A PROPER DIAGNOSIS IS ONLY HALF THE SOLUTION

Children with attention and concentration disorders need a diagnosis to define properly what exactly is troubling them. What are the parameters in identifying attention and concentration disorders? When will we know that a child’s conduct is symptomatic of a much deeper problem, not just simple misbehavior? Why is it so important to make a diagnosis and how did people manage in the past without treatment? The second of three informative articles on the subject.       

Translated by Michoel Leib Dobry

With regard to conduct called “mischievous” – this is quite common, particularly with the first child. Thus, there’s no need to be impressed by this at all. And how to improve those in need of improvement? With skilled educators according to their experience.

(Igros Kodesh, Vol. 20, pg. 296)

The way to educate children born with an emotional tendency for fighting and scuffles is to direct this tendency toward the proper path.

(26 Teves 5742)

Several years ago, Menachem (not his real name) came to the educational institution where I work. Every educator who encountered the boy gave him the classification of a child with an “extreme attention disorder,” incapable of sitting in his chair for more than a few minutes at a time. He disturbed his friends during class and spent most of his time in the corridor. Everyone’s first impression, including ours, was that this was a child who is easily distracted and needs immediate treatment before he reaches the higher grades and, G-d forbid, drops out of educational programs altogether.

Our analysis was sent to a reputable professional in this field, and we were quite surprised to receive a totally different and unexpected diagnosis. It turns out that the test reports showed that the child had no attention disorder whatsoever. His problem was completely emotional due to past childhood experiences, and the professional expert promised that if the child receives proper emotional treatment, we will see a complete transformation. The diagnosis was definitely a surprise, especially since the boy’s family has a history of attention and concentration difficulties. Nonetheless, we followed the advice of the professional and the boy began to receive treatment for his emotional issues. He had weekly meetings with a psychotherapist and his condition progressively began to improve.

We see from this anecdote that there are various disorders with external symptoms that mimic ADHD. Yet, it’s actually something else and Ritalin won’t do the job. In this article, the second in this series, we will examine the complexities in diagnosing such conditions. Weighty questions can be expected when we discuss this issue. Examples: How can someone meeting with a child for just one hour give a diagnosis of such a significant disorder? Are there various levels of attention disorders? Does the doctor recommend the use of Ritalin in all situations? We posed these and other questions to Dr. Jay Zuckerman, an expert pediatrician specializing in neurology and child development.

Dr. Zuckerman is one of the most renown experts in the field. He had previously run an institute on child development as part of a network of clinics with Maccabi Health Services, and was head of neurology and child development at the Schneider Children’s Medical Center in Petach Tikva. These prominent roles gave him considerable experience in treating people of various ages in all population sectors with attention and concentration disorders. Today, he is a highly reputable doctor, working for the Clalit and Maccabi Health Services at Yoseftal Hospital in Eilat and as the director of a successful clinic on the settlement of Oranit, where he resides.

As we begin this interview, we would like to hear briefly: What are the parameters in identifying attention and concentration disorders? When will we know that a child’s conduct is symptomatic of a much deeper problem, not just simple misbehavior?

It’s exactly on this point where the problem is hidden: It isn’t always easy to know whether there really is a disorder. I divide the children into three groups: In the first group, the disorder is so obvious, there’s no need for an expert to know that the child has a problem. As soon as he enters the examining room, the child starts “taking the clinic apart” or the doctors see the exhaustion of the parents chasing after him.

The second group has children in whom the criteria for the disorder appear, yet they aren’t that prominent. In this case, the testing process needs more time to get an accurate impression of the child, review the questionnaires, and make a thorough examination that can rule out any other problems. The third group consists of children who clearly don’t suffer from this disorder, yet they have certain external symptoms that might tend to confuse us.

What do we need in order to know whether the child is suffering from an attention disorder?

There are three categories in the diagnosis: attention deficiency, hyperactivity, or a combination of the two. In principle, there are nine criteria for attention deficiency. According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, when six of the criteria apply, we diagnose the child as suffering from attention and concentration disorder.

The possible symptoms characterizing attention deficiency are ‘failure to notice detail,’ ‘making careless mistakes in homework,’ ‘not paying attention when someone speaks to him directly,’ ‘difficulties in organizing tasks or activities,’ and ‘being easily distracted by noise or external stimuli.’

As with attention deficiency, there are nine different symptoms for hyperactivity. Here too, when six of the symptoms appear, we diagnose the child as being hyperactive. In this case, the classic characteristics include ‘restlessness during sitting,’ ‘a tendency towards shifting arms or legs,’ ‘getting up from his place when he’s expected to sit,’ ‘interrupting with answers before the end of the questions,’ and more.

When at least six criteria symptomatic of both attention deficiency and hyperactivity are in evidence, this leads to a diagnosis of “combined type ADHD.” It’s important to know that there are a few more conditions for a correct diagnosis: It can only be done if the symptoms exist for at least six consecutive months, ruling out a case of simple misbehavior. The symptoms began to appear at a relatively early age – around twelve, although in most cases, the symptoms are already in evidence before the child turns seven.

