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Sunday, October 4, 2015

What Causes ADHD and How to Treat It

  Many mental health researchers claim that ADHD is caused by genetics or chemical imbalances; many others consider ADHD to be a developmental disorder, caused either by some unknown, abnormal developmental process or a delay of unknown origin. According to the National Institute of Mental Health (NIMH), the cause of ADHD is unknown. The psychiatric manual used for diagnosing mental illnesses (DSM) does not attempt to explain the cause of any mental disorder. However, psychiatrists assume that all disorders are caused by biological problems - scientific data notwithstanding - which is why psychiatrists have "a drug for every symptom."

     Psychiatric** (biological) explanations for the cause of ADHD are the most well-known. This is not because there is more or better scientific evidence for a biological hypothesis (e.g., low dopamine or frontal lobe dysfunction). This is because of pharmaceutical companies promoting ADHD as a biological disorder in order to sell their products. ADHD drugs are some of the most commonly prescribed and profitable drugs on the market. They are easy to produce and because they are re-branded every five to seven years, they are patent protected. This allows them to maintain their "blockbuster" status (see example newsletter regarding Shire pharmaceutical drug Vyvanse: 

Shire pharmaceuticals slightly changed the chemical structure of amphetamine in order to acquire a patent, but it is nearly the same chemical found in "meth" - just time released through the liver. Similar tactics are used with other drugs. For example, Nexium is the same molecule as Prilosec; the molecule is just reversed (mirror image).
The subjective experience of using Meth is nearly identical to Adderall when snorted. Adderall addiction has become a serious problem in the United States. Many teens buy and sell Adderall prescribed to them for ADHD.

    Like many therapists (and parents and teachers), I don't believe in a biological cause for ADHD. That's because of the lack of scientific evidence against biological causes for behavior problems; it's also because there is so much scientific evidence showing that behavior problems are affected by environment, and it's also based on my own 15 years of clinical experience.
     There are correlations between genes and ADHD, but these correlations are either weak or very weak (.25 linear coefficient correlation). However, all correlations between brain "chemicals," and brain anatomical differences and mental health are weak, inconsistent, or spurious. Most studies of these issues have not been reproduceable. Personality theories (trait theories) that suggest ADHD is made up of one or more personality traits suffer from the same weak genetic correlations. Research into personality traits shows environmental correlations to substantially greater than genetic correlations (e.g., typically environment=~.75 v. genetics ~.25). 

Watch this video (it's funny but true) about pharmaceutical corporations and how they manipulate you and doctors into taking ineffective and potentially dangerous drugs:

     Psychiatry is largely a failed branch of medicine. It has not developed more than a few, significantly effective advances in the treatment of common mental illness, and peaked in the 1960's. All the effective drugs are best for short-term use. Nearly all drugs since the 1960's are replications of older drugs or of other newer drugs, and it turns out that SSRI medications are no better than placebos. That may come as a surprise, but that's what about 200 years of review and research shows. In fact, psychiatry's incessant focus on biological causes of mental illness has diverted attention from significant and treatable social and environmental factors. 
     This problem continues, but research on the relationship between environmental factors and mental illness has shown that environmental factors are much more significant than biological factors. Medication treatments have detrimental long-term mental and physical side effects; they lose their effectiveness over time, and for most people who take them, they offer absolutely no improvement in their condition. Some drug treatments are so dangerous, they are not worth trying. Other drug treatments - like sleep medications and anti-anxiety medications - are very addictive. Many of the drugs offer a very painful withdrawal period that some people find intolerable.

     Psychiatry's ignorance towards environmental factors is, in part, political. Most psychiatrists do not want to point out that the causes of ADHD, depression, or anxiety are mostly related to problems with life stress, violence, and socio-economic status. But psychiatrists benefit from life's misery; the most egregious example is the re-labeling of bereavement as depression which can then be treated with drugs. The list of examples like this is long, but the solution to all of the problems identified by psychiatrists is - surprise! - more drugs. Then there are other drugs to take to manage the side effects of the initial drugs. One client recently complained how she went from having no medications on her vanity to four in one month's time: one for anxiety, one for depression, one for insomnia, and one for constipation. With psychotherapy, she's been able to be medication-free.

     Normal developmental processes of Boyhood and childhood have been re-labeled ADHD; shyness, social anxiety; moodiness, bipolar. The criteria for mental illness have become so vague and broad that 50% of population can fit into it. Bipolar has more than doubled; but from the standpoint of pharmaceutical corporations, that just means larger markets:(1., 2.,, 3., 4., 5.

