Monday, November 29, 2010

My Interview with www.everydayhealth.com

I recently did a panel interview on ADHD.
Please check it out!

You can read the article here:
http://www.everydayhealth.com/adhd/expert-answers-on-adhd.aspx

Please check it out.
However, please read the actual questions and do not rely solely on the "headline" for each question.


My unedited responses are below.

1. Why are there so many theories about the causes of ADHD? What are the most common?

Like any psychological disorder, the number of theories comes from two main sources.
First, there are so many theories in psychology: neuropsychological, biological, cognitive, behavioral, social, etc. No one theory has ever perfectly covered a disorder and treatment so perfectly that it renders the others obsolete. For any given disorder and/or any given person, certain theories may have more dominance. However, a diversity of understanding and repertoire of treatment options in the hands of a skilled-practitioner is necessary to balance the strengths and weaknesses of any one theory by itself.

Although we have come a long way, we still have a lot to learn. This means that we have a lot of dots still unconnected. This allows for a lot of theories to exist parallel to each other. It also allows a lot of theoretical purists to act more like cultists than scientists. However, in time, the more that we learn and understand about ADHD collectively, the more theories start to converge and overlap. Some theories will not hold up to scientific research while others will be modified and/or supported.

Unfortunately, money also has influence. The pharmaceutical industry has plenty of detractors, and their opponents have a strong presence. However, they are not the only ones making money in the treatment of ADHD. Alternative treatments, with varying levels of scientific levels supporting them, have strong marketing towards parents and individuals that are desperate or frustrated. Individual practitioners also market their skills, and I bet that marketing a “Revolutionary and specialized program in the treatment of ADHD not provided by the competition!” is sexier and invokes more response than “Experienced in the scientific problem-solving model with multi-modal treatment.” Specialization and niche marketing do more to accentuate differences than unify commonality.

I personally give most weight to the work of Russell Barkley. When you review his research, you see that he has never done much, if any, direct research on the disorder. Instead, he absorbed, analyzed, and assimilated all of the valid research that he could get his hands on. Then, he used this information to synthesize the more comprehensive and unifying theory on ADHD. My preference towards his work is obvious. It is more inclusive of multiple theories, and it has a strong foundation in quality research. Also, he supports the set of tools that I have found to be effective in practice.

2. How can you explain the value of treatment to resistant parents? For example, “I survived my childhood with ADHD --and I was never diagnosed or treated. Why does my child need ADHD treatment?”

 My personality is very bottom-line oriented, so I do better with these parents than the more touchy-feely practitioners. I don’t push for “ADHD treatment.” I push for results. I push for a plan that is calculated to improve outcomes. I don’t have a standard response based on the disorder. Each person, as well as how ADHD manifests itself in them, is different. Let’s look at individual strengths and challenges.

I have two quotes hanging in my office, “They don’t care how much they know until they know how much you care.” (I don’t know the source.) I also have a plaque with Einstein’s, “Insanity: Doing the same thing over and over again and expecting different results.” If you are in my office, we can acknowledge that you probably want some result to come out better. This means, we cannot do the same thing over and over.

I call it “problem-solving” with my students and parents. I call it “data-based decision-making” with educators. So long as it works, who cares?

I also have external constraints on how I approach things. Although my wife and I have discussed private practice for years, we have yet to launch the practice. I am very cautious in making sure that I stay within the bounds of my professional duties and scope of practice while working for a school system. Do I have expertise and experience outside of my job duties? Yes, but it is not about me, my experience, or my opinions. It is my job to serve the community and the students that my employer serves. I have little patience for people who step outside of their proper role due to a sense of self-righteousness. I would rather play a smaller role, but play it to the best of my abilities.

If a parent asks me about medication, I will not share many opinions or answer many direct questions. However, I may help facilitate their ability to construct a set of questions to ask the appropriate medical practitioner. In the end, it is not my decision.

