A.D.H.D. - HOW, WHAT, WHEN, AND HOW MUCH?

Difficulty in maintaining proper attention and concentration is a common development disorder among children. Virtually every classroom has two or three students with this problem and it impacts the child’s ability to function in most areas of his daily life - learning, behavior, and social conduct. How do we identify this within the child? In what form does it take expression? What is sensory processing disorder? Ritalin - yes or no? What is the Rebbe’s position on the matter? The first of three informative articles on the subject.

Translated by Michoel Leib Dobry

Regarding his son… that it’s hard for him to be under supervision and to be under a constant schedule… What he writes about medicinal treatment - since this is something new, I hope that they will do this with the utmost care, in other words, the tests every “few” days should be the minimum “few”, not the maximum.

(5 Menachem Av 5718 - Igros Kodesh, Vol. 17, pg. 267)

Shlomo (not his real name) came to us when he was in the third grade. He had been transferred this year from a regular classroom to a smaller class due to emotional difficulties. Not a day passed without him fighting with his classmates. He had difficulties sitting on his chair for more than a few minutes without causing a disturbance. As a result, he would get reprimands and punishments from the school staff. The only time he was calm was when the teacher was telling an exciting story or during drawing class. However, his drawings appeared to be crying out over what was happening within him. The colors he chose were dark and somber, the drawings were militant - swords, axes, etc., and the figures were expressionless.

As the years passed, he developed a serious learning gap. His reading ability was negligible and his self-confidence was rock bottom. He didn’t like his teachers and he couldn’t deal with his classmates. It was clear that his conduct required the immediate involvement of professionals, something that had inexplicably been put off for years. Signs of the current situation had already been in evidence since he was in kindergarten, or even earlier - in daycare. He was sent to do three examinations by different experts specializing in this field, and they all came back with the same diagnosis - ADHD (attention deficit hyperactivity disorder).

The three doctors all recommended regular medicinal treatment - Ritalin. At first, the parents were hesitant, trying various alternative methods. However, it changed nothing. Eventually, they realized that there was no alternative and the boy began taking a pill each morning. The first few weeks were a bit complex: In the beginning there were side effects - headaches, stomach pains, loss of appetite. However, with the passage of time, they slowly dissipated. While the initial recommendation was for a higher dosage, as a result of the side effects, the doctor reduced the dosage to the minimum level.

In the first few months after regular treatment began, Shlomo was sitting in class, paying attention, and causing no disturbances. During this time, his peers renewed their friendships with him. Things slowly began to improve: A remedial teacher helped him considerably with his reading, and it turned out that he had a high level of intelligence, blessed with an amazing ability of comprehension. He managed to close a gap developed over a period of years within a matter of months.

The truth is that no one thought this would happen so quickly. However, the facts are that just a year later Shlomo was chosen as the outstanding student in his class on all levels. Even at home, after his parents received professional advice and gave their full cooperation, there was a tremendous improvement, and his mother confirmed the dramatic change for the better.

THE DIFFICULTIES FOR CHILDREN WITH ATTENTION DEFICIENCY DISORDERS

There are many students like Shlomo. According to current estimates, about one in ten Israeli students have attention disorders, thereby concealing their natural abilities. While they do exist, the difficulty in concentrating can prevent these abilities from being realized.

As mentioned, ADHD is a developmental disorder commonly found in children. Virtually every classroom has two or three students with this problem. It prominently appears in the child’s ability to function in most areas of his daily life - learning, behavior, and social conduct. Similarly, many of these children also suffer from a variety of deficiencies, e.g., learning disabilities, motor deficits, sensory dysfunction.

The main symptoms in ADHD children are: talking unceasingly, persistently moving and jumping around, difficulty remaining in one place for a lengthy period of time. They move in their chairs in a state of disquiet or they occasionally stand up. When they do sit, they shift their legs nervously, and they constantly say, “I’m bored.” It’s extremely difficult for them to concentrate on one thing for a long time, interesting as it may be, and their attention is easily distracted. The distant sounds of an airplane, a tractor, or classmates whispering are enough to break their concentration.

These children act carelessly and with forgetfulness. They appear absentminded and detached, making numerous mistakes stemming from inattentiveness and negligence, with a tendency toward losing things. Similarly, they have problems organizing basic tasks, and they avoid activities requiring prolonged cognitive effort, such as homework and sitting for long periods in class. Surveys show that children with untreated attention disorders are more easily dragged into a life of crime and addiction, and they are four times more likely to be involved in an automobile accident.

