Drugs for ADHD: Coursera ADHD Class Weeks 9 & 10

Drugs are one of the most common, if not the most common, treatment for ADHD. They can help individuals be more productive, calm, and in control of themselves, at least while the drugs are active. ADHD drugs are similar to prescription eye glasses. They help an individual function while they are in use, but they do not cure the underlying condition.

The Coursera class on ADHD takes the standard medical line that if used as prescribed and not abused, ADHD drugs, in most cases, cause no significant or long-term ill effects. Dr. Rostain cites statistics that stimulants are not over-prescribed for ADHD and that untreated ADHD leads to much worse outcomes than medical treatment of ADHD. Most studies on drugs for ADHD last just months, not years. Given that many individuals with ADHD take drugs for 5 years or more, and start at a young age, it is troubling that there aren’t better long-range studies on their effects.

Dr. Rostain covers many myths about stimulant drugs for ADHD. One stood out to me. The myth is that these drugs do not improve academic achievement. He states that stimulant treatment of ADHD improves work productivity, classroom conduct and rule-following, peer interactions, grades, and leads to reduced punishment, fewer days absent, and makes repeating grades less likely. So yes, on stimulants a child with ADHD will appear to be a better student and will certainly be easier for the teacher to have in class. Dr. Rostain didn’t mention that some studies have shown that psychostimulants have not been shown to achieve long-term positive changes in peer relationships, social or academic skills, or school achievement. He also did not mention that there is evidence that stimulant treatment of ADHD in juveniles can damage their developing brains. Long-term use of ADHD can also create a loss of motivation. Students, especially college students, may feel that their success is due to the drugs and a shift of agency may create a dependence on the drugs and low self-esteem.

There are three basic types of drugs used to treat ADHD: stimulants, non-stimulants, and antidepressants. Each affects the signaling of neurons in the brain in a slightly different manner and the lectures on them were too detailed to easily summarize. The comprehensive “What we know” brochure on Managing Medication for Children and Adolescents with ADHD from the National Resource Center on AD|HD is a good place to start. The last couple pages have suggested readings and then a handy reference chart for the drugs which includes the generic names, the brand names, the duration of action for each drug, the form the drugs come in, the dosage ranges, and the common side effects.

Even though there is a great deal of evidence that drugs can help treat ADHD symptoms in the short-term, they still carry risks. Risks that your pediatrician or health services provider may not mention. The best approach if you are considering ADHD drugs for your child is to learn all you can about the various drug options and then carefully, with the help of your child, monitor both the short-term and the long-term effects of any drug you give your child. Pay attention to both the physical side effects, such as stomach aches and sleep problems, and the more subtle psychological effects that may include decreased drive and motivation. Ask yourself, are you trading their initiative and innate personality for a child that is easier to live with and more compliant?

The Grown-Up Gifted Child

Recently I have been re-reading one of my favorite books on living with and raising gifted children, the award-winning, A Parent’s Guide to Gifted Children. Early in the book there is a table that lists, “Problems Associated with the Characteristic Strengths in Gifted Children.” As I was reading this list again I realized, I know these people. The funny thing is, they aren’t kids anymore.

When gifted kids grow up they don’t usually age-out of their gifted passions, strengths, intensities, and quirks. They may learn to act in a more socially acceptable manner and they, hopefully, gain a measure of perspective and self-discipline that they lacked as children. However, the essence of who they are and how they are different stays intact. One of the big arguments in favor of programs exclusively for gifted students is that they aren’t just bright. Their brains are wired differently and while, yes, they can complete typical school work at an accelerated pace, that isn’t what defines them. They are more passionate, sensitive, and intense. Merely completing the lesson plan isn’t enough. They want to go beyond the lesson plan, or alternatively, question its basic worth. They are more driven by deeper meanings and philosophical questions than other students their age. This can make them an under-achieving, dejected, argumentative, moody pain in the wrong classroom environment or the engaged, high-performing, thoughtful student in the right classroom environment.

The same is true once they grow up. Just look at the a few of the strengths and associated issues they can create as detailed in the book.

Strength Possible Problem
Acquires and retains information quickly Impatient with slowness of others; dislikes routine and drill; may resist mastering foundation skills; may make concepts unduly complex
Ability to conceptualize, abstract, synthesize; enjoys problem-solving and intellectual activity Rejects or omits details; resists practice or drill; questions teaching procedures
Enjoys organizing things and people into structure and order, seeks to systematize Constructs complicated rules or systems; may be seen as bossy, rude, or domineering
Thinks critically; has high expectations; is self-critical and evaluates others Critical or intolerant toward others; may become discouraged or depresses; perfectionistic
Creative and innovative; likes new ways of doing things May disrupt plans or reject what is already known; seen by others as different and out-of-step
Intense concentration; long attention span in areas of interest; goal-directed behavior; persistent Resists interruption; neglects duties or people during periods of focused interest; seen as stubborn
Sensitivity, empathy for others; desire to be accepted by others Sensitivity to criticism or peer rejection; expects others to have similar values; need for success and recognition; may feel different and alienated
High energy, alertness, eagerness, periods of intense efforts Frustrated with inactivity; eagerness may disrupt others’ schedules; needs continual stimulation; may be seen as hyperactive
Diverse interests and abilities; versatile May appear scattered and disorganized; becomes frustrated over lack of time; others may expect continual competence

In the work environment these possible problems can limit opportunities, cause issues with HR, and possibly lead to terminations. Perhaps this is why many gifted individuals become entrepreneurs. As their own boss they can find the best way to work with their strengths.

