When parents suspect their child may have ADHD and bring that child into my office there are two questions they want answered quickly: 1.What is wrong, and, 2.What can be done about it? The first step in the treatment of any medical or psychological disorder is to get an accurate diagnosis. The diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) has become more prevalent in the past decade, both in children and adults. One of the challenges in diagnosing ADHD in young children is the fact that young children are naturally full of energy. For this reason, diagnosing a young child as hyper-active is difficult in the same way that it is difficult to diagnose naturally moody adolescents as clinically depressed. This is why it is important to diagnose each child on an individual basis and understand the diagnostic criteria of ADHD within the context of each child’s unique, subjective personality and temperament.
Nobody knows a child-like their parents and parents can tell when something is wrong. Teachers can also often tell when something is amiss and other children are excellent natural barometers of whether a child is having trouble “fitting in”. Making a diagnosis is part art, part science. Information must be gleaned from every possible source and then the objective criteria of ADHD as described in the DSM (Diagnostic and Statistical Manual) must be applied to subjective situations. Professionally, this is known as “clinical sense” and it cannot be taught. It is a combination of knowledge, experience, and natural intuition.
There are two main types of ADHD. One is the “Hyperactive” type, which is the one we usually think of when thinking about ADHD. The other is the “Inattentive” type, which is less well known. One of the characteristics of the “Inattentive” type is a “daydreaming” quality on the part of the child. Many children daydream so one cannot diagnose based solely on the presence of this characteristic. A complete ADHD “diagnostic picture” has to present itself in order to make an accurate diagnosis. An accurate diagnosis is important for many reasons. We do not want to treat a child for something they do not have, and you cannot treat if you don’t know what you are treating.
Other childhood conditions, such as Mood or Anxiety Disorders can look like the Hyperactive or Inattentive Type of ADHD. A depressed child might have trouble focusing, be irritable, appear unmotivated, and often seem to be elsewhere or daydreaming. What looks like the hyperactivity of ADHD can be the anxiety of an Anxiety Disorder or the anxiety that is almost always a part of clinical Depression. Further, it is not uncommon that ADHD presents with another disorder simultaneously. Children with ADHD often have damaged self-esteem, and depressive and anxious symptoms can result. Conversely, depression and anxiety alone make it difficult to focus and this can be misinterpreted as the poor concentration that is part of ADHD.
Being aware that ADHD can mimic or disguise other disorders is important when deciding on medication. When a child has a mix of ADHD and Depressive type symptoms one often medicates the depression first. If treated effectively, the depression lifts, the child’s grades and behavior improve and the ADHD “goes away”. The ADHD “goes away” because it was never there.
Educated, well-meaning parents sometimes use their familiarity with ADHD to shield themselves from realizing that their child has a different condition which can be more or less serious. In these cases, one has to inform the parents that their child has a diagnosis that is different from what they assumed, in order that the proper treatment can begin as soon as possible. In some of these cases, psychotherapy is inappropriate or must be modified or combined with other modalities.
It is important to get a diagnosis from an experienced child psychotherapist. What school of thought they follow, whether Freudian, Jungian, or otherwise, is not particularly important. Neither is whether the therapist is a social worker, psychologist, or psychiatrist. Cost is likewise irrelevant. Paying a lot does not mean one will get a more accurate diagnosis or better treatment. Diagnostic skill, which is different from the skills needed to be an effective treating clinician, is the most important factor when looking for an accurate diagnosis.
Many parents are wary about giving their children medication. This concern is understandable. Medication does not have to be a first choice but should not be eliminated as a choice altogether. Medications can always be stopped and dosages can be changed. Concern regarding the possible side effects of medication should be weighed against the probable long-term effects of not using medications.
A mother brought her son (we will call him Roger) to my office for evaluation and treatment of possible ADHD. Her son was nine and presented with trouble focusing, poor grades, difficulty with organization, trouble completing tasks, difficulty sitting still, and general hyperactivity. A family history revealed that other relatives, including male and female siblings, displayed hyperactivity as well.
