorder—ADHD—the most common of all the childhood psychiatric illnesses. More than a million children in this country have ADHD. According to the most conservative estimate, 3 to 5 percent of all children have the disorder, and some estimates put it as high as 9 percent. The overwhelming majority of kids with ADHD are boys. The male-female ratio is anywhere from 4-1 to 9-1, depending on the study. As we become more aware of the symptoms in girls, that balance will shift.
ADHD is a behavioral disorder with three major symptoms: inattention, impulsitivity, and hyperactivity. Like all disorders, ADHD can be mild, moderate, or severe. Some children are somewhat fidgety (in fact, we expect all toddlers and preschoolers to be a little fidgety), while others can’t sit still for even a minute. There are kids who are terrors in large groups but do fine when the interactions are one-on-one. The children with the most severe ADHD have problems constantly and in all settings: at home, at school, and at play.
Although signs of this disorder are often evident during toddlerhood or even earlier, most children who have ADHD make their way to the office of a mental health professional a little later, most often when they start school. Parents and other loved ones may be willing and able to cope with or even ignore the behavior associated with ADHD, like the grandparents who indulge their “Sweet Destructo,” but teachers cannot and will not put up with it.
ADHD is a chronic, not an episodic, illness; the inattention, impulsivity, and hyperactivity don’t come and go as a result of circumstances. Normal children may have any or all of the ADHD symptoms temporarily as a result of something that happens in their lives—if their parents divorce, for instance—but that behavior will disappear after a short time. The symptoms of true ADHD won’t make a sudden appearance after a child is in school. The disorder usually starts early and gets worse over time.
Over the last few years ADHD has developed a high profile, and many misconceptions connected with ADHD have surfaced. The most widely held, and the most alarming, is the belief that children will outgrow the disorder. For example, if a child is physically aggressive at the age of two, a well-meaning pediatrician might tell his parents, “He’s just being negative and oppositional because he’s going through the terrible twos.” A year later, when that same child is even more badly behaved—more aggressive, more unpleasant, more active and inattentive—the pediatrician may well stick to his original interpretation: “He’s immature,” he might say. “It’s the terrible twos at three. He’ll outgrow it.” Three years later the child is six and in first grade, unable to stay in his seat and driving everyone crazy with his antics. Not only has he not outgrown his symptoms; things have gotten a lot worse.
Some children do leave the symptoms of ADHD behind once they reach puberty, but that fact doesn’t mean that this serious disorder should go untreated for ten years. If ADHD is ignored, a child may well end up going through puberty with rotten grades, no friends, and a terrible attitude. Studies have shown that more than half of all kids with ADHD will continue to have difficulties associated with the disorder as they get older. The most common problems are continued inattention, impulsivity, restlessness, learning difficulties, poor social relationships, and low self-esteem. The high school dropout rate for kids with ADHD is more than 12 times that found among high school students without ADHD. Further findings suggest that youngsters with ADHD who are aggressive in childhood are more likely to show antisocial behavior during adolescence and adulthood.
As far as I’m concerned, whether a child outgrows ADHD is beside the point. The point is that every child should be given the chance to enjoy school, to be liked by his parents, and to go to his friends’ birthday parties—without his mother or father. Children who can’t pay attention to their studies, who spend their childhood being yelled at and considered stupid, lazy, or just plain bad by family, friends, and teachers are not getting the start in life that they need and deserve.
THE SYMPTOMS
There are three different types of ADHD. The first type, and the least common, features behavior that is predominantly hyperactive and impulsive, characterized by fidgetiness and restlessness. (Theo, back at the beginning of this chapter, has this type of ADHD.) The kids in this category are the ones who can’t wait in line, have trouble remaining seated, and are likely to blurt out answers in class.
The children with the second type are predominantly inattentive, distractable, and disorganized—ADHD without the H, hyperactivity. Children with ADD make a lot of mistakes, often forget or lose their possessions, daydream, procrastinate, and fail to complete their work. (Peter, the boy who’s always getting lost on the soccer field, falls into this category.) They may be impulsive, but they’re not as active as the first type, so ADD is somewhat more difficult to diagnose than ADHD. Children and especially adolescents with ADD (no hyperactivity) may be perceived as lazy, willful, frustrated, and academically limited. Parents often describe children with ADD as charming in two-way conversations with friends and family but “a little off” in large groups. These kids aren’t disruptive, but they miss social cues and often seem out of step with the rest of the world. These kids may get by in elementary school, but the increased demands of junior high usually bring about their downfall.
The third type of this disorder—and the most common form—combines the symptoms of the first two, hyperactivity and inattention. Nicholas, alias “Sweet Destructo,” falls into this category.
One mother of two children has two types of ADHD in her own family: a son, Carl, who’s 11; and Amy, a daughter who recently turned eight. Both kids are in treatment now, but their mother, a schoolteacher accustomed to observing and reporting on the behavior of children, remembers very well what it was like in the bad old days. Here’s how she describes the differences in their behavior before they started their treatment:
“You’d never know they have the same disorder. It manifested itself so differently. Carl was impulsive but not hyperactive. If he saw something he wanted, he would just get up and help himself to it, without any thought for the consequences. With other children, if you say ‘don’t,
’ they don’t. If I said ‘don’t’ to Carl, he did anyway. It was almost as if he didn’t even hear me. He was always getting himself into awful situations. He was easily distractable, but periodically he could get it together and seem fine. Amy was much more hyperactive. Even when she was really small, she went nonstop. If I didn’t bolt the front door, she’d fly outside and into the street. When she was two years old, she climbed up the drawers of the dresser to reach something. Of course, the dresser came over on top of her, and she ended up in the hospital. Carl was afraid of a lot of things, so he was usually safe, but for a while my husband and I lived in terror because we just couldn’t seem to keep Amy safe. If we didn’t watch her every second, she’d run out into traffic. I’ll never forget the day a photographer asked me if Amy, who’s a pale blonde and very pretty, would be available to do some modeling. I had to laugh. I said, ‘Go ahead if you want, but I doubt you can get her to stand still long enough to take a picture.’”
Carl and Amy’s mom is right: ADHD doesn’t look the same on everyone. It’s the class bully who punches the other kids, grabs their books, and steals their cookies at lunchtime. It’s also the “nerdy” kid who always seems out of it, the one who forgets to do his homework or loses it on the way to school and never even realizes that his shirt isn’t tucked in. It’s the little girl who can’t swim but keeps jumping into the pool anyhow and the pre-kindergartner who shouts profanities at his teacher. It’s the child at the carnival who gets so stimulated that he moves from one ride to another without ever settling on anything.
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