In relationships, when the innate characteristics of gifted boyfriends, girlfriends, and spouses go unrecognized, unrealistic expectations from both parties can poison the partnership.

Gifted individuals need to understand themselves and how they may differ from others at home and in the workplace. Self-knowledge of natural strengths and how they can become liabilities is essential to long-term happiness and fulfillment. This information guides the grown-up gifted child in working through misunderstandings and frustrations with their significant others, at home. At work, it enables them to increase their productivity, improve relationships, and perhaps even realize when their current work place is just a bad fit and it is time to move on.

Developing self-awareness in gifted students is one of the primary goals of quality programs for the gifted. It is also one that is virtually impossible to reach when gifted “programs” consist primarily of accelerated, in-classroom, differentiation. The farther away from the mean a student is, the more likely it is that her strengths will cause her issues at some point in her life. Gifted educators need to mentor their students on how to live in and thrive in the regular world as a highly, profoundly, or exceptionally gifted individuals.

Is it really ADHD? Coursera ADHD Class Week 8 – Assessment

More and more kids in the US have ADHD. This has led many to feel that we are over-diagnosing kids that have other issues, or are just a bit slower to mature, with a psychiatric disorder where none exists. Others argue that we are diagnosing and then medicating students whose only “disorder” is being anti-authority. It reminds me a bit of One Flew Over the Cuckoo’s Nest.

In his ADHD Coursera course, Dr. Rostain makes a strong point that the diagnosis criteria are solid and if applied correctly, will not over-diagnose ADHD. A complete evaluation for a child that shows signs of ADHD involves many steps, checks, and a full case history. Unfortunately, in most cases, this complete workup is not done because it is too time-consuming and expensive. Instead, a couple quick surveys filled out by frustrated parents and teachers and your child too can get a prescription for ADHD “study” drugs.

A complete ADHD assessment includes interviewing both the parents and the child and looking at:

  • Identifying key symptoms
  • Tracking the developmental course of those symptoms and the corresponding concerns
  • Conducting clinic-based psychological tests
  • Complete review of prior school and medical records
  • Complete physical and possibly neurodevelopment screening to rule out other causes of disruptive/distracted behavior
  • Vision, hearing, and formal speech and language assessments
  • Individually administered IQ tests, educational achievement tests, and screening for learning disabilities
  • Differentiating ADHD from other disorders
  • Clarifying the developmental “inappropriateness” of those symptoms and concerns
  • Look for other causes of the symptoms including changes or stressful situations at school and/or home
  • Checking on sleep patterns. Lack of sleep mimics ADHD.
  • Evaluating co-morbid conditions
  • Determining the degree of impairment
  • Assessing the family situation and how they are adjusting and accommodating the child’s behavior
  • Identifying strengths and resources of the child and the family
  • Eliciting priorities for change
  • Identifying community resources

Most of the time all of the above is not done. Having gone through the diagnosis process in our family, I know it was much more straightforward. I just noted that I thought ADHD might be an issue, filled out a couple of surveys that were highly subjective, and presto, we had Ritalin. Since then we have let the prescription lapse. It seems that being in a better educational environment is more effective than drugs for producing happy, productive kids. There are many reasons why a child has high-energy and is easily distracted. If a highly gifted student is in a classroom that is moving too slowly, of course she may be distracted and not paying attention. If a profoundly gifted boy has a third grade teacher that is only covering science at the third grade level and he “corrects” her by pointing out inaccuracies in her explanations, is that a psychiatric disorder?

One of the most used surveys to assess ADHD impairment is the Vanderbilt Assessment Scale. Almost all the questions from the teacher survey can be answered positively when a child is highly or profoundly gifted and is in an inappropriate school environment, but does not have ADHD. If independent IQ testing isn’t part of the screening process, a child could be incorrectly diagnosed and medicated when all he or she needs is a more challenging class. Yes, the teacher survey does include questions about whether the child is above average or not in reading, math, and writing but again, if the gifted, bored child isn’t doing the classroom work, the teacher will probably not rank his “academic performance” as above average. This is one of the reasons SENG has started to heavily publicize the issue of misdiagnosis of gifted kids. Two of the top misdiagnoses of gifted and talented children are ADHD and Oppositional Defiant Disorder (ODD). ODD is frequently co-morbid with ADHD and these misdiagnosis are due to a basic level of ignorance among health professionals and teachers about normal social and emotional characteristics of gifted kids. The medical profession pathologizes that which is uncommon, even if it is just a different normal.

