Managing Childhood ADHD Without Drugs: Coursera ADHD Class Week 11

The last couple weeks of the Coursera class on ADHD focused on how to live with and manage ADHD symptoms without drugs. “Pills don’t teach skills” and whether parents of children with ADHD or adults with ADHD embrace the idea of medical therapy, drugs are not the only treatment approach for helping someone with ADHD thrive.

Students with ADHD need support both at home and within their school environment. In fact, the US Department of Education has put together a fairly comprehensive brochure on how to teach children with ADHD. After giving teachers some guidance on how to identify children with ADHD, it has three separate sections on how to help a child with ADHD be successful in the classroom. Although rumors abound about teachers that, subtly or not so subtly,  have told parents to put their kids on ADHD drugs, that isn’t one of the teaching strategies. Instead the pamphlet focuses on instruction techniques, effective behavioral interventions, and classroom accommodations. It suggests a student with ADHD should sit closer to the teacher and farther from distracting kids. Wow, who would have thought? I know some elementary school teachers are resistant to “special” seating “privileges” for students with ADHD, perhaps referencing this official brochure will help parents get the seemingly minor accommodations their children need. Multiple times the brochure makes the point that children without ADHD also thrive in classrooms that are structured to help children with ADHD. Basically, these are strategies that can help any teacher be more effective regardless of the makeup of their classroom in any given year.

At home, one of the most effective treatments for children with ADHD is teaching their parents better behavior management strategies. By acknowledging that their child has below age-level-norm organizational, self-control,  and coping skills, parents can structure the home environment with scaffolding supports to help the child succeed despite their ADHD symptoms. There are several different training programs for parents. Most have similar elements: stay calm and don’t get emotional, analyze what is working and what isn’t, rely on planning and praise to gain compliance, go to the child to give instructions — use eye contact and touch to get child’s attention before giving instructions, break large tasks into smaller ones, use labels, file cards, and other visual cues and organizers to make tasks less daunting, reduce time delays for consequences (positive and negative), and use warnings, “when-then”, token economies and time outs to guide behavior. Work with the child to create better habits and more effective behaviors. If the child is encouraged to help evaluate the results of the program, it can increase their commitment and desire to change.

One comprehensive parent behavioral training program covered in some detail was one developed by Russell Barkley. Dr. Barkley has written extensively about executive function, defiant children, and how to take charge of ADHD. Putting the effort into learning how to be a better parent for a child with ADHD is very worthwhile. Studies show that not only do children do better with more effective parenting, parental stress is also decreased and satisfaction is increased under these programs.

Adults with ADHD face slightly different challenges than kids with ADHD. Some of these challenges stem from the bad habits and/or negative thought patterns that can develop over a lifetime of living with ADHD. My next post, and the last in this series, will cover psychosocial treatments for adults with ADHD.

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?

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.

Improper regulation of neurotransmitters in ADHD – Coursera ADHD – Week 5

This week’s class gave us a more detailed look at the neurochemistry of ADHD. Much of it focused on monoamines, catecholamine synthesis, chemical structures, and neurobiology of the brain. I’ll attempt to distill the information down to what I, as a parent, find most helpful.

The neurotransmitters dopamine and norepinephrine are deficient or dysregulated in ADHD. On the molecular genetic level, research shows that the genes most likely linked to ADHD also affect dopamine and norepinephrine.

The entire mechanism of motivation and attention is complex and involves multiple brain areas and neurochemicals. Although it was not covered in detail, the transmitter serotonin is also thought to modulate brain function and affect the symptoms of ADHD. Because the system is so complex, researchers feel that the issue with ADHD might be more a dysregulation of the neurotransmitter system where the release of chemicals is out of sync than a systematic deficiency of dopamine or norepinephrine. That being said, most ADHD drugs work by increasing their production and/or slowing their re-uptake to extend their effect.

One of the lecture slides was a great venn diagram showing serotonin, norepinephrine, and dopamine functionality. The diagram here, from the World of Caffeine website, is a more complex version of the one used in class. It shows how the three monoamines balance to create optimal attention, motivation, mood, and cognitive function.