When Roger came into my office he came in with a bang – literally. He flew into the room, brushed by me with no eye contact, and went directly to a table where he started eating and banged his hand down while announcing in a loud, demanding voice “Hi! I’m Roger, what can we play?”
It was immediately clear why Roger might have been diagnosed with ADHD. It was also clear that certain aspects of his presentation were better understood as personality traits than as ADHD. I would quickly learn that Roger was direct, dramatic, attention seeking, smart, funny, undisciplined, and emotionally sensitive.
Assuming Roger had ADHD, where did the ADHD end and Roger the individual begin? ADHD, like any emotional disorder, becomes part of and is created by each person as they develop. Children with ADHD, like all children, grow up experiencing the world in their own particular way, and their experience of ADHD colors their perception of themselves and of their world. It was not hard to tell that Roger, like many children with ADHD, had poor self-esteem. He was obese, which seemed partially genetic and partially due to emotional overeating. Characterizing his behavior as hyperactive was simplistic. He was hyperactive but he also had poor self-control, difficulty with emotional regulation, and boundary issues. He buttressed his low self-esteem with his over the top performances. Roger may have been genetically loaded for ADHD, but he was just as much a product of his environment.
Roger’s mother had told me that Roger lived at home with his parents, 3 other boys, 1 girl, and 2 dogs. The father was often working and most of the child rearing fell on the mother who was overwhelmed. She described a chaotic home with little structure. She said that because of his disability she always felt bad for Roger and had difficulty denying him what he wanted.
Developing healthy narcissism in children is a tricky business which necessitates striking a balance between gratifying them so their emotional needs are met while teaching them to tolerate frustration so they don’t find life’s challenges insurmountable. Structure helps maintain this balance and is good for children for many reasons. It makes them feel safe, it orders their lives, and it sets clear expectations. Experiencing structure in their external world also helps children structure their internal world which will otherwise become one undefined morass over which they have no control. They will grow to feel helpless in the face of their feelings, thoughts, and wishes. They will not develop the confidence that they can control their inner lives.
In the terms of modern neuroscience, Roger had not developed adequate executive functions, which are located in the frontal part of our brains, an area that directs and regulates the emotions generated by the older, more primitive parts of our brains. In Freudian terms, Roger had not developed enough Ego capacity to modify the drives of his Id to meet the demands of reality.
Medication was definitely a possibility. ADHD psychostimulants work by stimulating the “brake” in child brains so that they slow down. But, there are behavioral approaches that also put a “brake” on unregulated energy. Instead of a dose of medication, Roger would first get a large dose of structure.
The time Roger spent in session was very important to him. He relished the focused attention that sessions provided him. One way to influence Roger’s behavior was to inform him that if a particular negative behavior didn’t stop the session would end. This had the desired effect of limiting his negative behavior while simultaneously letting him experience himself as the director of his actions. It allowed him to feel a healthy sense of power, power over himself.
In this spirit, I informed Roger that we could play any game he wanted as long as we both followed every rule precisely. I am not usually so strict, but one adapts one’s style to help the patient. One day, Roger cried when his wish to play a game “his way” was denied. His tears were understandable. Frustration tolerance is difficult. Remaining silent and letting him cry gave him room. Words would have taken up space that rightly belonged to him. After he was done crying, he went back to playing the game and seemed to enjoy himself more now that his frustration had been processed. He didn’t know it, but he was growing, maturing, finding more adaptive ways to deal with frustration, anger, and sadness. He was not giving in to his emotions but mastering them. This would help him with his ADHD, and with his greatest challenge, which was Roger.
After this routine was practiced during weeks of therapy, Roger came in noticeably more restrained and cheerful. He said “I’m in control today. Let’s play the game your way.” Gaining internal control made him feel safe enough to give up his need to control me. He then returned to a subject we had previously discussed. He asked me why he couldn’t call me “Bellin” and why I insisted (I usually don’t) that he call me “Mr. Bellin.” I said that “Mr. Bellin” was more respectful.
“But, I don’t know anything about respect” he said, partly oppositional, partly joking, partly sad.
“I know” I said, understanding, sharing his sadness.
Treat the person, not the diagnosis.