     Today, 1 in 5 adult women is using chemotherapy for depression (Prozac, Lexapro, Abilify, etc...). These drugs are not without harm. Many women will experience complete loss of sex drive, which may harm their marriage; many will gain 20 to 40 pounds in weight, hurting their self-esteem; they may experience increased risks for bleeding and further loss of bone density, just to name some side effects. Unfortunately, only about 1 in 7-8 who take antidepressants will benefit, but that benefit is no more effective than an active placebo (e.g., Benedryl) for nearly all persons who take them.

    The most common drug use problem in the last 10 years are prescription drug abuse. Mostly from Adderall, Oxycontin, and Xanax, but there are many others. Unfortunately, drug companies recognize the massive abuse of these drugs and are working to make more street drugs and club drugs available for prescription, such as Ecstasy and Ketamine. The pattern is always the same: drug companies make a class of drugs, sell them for years, the research finally catches up that the drugs don't really work and probably cause more harm then good, in the meantime, a new set of drugs hits the market, and the drug companies finally admit that the old drugs were ineffective, but only compared to the new ones. You can easily find examples of this when Haldol was replaced by Risperdal or when Elavil was repalced by Prozac. 
     It's easy to find articles almost daily about how Ecstasy and Ketamine are the new miracle cures for PTSD. Veterans are yet another vulnerable population that will be targeted with these drugs, and like Adderall, Xanax, and Oxycontin, they will just end up being abused and destroy more lives.
     You might say, "The FDA will make sure this doesn't happen," or "Doctors learned their lesson with Oxycontin." However, the FDA now approves about 95% of all new drugs and will probably fast track Ecstasy (Molly) "to help these veterans who are suffering from PTSD," And, physicians clearly have not learned from their mistakes with Oxycontin, or Adderall and Xanax. We continue to see excessive and careless prescriptions of these drugs to teens and adults.  

But what is the cause of ADHD?
     The cause of ADHD is complicated. Please be aware that all syndromes in the DSM are syndromes with no ideas of cause or treatment. It is unlike any other medical book you'll find. 
     Also, keep in mind that ADHD is a behavioral syndrome and that the implication is: if someone has these behaviors it must mean that they have trouble paying attention. But behavior is vague and any one behavior can have many causes and reinforcers.
     Like most mental illnesses, ADHD is caused by a combination of many factors that work together over time to create the behavior symptoms that make-up the of ADHD. But, for many cases, understanding the cause of ADHD is not as complicated as you might think; yet, in other cases, it can be very difficult to understand the cause.

I have yet to work with one child who "needed" medications to treat his ADHD. All of the children I have worked with over 15 years could have or did resolve their problems using psycho-therapeutic techniques and recommended changes to their environments. 

Adderall is so widely abused by Americans
that it has become a not-so-funny joke. Americans have about the
same rate of ADHD diagnosis as European countries, 
but Americans consume about 75% of all ADHD drugs.

Here are some examples of kids that I have worked with over the years who had been diagnosed with ADD/ADHD and came to therapy for help since the medications were not working or because the parents did not want to use medications (these examples are not in any type of order and since identifying information has been changed, any similarity to a specific individual is purely coincidental; I don't necessarily go into the actual case details, but rather I summarize the primary causal factor of the ADHD behavior problems and interventions):