The symptoms must exist in at least two out of three or more places where the child is during the day, e.g., home, school, with friends, or at play. They interfere with the child’s ability to function socially, in his studies, etc. Naturally, we must reject other disorders that might cause identical symptoms, particularly psychiatric conditions such as fear and depression, and learning disabilities that appear similar to ADHD.

As someone who has specialized in this field for many years, do you believe that science has made it more possible to identify the source of the disorder and the most effective treatment? In other words, do we know more about the problem now than we did in the past?

There is no question that science has progressed, especially in the field of understanding the location of certain areas of the brain that have difficulty functioning by ADHD children. Similarly, we now know that there is a dominant genetic-hereditary component that causes a high percentage of such cases within families. Today, we realize that in many instances, we are dealing with a combination of genetics and environment.

What is the three-level diagnostic approach you employ and what makes it unique in comparison to other approaches?

In the threefold ‘model’ I have publicized, I describe the interaction between the three functions and their influence upon the child’s ability to function, concentrate, and focus his attention:

1) The essence of the attentional function, the ‘personality,’ including most of the brain’s “administrative functions,” is primarily established by genetics and heredity. In most children for whom the attentive disorder is quite prominent, there is usually a clear family story: one of his parents or siblings had ADHD. 2) The learning function, which includes all of the brain’s tasks. There are at least one hundred and fifty known functions, required for success in scholastic studies, e.g., reading, writing, mathematics, reading comprehension, visual and hearing recall. Among small children, this also includes the motor and lingual-cognitive function. 3) The emotional and behavioral function – influencing the environment primarily within the family.

In this model, particularly for young children, we try to understand where the focus must be on solving their problem. For example, when a child with a cognitive/developmental deficiency sits in a regular classroom and fails to understand the material being discussed in class, this has a direct influence upon his ability to pay attention and concentrate. He loses interest more quickly than his fellow classmates, leading to the conclusion that he has ADHD and needs to take medication. I claim that first we should check to see if we have done everything possible to help the child fit into his current learning program.

In younger children, this includes treatments such as occupational or speech and language therapy, and if the child requires special education, placing him in a smaller classroom might solve or at least reduce the attention disorder. If these measures are not applied, the influence upon the brain cells becomes more ‘permanent’ and the attention disorder even becomes the main problem. As a result, there is no alternative left except to provide treatment with medication.

Another example: A child from a broken family via divorce or the premature death of a parent, or a child who grew up in a family with a very rigid parental style and developed a somewhat hyperactive mode of conduct. According to the model, without the necessary involvement, this interaction creates the difficulties – whether emotional, behavioral, or those related to attention and concentration deficiencies – and they merely intensify. In such a case, considerable importance should be attached to improving the environment, including parental training, emotional treatment or therapy. In more extreme situations, there will also be a need for medicinal treatment. According to the model, if we begin proper treatment early enough, it will be possible to prevent or least lessen the “outbreak” of attention difficulties at a later age.

Can there be something such as a mild attention disorder? Can there be a situation whereby we decide that there is a problem, yet it is unnecessary to take any medicinal treatment?

Absolutely. As with any disorder affecting a person’s ability to function, there are different levels of severity. Children with milder difficulties are usually able to manage with ‘preventive’ treatments – assistance in their studies, parental guidance, and outlining a good pattern of behavior. This is even more true among young people when the requirements within their educational system are low, while those with a high level of intelligence succeed in ‘bypassing’ the problem altogether. This is also true in the event that parents and educators are extremely attentive to the child’s needs and they know how to work with and strengthen him.

Many parents come to a diagnosis through a neurologist or psychiatrist, or even a series of computer tests, and they receive a ‘Yes’ or ‘No’ answer. Since we know that this is often a most complex analysis, do you address this matter in your approach?

In my approach, I attach great importance to a comprehensive examination in order to distinguish the child’s attention deficiency in terms of all other difficulties he encounters, not just one aspect. At the end of the procedure, I provide a list of recommendations wherein medicinal treatment (if recommended) is only one among many, and this must be the approach of all professionals dealing with the problem.

ACCENTUATING THE POSITIVE AND ELIMINATING THE NEGATIVE

Why is it important to have a diagnosis and how did people manage in the past without treatment?

Children who don’t receive a proper diagnosis, especially in those instances where there isn’t an adequate supportive environment, eventually fail in their studies and their absorption into today’s society. They are allowed to slip through their educational program and even reach the outer fringes of society, including crime. The difficulty with functioning in their daily lives, even as adults, can have a most negative influence upon their marriages, their relationship with their children and other people.

In the past, such children were often just removed from their standard learning programs and sent to vocational or art schools. There are numerous artists and other people of culture who have suffered or suffer from attention disorders.

