On my mind: The dilemma of treating ADHD in children


At least once a month, as part of the MV Times’ ongoing Mental Illness series, Dr. Charles Silberstein will write a column that directly addresses issues Islanders have with mental health. Dr. Silberstein is a psychiatrist at Martha’s Vineyard Hospital.

An anxious parent recently asked my thoughts about her child starting Ritalin or Adderall for ADHD.

I once knew a first grader who came home from school and said, “I hate my brain. I am so stupid!” His teachers treated him like a difficult, not particularly gifted child. His parents had him psychologically tested and learned that while he was highly intelligent, he found paying attention challenging. The testing led to two major changes in his life. First, seeing how gifted the boy was, and now understanding his potential, the child’s teachers began nurturing him and treating him with the special attention that all children deserve.

The boy also started taking Ritalin, an amphetamine-like medication that is one treatment for ADHD. For years, he felt transformed by it. His grades, his relationships, and his self-image all improved. Nonetheless, in high school he decided to stop taking medication because he felt it “made me not myself … it dulled me.” Now in graduate school, he uses coffee when he needs extra focus. “Focusing is still not easy without Ritalin,” he told me recently, “but I am happier and more myself. As I get older, the ADHD is no longer so noticeable. I don’t regret taking Ritalin, because there were elements of my life that it helped. But It didn’t feel good to be labeled, and it felt worse to have my personality dulled.”

Who knows what turns the young man’s life would have taken without Ritalin? There is debate about whether stimulants stunt children’s growth; perhaps Ritalin cost this boy a couple of inches. He did develop tics while on Ritalin, but they ceased when he stopped taking it. Would he have learned other coping skills for his troubles with attention earlier on? Ned Hallowell, M.D., the author of the landmark ADHD book “Driven to Distraction,” likes to say that having ADHD is like having a Ferrari brain, and needing to learn how to use the brakes.

‘A Ferrari brain’

As both a physician and a parent, I am uneasy with the idea of putting a child on a chemical that could affect the development of his or her brain. However, there is evidence from MRIs that stimulants change areas of the developing brain where dopamine receptors are concentrated, so that they look like those of a child without ADHD. I also recognize that traditional schools require that children sit still and focus for extended periods of time — things that their brains are not prepared to do. ADHD medication can help them thrive in these unnatural settings. Children with ADHD who are treated with medications often have improved academic, social, and occupational performance. They may have lower rates of substance abuse and fewer accidents (both more common with ADHD). Sorting out the dilemma of whether to treat ADHD pharmacologically is one of the reasons that I admire good pediatricians and child psychiatrists.

Melanie Miller, M.D., a pediatrician at Martha’s Vineyard Hospital, says she does not diagnose ADHD without input from the school, parents, and the patient, in addition to making sure that the child’s behavior has no other medical roots. She usually begins by prescribing Ritalin (methylphenidate) because it is more targeted in the brain than Adderall, and she suggests taking fish oil, a supplement that may enhance attention. While she sometimes prescribes nonstimulant pharmaceuticals (such as Strattera and clonidine) that can treat ADHD, they all have their own risks and side effects, and they generally don’t work as quickly and effectively as stimulants.

Treating ADHD is more of an art than a science, and every child will respond differently, but a few fundamental recommendations should hold:

  • Get good psychological testing for your child. (This can be done by professionals in the schools.) Find out more about how his or her brain works. Other neuropsychological deficits or learning disorders can affect the ability to focus and sit still.
  • The Martha’s Vineyard schools employ wonderful special ed teachers and psychologists. Many kids have individualized educational programs (IEPs), and they can make all the difference.
  • A full medical evaluation is also important. Depression, anxiety, learning disorders, child abuse, and posttraumatic stress disorder, giftedness and resulting school boredom, sleep deprivation (beware excessive video game playing), can all cause poor attention, hyperactivity, and impulsivity.
  • While studies do not conclude that diet has a big impact on ADHD symptoms, I have seen children who become notably less restrained and more distractible when they eat a lot of simple carbohydrates. Sugar may be the demon here, and it’s important to remember that simple carbohydrates turn almost instantly into sugar once ingested. Hence, diets high in sugar-loaded processed foods and simple carbs like white rice, potatoes, pasta, bread, corn, etc., may aggravate your child’s ADHD. Nurture your child with a diet high in vegetables, fruit, fish, beans, nuts, and lean (preferably organic and grass-fed, but most certainly hormone- and antibiotic-free) meats. Avoid all sugary drinks, including fruit juices (eat the whole fruit instead) and anything artificial. Why add more chemicals with unknown effects?
  • Mindfulness training and cognitive behavioral therapy effectively treat ADHD. Therapists from the Cape and Islands Cognitive Behavioral Institute (CICBI) now come to the Island twice a week. Another option is to work with an off-Island expert by Skype.
  • If there is conflict, overt anger, or substance abuse in your home, get help. These are frightening for anyone, but especially for a child. Anxiety is a major impediment to focus, concentration, and a relaxed body.
  • Get your child moving. Encourage the school to have lots of physical activity. There is evidence that “sitting is the new smoking” — that inactivity makes our bodies and minds atrophy. Isn’t it curious that we call people who like to move a lot “disordered”? Get the book “Spark: The Revolutionary New Science of Exercise and the Brain” by John J. Ratey and Eric Hagerman. Exercise is a wonderful treatment for ADHD, anxiety, and depression. There was a good article on this recently in the New York Times (March 21, “Why Kids Shouldn’t Sit Still in Class”).
  • Consider homeschooling or other alternative school settings that might be more tolerant of your child’s challenges. Some children will outgrow their ADHD and later function well in traditional settings.
  • If you and your child’s doctor decide to treat your child with a stimulant, find the lowest dose that works, and consider “drug holidays” at times when medication is less necessary. Think carefully with your child about when he or she most needs medication. Some kids need it during unstructured homework time on weekends, when studying for tests or writing papers, but don’t need it as much at school if the environment is stimulating and structured.
  • Check out chadd.org, “The National Resource on ADHD.”