Case #1. Primary problem: Corporal punishment.
       I've had many cases where the primary causal factor for the ADHD syndrome was chronic corporal punishment. Close to 95% of all studies on corporal punishment show a correlation between spanking and childhood anti-social behavior; one sign of anti-social behavior for children and teens is poor academic performance. This issue is almost always overlooked by mental health providers. The two problems (hyperactivity and poor academic performance) need to be related to the same cause. Between 40% and 60% of American parents use corporal punishment (spanking, hitting, slapping, pushing, punching, pulling hair, pinching, kicking, and many others - "hot sauce" on the lips, , twisting arms or legs, etc.). Given the high correlation between corporal punishment and anti-social behaviors, and how common it is in the U.S., I suspect that corporal punishment is a primary or secondary factor in at least 50% of all cases of ADHD (ADD). Strangely enough, there are very few studies evaluating the link between ADHD and corporal punishment. Studies on the effects of corporal punishment focus on anti-social behaviors and negative outcomes (unemployment, teen pregnancy, and others). Hopefully someone will study the link between CP and the ADHD construct.** On a side note, the category of behavioral symptoms of hyperactivity may be present with or without poor academic performance. The popularity of corporal punishment might have discouraged research on the issue.
       One of the first questions I ask parents is, "Do you use corporal punishment?" It's like asking someone with a cough, "Do you smoke?" The first recommendation is to stop using any form of corporal punishment. There are always secondary factors along with usually one or two primary factors. The cessation of physical punishments alone can be very effective, but the negative behavioral effects of corporal punishment can last a long time. However, parents are required to react to their child's behavior problems using other techniques. Over time, the "defiance" alleviates, and as pro-social behaviors are reinforced, the parents bear witness to a "new kid." The severity of the school behavior problems seems to correlate well with the intensity of corporal punishment. For example, a child who is punched or pushed or pinched hard will probably display worse behaviors in school than one who is spanked with an open hand on their bottom.
       The type of anti-social behavior will manifest differently from one child to another. But since ADHD is an incredibly vague behavioral syndrome (it's like an astrological reading), almost any behaviors can be plugged into it, especially childhood behaviors. Some children will act out more than others, and if they are expressive to begin with, they may be more likely to hit other kids, while introverted children may be more likely to "forget their homework." Children who are hit by their parents are in a position where they cannot, or usually will not, direct their anger at their parents for being hit. So, over time, they may start to act out their anger at school, with peers or teachers. Their behavior can appear inexplicable, irrational, or impulsive, but from a child's world-view, it makes perfect sense to cut off your nose to spite your face when you have no other options for expressing anger and frustration at your parents.
       The very high rates of "co-morbidity" of ADHD with other disorders, especially Oppositional Defiant Disorder, is to be expected when the cause of anti-social (ADHD) behaviors is explained as a child's reaction to corporal punishment. Another interesting finding in the research on corporal punishment is how the anti-social behavior is more noticeable among white male children compared to other sub-groups. For more information on this issue, please read
       Many parents who use CP are also victims of domestic violence, either from their own parents, or currently from their spouse, most often the male (~95%). A small percentage of women are perpetrators of domestic violence, but most are men, and these men will often abuse their children and pets. Other problems are usually present, such as addictions or personality disorders, such as narcissism.

Case #2: Primary problem: Marijuana abuse.
       This issue is more common for teens, ages 14-18, but I've seen it as young as 12 and in college students as well. Marijuana will likely cause ADHD in nearly all individuals who use it, depending upon frequency, dose, and intensity. Since marijuana is unregulated in most places, it is also probably adulterated with chemicals like formaldehyde or other drugs that can cause additional types of cognitive dysfunction. Marijuana also causes short-term memory problems, but since it has a spell-binding effect, the users often "feel fine," or even "better than usual." I am always amazed at how drug users are unable to see their own decline in functioning. Marijuana will cause a loss of motivation in most users, too. Most of them will become like the proverbial lotus-eaters, satisfied with sitting around getting high and not doing much else.
       Teens will blame their newly dysfunctional attention span, memory problems, and loss of motivation on ADHD or depression. It is possible that marijuana may permanently alter the neurological development of teenage users. For teens who are prescribed Adderall or other amphetamines or stimulants, they can sell it to other teens for $20 per pill and use the money to buy more marijuana. Some will just end up abusing the amphetamines or stimulants when they can't find marijuana, taking 2-3x the prescription dose, while others will combine the ADHD drugs with marijuana for enhanced highs.
       Marijuana is a complicated drug, affecting nearly all microcircuits in the brain. As research on the effects of marijuana continue, it's becoming clearer that teens should not use any marijuana due to the risks. Another problem with marijuana is the dosage; in 1980, the average "joint" contained about 2mg of THC, and now the average joint contains about 20-30 mg. It's not the same drug it was in 1980.
       We don't have to get teens to admit to using in order to get them to stop. Parents are usually willing to do weekly to bi-weekly random drug tests and test for other drugs as well. Cheap 6 or 10 panel drug screens can be purchased online along with cups for quick reads here: If they refuse the test or test positive, then they are given restrictions, punishments, or referred to some form of drug treatment.*** Some teens like having the excuse for their friends, "I can't smoke weed anymore because I'm getting tested all the time." To their shock, they usually lose those so-called "friends," who get tired of hanging around a kill-joy, and after a month of being sober, many realize how much it was negatively affecting them. 
       Some teens need longer-term therapy because of a deeper addiction and more serious parent-child relationship problems. For example, many teens who use drugs are also getting abused or neglected by their parents. In general, the worse the child's symptoms, the worse their home environment; that's not true for all cases, but I find it's true for many. But, again, there are many factors that contribute to these behaviors; getting stuck on one label like ADHD over-shoots the breadth and depth of the many factors that cause human behavior problems.

