The Best Medicine for ADHD isn't Necessarily Medicine
CDC Report: Behavior Therapy, Not Meds, First for Young Children with ADHD
Posted May 13, 2016
Steve and Michelle were desperate—their 6-year-old son, Sam, was diagnosed with ADHD soon after entering first grade. Sam’s behavior seemed outright defiant—he “ignored” being called and he moved constantly, often from room to room even when being directly spoken to. Sam let out bloodcurdling screams when forced to stop playing a game on the iPad. Sam’s teacher had struggled with some similar behaviors in class and his guidance counselor said Sam needed to be on medication. Steve and Michelle were not so sure, but began to wonder if they were being negligent by not putting him on Ritalin or something similar.
Despite the relentless advertising in parenting magazines and websites, and the occasional coercion by some school personnel, there is a good chance your young ADHD child may not need medication. Or at least not yet. The Centers For Disease control just released results from their first national study to look at therapy, medication, and dietary supplements to treat kids with ADHD ages 4-17. The principle investigator, Ileana Arias, stated:
"Because behavioral therapy is the safest ADHD treatment for children under the age of 6, it should be used first, before ADHD medication for those children."
The CDC study revealed that of the children diagnosed with ADHD, 4 in 10 were treated with medication alone, only 1 in 10 received behavior therapy alone. This study reflects how the “medical model” pervades the way we think today about most developmental and mental health issues- psychological and behavioral problems are diseases with underlying biological causes within a person, and require a medical solution, most often medicine. The medical model is appealing because it is logical and seems to best embody the scientific method of objective and measurable observation. It also reflects our implicit theory of humans- a person’s actions are a function of his personality, that is brain activity and current state of mental health. While enormously helpful in many instances, it can be woefully inadequate with complex issues such as ADHD, because many of the symptoms of ADHD are problematic only in certain contexts, and have the potential for dire social and academic consequences.
ADHD provides an unyielding challenge to the assumption that parents should be able to control their kid’s behavior and that good parents can do that consistently. Although individuals are diagnosed as having ADHD, after 30 years of clinical work, I believe it is more constructive to think of the family as “having” ADHD, with most of it concentrated in one person. Concentrating all efforts on the attempt to help or “fix” the child usually falls short. But understanding ADHD as primarily a biological problem requiring a medical solution is a hard habit to break, even for health professionals.
Most beleaguered families relentlessly strive to solve unrelenting problems, and they often get “stuck”, that is, the attempts to fix the problem become a problem. While all family members hated Sam’s meltdowns, his howls were most disturbing to Sam’s maternal grandmother, Gail. Gail often reminded Michelle of how “good” she and her brother were at Sam’s age. Her mother tirelessly pointed out how she never allowed her daughter to engage in the behaviors that formed Sam’s default repertoire. Some fortunate parents, like Gail, have the task of raising a kid who came into the world with an “easy temperament”. These kids respond to transitions smoothly, focus efficiently, and cooperate easily. Their parents often attribute their kids’ enviable assets to their own excellent parenting, paraphrasing from baseball, that their “kid was born on third base and these lucky parents think they hit a triple.”
Other parents are drafted into raising a kid with ADHD, like Steve and Michelle. This experience is more like a scrappy baseball game that goes into a lot of extra innings. Like embattled infielders, these parents may have the feeling they are playing out of their league. Unlike those “born on third base”, these parents often feel anxious and stressed. And if there is a close relative blaming them for their difficulties, these parents are made to feel incompetent. How does a grandparent get so much power?
It starts early.
When Steve tried to support Michelle by standing up to Gail, pointing out to her that Sam is a different kid than the ones she raised, Michelle immediately felt compelled to defend her mother. These folks were stuck.
Family therapy is a behavioral therapy based on scientific understanding of “family systems." The “systems” model, as it is often referred to, does not question the validity of medical conditions, but looks more closely at human connections and the potential they hold to cause and maintain problems or be harnessed to improve things, even mental disorders and diseases. Family therapists look for “frames”—novel ways of looking at the situation that evoke new behaviors to help get things unstuck.
Most new parents are eased into what will be the ride of their lives. The infant years are harrowing, but delightful. In exchange for enduring a large amount of anxiety and an adequate amount of sleep, parental newbies are rewarded with enchantment on a daily basis. This is a key time for rookie parents to develop their chops- the necessary skills, for sure, but also the increased feeling of competence: “We can do this." And expert help is generally nearby. Despite the perception of an “American Diaspora," the median distance adult Americans live from mom is 18 miles. In Michelle and Steve ’s case, Grandma was about a block away.
