ADD: ATTENTION DISORDER AND ADOPTION
David W Soule MD
August 6, 1995
(as found at the FAQ site)
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S.K., a boy born to a 21 year-old single woman in Providence, R.I,
was hospitalized twice in his first two months of life because he was
losing weight. Complete work-up for physical problems both times
found nothing wrong with him. He was "an engaging, easily soothed,
attentive infant with a vigorous and effective suck ... This was a
wanted pregnancy ... and she exhibited appropriate expectations and
concern for the child. The videotaped feeding revealed that the
mother was extremely distractible, inattentive to the child, and
constantly fidgeting. These behaviors appeared to interfere greatly
with her ability to engage the infant during feeding. She was easily
distracted by noises in the room and hallway and by nurses and family
members entering the room, and she had difficulty remaining on task
of feeding the infant or engaging in sustained eye contact with him
.... The mother reported a long history of distractibilty, fidgety,
and impulsivity throughout her life .... At this time the mother of
the child agreed to a trial of methylphenidate, 5 mg three times a
day." There was a "marked decrease in the mother's distractibility
and a significant improvement in the mother's ability to feed the
child. The mother noted no benefit and no adverse effect from the
medication. Subsequently, the child continued to gain weight at an
appropriate rate and has not required rehospitalization." JOURNAL
OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY V. 34:1,
ADD is more common in adopted children. Why? It has long been speculated that one reason is that parents with imrecognized ADD are at high risk for not being able to cope with parenthood, and so may give up a child for adoption or lose the child because of apparent neglect. Since ADD is genetic, the child is at risk for ADD. Under other circumstances the above child might have been placed for adoption. This recent article is the first to document this effect at such an early age.
The following article was written by Dr. Soule for the "Adoption Link" a Dublication of Children Awaiting Parents, Inc. and was published in the fall of 1992:
Attention deficit disorder (ADD, ADHD) is one of the most common and most confusing medical conditions which parents of adoptive children have to deal with.
ADD is most simply defined as the combination of three characteristics: physical restlessness, distractibillty, and impuisivity. Confusion arises because ADD can appear in various forms from the hyperactive preschooler to the high school student who is frustrated by his inability to get organized. Furthermore, there is no specific diagnosit test to 'dentify ADD.
The first report of succesful treatment of ADD with stimulant medication was published in 1937: "Fourteen children responded in a spectacular fashion...Speed of comprehension and accuracy of performance were increased in most cases."(1) Hundreds of studies since then have confirmed and expanded this basic observation.
Although dozens of medications have been tried, the stimulant Ritalin (methylphenidate) has become the mainstay of treatment because of its outstanding safety and effectiveness. Over 1 million children and teenagers take Ritalin daily to enable them to settle down and focus on thcir school work. Usually medication enables students to succeed in the mainstream rather than need a special education class. Thirty years of widespread use and study of Ritalin have shown that there is no problem with dependency or subsequent stimulant drug abuse.
Although the usefulness of Ritalin in the classroom is well known, this is only half the story. The purpose of this article is to review some of the interesting research of the past few years which goes beyond the classroom: to home, the playground, and the baseball diamond. In every study cited, the results were obtained using low dose (0.3 mg/kg/dose) Ritalin, the dose most often used in practice. However, doubling the dose usually increased the effect.
The social problems of chdren with ADD are increasingly being recognized as a central part of their disability. They are typically disruptive and socially inept. They have a hard time making and keeping friends. Thus their self-esteem gets battered by negative reactions not only from parents and teachers but also even more damaging from playmates.
Since social relationships are a two way street, it is not surprising that treatment of the child with Ritalin produces changes in the behavior of all those around him. It has been evident for years that Ritalin reduces negative social interactions, but a recent study from Los Angeles looked for a more positive effect.(2) The investigators observed boys in a summer camp setting, measuring helping, sharing, and problem-solving behavior. In one group of 14 ADD boys, these positive behaviors doubled during the periods when they received Ritalin.
The behavior of parents and teachers has been observed as they related to ADD children: the adult s became less controlling and less negative when the children were treated.(3)
A 1992 study on Long Island observed ADD boys in the classroom and the three boys sitting closest to each one.(4) Their aggressive behaviors were counted and scored on an arbitrary scale. 'When the boys with ADD were receiving Ritalin their aggressive behavior score dropped from 3.1 to 2.3, but their classmates' scores dropped from 2.5 to 0.8 at the same time. This illustrates the contagious nature of disruption in the classroom and why it is often hard to maintain untreated children with ADD in a regular classroom.
A 1987 study on a playground in California documented the behavior of ADD children during unstructured play.(5) The same decreases in negative social behaviors that occur in the classroom with Ritalin were observed at play.
A 1990 study from Pittsburgh, appropriately entitled "Who's on First?", studied the effect of Ritalin on the performance of boys with ADD playing baseball.(6) Ritalin did not improve their skills: They swung at just as many bad pitches. The striking improvement was in their alertness in the outfield untreated, they were alert and watching the batter when the ball was pitched only 26% of the time. With ritalin they were alert and ready 56% of the time. The authors oberved that boys with ADD "make errors due to inattention that result in poor performance and social ostracism. Peers may be willing to forgive a child who tries but fails as a result of poor ability (but they) may be much less forgiving of the child who is facing the wrong way and apparently not trying."
As might be expected from the above results, a 1987 study from California documented that a boy with ADD is 30% more likely to be picked as a best friend when he is taking Ritalin.(7)
The common theme of these studies is the impact of ADD on the social relationships of children and the possible bcenefit of Ritalin in improving their social interactions, their status among their peers, and their self-esteem. Alternative treatments, such as behavior modification(8) and parent training, are inadequate alone and work best in combination with medication. It should be stressed that in all of these studies there were wide variations in how well individual children responded to treatment. It is also generally accepted that 20 to 25% of children with ADD do not respond well to Ritalin. In these children other medications and other methods can be used.