Case #3: Primary problem: Absence of father. (Dr. Peter Breggin refers to ADD as the "Absence of Dad Disorder"
       John and his father were close until he was 10 years old. He wanted to stop playing football because he was scared of getting hurt. His dad called him a sissy for it. He felt like his dad hated him. John's dad would only spend time with him if John would do what his dad wanted to do, never for something that John wanted to do. In short, John felt hated and rejected by his dad; in some ways he was. When John was 12 and 13, his dad started spending more time at work, getting home at 7 or 8 pm. John was angry and frustrated with his dad, but he never told him how he felt, and more importantly, Dad never asked. John thought that this meant his dad didn't "care enough to ask how I felt about anything." 
       As he entered 6th grade, his school performance slowly declined. He started getting B's, then C's, and missing assignments. His parents reacted with yelling, criticism, and punishments like grounding - sometimes for months. These negative reactions by his parents led to John feeling even more hated, which led him to act out, becoming more careless at school. To "hate school" was his way of acting out his frustration and anger at his dad, and now his mother, for yelling at him and not caring about how he felt. What John saw were two parents who only cared about school and didn't care about him. When I met John, he had been on Ritalin, Focalin, and had tried Adderall. None of these medications were helping him perform better in school, but the parents kept him on them anyway. "We don't know what else to do, and we figured it's better than nothing."
       I explained to the parents that I prefer to work with people who are not taking any drugs prescribed by a doctor or by themselves (many people take over-the-counter or "natural" drugs, which are just a waste of money but often promoted by book sellers like Dr. Daniel Amen). In this case, the parents agreed to talk with his doctor and ween him off. I recommended no punishments, no yelling, and no criticism. I also recommended that John's mom and dad take turns doing homework with him each night. Even if he didn't ask for help, I recommended that they just sit there with him. I also suggested that Dad start spending time with his son on a regular basis doing whatever his son wanted to do. Dad had difficulty with that at first, saying, "I don't like video games, I don't like checkers or board games." I explained to Dad the need for his son to feel loved by him, that relationships can't be a one-way street. 
       It took a little time for John to get over his anger at his dad. Some sessions where John was able to express his anger at his dad without his dad being defensive, but instead apologetic, were very helpful. In a matter of a few months, his grades improved back to A's. He was no longer depressed, and his self-esteem was dramatically improved.

Case #4: Primary problem: Neglect.
     Many parents ignore their child's attempt for connection and positive interactions, labeling them as "annoying," "attention seeking," "rude," or "interrupting." These parents are misunderstanding the basic relationship needs of their children. Since most children cannot articulate their needs, but instead act out, they are either punished or ignored. The escalation of behavior problems further erodes the child-parent bond, leading to more behavior problems, more punishments, and so on.
     As with children who experience corporal punishment, neglected children often experience emotional ups and downs, from frustration to sadness and anger to apathy. Again, one way children act out their anger is by avoiding homework or not turning in assignments. ADHD medications will not improve academic performance in children who are not motivated to do homework or learn; the essence of ADHD is that it is a motivational problem. Kids don't want to do the "right thing," and there are many reasons why.
     In this case, passive-aggressive behavior is an expression of frustration and anger - it is the child reciprocating rejection. This is a form of oppositional behavior. Close to 1/3 of children diagnosed with ADHD also meet the criteria for ODD (Oppositional Defiant Disorder). Kids know that homework is important because the parents will yell at them to "get busy," and "turn in your assignments!" So, what better way to get back at parents by hating school?
     I often meet children and teens who lack any interest in school. They seem to lack even a basic understanding of why they go to school, and they feel about homework the same way they feel about making their bed - bad. At home, they have a history of being neglected by their parents, either academic neglect, social neglect, or both. Kids that are neglected socially by their parents often have other behavior problems, too, like over-eating, probably to alleviate chronic feelings of emptiness directly related to the emotion of sadness from parental rejection.
     Academic neglect is a common problem that seems to be passed down. The child's parents did not learn from their parents how to effectively relate to their kids in order to instill a positive attitude toward homework and provide meaning for homework in the large picture of the child's life. From the very start, the child associates homework with loneliness, boredom, and other negative emotions from arguing. In effect, these children are being raised to be low-wage workers or "lost" children with no direction in life.
         Neglectful parents are often narcissistic, too busy or distracted by their own wants rather than putting their child's needs above theirs. I often meet parents whose unrealistic expectations for mature and independent behavior are based upon their own selfish desires to have more free time and not be bothered by their kids; they actually encourage their child to play alone or allow excessive amounts of TV or video games. This is sometimes referred to as covert narcissism. There may be no overt signs of neglect or abuse, like starvation or broken bones, but the emotional, social, and academic neglect ‘ present and the child is blamed for it: "he (or she) has ADHD.... let's put him on meds."