The early phase can also be anything but easy. Sam came into the world a handful, preciously labeled a “fussy baby” by developmental specialists. Fussy babies are infants who have sleep and eating problems or cry excessively. While a transient phase for most infants or responsive to gastrointestinal tweaking, there are some babies that remain inconsolable. A baby crying for six or more hours a day who fails to respond to heroic soothing efforts results in caregivers feeling utterly incompetent. Michelle was worried and desperate. While Gail did not raise a “fussy baby” herself, she maintained a sense of calm and confidence that astonished Michelle, who was grateful that her mother was close by and relied heavily upon her in those early months.
Fussy babies do not always grow up to have ADHD, but it happens, and it did with Sam. As he grew from toddler to school age, his impulsive behavior and emotional reactivity became more problematic. As is often the case with such frustrating behavior, parents lose their patience, yell, threaten and punish with few positive results. This is hard enough for parents, but in this family, the situation was worsened by Gail’s criticism that Steve was “scaring” Sam, while also indulging her grandson when he was on her watch. Michelle was torn—her mother helped her survive the “fussy period”, and Gail still seemed as calm and confident as she did back then.
Every family is complex- there are so many moving parts. A couple’s move into parenthood often includes some tension with one or both of their own parents. These initially emerge as little declarations of independence, of the new parents’ being “in charge." For example, “We decided to not have Luka look at anything with a screen until high school or eat anything with white flour in it...and it's “Luke-A” not “Luke." While not easy, most parents and grandparents eventually make it through this period, and grandparents learn to respect their children’s authority.
“Emotional regulation” is the current jargon that means all we do to hold our act together when it is so, so tempting to lose it. In ADHD-land, the buzzword usually refers to something lacking in an individual: A child’s inability to inhibit his intense reactivity to some frustration that results in inflexibility and outbursts. Parents are just as prone to emotional reactivity, and that can prevent their achieving their own goals.
The Triangle of Life
There is an old song that goes, “one” is the loneliest number; and “two” can be as bad as one." But “three” can really muck things up. A family therapist often thinks in “threes” as a way of understanding “twos," when helping with a stubborn problem within a family. These triangles thrive as emotional triggering bands of energy that take on a life of their own. The Michelle, Steve & Company predicament is an example of such a process, aptly called “triangulation." And that old song I just referred to? It is by Three Dog Night. Coincidence? Well, yeah, probably.
But triangles are no joke. The troublesome troikas in this situation were “Michelle-Gail-Steve," “Michelle-Sam-Gail," “Michelle-Sam-Steve," but the Michelle-Gail-Steve trio was the most out of tune. Confusing feelings prevented Michelle and Steve from relying on each other in stressful moments with Sam. Michelle had the awful feeling she was “betraying” her mother if she did not convey her mother’s concern that Steve was scaring Sam. If she defended Steve, Michelle also feared that she might lose her mother’s support, something Michelle believed she still critically needed. Michelle wanted a full partner, but defending Steve felt too risky. This situation improved slowly when Steve was able to grasp how difficult a spot his wife was in. In the heat of battle, Michelle was soothed by a glance or touch from Steve that conveyed “I get it. I am on your side. You don’t have to take care of me this second." Michelle helped Steve navigate this by expressing gratitude for the ways he adeptly handled Sam with goofy humor that she could not. When Gail jumped in to “protect” Sam from his father’s fearsome, not very raised voice, Steve deliberately restrained the urge to defend himself- reminding himself that it was not so much an act of submitting to his mother in law as much as a little gift to his wife.
It usually takes a number of behavioral tweaks to change the negative charge of a triangle to positive. These tweaks are the numerous small (but not easy) changes that accumulate, like a battery storing electricity that eventually can power more consequential and enduring change. The bias toward resolution and growth in families is strong once the most significant obstacles are removed, but it is never perfect. Triangles do not yield gently; the negative emotion can rear its head in a flash. And a kid with ADHD will trigger the most Zen parent in the trek of getting through the day. There are some very old professions, but parenting is not one of them- it has always been an amateur sport. Of actual sports, baseball comes closest. Parenting, like baseball has a very long season; and both can endure a lot of failures and ultimately succeed. A slugger could have a pretty remarkable career, perhaps even make it into the Hall of Fame with a .333 batting average. That means that the Hall-of-Famer struck out two thirds of the time they were at the plate.
Family members, too, can bring about considerable change even if they only get the small, difficult stuff right- even just a third of the time. While medication for ADHD symptoms may eventually be necessary, having effective behavioral strategies in place can delay how early a child may need to start taking them and help keep doses as low as possible. There is no clock in baseball, the game will take as long as it has to, thank you. Similarly, everything takes longer with ADHD. Patience is a virtue, persistence is priceless. And there is always your next at-bat to potentially spark a rally.