We’ve been using this space to bring you information about National Children’s Mental Health Awareness Week along with the not-for-profit Child Mind Institute, who has been sharing some important and helpful information with us.
Steven Kurtz, PhD, ABPP, of the Child Mind Institute, is one of the nation’s leading clinicians in the treatment of children’s behavioral problems and disorders, particularly attention-deficit hyperactivity disorder (ADHD).
He is a widely respected clinical researcher and child psychologist, one of sixteen master trainers in Parent-Child Interaction Therapy endorsed by PCIT International, and a dedicated advocate for children with special needs.
Welcome, Dr. Kurtz. Can you tell us what’s new in the area of diagnosis of ADHD? There is concern among some parents that it is being over-diagnosed, and does the research support their concerns?
Diagnosis of ADHD is still made by a good family history and school history, with parents and teachers describing behavior that is consistent over time. For a valid diagnosis a child must show hyperactive, impulsive symptoms or inattention symptoms in more than one setting—if it were only happening at home, for instance, or only at school, the behavior isn’t likely to be ADHD.
To address parents’ concerns about over-diagnosis, a good clinician is careful to screen out children who are just exhibiting normal impulsivity, normal hyperactivity, and normal inattention. A child with ADHD will score 3 times higher than typical kids on rating scales for these behaviors, and they will be seriously interfering with his ability to function in school, with friends and with his family. While we can assume that some kids are misdiagnosed, a much bigger problem is the many children who are not diagnosed and not treated, who are failing in school, in conflict with friends and families and at risk for dangerous behavior.
Please share with us some of the latest treatment approaches you use. Any case story interests our readers.
There’s no evidence that things like play therapy and talk therapy actually help alleviate ADHD symptoms in real-life settings. What we do is work through teachers and parents to set up environments for success for kids. And we use specialized behavioral therapy—with systematic reinforcement—to help kids learn to focus their attention, and reel in their impulsive and hyperactive behavior.
We teach organizational skills, where we prompt kids to pack their backpack, then check that it’s packed properly, and then reinforce them for doing it. It might seem obvious how to pack a backpack, but these kids need a lot of help building what we call executive function skills: planning and organizing and following through.
Those are some of the latest treatments on the behavioral end. Another very important element is Parent-Child Interaction Therapy, which can be amazingly successful in helping parents and kids together manage the disruptive behavior that often comes with ADHD. In fact research is testing whether this alone can reduce ADHD symptoms and impairment.
On the medication end, we have an increasing number of options. The most common and most effective treatment for ADHD is stimulant medication. There are also non-stimulant medications that help some kids who don’t respond to stimulants, or who experience negative side effects from them.
For example, I had a boy about to turn 4. He was the most hyperactive preschooler I have ever seen (and this is saying a lot given that I’ve been seeing kids for 30 years!) He could not stay in the treatment room. He could not even get into the room—everything outside was too interesting. Once he finally did get inside, he spent on average 20 seconds on every activity available–enjoying every one of them like it was the most fascinating activity in the world, but moving on almost immediately.
When asked to count, he couldn’t get past the first few digits before careening off to something else. Once he started taking medication, he counted the toys he had lined up in front of him. He made it all the way from 1 to 14, and at the end of the row of toys, he double fist pumped and said, “I got to the end of the line!” The medication helped him focus and actually enjoy the activity.
Is there any research being done on causes of ADHD and possible prevention?
Research is being done to understand how genetics and environment combine in kids with ADHD.
On the genetics end, ADHD does tend to run in families and is considered one of the most heritable of psychiatric disorders.
On the environmental end, it’s been connected to low birth weight, a mother’s alcohol or tobacco use during pregnancy, and exposure to lead early in life. It’s also been linked to exposure to multiple psycho-social stressors, such as marital discord, neglect and abuse.. Neither diet nor TV viewing has been shown to increase the risk of getting ADHD.*
Tell us more about parents’ roles in treatment.
Parents are central to behavioral treatment for kids with ADHD. It’s the parents, working with the therapist, who will coordinate sending and receiving the daily report cards that are key to the treatment. It’s the parents who will coach their kids about behavior expectations and then reinforce that behavior at restaurants, church, temple, family gatherings, etc. It’s the parents who will help children learn to prioritize, and give them feedback.
That’s why it’s critical that parents and children with ADHD have a healthy relationship. If a child’s distraction, hyperactivity, and impulsivity have him on a collision course with parents—if his behavior is out of control— it’s important that the family restructure their relationship through a program like PCIT. Parents can learn effective techniques for reinforcing appropriate behaviors and discouraging negative ones. Kids can learn to more effectively rein in behavior, so they can be happier at home and at school.
Above all, children need their parents to not give up on them. Children with ADHD can be demoralized or stop believing in themselves. Children appreciate parents and teachers who they know won’t give up on them.
Your use of the word “coach” is important. When parents view themselves in the active role of “coach” (obviously, in addition to viewing themselves as parents), they are able to depersonalize a bit more and give thoughtful, specific feedback rather than emotional and reactive, feedback to inappropriate behaviors.
Can you recommend some books for Therapy Soup readers?
Books for adults:
Taking Charge of ADHD, by Russell Barkley
Book for kids:
Putting on the Breaks: Young People’s Guide to Understanding Attention Deficit Hyperactivity Disorder, by Patricia O. Quinn and Judith M. Stern
Thank you so much for your time, Dr. Kurtz.
Steven Kurtz, PhD, ABPP, is one of the nation’s leading clinicians in the treatment of children’s behavioral problems and disorders, particularly attention-deficit hyperactivity disorder (ADHD) and the social anxiety disorder selective mutism (SM). He is a widely respected clinical researcher and child psychologist, one of sixteen master trainers in Parent-Child Interaction Therapy endorsed by PCIT International, and a dedicated advocate for children with special needs. To read more interviews with Dr. Kurtz, please visit the Child Mind Institute.
Note: In past posts on the topic of children and mental health we’ve had a lot of conversations with readers including parents and clinicians. As readers know, we’re big on healthy eating and have what could be termed a holistic approach to mental health, here at Therapy Soup. We believe body, mind, soul are all important factors in mental (behavioral) health. While we don’t discount the role of medication and other treatments, we believe there is evidence that diet does influence mental (behavioral) health, although we know this is still a controversial perspective. We believe that a healthy diet is one of several factors important to emotional/mental well being and that it does have an impact on behavior, including children’s. There are scholarly and popular articles on the topic and to be fair, research findings are mixed. There are a variety of clinical and personal perspectives on both the cause and treatment of ADHD.