World of Caffeine also has a nice summary of how caffeine affects the neurotransmitters. Caffeine is frequently the ADHD stimulant medication of choice for adults with ADHD symptoms.

Outside of the formal lecture, responses to the office hours questions were also posted this week. Amid general course and detailed brain anatomy information, were a few answers about kids and ADHD that stood out:

  • ADHD diagnoses decrease with age due most likely to several factors including the disorder naturally improving with age in some individuals.
  • The current definition of ADHD and system of diagnosis will not over identify children if clinicians are careful in their assessments and look for other explanations for problems with impulse control and attention regulation other than ADHD. However, too often our healthcare system doesn’t allow adequate time for evaluations. This can also lead to missed diagnosis.
  • Exercise and diet cannot prevent the onset of ADHD but they can help improve the symptoms. Dr. Rostain recommends the book Spark by Dr. John J. Ratey for anyone interesting in learning more about using exercise to improve ADHD.
  • ADHD is linked to poor sleep. It is possible the same brain difficulties that lead to ADHD symptoms also interfere with sleep regulation.
  • Although autism and ADHD  are entirely different entities, the same genes are involved.
  • Psychosocial stress increases ADHD risk and insufficient sleep diminishes focusing and productivity for everyone.
  • Brain training can build focus, attention, and cognitive processing but there is limited data on which programs are most effective because the field is very new.
  • There is no correlation between ADHD and IQ other than as a group, children with ADHD have a slightly lower average IQ of 95 rather than the 100 of the general population. This little fact, to me, says that if a child who is highly or exceptionally gifted has symptoms that look like ADHD, extra care should be taken in trying to determine what is actually going on. It might be ADHD but it might just as easily be normal behavior for a stressed, high-energy, gifted child.

In a few of the office hours answers students were referred to Judith Warner’s recent article on ADHD in Time. The gist of the article seems is that ADHD is a true medical condition and if we get too worried about over diagnosis we run the risk of having insurance companies or congress deny effective treatment options to vulnerable kids. She states that it is a developmental disorder not a symptom of social pathology.

Yes, ADHD is a real problem and is classified as a developmental disorder. Yet, carefully treating kids negative affected by it does not preclude an in-depth discussion on modern childhood. It is a disorder triggered or amplified by certain environmental conditions. This makes it all the more important to closely examine what has happened to childhood over the last 20 years to see how we may have turned on the ADHD genes.

Stimulants for ADHD don’t improve long-term outcomes – Coursera – ADHD – Week 4

I am now 1/3 of the way through the class and overall I’ve really enjoyed it. The course description estimated the workload at 2-4 hours per week and that has been correct. The TA’s have done a good job responding to questions about the weekly quizzes and making changes when there is a consensus that a question had confusing wording. This week they are adding another unique feature for a Massive Open Online Course (MOOC) — office hours!  We can submit questions to the professor and Friday he will answer as many as he can.

This week we explored the neuro-imaging of ADHD. Although there are differences seen in PET and fMRI scans in adults with ADHD versus adults without ADHD, neuro-imaging cannot be used to diagnose ADHD. Looking at ADHD from a parenting or educator lens, here is the information I found most relevant.

First, while maximum brain volume is typically reached by age 16 for all children, those diagnosed with ADHD show about a 3-year lag in brain development. This is most likely one of the reasons they seem less mature than their classmates. Once their brains are fully developed at about age 16, people who have ADHD still show smaller and less active orbital-prefrontal cortexes, basal ganglias, and cerebellums. The size difference of these regions compared to a more typical brain is directly correlated with how sever the ADHD symptoms are in a given person. Individuals diagnosed with ADHD also show lower levels of dopamine transporters in the brain’s reward center. Although the lecture didn’t cover it, I suspect that an impaired reward system is one of the reasons some ADHD individuals are susceptible to drug abuse and addition.

