Part II In Part I we described the symptoms of attention deficit disorder, along with some problems of diagnosis and theories about its origins. In this part we discuss how it is treated and the best way to cope with the symptoms. 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 patients 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. The drug is started at a low dose that is gradually increased if necessary; parents can make adjustments according to the 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 experts 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. Several other kinds of drugs are also used in treating ADD, especially when the patient does not improve on stimulants or cannot tolerate their side effects. Beta-blockers such as propranolol (Inderal) or nadolol (Corgard) can be prescribed along with (or occasionally instead of) stimulants to reduce jitteriness. Tricyclic antidepressants, especially desipramine (Norpramin), are sometimes effective at doses lower than those used for depression; their most serious potential side effect is disturbance of heart rhythms. Another drug occasionally prescribed for ADD is clonidine, which is ordinarily used to lower blood pressure and suppress tics. Its most common troublesome side effect is drowsiness. Most of these drugs alter the effects of one of the catecholamine neurotransmitters, norepinephrine or dopamine; either the transmitter's rate of release or reabsorption is changed, or the brain's sensitivity to it is affected. Neurons that produce these transmitters are located in the RAS and nucleus accumbens, among other regions. Although brain systems using catecholamines are clearly essential for the regulation of attention, the precise way they work is not yet understood. The effects of stimulant drugs were once described as "paradoxical" because they seemed to make children with ADD calmer rather than more active. The paradox, if it is one, is not confined to people with ADD, since low doses of stimulants have been found to improve concentration and reduce restlessness in most children. 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 solid evidence that their schoolwork improves 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. Far from becoming addicted to stimulants, children and especially adolescents with ADD are often reluctant to take the drugs 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. In one study, 20% of hyperactive children who had agreed to take drugs for a year stopped by the fourth month, and nearly 50% by the tenth month. Another study found that only 22% of children given prescriptions for stimulants continued to take them for as long as two years. 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 excluded. 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. Getting reassurance 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. (It is often best to ask children to talk not about themselves but about their reactions to other people's complaints.) 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. Some therapies work on the assumption that ADD patients have an inadequate sense of the past and future and must learn how to anticipate the consequences of their actions. Group therapy is often helpful, not only for mutual support and exchanges of advice, but because group meetings are a laboratory in which the situations most troublesome for these children can be recreated and they can see in others what they have not been able to see in themselves. Children 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. It may be necessary to ask them repeatedly what they have just done, how they might have acted differently, and why others react as they do. Especially when young, these children 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. Other children in the classroom may show more tolerance if the problem is explained to them in terms they can understand. 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 may be useful to prevent a particular kind of aggressive or disruptive behavior that occurs in a few specific circumstances, 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. Some behavior therapists have added cognitive techniques designed to change self-defeating thoughts, with inconclusive results. 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 his excuses or believe in his 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. Role-playing may help a child with ADD to see how others see him. Family therapy or counseling, parent groups, and child management training are sometimes 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. It may help to list complaints and recommendations and set aside time to spend together, scheduling it if necessary. The effectiveness of treatment for ADD is difficult to judge. Patterns of change vary greatly and unpredictably with both drugs and psychotherapy, and there are uncertainties even in the standard measures of outcome; for example, some studies suggest that a child's own feelings about himself, observations of his behavior, and the judgments of other children about him do not change in the same ways or at the same time. Another problem is that the available studies are mostly short-term, although the issues are long term ones. Researchers may never know whether childhood drug treatment has lasting effects, since assigning children at random to a drug or a placebo is no longer considered acceptable. Treatment may become more precise and reliable when the diagnostic standards for ADD are refined and subtypes are differentiated through the study of genetics, family histories, responses to drugs, neuropsychological tests, and the associated learning disabilities and antisocial behavior. Resources The following are sources of information and referrals for people with ADD: Children and Adults with Attention Deficit Disorders, 499 Northwest 70th Avenue, Suite 308, Plantation, FL 33317; Tel: 305-587-3700. National Center for Learning Disabilities, 99 Park Avenue, New York, NY 10016; Tel: 212-6877211. Attention Deficit Information Network (AD-IN), 475 Hillside Avenue, Needham, MA 02194; Tel: 617-455-9895. For Further Reading Edward M. Hallowell and John J. Ratey. Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood Through Adulthood. New York: Pantheon Books, 1994. Paul Wender. The Hyperactive Child, Adolescent, and Adult. New York: Oxford University Press, 1987. Russell Barkley. Attention Deficit Hyperactivity Disorder: a Handbook for Diagnosis and Treatment. New York: Guilford Press, 1990. � President and Fellows of Harvard College, 1995. Reprinted with permission. Internet Mental Health (www.mentalhealth.com) copyright � 1995-1997 by Phillip W. Long, M.D.

 

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