February 16, 2009

All he needs is tough love, an ADHD story

His mother said that she was getting a very hard time from her parents. Her father said that if she left her son with him for a week, he wouldn't misbehave any more. He told her she was a weak, ineffective parent who just wasn't strong enough to give this boy what he needed. She asked me if the child's medication was really necessary, since her father didn't think it was.

You don't need to be completely freudian to hear the echoes of a mean father used to treating his daughter with judgemental negative feedback. I didn't ask how his comments made her feel. How would that help? We are all adult children, and many of us get treated like children by our parents--and sometimes act like children when we are with our parents. It's the pattern we know from a lifetime of practice, induced by the pavlovian stimulus of a critical parent or maybe just the smell of your mother's cooking.

I try to enable the parent of the child I'm treating. When they are supported and strong, their children are more likely to be supported by them. It's a team approach. I'm all for indulgent grandparents, of course, but the ultimate victim here is my patient, and don't ever mess with my patient.

I would never, ever medicate--indeed, treat--anyone unless I thought the treatment would be helpful to them. Medication is often not needed for behavior problems. And every medication has its risks, side-effects, and costs. We don't yet have the technology to predict which person will respond best to which medicine. For any of the psychoactive medications, and this includes many which are not primarily targeted to the brain (prednisone, for example) some of the effects on emotions and behavior can be surprising. And it's hard to know what the optimal dose might be for any given person. So medication isn't ideal.

Let's look at this from the kid's point of view. Every day, this boy is getting in trouble at school. He's being sent to the office almost daily. His teacher doesn't like him, the teacher in the schoolyard or the lunchroom doesn't like him. Most of his classmates don't like him. He interrupts so often that even the 2 boys he calls his friends don't want to be with him on weekends. He doesn't understand why no one likes him, and has asked many times why this is. It's not better at home. He's constantly being punished for something, grounded for something he doesn't remember doing. The groundings seamlessly dovetail from one to another. In this way, the child sees that being grounded is normal for him. So he knows very clearly that he is being treated differently and not as well as his siblings. From the moment he wakes up in the morning, he is criticized and corrected. There are no compliments, there are no treats. Every reward his siblings get, he misses for something that may have happened days ago. He is a beaten dog, kept on a short chain at home and a shorter one at school. It's not surprising that school isn't fun and he believes he might as well spend his time sitting in the office, alone.

What if there were a way to pluck him out of this spiral of failure and criticism, this pre-fairy-godmother-cinderella life of loneliness and hopelessness? What if we had a way to help him restrain his impulsivity and give him the ability to pay attention to the teacher for a substantial part of a lesson? When this happens, there's an upward spiral. He does well on assignments, proudly brings home good grades. His teacher tells him, in front of everybody, that he's doing a good job. His parents are proud of him and tell him so.

Fill in the blanks: an angry, lonely kid who doesn't like school or home growing into a teenager who.... Sure enough, studies show that the kids with ADHD who don't get treated have higher rates of substance use, school failure, and, maybe, prison. Or, with some help, a kid who gets to like school and succeeds like every other kid to go on to work, college, life. Who's better off? Do you really think that it's an even trade-off between the 'benefits' of not being treated and being able to live like everybody else?

Many parents lecture me on the risks of medicating their child. But what, exactly, are the benefits of not medicating? How loving a parent are you for leaving the stumbling blocks in front of your child, for crushing his self-esteem? I want to hear what the benefits are.

This patient came to me after mom had run out of his medication for 6 weeks. Some parents ask if it's OK to take a break from the medication, presumably so they can be reminded of the benefits of not medicating. This parent didn't ask. He needed his life back, and I was happy to prescribe it.

1 comment:

  1. Wow, thank you for this, Dr. Nadoolman.

    I know of MANY situations like this, and they are all heartbreaking.

    I am late finding your blog; it would have saved me a lot of writing in countering such ignorance! :-)

    Gina Pera, author
    Is It You, Me, or Adult A.D.D.?


Please let me know what you think. Do you know a child or situation like this?