One area of brain anatomy and function covered in-depth for the first time this week is the role of the anterior cingulate cortex. Individuals with ADHD have less activity in the anterior cingulate cortex than more neuro-typical people and this can significantly impair their performance. The anterior cingulate cortex is an essential part of the cognitive and emotional executive attention system and has a role in emotion, motivation, timing, focused attention, willed motor control, working memory, pain, error detection, reward, monitoring, and feedback-mediated decision-making. One of these, working memory, is explicitly tested for in IQ tests such as the Stanford-Binet and some researchers feel that working memory is more important than IQ when predicting overall achievement. A child may be highly gifted but not perform as expected if their working memory (and attention for that matter) is less than ideal. Although some high-energy gifted kids are incorrectly diagnosed with ADHD, there is most likely another group of gifted kids that are not recognized as being gifted or having ADHD because their performance is average and their behavior isn’t annoying enough for the adults to suspect ADHD.

So what effect do drugs, especially methylphenidate, have on brain function and anatomy as viewed with neuro-imaging? They definitely increase brain activity while they are in the system, however, they do not change brain structure. The medications can help a child improve their classroom behavior, performance, and teacher and peer interactions in the short-term. Yet psychostimulants do not seem to create long-term changes in outcomes for peer relationships, social skills, academic skills, or school achievement. This little tidbit, buried at the top of page 146 of the 1999 Surgeon General’s report on ADHD, assigned for our week 5 reading, sent me on a search for more studies and more information.

If ADHD medicine is only a short-term fix, why are we drugging our kids’s developing brains? Aren’t there other ways to change their behavior?  And if their symptoms are so bad, why is it common to just prescribe drugs without also helping them with behavioral techniques? The combined treatment of drugs plus behavior modification has better results than just treatment with drugs alone. The drugs may make a child more attentive, less impulsive, and less disruptive but they have no effect on academic achievement. Just because a child is sitting still, better at completing homework, and easier to handle in class, does not mean that child is actually learning more. The lack of long-term improvement with the use of stimulant medication, combined with study results that indicate that they may increase depression in some children and have negative long-term cardiovascular implications, makes me question why they are prescribed so freely in the US. This in-depth, long-term view is beyond the scope of the Coursera class which is more focused on the basics of how ADHD is viewed, diagnosed, and treated by doctors today.

People with ADHD can have a more difficult time completing tasks and attending to directions, especially if they are not interested in or are bored by the subject matter. Our current view has classified ADHD as a disorder because of this impairment. What if evolutionarily speaking, this isn’t the case? What if ADHD tendencies are a different way for a perfectly normal brain to function and the ADHD brain is optimized in some other way that isn’t compatible with our current education system?

The most interesting part of the lecture this week, for me, was something I noticed on a brain scan that wasn’t directly addressed. The brain scan from a study on anterior cingulate cortex dysfunction in ADHD, left me with a strong desire for more research. In it we see differences in brain activity during a counting stroop task for individuals with “normal” brains vs individuals with diagnosed ADHD. The “normal” brain on the left shows the anterior cingulate (green rectangle) lit up with bright yellow and red activity while the ADHD brain on the right shows nothing going on in the anterior cingulated cortex but lots of activity in the frontal stratal, insular and thalamic network. The lecture highlighted the fact that ADHD individuals had to work harder and were slower at solving the task than were other individuals because they were solving the task with a less than ideal brain region. This begs the question, what are the ADHD individuals thinking about and what connections are they making? Clearly there is a lot of something going on in their brains, by colored area alone there is actually more activity than in the “normal” brain. Just because they can’t perform as well on the counting stroop task does not mean that this activity should be deemed suboptimal. See the images yourself on page 1547 of the study.

We know that studies of scans of men’s and women’s brains clearly show that men and women process information differently and use different areas of their brains to solve the same problems. We also know that men’s brains are, on average, larger than women’s brains. This does not mean that men are smarter or that one sex uses the more correct areas of their brains. Perhaps the same is true in people with ADHD. Individuals whose brains are more wired with ADHD tendencies may struggle with tasks that are easier for people with more typically wired brains but does this really mean that ADHD is a disorder?

Coming up the course will explore the neuroplasticity of the brain and interventions shown through neuro-imaging to improve brain functions in individuals with ADHD. Given the lack of proven long-term positive outcomes with drug therapy, I am looking forward to good data on behavioral interventions.

