October 5th, 2011
07:37 AM ET
Dr. Claudia M. Gold is a pediatrician and author of "Keeping Your Child in Mind: Overcoming Defiance, Tantrums and Other Everyday Behavior Problems by Seeing the World Through Your Child's Eyes."
Five-year-old Max came to see me in my pediatrics practice because his kindergarten teachers were convinced that he had ADHD. They knew little about his life, yet they were pressuring his mother, Alice, to come to me in the hopes that I would prescribe medication, because his behavior in class was increasingly disruptive. Alice came to the first visit armed with the standard forms, indicating that he had scored in the high range for ADHD.
My approach to the diagnosis of ADHD, up a startling 29% according to a recent CDC report, has grown out of over 20 years practicing general and behavioral pediatrics, while simultaneously studying contemporary developmental science at the interface of genetics, psychology and neuroscience. I have come to recognize the essential role of understanding the meaning of behavior, rather than responding simply to the behavior itself, in promoting healthy emotional development.
Evaluation and treatment of ADHD is currently focused on behavioral symptoms, primarily hyperactivity, inattention, and impulsivity. Rating scales are routinely used for diagnostic evaluation, and if a child has enough of the behaviors, or symptoms, treatment with medication is often recommended. But we should be asking: “Symptoms of what?” In other areas of medicine, we treat the underlying cause, not simply the symptom. In treating bacterial pneumonia, for example, we use an antibiotic, not a cough suppressant.
These behaviors are, in fact, symptoms of problems with regulation of behavior, emotions, and attention, which together may be labeled as ADHD. So the question becomes not “How do we control the symptoms?” but rather “What is making self-regulation difficult for this particular child?” followed by “What can we do to help promote self-regulation?”
Typically the "problem" of ADHD is viewed as residing exclusively in the child. Extensive research has shown, however, that children develop the capacity for self-regulation in relationships. Exploring family relationships is an essential first step.
Family conflict may go unaddressed while focusing exclusively on management of a child’s symptoms. While certainly there is a strong genetic influence in ADHD, research in the growing discipline known as “epigenetics” shows the complex interplay of genetics and family environment in determining the development of any one individual child.
For example, a study last spring shows that a person might have a gene that puts him at risk for ADHD. But if that person lives in a home filled with conflict, he is more likely to actually have ADHD. Put in a more positive way, just because a child has the gene, it doesn't mean he will have the disorder. Addressing family conflict may protect him from the genetic risk.
Research by psychiatrist Bruce Perry has shown that physical activities are another necessary first step for a child who is “dysregulated.” These activities actually calm the brain down. Extracurricular activities, if they are carefully planned and well thought out, are an essential part of treatment. It is best to have some kind of a calming activity interspersed with homework, tutoring or therapy.
Many know the story of Michael Phelps’ struggle with ADHD. Swimming can be a very regulating activity, but some kids with learning and behavior problems also have sensory processing difficulties and can't stand to have their head under water. Clearly swimming isn't the right choice for them. Horseback riding, martial arts, drumming and dance are examples of other activities that can serve to achieve this kind of calm.
The first two steps in helping a child with symptoms of inattention, hyperactivity and impulsivity are, therefore, to find a regulating activity and to address family conflict. Third, medication may be considered.
Medication may be indicated if symptoms are so severe as to impair a child’s ability to learn and to function in a social environment. They may calm down the symptoms sufficiently to allow a child to make use of other forms of help.
It is essential, however, to offer the opportunity for on- going discussion with a child about his diagnosis and issues of importance to him. In particular, talking with a child about his understanding of what it means to him to be taking medication for his behavior is very important.
Assessment of family relationships, supporting engagement in physical activity followed by, in some cases, careful prescribing of medication should help a child struggling with problems of self-regulation, as represented by the constellation of symptoms now called “ADHD.”
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