It's Nobody's Fault (14 page)

A decrease in a child’s rate of growth is a possible side effect of Ritalin, but that doesn’t happen very often. Most youngsters experience minimal negative side effects or none at all. The most common side effects are reduction in appetite, delay in falling asleep, headaches, and tearfulness. These side effects almost always disappear over time or with an adjustment in either the timing or the dosage of medication. Stimulants have been known, rarely, to cause tics, usually in children whose families have a history of tics. When a child is genetically vulnerable to tic disorders, particularly Tourette syndrome (described in
Chapter 13
), we look to other medications for treatment.

Ritalin is unquestionably the medication of choice—the first line of attack—with ADHD; but when Ritalin doesn’t get results or when the negative side effects are such that it must be discontinued, several other medications are routinely prescribed. The other stimulants that have proven to be effective are Dexedrine, Adderal, and Cylert. Dexedrine lasts longer than Ritalin and has similar, more frequent side effects: decrease in rate of growth, decrease in appetite, and delay in onset of sleep. Both Ritalin and Dexedrine are available in sustained release (SR) pills, which have the advantage of not requiring a school nurse to give the lunchtime dose. Frequently children taking Ritalin SR will also need to take regular Ritalin with their morning dose and an additional dose of regular Ritalin after school. Adderal is long-acting and similar to Dexedrine spansules. It lasts for about six hours, and since it comes in tablet form, it is easy to adjust the dose. Cylert lasts about ten hours, so it can be given once a day. Unlike the other stimulants, which work very quickly, Cylert may require two weeks before the full effects are felt. Cylert’s side effects are a little different from the others; appetite, sleep patterns, blood pressure, and heart are less often affected, but inflammation
of the liver may occur in a small number of children. The manufacturer of Cylert recently reported on a series of youngsters who developed liver failure while on Cylert. At this time, it is not clear if this is a side effect of the medicine or a coincidental finding; however, given the serious nature of this side effect, Cylert should be used only for youngsters who have been nonresponsive to other medications.

Wellbutrin, a new antidepressant, has proven to be effective in children with ADHD who have had a poor response to stimulants. The side effects are similar but less frequent than those associated with the stimulants. There are three tricyclic antidepressants (TCAs) that psychiatrists turn to in treating ADHD, especially when the child being treated is vulnerable to tics: Norpramin, Pamelor, and Tofranil. These antidepressants have their own side effects, of course. They may cause tiredness, dry mouth, and constipation. More important, they may have an effect on heart rate; a child taking any of these medications must have an electrocardiogram before starting the medicine and before the dose is increased. Until recently Norpramin was the TCA used most frequently because it has fewer of the bothersome side effects, but over the last year or so several sudden deaths have been reported in children taking this medicine. Although there is not sufficient evidence to link those deaths with the Norpramin, it is rarely prescribed; Pamelor and Tofranil are now the medications of choice. The doses of Pamelor and Tofranil that are prescribed for children with ADHD are lower than those prescribed in the treatment of depression, and they need from one to four weeks to take effect. Because the medicine lasts a long time, it is taken in the morning and at bedtime.

Two antihypertensives, Catapres and Tenex, have been used when children have tics as well as ADHD. (An antihypertensive is frequently given in combination with a stimulant.) The medicine lasts a short time, so children must take it three or even four times a day. Catapres is available in a skin patch, which eliminates the necessity for the multiple doses. Side effects of Catapres and Tenex are minimal—sedation, headaches, nausea, dry mouth, and constipation—and they usually disappear with time. Antihypertensives don’t have the same cardiac effects on children as they do on adults, who take the medicine for high blood pressure, but an electrocardiogram is necessary before the medication is started. The child’s blood pressure and heart rate should be checked on each visit.

BuSpar, an antianxiety medicine, is currently being studied for use in children who have Attention Deficit Disorder and symptoms of anxiety. Some antipsychotic medications, especially Haldol, Thorazine, and Mellaril, reduce the symptoms of ADHD, but their side effects are such that they’re not ordinarily prescribed for this disorder.