 

 

 

Checking out Coursera – ADHD Class – Week 3

Well this has been quite the week for anyone interested in ADHD. As the New York Times reported on Sunday, the number of children diagnosed with ADHD has risen by 41% in the last decade. Clearly there is something going on here.  While this statistic has gotten a great deal of publicity, it seems to me people aren’t quite sure what to do with it. If other illnesses, say, cancer or cholera increased by 41% in 10 years there would be a massive mobilization on all fronts. We wouldn’t just treat symptoms. We would take a hard look at environmental factors. We wouldn’t assume that better screening was catching cases that have always been present. We would know that something radical had changed in the world of children that was causing them harm.

There is no definitive test for ADHD. There is no way to know, for sure, if we are catching cases that have always been present.  One hint may lie in the DSM-IV criteria for diagnosing ADHD which requires impairment caused by ADHD symptoms. In other words, if ADHD-type behavior and thinking causes no impairment for the individual, then there is no diagnosis.

Have we changed the environment and our expectations of children, especially boys under 10, significantly in the last 10 years? Is their world different enough that their normal, natural behavior is now an impediment to their success in school and life? Or, are they actually behaving differently and there is something vital to ideal development that has disappeared from the typical life of children, especially young children.

I would love to hear Dr. Rostain’s take on all the above questions. If this were a regular university class with live lectures, I am fairly certain that some of this week’s lecture would have been devoted to the recent CDC report. One of the major drawbacks of this type of Massive Open Online Course (MOOC) is that everything is prerecorded, and pre-formulated. While students have been discussing the latest statistics in the online forums, the instructor hasn’t officially given us his analysis of the data. Although it would increase the instructors’ workloads, I think MOOCs would benefit from weekly written or video blog posts by their instructors — tying the prerecorded course materials to recent headlines and perhaps to student concerns from the forums.

This week’s lecture and readings are about the neuroanatomy of ADHD. Although issues with the orbital prefrontal cortex and its control of working memory and executive functions get all the publicity, there are two other regions involved with ADHD. The basal ganglia, which is responsible for motor coordination and procedural knowledge, and the cerebellum, which controls movement and cognitive processes that require precise timing, are also affected. The three different types of ADHD, inattentive, hyperactive-impulsive, and combined, correspond with different levels of impairment in these three different brain regions. The lecture was dense with medical terms and brain anatomy and I’ll have to watch it a few more times.

There is a 3-10% reduction in the regional volumes of all three of these brain regions in people with ADHD. In people diagnosed with ADHD these regions work less effectively and efficiently. Now, here is the kicker, drugs increase the neurotransmitters norepinephrine and dopamine in these areas to help them work better but they do not change the biology of the areas. They do not make these brain areas larger and only make them more effective on a temporary basis when the drugs are present. I suspect that although they can cause immediate relief from some ADHD symptoms, drugs are not the best way of treating ADHD, especially in young children with rapidly growing and changing brains.

We know from the London cab drivers study that our brains can physically grow to keep up with the demand to learn new and specialized information. Thomas Elbert’s study of the brains of violin players shows that our brains change to conform to the current needs and experiences of the individual. Changing our children’s environments and what they do with their time may help their brains, at least in some cases, literally grow out of ADHD. Personally I think that the decrease in recess and child-directed play, especially outside play, needs to be taken more seriously. The lowering of the age for teaching formal academics combined with the child abduction and molestation fears that keep kids supervised and inside have changed the childhood experience. Add in the rampant lack of sleep that can create ADHD-like symptoms and it is no wonder diagnoses of ADHD are increasing. Perhaps instead of increasingly medicating childhood we should bring back PLAY, and regular bedtimes.

Checking out Coursera – ADHD Class – Week 2

Week two the Coursera class on ADHD Through the Lifespan taught by Dr. Anthony L. Rostain, M.D., M.A. of the University of Pennsylvania is focusing on the causes of ADHD. The lecture was well put together and very informative. The reading is from Brain Facts, a free publication from the Society for Neuroscience.

