In the two previous articles of this series, we discussed the reasons and modes of treatment for attention and concentration disorders with the help of two of the most prominent experts in the field. In this third and final installment, we have chosen to deal with the prevalent myths surrounding conventional treatment. For this purpose, we have been assisted by a well-known specialist in diagnosing and treating children with attention disorders – Dr. Gil Maor (“Dr. Keshev”).
Translated by Michoel Leib Dobry
I was shocked to read in her letter that someone advised her to take a small child and hold him in a dark room, etc., since in her opinion, he is hyperactive, and I was pleased [to see] in the continuation of her letter that she did not take this terrible advice. You should raise him and your children, sh’yichyu, together with your husband to Torah, chuppa, and good deeds.
(Correspondence from 23 Kislev 5740)
Inspired by this extraordinary letter from the Rebbe, we present this article on “attention and concentration disorders in children.” We will illustrate to all those opposed to ‘Ritalin’ how people dealt with ADHD children in the past. At best, they simply chose to ignore the problem and the child found himself constantly discouraged, confused, and insulted. In even worse cases, educators simply used scare tactics or corporal punishment. Naturally, this failed to bring a solution or cure to the problem. Instead, the situation worsened, and the child remained sad and frustrated.
Anyone who suggests going back to treat this condition according to the old approaches would be advised to check how the problem had been treated in the past and the treatment’s effectiveness. In the two previous articles on this subject, with the assistance of two prominent experts in the field – Drs. Guy Schusheim and Guy Zuckerman – we discussed the reasons for the disorder and the means of diagnosis. In this third and final article, we chose to deal with the widespread myths surrounding the more conventional treatments. We enlisted the help of one of the most prominent figures in the field of treating and diagnosing ADHD children – Dr. Gil Maor, also known as “Dr. Keshev (Attention).”
Dr. Maor is a reputable expert and well-known lecturer in education. Together with his wife, he operates the “Dr. Keshev” Institute in Akko. His clinic employs fourteen staff members, including doctors, psychologists, didactic examiners, and treatment specialists for patients with attention disorders. The institute provides diagnostic services, guidance and treatment for children with attention disorders and their families, psychotherapy, CBT (cognitive behavioral therapy), and guidance for educational institutions and teaching staffs in the ultra-Orthodox state school system.
Before we begin, perhaps you can say a few words about yourself, the center, when it opened, and what you do there?
I was born in 5735 and was diagnosed as suffering from attention disorder, dyslexia, dysgraphia, and coordinative problems. Until the age of twenty-four, I had no idea why things were so difficult for me. Then, by Divine Providence, a student did a research study on the subject and sent me for a diagnosis. Since then, my life has changed dramatically. The fact that I knew what had been ailing me until now and what could be done to improve my ability to function did wonders for my overall mood.
In 5765, as part of my doctorate work, I opened the “Dr. Keshev” Institute to create greater awareness on dealing with and treating attention disorders in a proper manner. Among our services, we provide support under the auspices of the Israel Ministry of Education to the pre-elementary school system (kindergartens) and developmental guidance staff personnel in the Haifa region to help teachers in dealing with attention disorders and learning disabilities among their students.
DOES THE CHILD
REALLY NEED RITALIN?
When we speak about attention and concentration disorders, it would seem that we immediately have to raise the issue of Ritalin. Is it appropriate for everyone? When is it and when is it not?
Before talking about Ritalin, I want to say a few words about understanding what is ADHD and hyperactivity. We’re talking about an external trait that indicates a high level of irritation within the nervous system. It falls within the category of disturbances known as “sensory attention disorders.” About a quarter of those with this disturbance meet that definition, classified in medical textbooks as a neurodevelopmental disorder, thereby requiring a diagnosis according to medical standards.
ADHD treatment combines guidance, symptomatic medicinal support, and psychological treatment as required – most often cognitive behavioral therapy (CBT). Today, there are three accepted methods of medicinal treatment:
Treatment with stimulants – This is the most common and effective form of treatment. It is suitable for 85% of those suffering from attention disorders.
Treatment with regulating medications – This is an alternative treatment with anti-anxiety and anti-depression medications. There’s also a third group: Relaxants. This mode of treatment is less recommended and is often combined with stimulants or prescribed for people who can’t tolerate stimulants.
As mentioned above, the most common and effective form of treatment is done with stimulants. In the United States there is Adderall and its sister drug Ritalin. In Eretz Yisroel, due to drug import laws, Ritalin became the more prevalent medication, prescribed in about eighty percent of the cases. It is considered a good medication, with very few known side effects, though requiring a doctor’s supervision. In the other twenty percent of cases, Ritalin is deemed an inappropriate form of treatment. Surveys conducted over the past three years have detected certain patterns of brain activity for those ill-suited for Ritalin usage. The medication is effective after the person has been diagnosed as someone suffering from attention disorders and reacting well to the medication upon determining the proper combination and dosage.