Anyone who has worked in the field of education knows that a sizable percentage of school dropouts have attention deficiency problems that were not treated in time. People think that attention deficiency is a passing stage in the child’s development - but they’re mistaken. The life of a child with ADHD who is not diagnosed as such is paved with failures, frustration, and limited achievements. The child carries these disappointments throughout his entire life and his family will eventually suffer as well.

We are setting out on a three-part journey dealing with attention disorder in a variety of forms. With the help of professionals and experts in the field, we will examine: What is attention deficiency? Where does it stem from and what are its symptoms? We will determine the best ways for diagnosis, and most important - why is it necessary to treat the condition and not neglect it?

In this series of articles, we will present a wide range of views in the field - from both the conventional and alternative approaches.

For this first article, we spoke with Dr. Guy Schusheim, one of the leading experts in Eretz Yisroel on diagnosing and treating attention disorders, a child/youth psychiatrist and the director of the youth mental health clinic at the Emek Medical Center in Afula. We asked him to give us first-hand information on attention deficiency disorders and the importance of proper treatment.

As parents or educators, how do we identify attention disorders within our children? Can these symptoms stem from various other reasons - emotional, sensory imbalance, nutritional, and even anxiety or the lack of hormonal balance?

The first signs of attention disorders usually appear at a very early age. According to the guidelines for making such diagnoses, it occurs before the child turns twelve, and in most cases, it happens much earlier. It takes expression in a combination of symptoms: inattentiveness, hyperactivity, and impulsiveness. The diagnosis must be made by a professional, e.g., an expert pediatrician, child neurologist, or youth psychiatrist.

In truth, these symptoms are often the product of other disorders, or from a combination of attention and other deficiencies, e.g., anxiety or other emotional difficulties. In more rare instances, attention disorders are caused by nutritional deficiencies or other medical problems.

What are the reasons for attention deficiency disorder? How many types of this disorder exist?

We don’t know the exact reason for this condition, as with most disorders of this type. However, it’s quite clear to us that there are numerous causes, and the connection between them is complex. Sometimes, it’s possible to identify a significant hereditary component, which occasionally establishes a connection between the disorder and complications before, during, and immediately after birth.

Premature birth, for example, has a strong connection to the emergence of attention disorder. However, external causes such as a difficult environment for a young child’s development can also bring about this condition. In principle, there are three subtypes of disorders - attention deficiency, hyperactivity, and a combination of the two.

How is this condition diagnosed?

The diagnosis is made by a professional and it must include an examination of the child and information from the parents, the school, and other sources. Questionnaires can be used, and there eventually will be a need to meet a minimum number of basic definitive criteria to reach the necessary conclusion. Another possible option is to use computer tests that can better characterize the nature of the attention disorder. However, even these tests can “miss” an existing disorder or diagnose one that doesn’t exist.

There are benefits and drawbacks to all kinds of drugs in use for treating ADHD. How do we come to the right dosage?

There are a relatively limited number of medications for treating the disorder subsidized by the Israel Ministry of Health and several more unsubsidized medications that are regrettably much more expensive. Medications for this condition are relatively more effective than other drugs for treating emotional disorders and they can even improve the situation far better than accompanying methods, such as guidance for parents and educators, or more personalized treatment for the child. Medications can have many side effects, but they are usually few in number and can be overcome or pass quickly. 

The most common side effects are headaches and stomach aches, which often tend to dissipate. In contrast, a loss of appetite usually poses a serious challenge to the treatment process. Other possible phenomena include anxiety, nervous ticks, and more. It isn’t easy to predict what the reaction will be and the treatment is a form of trial and error.

Is there any importance attached to making an early diagnosis?

We believe that there is great importance to an early diagnosis since untreated attention disorders are liable to harm a child’s emotional and functional development, influencing how he relates to his environment, his self-image, and increasing the danger of additional disorders appearing in the future.

How was this problem dealt with in the past? Is there historical testimony on this disorder and the methods of dealing with the condition?

The disorder in its present form has been recognized for decades. Yet, awareness of possible treatment was very low in the past. Our way of life was different in those days, and there were more possibilities available for dealing with the problem. If someone couldn’t sit quietly for a lengthy period of time, whether in class or anywhere else, he would be sent to learn in a trade or art school. Today’s society is more achievement-oriented, relying more upon a certain type of learning ability.

There’s a feeling that the number of children diagnosed with having ADHD has been increasing. Is this true?