I am getting more enthusiastic about the course now that we are starting to tackle some of the science of ADHD. Although diagnosing ADHD can be an exercise in subjective opinion more that unbiased reality, ADHD does have a biological basis. The problem is that it is a complex genetic disorder where various factors alter the neural pathways. It doesn’t follow simple Mendelian inheritance rules although it is one of the most inheritable psychiatric diagnoses. The mean heritability of ADHD is 0.75 this is almost the same as the mean heritability of height and greater than the heritability of asthma, high blood pressure, breast cancer, or alcoholism. As an aside, autistic-like traits are 0.82-0.87 inherited which is something to keep in mind with the increase in autism diagnoses over the last 10 years.

The best data tells us that 65-75% of ADHD is due to genetics and 25-35% is due to acquired central nervous system injuries. If a parent has ADHD, their child has a 40-54% chance of having ADHD. The chance of a child being diagnosed with ADHD skyrockets when both a genetic factor and an environmental factor are both present. Specific genes associated with ADHD are serotonin and dopamine receptors and transporters, and synaptosomal-associated protein 25. The different types of ADHD may be associated with different genotypes and specific ADHD medications may be more or less effective, depending on which genes are contributing to ADHD in a specific individual.

Taking all this together, I believe there are some strong implications for public policy and preventative parent education programs. For example, after heredity, the largest cause of ADHD is low birth rate. In fact, low birth rate by itself is associated with ADHD as much or more than fetal alcohol syndrome, lead exposure, and the mother smoking during pregnancy, combined. Parents with low birth weight children should be educated on ADHD while they are still in the hospital. They need to know that if one parent has ADHD and their child has a low birth weight, there is an increased likelihood that child may eventually be diagnosed with ADHD. They must also be given ideas and tools for how to help their child learn impulse control and organization skills.

It is interesting to note the increase in ADHD, especially in boys, seems to parallel the decrease in recess, walking to school, and physically active gym classes. We know that serotonin and dopamine are positively affected by exercise and exercise can alleviate ADHD symptoms. I am hoping that Dr. Rostain includes exercise as a treatment option. Many parents, especially of very young children with ADHD, are looking for ways to help their children without medication. Again, if parents are aware of the genetic+environment risk factors for ADHD, they will hopefully be more proactive in helping their kids get effective, regular exercise.

Just like with autism, early intervention and extra effort can lead to improved outcomes for individuals with ADHD. It seems it is far better to help kids proactively develop good habits and coping skills instead of letting untreated or acknowledged ADHD symptoms derail their academic and social lives.

 

The importance of friendships

Some time ago when chatting with an expert on gifted kids, I asked how I would know if my children were in the correct academic environment. How would I know if their classes were challenging enough or whether I should switch them to a more rigorous school. She answered by asking whether they were happy — whether they had good friends with whom they could be their true selves.

So much of the time when raising highly and profoundly gifted kids, we focus on academics. Are they in a school with enough advanced classes? What summer enrichment programs should they enroll in to make sure they get the academic resume edge that will take them to the next level? We want to make sure they aren’t wasting their potential.

Frequently the social aspects of their schooling are a secondary consideration. One we only pay real attention to when things are bad. We notice if they have zero friends or are bullied. We don’t necessarily notice when they have friends, but not ones they can completely relax with and just be themselves.

Watching the 2013 Golden Globes last night I was struck by the fact that two of the most creative and brightest women receiving awards, Lena Dunham and Jodie Foster, both mentioned loneliness. Everyone feels alone at times, it isn’t just a burden for gifted kids. However, it is something that we as parents of sometimes quirky gifted kids need to keep on our radar. Forming friendships is tricky, especially for introverted, analytical young people who see the world differently than most of their peers. Highly and profoundly gifted girls are particularly at risk of feeling alone. This is due to a variety of factors. First, there are fewer profoundly gifted girls than boys and they are less likely to be identified because they “blend” better.  Gifted girls tend to hide their intellectual abilities and instead pour their energy into social relationships. As they reach their teen years, they are valued more for their appearance and sociability than their intelligence. Gifted girls in middle school frequently face a not so subtle choice between high achievement or social acceptance by their peer group. Many girls decide to suppress their innate abilities, others who continue to aim high and succeed at rigorous coursework, may end up depressed and with lower self-esteem than boys with equivalent GPAs.