Case #5: Primary problem: Stress.
        ADHD symptoms are often related to stress. The primary examples are children and teens whose parents either allow them to partake in most every sport and activity they wish or push them into too many activities in order to keep-up-with-the-Joneses. Conventions like travel-sports are a complete waste of time, money, health, and hope for probably 90% of the kids enrolled - and the cost related to lost time for family bonding, injuries, promoting childhood narcissism, and increased stress is just not worth it.
         I've met kids who are involved in 1-2 activities in addition to honors classes. Parents often tell me, "I heard that to keep your kids off drugs, you should enroll them in sports." This idea is used as a selling point by everyone from coaches to karate and dance teachers. However, it's completely false. There is no cause and effect relationship between sports and drugs. In fact, at this time in American history, sports involvement will probably predispose your child to early alcohol use, opiate abuse, and amphetamine abuse. About 75% of heroin users start the addiction process after being prescribed OxyContin (Percocet, etc...) from a medical doctor who stupidly and unethically keeps prescribing the drug for more than a week (they probably shouldn't prescribe it to a teen to start with due to their susceptibility to addiction compared to adults anyway).
      Other kids will abuse Adderall and other stimulants in order to improve their performance. In fact, Adderall is the most commonly abused amphetamine in the US - Major League Baseball players are among the most common abusers. Finally, about 40% of American parents drink alcohol on a regular basis, and many of these parents model drinking at their kids' sporting events. So, the association between drinking and sports isn't just the beer commercials.
       Stress contributes to attention problems directly and indirectly, because the effects of stress are so broad. When kids have too much on their plate, they just won't have enough time or energy to do it all. Homework often comes last. As kids get older, they're more prone to taking short cuts and procrastinating. I'm amazed at how parents seem oblivious to these problems; in some cases, I've known parents who later admitted to knowing their kid was cheating on homework assignments, or doing their kid's homework, so that they could continue two- hour practice sessions four or five nights a week.
       Stress has more than one meaning. Another word for stress is demands; the more demands kids have, then the more stress hormones they produce. These stress hormones contribute to racing thoughts, impulsivity, hyperactivity, distractability, and other problems that are easily labeled as ADHD by uninformed parents and careless psychiatrists.
       The real solution to the problem is to lessen the child's stress or demands and think long-term. What's in my child's long-term best interests: learning to play baseball and playing high school sports or having a healthy body and a solid education? Some parents believe that their child will end up playing professional sports, although the odds of this are about as low as winning the lottery. Some parents bask-in-reflected-glory of their kids' success. They want to say, "That's my kid out there making great plays." It feeds the parent's narcissism or nostalgia, but at the cost of the child's well-being. Not all parents are like this, but many are, and it creates a lot of stress for the kids.
      Some kids are honors students who are anxious due to demands and worries related to perfectionism and over-achievement. These kids will often report distractability, insomnia, hyperactivity, and other problems and again, because the ADHD syndrome is so incredibly vague, they are often misdiagnosed. I've known some parents who are happy to put their kids on ADHD drugs out of fear that they'll fail out of honors classes if they're not given this performance edge. Many kids with anxiety will see no difference on ADHD drugs, and many will become worse.

Case #6: Primary problem: Trauma.
     Some kids have been through traumatic events that cause anxious or depressive reactions that underlie behavior problems and lack of interest in academics. How can we expect a traumatized kid to be interested in school when they're too busy worrying about issues of life and death, or dissociating much of the time in order to cope with memories of trauma?
     I once worked with a boy and girl who were victims of a home invasion where the family was held hostage for a month by two criminals. The horrors that ensued were unfathomable, and the personal consequences are still being realized by each of them 14 years later. Not only was their interest in academics completely diminished, but also their cognitive abilities were impaired, such as memory and impulse control. This is probably the most extreme case I have known. However, trauma does not have to be that severe to have a serious impact on academic motivation. Kids who have experienced trauma will almost always have some hyperactivity.
    Trauma is complicated because it is subjective. Some kids are more easily traumatized than others; some are able to cope better than others. I've worked with some children who were traumatized by a parental illness or sibling illness, or by their own serious illness - even a serious asthma attack can lead to preoccupation with sudden death and serious anxiety. Sometimes a response to trauma is confused with OCD, or sometimes the response is the development of OCD. OCD can underlie academic performance problems and behavior problems. 
    When a child witnesses injury or death, then it may be necessary to monitor them for a while for signs and symptoms of childhood PTSD, depression or anxiety. Bringing children to therapy too soon after trauma can actually lead to PTSD rather than prevent it. However, a mental health evaluation after trauma is probably a good idea.