ADHD Psychology, Co-morbidities, and Outcomes – Coursera Class Weeks 6 & 7

ADHD is complex. While defined as an executive function impairment, there are different genes, parts of the brain, brain chemicals, and behaviors involved. We know that certain drugs and behavioral interventions can relieve symptoms of ADHD, yet the medical establishment does not know what combination of interventions will promote optimal functioning in any given ADHD patient. Frequently the best course of action and medication is found through an educated trial and error method. This is stressful for both the child and the family. However, finding ways to manage and treat ADHD impairments is essential. Weeks six and seven in Pay Attention: ADHD Through the Lifespan have focused on the functional impact and complications of ADHD. It has been a bit depressing.

Disorders seen with ADHD include oppositional defiant disorder (ODD), conduct disorder (CD), anxiety disorder, mood disorders (including bipolar disorder, persistent minor depression, and major depression), learning and language disorders, Tourette syndrome, obsessive compulsive disorder (OCD), autistic spectrum disorder, fetal alcohol syndrome, sleep disorders, substance use disorders, and post-traumatic stress disorders.  Whew. The more sever the ADHD, the more likely it is to co-exist with one or more of the above disorders. Parental issues such as depression, low-income, and decreased interest in the child and a deviant child peer group will also increase the likelihood of a comorbid disorder.

Children with ADHD:

  • Are more likely to have learning issues:
    • Speech, language, reading, spelling, math, handwriting, and listening comprehension deficits can all present at higher than normal levels in children with ADHD.
    • Overall, drugs do not correct the learning problems that may be present with ADHD and parents should insist on additional educational help for their ADHD kids with learning issues. Medical interventions can make a child behave better in class but they do not make the child learn more. Specifically, reading, spelling and math issues do not improve with ADHD stimulants although the stimulants may improve handwriting and comprehension. Atomoxetine (Strattera) may sometimes help with reading abilities.
  • Have lower than average intelligence (possibly the result of poor executive function);
  • Are less self-sufficient.

Perhaps due to their initial ADHD-caused difficulties academically and socially, children with untreated ADHD can develop low self-esteem and a type of learned helplessness. They prematurely give up when faced with seeming difficult problems and don’t develop the ability to seek challenges, expect success, persist, and take failure in stride.

The behavioral and cognitive effects of ADHD can cause lifelong issues. 30% to 80% of children diagnosed with ADHD will continue to have symptoms in adolescence and up to 65% will have them as adults. ADHD may just look different as a child grows up. External manifestations such as high activity may decrease, yet internally, inattention and disorganization can persist. The world expects us to develop more and more executive function as we age and this expectation can create real issues for adolescents and adults with ADHD. When key executive functions such as self-regulation, sequencing behaviors, planning ability, organization, working memory, and internalized self-talk are impaired, personal relationships and careers suffer.

Adults with ADHD are more likely to:

  • Have an annual income of less than $25,000;
  • Be high school dropouts or if they do graduate from high school, they are less likely to graduate from college;
  • Be addicted to tobacco and/or use recreational drugs;
  • Be unemployed;
  • Be arrested;
  • Be divorced;
  • Have poor driving records, including revoked licenses, and vehicle crashes;
  • Have poor money management;
  • Have trouble organizing a household and raising children.

The lack of executive function that is a primary deficit in ADHD can cause secondary executive function problems, similar to the learned helplessness created in children with ADHD. These secondary EF problems may respond to coaching and training. People with ADHD can live in the moment and while they may know what to do, they have trouble with execution. Lecturing someone with ADHD or merely teaching them organizational skills is rarely successful. They know what is expected, they just don’t have the internal support to always follow through.

Instead of assuming individuals with ADHD will change their brain wiring and suddenly have organizational skills, it is more effective to “reverse engineer” and externalize executive functions. Technology is making this easier. Smart phones can give time reminders and have nagging due lists. ADHD coaches can help individuals learn how to break tasks into small steps, externalize sources of motivation, and post critical reminders at the point of performance. While drugs are an important treatment component for some people with ADHD, behavior training is essential. Natural settings should be restructured to externalize executive functions and then these accommodations must be maintained.

Given the increasingly high societal and economic cost of ADHD, it is distressing that the current sequester has cut programs for low income children. Early interventions for children with parental support is one of the most effective ways of preventing the negative comorbidities associated with ADHD. Individuals with ADHD have the greatest success when important people in their lives compassionately and willingly help them with their organizational needs. This is only possible if parents, educators, and spouses understand how to best support someone with ADHD.