We prescribe “drug holidays” for children who take stimulants, suggesting that parents discontinue the medication for at least four weeks each year. There are two reasons for a drug holiday: first, it allows kids whose rate of growth or weight has been affected to catch up; and second, it lets us know if the medicine is no longer necessary. (Some children with ADHD do get better.) Most parents are inclined to declare the drug holiday in the summer, when a child’s school work won’t suffer, but it’s harder to assess a child’s progress in the summertime, because there is relatively little pressure on him to perform when school is not in session.

No matter when the drug holiday comes, most parents
dread
it. “I have a very hard time with drug holidays,” said one mother of a 10-year-old boy being treated for ADHD. “My whole life turns upside down, and the rest of the family goes a little crazy too. He is so different off the medicine, and by
different
I don’t mean
better.
July is the longest month of the year.”

Another mother wanted to give her son the summer off between fifth and sixth grade, but the child’s baseball coach pleaded with her to put him back on. The medication made a critical difference in his performance. Since playing the game well also made a critical difference in the child’s happiness and self-esteem, the mother gave him back his Ritalin after two weeks.

I’ve known parents who flat-out refuse to give their children a drug holiday. “We just couldn’t take drug holidays,” said one such mother, whose 11-year-old daughter has been taking Dexedrine for five years. “It’s not just that she’s incredibly unpleasant. We could deal with that. It’s that she’s so reckless. She gets into terrible trouble. She can’t make rational decisions and get on with her life without the medication. We worry about her too much to take her off it for any length of time.”

Then there are the parents of children with ADHD who say that their kids seem to take a drug holiday every day, when the lunchtime dose of Ritalin wears off. (Some children taking stimulants experience
behavioral rebound:
several hours after the last dose of the stimulant taken, there’s a
dramatic increase in hyperactivity, hypertalkativeness, and irritability.) I’ve often talked to parents who disagree about their child’s diagnosis depending on the time of day they’re most likely to interact with him. For example, a mother says her son needs an extra dose of Ritalin. At the moment he takes it twice a day: in the morning and at lunch. Mom tells me that her son has trouble following directions after school; he has temper tantrums at home; he doesn’t always behave on the bus in the afternoon; he loses his focus when he’s doing his homework. Dad says that the twice-a-day regimen is just fine. “He’s great at Little League, and he’s fun to be with. We wrestle together and have a terrific time. My wife is making too big a deal out of this,” says the father. The explanation for their difference of opinion is quite simple: the father nearly always spends time with his son on weekend mornings, when he’s on Ritalin. By the time Dad gets home from work every day, and the medication has worn off, the child is in bed asleep. Mom is there when the little boy gets off the school bus, already a little out of control. She was right about the extra after-school dose of Ritalin.

Stimulants and the other medications used for ADHD have many miraculous powers, but they cannot and do not solve all the problems associated with ADHD. Stimulants help a child to pay attention, but they don’t automatically make him more organized. However, they do make him more able to benefit from other interventions. A child with ADHD may need to work on improving his organizational skills and study habits, ideally with a tutor who specializes in psychoeducational tutoring. Parents can help with this too, of course, by working with the child and the tutor to come up with new strategies for behavior and then reinforcing the new behavior with a system of rewards. For instance, parents may tell a child: “If you come home, have a snack, and then settle down to do your homework right away, you get a star. If you don’t have a fight with your brothers and sisters today, you get a star. For every day your teacher says you worked quietly without interrupting in class, you get a star. For every three stars you earn, you get to play a half-hour of video games at the arcade.” The reward will be different for every child, of course, but the principle stays the same.

Most children with ADHD will need some social skills training as well. Unlike children with social phobia (see
Chapter 10
), who must be encouraged to take part in the events around them and learn how to do
more
in the way of socializing, kids with ADHD have to learn to do
less.
In all probability they’ve been accustomed to leaping before they look; they have to learn that their social actions have consequences. (“Stop. Listen. Look. Think. Act.” That’s the cognitive behavioral mantra taught to children with ADHD.) Being in control takes practice; most of these kids don’t even know what it feels like. A child psychologist who specializes in behavioral therapy or a social worker with a specialty in social skills training can be of great help to a child just learning how to behave in social situations. As strange as it may seem, some children don’t know the first thing about how to act at a birthday party. Professionals can show them the way.