Many lonely gifted kids eventually find good friends and soul mates at college and beyond but the harm done by feeling and being alone for much of elementary school, middle school, and high school can leave lasting damage. The suffering could manifest itself in great works of art yet it can just as easily create an adult who never really finds their place in the world. While it is sad for the individual, society can also pay the price. Although there is a tendency to describe mass shooters as loners, they are generally more likely to be individuals that struggled to connect with their peers and form meaningful friendships.

While we can’t create friendships for our gifted kids, there are things we can do to make it more likely that they will form their own. Generally it is easier to make friends with people who are like us. Take a good look at your child’s school and extra curricular activities. Do they seem to be populated by kids that are similar to your child? If your kid likes Dr. Who and National Geographic are you making sure he or she has a chance to hang out with kids who like to discuss rain forests and David Tennant vs. Matt Smith? Take your child to festivals, chat nights, and seminars that interest them and help them keep an eye out for kids they can talk to. Hanging out isn’t just in person. The Internet has been used since its beginning as a way for ubergeeks to connect. Help your kid find other kids they can relate to and then encourage them to use phone calls, email, and Skype to stay connected. Be ready to drive outside your neighborhood to help your kids meet up with their new friends. Facilitate outings and sleepovers to help the friendships grow. Teach your children that good friends are worth the extra effort.

Personal Responsibility: Summer Report Card

Summer is almost over. Next week we have our back-to-school night and then school starts just after Labor Day. It is time to evaluate the results of my summer project to push the kids to take on more personal responsibility.

Well, apparently I am not so much a chart person. The chore chart idea only lasted a week and a half. They stopped filling in the charts and I stopped printing out the charts. Grade F for charted chore tracking.

Digging deeper into what exactly they were supposed to do, as defined by the unused charts, things start to look a bit better. On the personal chores list, even without a checklist, the kids consistently were about 90% successful in getting things done. While beds were not made, they used sunscreen enough to avoid burns, practiced piano, and brushed their teeth. They did need more reminders than would be ideal and there was a direct correlation between my reminders and their success. Since I rarely reminded them to make their beds, and they had no personally compelling reason to make them on their own, beds were not made most of the summer. The one exception to this happened about every two weeks when I forbid them from playing or having friends over because their rooms had gotten too messy. At those points the bedrooms were carefully cleaned.

The family chores followed basically the same pattern. They were/are perfectly capable of helping keep the house clean and did so easily when directed. They just didn’t reach the point where they would do it without being asked. I suspect part of this is the fact that since I specifically did not assign chores, each of the three kids waited to see if someone else would jump in and do the work. Reversing the pattern of 11 years, as often as possible I made sure it wasn’t me doing the chores when things were left undone. Instead I stepped in to directly assign chores as needed. Since June I have done the dishes less than 5 times. The kids no longer assume that it is my job. They just hope is isn’t their job. Overall I’m giving the concept of the kids taking on more responsibility for the house a grade of C. They know how to do the work and they are willing to do it, they just aren’t proactively seeing a need and filling it.

Most households with kids specifically assign jobs to each kid and I may have to adopt this strategy for the upcoming school year. However, I’d still rather see them treating the house as their own and doing what needs to be done without being told. Before we go to strictly assigned chores, I’m trying one more strategy. They now have to make a daily list of all household chores to do that day and then collaboratively split the jobs among themselves. We will see how it goes. . .

One chore that received an A+ wasn’t even on my radar back in June. Laundry. I showed the kids how to use the washer and dryer and told the older two, ages 11 and 9, that if they needed clean clothes they knew how to get them. (The youngest, age 7, has helped out with his clothes though he is physically too small to take over 100% of the job.) Over the last month, I haven’t washed the two older kids’ clothes at all.  The kids have proactively carried their clothes to the basement, washed and dried them, and returned the clean clothes back to the bedrooms. They haven’t even called my attention to this extra work they are doing. I guess having clean clothes to wear is a powerful motivator.