Case #7: Primary problem: Sleep.
     Kids just aren't getting enough sleep these days. I've met many kids where sleep was a primary problem. In fact, it is one of the first things I will assess for nearly everyone who comes in the door. Sleep is probably the single most important activity we do every day, and not getting enough of it can lead to problems with memory, attention, distractibility, general health, longevity, growth, and rebound from stress, depression, and other issues. In fact, if a sleep problem is present with someone who complains of having ADHD, I recommend not doing other primary interventions until they fix their sleep problem.
     The issue is that so many Americans are just not willing to fix their sleep problem. We have overloaded schedules, and the late hours of the night are when adults have time to themselves, and this is true for many teens, too. People would rather sacrifice sleep for leisure time, not realizing that if they had better sleep, their quality of life would be a remarkably improved. They would also probably work more efficiently and effectively, make better decisions, be less impulsive and less irritable, and in the end, they would probably have just as much leisure time earlier in the night.
     Chronic poor sleep in childhood and teenage years may even lead to problems with neurological development and be a causal factor for depression and anxiety disorders in young adulthood. The presence of stress hormones for such long periods of time, over the course of years, combined with not enough restorative sleep, along with other factors (e.g., drug use), may contribute to more serious mental illnesses like Bipolar disorder or Schizophrenia.

Case #8: Primary problem: Anxiety.
     If anxiety is present along with concerns about attention problems, then it's important to address anxiety first. Anxiety is the excitation of the central and peripheral nervous system (sympathetic nervous system, which is part of the autonomic nervous system). It's a normal process that people find distressing, and it can be distracting. I think that anxiety problems are one of the leading causes of distractibility for children, teens, and adults.
     Anxiety has four non-medical causes, and worries and demands are the two primary causes for non-medical anxiety. Most people who complain about anxiety are not experiencing anxiety related to a medical condition, like hyperthyroidism, but instead are suffering from typical mental causes for anxiety.
     Anxiety doesn't just impact your ability to pay attention; it will also cause fidgetiness, restlessness (restless leg syndrome), and "hyperactivity," in children, all of which is easily misunderstood as ADHD.
     Treating someone for ADHD when they are suffering from anxiety will often lead to an increase in anxiety symptoms, like hyperactivity, or even trigger a manic episode. This is because the nervous system is already over-stimulated, and medications commonly used for ADHD are causing further autonomic arousal. It's common for people to have elevated blood pressure, body temp, and heart rates when they take ADHD medications; this effect is more noticeable with Adderall or other amphetamines.

Case #9: Primary problem: Math / Math teacher.
     One child I worked with was diagnosed with ADHD by his pediatrician and given Concerta. His parents brought him in because his math grades became worse when he was treated for ADHD, when they expected his grades to improve.
     I explained to the parents something that most people find confusing, that ADHD medications will not cause improvement in academic performance. When I explained why, the parents understood, and this led the parents to finally ask, "What's causing him to do so poorly in math when he used to do so well and he does well in his other classes?"
     When I reviewed his symptoms that led to his diagnosis, it was clear to me that he had been misdiagnosed and mistreated. Kids can have trouble paying attention, but if they're functioning within a normal range, then they do not have ADHD. Also, poor performance in only one class is not symptomatic or an indicator of ADHD. In addition, a decline in performance is generally not considered an indicator of ADHD, especially when it's so specific to one class, and at his age.
When I interviewed the child, he had many complaints about his math teacher, including not feeling liked by her, feeling like she moves too fast without explaining things, and he said she seemed like she had favorites in the class. I explained to the parents how these feelings can lead to motivational problems that will undermine performance, as well as lead to the presentation of hyperactivity in the math class. For example, most children will experience anxiety from worrying about performing poorly in class; the anxiety will be amplified by other negative feelings, like anger at the teacher for treating him unfairly (perception or not), and frustration for not being able to improve his performance.
     The parents were dismissive of their child's feelings and saw them as excuses at first, but a family friend suggested ADHD and medications like their son was taking. When I recommended a new treatment plan that included no medications, the parents were reluctant to change, but tried anyway. I recommended a tutor as well as Khan Academy with parental assistance. I also recommended a reward system for effort (not outcome), and that the parents at least affirm their child's feelings about the teacher, but then look at it as a relationship problem to be solved; this included a parent-teacher conference to ask the teacher to try to have more positive interactions and encouragement with their son.
In this case, the plan worked very well and the child was able to maintain his status in a higher level math class.