A psychologist can help with parent training and counseling too. A child with ADHD on medication is more attentive, less hyperactive, and less impulsive, but he still has to be managed, and the job of child management falls primarily to the parents. Parents have to learn to exercise control over their children without losing control themselves. The message a parent must convey to children who misbehave is: “This is unacceptable behavior. It will not be tolerated. It keeps you from functioning in the world.”

When that doesn’t work—and everyone knows that it sometimes doesn’t—parents have to know when and how to go to the next level: “Look, I just gave you a warning. You didn’t listen to me. Now you’ve lost 15 minutes of television for tonight. Please get up and go to your room now. You’ve already lost 15 minutes. The next time I tell you to leave, it’ll be 30 minutes. Are you leaving? No? Okay, you just lost 30 minutes.” The parents’ request and the consequences for noncompliance are both clear. The parent is calm and in control, and the punishment is meted out without rancor or malice.

If and when the battle escalates, a parent moves to level three: “Now you need a time-out. Your behavior is intolerable. I won’t put up with that kind of talk. You know you’re not allowed to bang on the furniture.” By now the parent is taking the child by the arm and walking him to his room. “You have to stay in your room for five minutes.” The older the child, the longer the time period should be. At the end of the time period the child is asked, “Are you ready to come out and join us?” If the child is still not in control, he goes back for another five minutes.

When the child comes out of the room, the punishment still stands, of course. He still loses 30 minutes of television. The final message from Mom and Dad should reinforce all the others. “We still love you. We
still want to hug you and give you a kiss. Life will go on. But tonight it will go on without television.”

These kinds of parenting skills don’t come naturally; they have to be learned and practiced. Children with ADHD need an immediate response from their parents. “If you do that one more time, you’ll be punished” doesn’t work with them. Parents have to be ready to respond to any and all situations. With normal children parents can get away with, “I’m not sure yet what your punishment is going to be, but it’s going to be a whopper.” With these children parents have to be ready with specifics. Parents of children with ADHD also have to be absolutely consistent. Kids who have ADHD need structure, because it helps them to learn rules and establish limits.

Another aspect of ADHD that therapy can address is the youngster’s self-esteem. There’s no empirical evidence at the moment that being liked by parents and teachers is good for a child, but we don’t need statistics to know that being yelled at and put down on a regular basis doesn’t make a child feel good about himself. Unfortunately there is no medicine that works on a child’s self-esteem. Some of these kids become so accustomed to failure that it’s hard for them to acknowledge anything else.

I was reminded of this fact when Teddy, a seven-year-old boy I was treating for ADHD, came to my office for a checkup after three months of Dexedrine. He was responding beautifully; his parents and teachers were delighted with his behavior. I asked Teddy how he was feeling. He told me that he felt the same as always. Then came the kicker: “Since I started taking medicine, my teacher and my parents are much nicer,” he told me.

“I wasn’t prepared for this,” said the mother of Cheryl, a five-year-old girl with severe ADHD. This was before her daughter started taking medication. “My idea of having kids used to be dressing them up in cute little outfits. Then I thought we’d all do things together as a big happy family. I never knew so many things could go wrong. We went to Disney World for vacation, and it was a nightmare. Cheryl was impossible. She didn’t want to wait in line. She didn’t want to sit still when we got on
one of the rides. When we went to the gift shop, she couldn’t make a decision; she wanted everything, and she didn’t want anything. Sometimes my husband and I play a game called ‘Normal Family.’ We take the kids out to dinner, sit down at the table, and pretend that we’re totally relaxed, not at all worried that Cheryl is going to pick up the butter dish and throw it across the room. We always wonder if people can tell how much work it takes just to keep her in her seat.”