This article has briefly presented just one aspect of ADD and its management. For an up-to-date general discussion of ADD based on the experience at The Children's Hospital of Philadelphia, see "A Parent's Guide to Attention Deficit Disorders" by Usa Bain, published in paperback by Dell in 1991.
RITALIN/methylphenidate: the best studied, safest, most widely
used medication: in daily use by about 1 million Americans. Effective
in about 80% of patients. In the other 20% it may cause stomach
aches, irritability, or fatigue, or just not be effective. Available
in both short (4 hour) and long (8 hour) acting forms. After 30 years
of experience: no long-term side-effects.
DEXEDRINE/dextroamphetamine: Effect is comparable to Ritalin, but the pattern of side effects can be different, so one medication may be better tolerated than the other. Also available in both short and long-acting forms, but the long-acting 'Spansule" is available in three strengths, Ritalin in only one. Used less often than Ritalin primarily because of its reputation as a street drug. 5 mg Dexedrine is equivalent to 10 mg ritalin.
CYLERT/pemoline: -main advantage: longer lasting effect. Not used as often as the above medications because it is often less effective, and requires routine blood tests to watch out for the uncommon occurrence of liver toxicity.
ANTI-DEPRESSANTS: People with ADD are not depressed, but anti-depressant medications have long been known to be effective in treating ADD. They are usually used when stimulants can not be used for some reason.
TRICYCLIC ANTIDEPRESSANTS (TCA): TOFRANIL/imiprn-rnin(@ NORPRAMIN/desipranune PAMELOR/nortriptyhne Because of cardiac, GI, and other side-effects with the TCAS, the newer antidepressants have been tried. PROZAC is not usually helpful but WELLBUTRIN/bupropion, an anti-depressant with mild stimulant effects has been very effective. Although one recent study in 7 to 17 year olds compares it favorably to Ritalin, I have found it to be more effective in teenagers and young adults than in children. Some patients have commented that they can't tell they are on medication because of the complete lack of any side-effects.
BLOOD PRESSURE MEDICATION: People with ADD do not have high blood pressure, but one type of medicine which has been used for years for treating high blood pressure is also effective in ADD. These medicines do not improve attention span, but can be very effective in reducing aggressive, oppositional hyperactive behavior. Usually used in combination with a stimulant, because the effects in complimentary. CATAPRES/clonidine: available in oral tablet, and a patch for sustained absorption through the skin. Although it could cause low blood pressure, the actual side-effect which limits the dose is sedation. Since other sedatives tend to pep up kids with ADD, clonidine can be used at bedtime for kids who can't unwind. TENEX/guanfacine: although this is not a new drug, it is only now being tried for ADD. It may prove to be useful because of less sedation and longer lasting effect than clonidine.
As the selectioia of useful drugs has increased in recent years, we now have the option of combining medications. By using combinations it is possible to customize the medications more specifically to the individual, and often to use lower doses of each which means less side-effects. Ritalin plus clonidine is a comrnon combination, but I also have found Ritalin or Dexedrine plus Wellbutrin to be useful.
His most extraordinary quality, even more remarkable than his height [6ft, 7in] was his titanic energy. He could not sit still or stay long in the same place. He walked so quickly with his long, loose-limbed stride that those in his company had to trot to keep up with him. When forced to do paperwork, he paced around a stand-up desk. Seated at a banquet, he would eat for a few minutes, then spring up to see what was happening in the next room or to take a walk outdoors. Needing movement, he liked to burn off his energy in dancing. When he had been in one place for a while, he wanted to leave, to move along, to see new people and new scenery, to form new impressions. The most accurate impression of Peter the Great is of a man who throughout, his life was perpetually curious, perpetually restless, perpetually in movement.
On his eleventh birthday, in June 1685, Peter abandoned wooden cannon for real cannon with which, under the supervision of artillerymen, he was allowed to fire salutes. He enjoyed this so much that messengers came almost daily to the arsenal for more gunpowder.
By the time Peter was fourteen and he and his mother had settled permanently at Preobrazhenskoe, martial games had transformed the summer estate into an adolescent military imcampment. Peter's first "soldiers" were the small group of playmates who had been appointed to his service when he reached the age of five...... Eventually 300 of these boys and young men had mustered on the Preobrazhenskoe estate..... Rather than taking for himself the rank of colonel, he enlisted in the Preobrazhensky Regiment at the lowest grade, as a drummer boy, where he could play with gusto the instrument he loved. Eventually, he promoted himself to artilleryman or bombardier, so that he could fire the weapon which made the most noise and did the most damage..... drummer boys had more fun and made more noise than majors and colonels.
One consequence of this free, open-air boyhood at Preobrazhenskoe
was that Peter's formal education was discontinued. When he left the
Kremlin, hating the memories associated with it, he cut himself off
from the customs and traditions of a tsar's education. Bright and
curious, he escaped to the out-of-doors to learn practical rather
than theoretical subjects. He dealt with meadows and rivers and
forests rather than paper and pens. The gain was important, but the
loss was serious, too. He read few books. His handwriting, speaking,
and grammar never advanced beyond the abominable level of early
childhood-....Like any intelligent child taken out of school at the
age of ten and given seven years of undisciplined freedom, his
curiosity led him in many directions; even unguided,
he learned much.
excerpts from Peter the Great, His Life and World by Robert K
Massie Alfred A.Knopf, 1980
Ruth E. Harris, Northwest Reading Clinic
Ruth E. Harris, Northwest Reading Clinic, Source: CH.A.D.D.er Box, April, 1992.