What other diagnoses should be made and why do we need to do them before prescribing treatment?
An attention disorder diagnosis is a medical diagnosis signed by a doctor. As part of the diagnosis, the doctor summarizes the symptoms, checking the patient’s medical history and the family’s development background. In the event that there is a plan for medicinal treatment, it would be advisable to make use of computer tests as a means of ensuring the most effective response of the child to the prescribed medication. The most widely accepted examination is the Test of Variables of Attention (TOVA). In addition, examination should be conducted to ascertain if the child has any cardiovascular trouble. In the event that such problems exist, it would be advisable to run an EKG test to determine if the child can safely take the medication.
GUIDANCE TO PARENTS
Why is guidance for parents so important?
At the first stage after a diagnosis of attention and concentration disorder, it is highly recommended to receive proper guidance. The guidance gives direction to the parents, the educational staff, and children of all ages. Since we’re talking about a chronic disorder that has an impact upon a wide range of functions for the child and his family, it’s important that the adults in the child’s life know how to deal with him and help him in those areas requiring direction and guidance.
While a child with medicinal treatment will have better concentration, if he will not develop more effective skills, the treatment will not be as effective and his ability to function will not improve significantly. The combination of personal guidance and medicinal treatment is critical.
Why is it appropriate to diagnose and treat children in the first grade and not wait until they reach fourth or fifth grade?
It is appropriate to diagnose a child as early as possible. Dr. Russell A. Barkley, one of the most internationally recognized authorities in this field, avers that a child with ADHD is like a car with an engine but without brakes. It would be advisable to make a prompt diagnosis and provide his guardians with knowledge and proper tools to deal with the condition. A child who is diagnosed at a later age already suffers from acquired disorders and has formed ineffective work habits for himself. These are sometimes harmful, particularly in relation to his ability to handle challenging tasks. The diagnosis and treatment should begin as soon as possible, even before the child starts first grade, in order to prevent acquired secondary damage.
ATTENTION DISORDERS IN TORAH OBSERVANT CHILDREN
What is the difference between learning disabilities and attention disorders, and could they appear simultaneously?
Learning disabilities and attention disorders are diverse phenomena. While they often appear together, each one is discovered and diagnosed in a different manner. ADHD is a medical diagnosis made through a process similar to any other ailment.
A learning disability is diagnosed through a didactic procedure designed to monitor basic learning functions and determine the child’s functioning in relation to the expected norms for his age group. The treatment is also different for each disability. ADHD requires both guidance and medicinal treatment. On the other hand, treating learning disabilities is done through guidance and proper education, without the use of medication.
Is there a difference in the diagnosis or treatment of a child with attention disorder in the general population as opposed to the ultra-Orthodox community?
From the perspective of the diagnosis, the process is similar for all, regardless of age or demographic. The diagnosis includes a clinical examination by a doctor, usually a neurologist and/or psychiatrist, an emotional evaluation, and completion of a detailed questionnaire report by the parents and the educational staff. As we stated previously, most doctors make use of computerized tests as aids.
However, a child from the ultra-Orthodox community is treated differently than a child from the general population due to differing structures in their respective educational systems. The ultra-Orthodox child is educated from a young age to develop his own Torah abilities to become a Talmudic scholar. The chareidi lifestyle is more organized and controlled. On the other hand, the secular child is educated from a young age to be independent and has a far less structured lifestyle. Therefore, the doctors providing treatment to ultra-Orthodox youngsters must relate to unique characteristics as it pertains to the different daily agenda.
DISPELLING THE MYTHS
I would like you to dispel several myths on this issue. First, there is a myth that anyone who comes for a diagnosis leaves with a prescription for Ritalin. Is this true?
Certainly not. Today, about a third of children in every educational institution display some form of sensory processing disorder. However, only a quarter of them have been diagnosed as suffering from ADHD and not all of them require medicinal treatment.
Most children come to psychiatrists or neurologists for a diagnosis in attention disorder because some problem exists. It stands to reason that if the child has a behavioral problem, there must be something bothering him. ADHD is one of the most common causes of behavioral problems in children. However, there are many people who come to a doctor, and it turns out that the source of the disorder is emotional in nature – fears, bad parenting, etc. In such cases, the children receive appropriate treatment, as opposed to Ritalin. In order to prevent improper treatment, considerable importance is attached to a full and reliable diagnostic process.