In conclusion, we would like to hear a few practical tips for parents with an “attention disorder”: How can we make it easier to deal with this problem?

Among all the important tips, we must provide more love and ‘positive feedback.’ As we always say, for every negative comment, give seven positive comments. The purpose is to break the cycle of anger and low self-image. However, it is also important to place clear limits, activating ‘parental authority’ in a positive manner. Of course, it would be preferable to give prizes for good behavior as opposed to punishments, unless there is no alternative.

If an argument ensues, sometimes there is a need for a five to ten minute break – no physical contact and no anger to let things cool off. Afterward, give him a hug, but without making any compromises. It’s important to establish some quality time with the child; play a game with him. Don’t limit the time together to when he does his homework, something he hates, and try to understand his frustration and his problems.

AN IMPORTANT TIP FOR PARENTS

In conclusion, here’s another important tip: Surveys show that children with attention deficiencies have been blessed with a heightened sense of justice, possessing greater concern for the weak than among other children their age. In general, everything they see is either black or white, without any weak pastel colors. Therefore, they sometimes respond in a way that appears as extreme or insolent, and we are quick to judge them for their chutzpah. It would be appropriate not to be too hasty about punishing the child, trying instead to understand why he reacts as strongly as he does.

Similarly, it would be a very good idea to speak gently with these children, even in situations when they’re angry (and that happens often enough). In any case, the child suffers from a level of low esteem, feelings of blame and frustration, and there surely is no need to make matters worse. We must work consistently with them and help them to see more aspects of life, particularly the positive ones. If we think about it carefully, we can easily find positive aspects within these children – and plenty of them.

TEN TIPS FOR TEACHERS DEALING WITH CHILDREN DIAGNOSED WITH ADHD

At the start of each class, give specific details, both verbally and with written instructions on the board, of the learning material to be covered. The child must know what is expected of him. This is important for maintaining his peace of mind.

Check that the student’s table is in proper order, and limit the number of items he’s allowed to keep on the table, according to the need. Too many textbooks and workbooks can easily distract him. If the child also suffers from sensory processing disorder, you should allow him to place a few items on his table. However, make certain that they actually help him.

Go over to the student personally and ask him to repeat the instructions given during the class. Make every effort to do this privately and not embarrass him in front of his classmates. When you prepare to ask him a question, repeat it again slowly and stand near him. This way, he’ll understand that he’s about to be asked something.

Come to an agreement with the child on fewer class restrictions. Half an hour into the class, he can go outside to get some fresh air for five minutes by raising his hand at a set time. Allow the student to do some physical activities during a respite in classwork, e.g., running errands for the teacher. In addition, make certain that he’s not taking advantage of the situation and remaining outside for longer than agreed upon.

Place a student tutor with positive influence at the side of a student having difficulty behaving in class. This provides support for a child with ADHD, serving as a personal example of diligence and a reminder for him to finish his classwork.  The student tutor can participate in a reinforcement program with prizes in accordance with the child’s successes in class. You should choose a calm and relaxed student who doesn’t give up quickly.

Use a variety of sensory communication tools to strengthen the level of concentration and effort invested in class. Examples: touching the student’s shoulder to remind him to continue his assignment, giving simultaneous verbal and written instructions, using non-verbal reminders such as pointing to the board or giving a smile. Most importantly, maintain proper eye contact as a means of impressing upon the student that you are watching him.

It’s important to use positive reinforcement, preferable to getting into a cycle of endless punishments. Give out tangible prizes from the natural environment, e.g., a positive note for his parents, placing a star next to his name on the class achievement board. In addition, the prizes will encourage him to show greater responsibility within his surroundings and strengthen his self-confidence. Give clear and specific assignments, not general tasks or those that require lengthy periods of concentration. 

Be creative. This will help all students in connecting to their studies, not just those with attention disorders. Place greater emphasis upon creating an enjoyable learning experience through games, stories, parables, and opportunities for children to express themselves during class. While the amount of learning material covered might be less than usual, the level of comprehension will grow.  

Learn the subject of ‘attention and concentration’ in depth, understand what the child is dealing with and the degree of investment required for him to fulfill tasks that other children handle with greater ease. This will make you more empathetic towards the child, and in turn, he will feel that the teacher understands him. I’m in favor of speaking openly with the child about various aspects of his learning that are difficult for him. This strengthens the connection between you and your student, and makes your job much easier.

 Don’t compromise on a diagnosis and basic treatment. Today’s parents, and even the school’s senior staff members deeply entrenched in their work, will do nothing if you don’t put on the pressure. Even if your student is surviving, that doesn’t necessarily mean that things will get any easier with his teacher next year. The learning disorder and its symptoms will only get worse, and his social and scholastic condition will deteriorate. Even if your firm position causes several staff members to become angry with you, don’t give in. The child’s best interests are the only thing that should concern you. As more time passes without a proper diagnosis and treatment, his frustration will intensify, as will the difficulty in improving his overall state. Have pity on him.