Most definitely, and the apparent reason for this comes from a variety of sources: Today, there is a greater sense of awareness of this disorder - and with greater awareness, there are also more diagnoses. However, we can also say that people have sometimes been identified as having ADHD when they really don’t have it, resulting in an improper use of the diagnosis and the subsequent medicinal treatment. I believe that even today, it’s much harder than in the past to live with attention deficiencies due to changes in our lifestyle. Furthermore, today’s way of life is a much greater cause of the attention disorder phenomenon than in the past, although this fact has yet to be scientifically proven.

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In any case, according to the Rebbe’s answer brought at the beginning of this article, it would be appropriate to check if a lesser dosage of Ritalin or other medication helps, and if it does, there is no need to take a larger dosage.

There’s one thing all doctors who treat this disorder agree upon: it is absolutely forbidden for us to delude ourselves and neglect the condition. If the child has difficulty concentrating, if we receive numerous complaints from the school - or even earlier from the daycare attendants and kindergarten teachers - go for a diagnosis and an examination. Every passing year without treating the problem intensifies the child’s emotional distress.

In the next two articles, we will deal with methods of diagnosis and treatment.

TEN TIPS ON HOW TO IDENTIFY AND TREAT
AN ADHD CHILD AT AN EARLY AGE

1.     The child is already more than six months old. He’s passed the colicky stage, yet he continues to cry incessantly. It’s possible that this stems from sensory processing disorder. Parents should patiently try and see if there are certain clothes without which the child is calmer. An embrace or a loving touch will also help to soothe him.

2.     The child wakes up several times during the night or his afternoon nap is unusually short. Every little thing disturbs him. Try and put him to sleep in a dark and totally quiet room.

3.     Your child is now two years old. While he’s known how to walk for some time, he bumps into things and is prone to falling. Remove all stumbling blocks and make certain that potentially dangerous items are nowhere in sight. When you go out with him in public don’t take your eyes off of him.

4.     You had your child’s hearing tested and he hears fine. Nevertheless, when you call him, it takes him a long time to react. It often appears as if he can’t hear you at all. There’s no reason to get angry at him. Any time you want something from him, turn towards him. Start speaking with him only when you’re certain that he’s looking at you attentively.

5.     Your child doesn’t like to be in an unfamiliar environment, always preferring what is known and familiar. This derives from a high level of sensitivity and proneness to distraction. Make certain that when you come to a new place keep your child close by and give him special treatment. It’s always appropriate to prepare the child before leaving. Don’t talk to him in riddles; speak clearly and in particulars.

6.     Your child has a tendency for frequent angry outbursts. His thoughts are a jumble and his reactions are impulsive. It appears that even in seemingly commonplace situations he becomes impatient and reacts angrily. It would be appropriate to keep things in proper balance when dealing with him; no need to be stubborn about everything. Choose a few things that are very principled for you, and remain as steady as a rock on them - firm but considerate. In this manner, the child will learn that he gains nothing by his angry outbursts.

7.     Children have many fears and anxieties according to their age and development, while some show a reckless disregard for danger, e.g., climbing tall trees or poles. Listen to your child, show firmness in potentially dangerous circumstances, and be alert. This is a stage that usually passes with time.

8.     There are children who need things to be done in a certain way, and if not, they become uneasy. Similarly, it’s hard for the child to get organized in the morning, promptly or not, and when he tries to do so, he cries and feels pressured. This comes from a high propensity to distraction and organization difficulties. Try and help him with a clear checklist of morning tasks for getting organized. Similarly, make certain that his room contains a minimum of items that can possibly distract his attention. In addition, have his clothes prepared beforehand, preferably before he goes to sleep.

9.     Your child sustains a serious fall and doesn’t cry, while on other occasions, he bursts into tears and becomes hysterical at the slightest touch, as if someone punched him. Sometimes, the child refuses to touch sand, mud, clay, etc., or he feels a need to touch such material to the point of even eating them. Such children are suffering from sensory processing disorder. Many of them put paint peelings in their mouths. It would be appropriate to take such children to see an occupational therapist as a means of exposing them to things that can counterbalance this inclination.

10.   Some children have difficulty tying their shoelaces or with any other form of weaving. This is another case for the occupational therapist. In the meantime, the child should wear shoes with Velcro strips. Before buying clothes for the child, it’s always a good idea to find out what’s most comfortable for him.

In conclusion, it’s important never to get angry with your child because of these difficulties. It’s hard enough for him to handle such challenges. However, you must always remember that G-d created him and he can’t change who he is, especially not at a young age. Furthermore, he’s not to blame for this. All your stubbornness in this matter will merely deepen his frustration and stress. Quite often, the child himself doesn’t understand what’s bothering him, and therefore, it would be appropriate to bring him into the picture and let him talk about it.