Perhaps the most widespread myth is that since teachers today don’t know how to educate children as they did in the past, there are more cases of ADHD diagnoses.
Today’s style of education can explain the increase in sensory and behavioral problems among children, known as attention and concentration disorders. However, since ADHD is hereditary in nature, there is no connection to education. It has been described in books and articles since the seventeenth century and has been classified as a medical syndrome since the beginning of the twentieth century. This is nothing new and it has characterized people throughout history. One thing is certainly true: The proficiency of the diagnostic process has grown in recent years, thereby contributing to the increasing number of diagnoses.
Another point: Due to ADHD’s hereditary nature, there’s a good chance that if one of the parents has an attention disability, most of his children will have the same condition. Therefore, it is quite natural today that there are more children with this disorder. However, this still doesn’t explain the increase in recent years.
There are those who claim that a child is asked to take Ritalin to give the teacher some quiet in the classroom. Of course, this is simply not true; Ritalin is prescribed for the good of the child. Medicinal treatment is given to make it easier for the student to function. Giving the child a remedy (often Ritalin) merely strengthens his brakes, and if he wants to learn and work in class like everyone else, he will succeed. In light of the fact that most children truly want to succeed, we see that when we provide treatment to a child and he responds to it, the child almost immediately improves in class.
Another myth: They say that certain foods, such as vegetarian or organic, alongside changes in lifestyle, can reduce or worsen the attention disorders. Is this a fact?
The food relationship is rather complex. As a rule, the function of our brain is influenced by the nourishment it receives from the body. This gets the brain to start working, and it includes energy, minerals, and vitamins. Healthy nourishment together with healthy sleep habits improves bodily functions for all people, including children with attention disorders. There’s a group of people with allergies or sensitivity to certain foods who occasionally show symptoms that mimic ADHD.
One of the biggest myths is keeping stimulants such as chocolate and cola away from children who suffer from attention disorders. This myth has long since been refuted. On the contrary, stimulants like chocolate and cola are some of the most natural rewards to help children deal with the need to concentrate.
When there is a case of attention disorder, chocolate and coffee have no effect upon hyperactivity. On the contrary, coffee can increase the level of concentration and lower hyperactivity, albeit slightly. When there is a display of hyperactivity and unruliness, it is recommended to seek a doctor’s advice and do blood tests to check the function of the child’s joints and glucose tolerance: There could be a latent case of diabetes. In addition, there’s likely to be an allergic condition toward various substances, without any connection to ADHD.
Some say that Ritalin causes ticks and is liable to arouse feelings of depression and anxiety.
One of the identifying characteristics of attention disorder is mood shifts. At the start of Ritalin usage, they sometimes become more severe, commonly called a “rebound” effect. When they appear, we regard them as side effects to ADHD and then discuss the appropriate mode of treatment with a doctor.
With regard to depression, Ritalin enables greater concentration and focus, and the child’s quiet tendencies and lack of “foolishness” is interpreted by his environment as depression. A distinction must be made between a state of depression and calm deriving from concentration.
I recently heard another argument from a parent: Ritalin stunts a child’s growth.
This myth is based on two research studies in the eighties, showing that the children between the ages of fourteen and eighteen who took Ritalin reached a height two centimeters less than other children of the same age group.
Today, we know that ADHD is actually a sensory disorder, and it can also have an influence upon biological rhythms, including the rate of height. It is also known that the timeline of physical growth among ADHD children is longer, continuing until the age of twenty-four on average (as opposed to nineteen for other children). Thus, it is the attention disorder that adversely affects the child’s growth, not Ritalin.
A child with attention disabilities is usually far more sensitive than other children. Similar to any other child, he wants those in his surroundings to be proud of him. While he also wants to achieve success in his life, this isn’t always possible due to his lack of focus and concentration. What follows are ten characteristic responses of such a child towards his parents and his environment.
- Tell me that you love me, despite the fact that I know that you love me.
- Share with me what you think about me. I also need and want to know how I am perceived by you.
- I’m sick of hearing the sentence ‘You have tremendous potential that you are failing to realize.’
- Remember, I’m not mentally retarded, lazy, or stupid – I just have problems concentrating.
- Tell me also when I do things right. Sometimes I act like all the other children.
- Please help me! I no longer have the strength to pretend.
- Have patience with me. Even if it takes me more time to understand something, I also need to feel that I’ve succeeded.
- Please don’t try to understand me because I also don’t always understand. Know what bothers me and don’t focus so much on why it happens.
- Find the time to listen to me, even if I talk too much – and don’t get angry with me if I forget something. It’s not done on purpose.
- When I say, “I’m sorry,” I mean it, even when the same thing happens over and over again.