Case #10: Primary problem: Boredom; low frustration tolerance.
I have worked with many kids, mainly boys, who are just bored with academics. In one case, I found this young boy completely obsessed with video games to the point where he saw the entire school day as one giant obstacle to his ability to play video games. His excessive wanting of video game playing led to extreme frustration, which led to other behavior problems in school. When he was at home, he was fine because his parents were very permissive with video game playing, so at home he was happy - satiated.
Boredom can be the cause of serious behavior problems like poor academic performance and distractibility. Boredom is a form of frustration; the difference is that when you are frustrated, it means that you are having trouble getting what you want. When you are bored, you have to do something that you don't want to do. Most of the time, kids can manage their feelings of frustration in a school setting because of a high degree of social pressure, But there are always some kids, usually boys, who are more expressive and aggressive, and their frustration or boredom affects their behavior.
In this case, he was constantly in trouble, mouthy to teachers, talking in class, and in some cases, physical with other kids or would throw things in a rage. The frustration would pile up all day, not just about wanting to be home playing video games, but from the constant feelings of boredom that would escalate through the day. The more severe behavior problems were during gym and lunch, when many kids seem more vulnerable to blowing off emotional steam. 
     Teachers would unwittingly reinforce these behavior problems by taking him out of class to sit in a special room to vent his feelings, after the fact, or by sending him home several times a week, at which point he would be "perfectly behaved," playing video games.
     The parents were reluctant to give him any more medications; they had tried everything, even a neuroleptic, Risperdal, that can cause brain damage or other severe side effects (even breast development in boys). Nothing worked, but the parents reported that school staff was encouraging medications, which they're not supposed to do.
     Therapy for this child was difficult because his negative ideas about school were so entrenched, and those negative behaviors had been so poorly managed along the way. Behavior modification with some therapy was the combination that led to improvement, although slow. No medications were needed and therapy tapered down as his behaviors improved. Some time for developmental maturity also played a role in improved behavior. The parents agreed to use contingencies, for example, "If you don't act out in school, then you can play video games at home, and if you act out in school, then no video games at home," and this was on a day-to-day basis. It seemed to help more often than not. However, his academic performance did not improve much; this is because his ideas about school were intractable and the parents were not making the recommended changes at home that would usually lead to improvement in academic performance. 
     Kids have difficult managing their emotions, but as the grow-up, they tend to be able to contain negative emotions. In general, when kids feel good they behave good and when they feel bad, they behave bad (Adele Faber and Elaine Mazlish).

Case #11: Primary problem: Lead exposure or TBI.
Lead poisoning is a terrible thing to experience. Once a child has been exposed to lead, it can be difficult, if not impossible, to leach it from their system. By the time you see cognitive side effects from lead toxicity, it's usually too late to do anything except prevent further exposure. 
     Lead exposure is more common in older neighborhoods, both "rich" and "poor." When people are rehabilitating old homes, they may not take the threat of lead exposure seriously, but it is a very serious threat to cognitive development in children.
     I have only known one child who had lead exposure that may have caused cognitive problems. One difficulty with lead exposure is that some of the more serious behavior problems might not emerge until late teenage years; kids can become impulsive, violent, and are more likely to experience unemployment, incarceration, and drug and alcohol abuse.
If you have an older home, have the paint tested for lead and follow the guidelines for lead removal or management. There are some effective and affordable methods of dealing with lead, but for some situations, it requires removal of older doors and windows or replacing walls. The fine dust that is created from opening and closing windows is the primary way that lead enters the child's body; this dust will cover most of the contents of the home in a fine layer and might not be noticeable. It is inhaled and ingested.
     Another factor is TBI (Traumatic Brain Injury). Many people might skip over this one, thinking, "I've never had a TBI." However, if you've had a concussion, then you've had a TBI. A concussion is a Traumatic Brain Injury. TBI can be minimal, to mild, moderate, severe or profound. Most people think a concussion is not that serious as evidenced by the fact that kids were allowed to continue to finish a game after getting hit in the head. TBI or concussions are very serious, and the long-term effects of TBI are only beginning to be thoroughly researched. It seems very possible that concussions can lead to attention and memory problems, and worse, these attention and memory problems may become worse with age in some people; so, in other words, the concussion never fully heals and the damage continues.
     The risk of TBI is not limited to football players; soccer players who head-butt the ball, LaCross players who are hit in the head with a stick, hockey players who are hit by a puck, stick, or from falls, all experience some degree of TBI. The negative effects these concussions are not known because no one has studied children before and after, and over the course of time. In one study of professional soccer players, their IQ dropped nearly 10 points by the end of their career (it should of stayed the same or increased).