3. What role does a child’s school have in helping him or her with ADHD?

The school’s role is to teach - to teach well. First and foremost, students with ADHD need excellent teachers. They need to be engaged in learning from door-to-door and bell-to-bell. They need a structured external environment that offers the right combination of support and challenge. They need to be engaged through a variety of methods and modalities. In addition, students with ADHD often need to receive explicit instruction in certain skills that students are usually just expected to “pick-up” along the way – social skills, study-skills, time management and organization, etc.

Not only am I a pragmatist, but I love to read about Zen philosophy.  There is a beauty in the fact that less is more. It is better to do fewer things, but to do them very well. Conversely, it is also a simple maxim in organizational leadership that if we try to make everything a priority – nothing is a priority. I am supported by the emerging body of research on personal productivity against the idea of “multi-tasking.” Focus is as important to an organization as it is to the individual.

This is my biggest pet-peeve is with the type of educational advocates that have a “more is better” mentality. They take my approach as evidence that the school is “trying to withhold” and  they refuse to see the harm in their ways. I cannot tell you how many high school students have mentally given up after their advocates have "won" huge amounts of outside services in legal action. After a day of struggling at school, the only thing that they have to look forward to is more hours of after-school counseling, therapy, groups, tutoring, interventions, etc. I have seen far too many burn-out and give up.

This does not mean that I am minimizing the role of educational planning,
accommodations, 504s, IEPs, or supplementary services etc. However, I do believe that these are merely the means to an end. They should be the means to allow the student to benefit from quality instruction. If we focus too much on process, we tend to lose focus on what the process is supposed to deliver. Energy and concentration are precious commodities, and children only have so much that they can deliver in a given day. We need be wise and strategic because concentration is even more limited when dealing with ADHD.

4. Are the medications recommended for ADHD safe for children? What are the potential dangers?

I think that there are way to many variables to answer in general: each child’s therapeutic response to a medication, each child’s sensitivity to potential side-effects, the quality of the practitioner prescribing the medication, the external constraints on the prescribing person (such as caseloads or funding issues), etc. Medication can be a wonderful and safe option, but it can also be a dangerous thing. The problem is not in the chemicals themselves, but in how well the adults monitor and administer the medication.

For example, I have seen heavily-medicated students not receive any follow-up after the medication calmed their behavior. Pills do not teach children study-skills, coping methods, or proper social interactions. The medication’s job is to create a window of opportunity for those skills to be developed. It is the adults’ job to exploit this opportunity.

I have seen a lot of variance in how students respond to medication. This is why I get scared when I see initial prescriptions that have not gone through a rigorous process. I am not a medical practitioner, and I would rather defer commentary on specific medication to those folks. My favorite medical doctors titrate dosages. Titration is a term that comes from chemistry. It means starting with a low dose and slowly increasing over time while monitoring therapeutic benefit and side effects. They treat each patient as a miniature single-subject case-study. This allows them to maximize therapeutic benefit while minimizing side-effects. They also understand that things change as children develop. Unfortunately, I see this method utilized less and less. The ten-minute parent consultation is becoming too common. This may be fine once the ideal prescription is established, but it concerns me when it happens in the initial stages.

When I hear parents say that they will not consider medication because, “they had a bad experience with medication.” I often wonder if the problem was with the medication or the manner that it was implemented?

5. What are the most common side effects of ADHD meds?

Anyone on the internet can read about the common possible side-effects: decreased appetite, increased blood pressure, sleeplessness, etc. I would like to focus on one side-effect that is extremely common, but that very few talk about. It is the subjective side-effect on how the child feels.

Many people on medication do not feel like themselves when they are on medication. They can feel like they have a different, artificial personality or that their true personality is inhibited. This can have some serious psychological impact to children based on how adults talk to them. How many adults have communicated the following to kids who take ADHD medication?   
Oh no, someone did not take their meds today!
Who are you? You are such a good kid when you take your medication, where did that kid go?
etc. etc. etc.
Via the transitive property of algebra, when people say these things, many children really hear:
If you are someone else when you are on your meds, and I like you better when you are on medication, THEN I don't like the real you.
Those little comments can slip out so easily, but how many people realize the impact of their words?


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