Case #12: Primary problem: Depression.
Children can experience depression. However, it can manifest differently than in adults. For example, children might be more likely to become hyperactive when depressed; that sounds counter-intuitive, but the same thing can happen in adults. The immaturity of the nervous system underlies this increase in hyperactivity, and it can easily be mistaken for ADHD. Another symptom with childhood depression is loss of motivation to do things that are important, like schoolwork. A decline in functioning is indicative of depression, not ADHD.
Again, ADHD is more likely to be present in kids who have parent-child, teacher-child, or other relationship problems where the symptoms of ADHD are the child's reaction to the relationship problem. The other primary cause of ADHD is just developmental delays that improve with time. As mentioned before, a child's attention span is brief, but academic and parental demands on children continue to increase. This combination is stretching their capacity to its maximum.
     Kids can have delayed depressive reactions to trauma, death of a loved one, or other situations, even moving to a new neighborhood and school. There have been many kids I have worked with over the years who have been depressed; their depression was misunderstood, misdiagnosed, and mistreated. Stimulants and amphetamines can alleviate feelings of depression, but there are many, potentially serious drawbacks to drug use, such as weight loss, stunted growth, cardiovascular problems, chronic depression later in life, psychological dependency on drugs, and other drug use.
Parents are often reluctant to acknowledge depression in their children, probably for many reasons. Many parents just fail to make connections between their child's depression and family issues, such as death of a parent or grandparent, domestic violence, the stress of dealing with the behavior problems, drug use, or disability of an older sibling, corporal punishment and other problems. Many mothers feel over-responsible and excessively guilty for not shielding their children from the emotional consequences of these problems. So to acknowledge their impact on a child, rather than minimize it or pretend it doesn't exist, seems common. 
     Family therapy, interpersonal therapy, and cognitive behavioral therapies work very well for addressing childhood depression. Other approaches, such as parent management training, can enhance the effectiveness.

    All too often I see physicians and psychiatrists (and parents) apply the diagnosis of ADHD based on the presence of "symptoms" of ADHD. This seems logical for the parents, but the problem is that symptoms of ADHD, for most people, are caused by social and psychological factors, not biological factors. To assume ADHD is caused by biological factors is nothing more than an assumption, since there is not a single biological test after over 100 years of psychiatrists trying to find one. In the meantime, not a week goes by where I haven't helped a child and family understand, manage, and overcome childhood behavior problems that are often called ADHD. When we work together, we can see the development of the problem and the causal factors become clear; at that point, the treatment becomes obvious as well. Some people struggle more than others, but persistence with the right techniques and approach tends to yield to success without any medications at all.

** ADHD (ADD) is a construct that means that it is not a true disease. In other words, ADHD is a label for an arbitrary group of behaviors, ironically, none of which have to do with attention span, per se. The assignment of some behaviors to the ADHD syndrome and exclusion of other behaviors is completely arbitrary and non-scientific. Read more here:

**Many people do not understand the differences between a psychiatrist, psychologist, social worker, counselor, or "psychotherapist." In general, psychiatrists are different from all other mental health providers because they usually only prescribe drugs (chemo-therapy), while the other professions only provide psycho-therapy. While psychiatrists are medical doctors who entered the simplest and most profitable type of medicine, psychologists, social workers, and counselors are all psychotherapists who provide the exact same types of therapeutic services (aka, "therapists" and this is used interchangeably with "counselor" by many). It is uncommon to find a psychiatrist who provides psychotherapy. Psychologists also conduct proprietary "psychological testing," whereas social workers and counselors usually use open-source mental health tests - both of which are equally reliable as screening for mental health problems, with the exception of IQ testing (which can't predict much of anything) and learning disabilities. All provider types are eligible to be licensed by states to diagnose and treat mental illness. Psychologists usually charge the most for the same service, even though there is no basis for the higher fees they usually charge other than professional self-aggrandizement. Also, the idea that psychologists should be referred to as "doctors" is unnecessary - all mental health providers are about as far from being a medical doctor as is an accountant, and having a PhD or Psy.D will not make someone a better therapist. What makes a good therapist, among other things, is a combination of broad and deep knowledge about mental health problems, the ability to form a connection with another human being, and the ability to effectively provide scientifically supported techniques.    

*** Be careful where you go for drug treatment. Since effective treatments for addiction are the same wherever you go, you may end up paying a lot more for amenities that are not necessary, like Zen gardens, nice furniture, and fancy meals. You probably will not find any information on the effectiveness of drug treatment programs, which calls into question the whole industry. For many people, one-on-one therapy is all that is necessary and effective, but some people need detox and inpatient. The primary intervention of inpatient treatment is prolonged abstinence from the drug, in order to give the person time to develop the insight and strength to resist the drug when they return to the community.

Mental Health Advice Disclaimer: The information included in this post and blog are for educational purposes only. It is not intended nor implied to be a substitute for professional mental health treatment or medical advice. The reader should always consult his or her mental health provider to determine the appropriateness of the information for their own situation or if they have any questions regarding a mental health or medical condition or treatment plan. Reading the information on this website does not create a therapist-patient relationship.

1 comment:

  1. ADHD children have their own mind and ideas which sometimes can deal to ADHD behavior problems.