Looking for answers but asking the wrong questions
A medical approach to so-called ADHD begins with a diagnosis made on the basis of answers to a number of questions usually based on criteria from the DSM. Here are some (I have selected just 5 as a sampler) of the supposedly problem behaviours looked for when diagnosing ADHD (usually put to the parent in the form of a series of questions):
- Does your child often fail to give close attention to details or make careless mistakes in schoolwork, or other activities?
- Does your child often avoid, dislike, or is reluctant to engage in tasks that require sustained mental effort [such as schoolwork or homework]?
- Does your child often lose things necessary for tasks or activities at school or at home [e.g. toys, pencils, books, assignments]?
- Does your child often blurt out answers to questions before they have been completed?
- Does your child often interrupt or intrude on others, e.g. butt into conversations or games?
As you can see, the criteria casts a wide net and is likely to include most children (and ourselves too!). It seems to me that the wrong questions are being asked. Ask the wrong question, and you get the wrong answer: it’s basic. “Why is the moon made of cheese?” is unlikely to give us the answer to the geological composition of the moon. But these (and similar) questions around the child’s behaviour are assumed to lead to a conclusive diagnosis of ADHD. And once we have a diagnosis the correct treatment can be prescribed; well, that’s the assumption. How about we look at this from a different perspective, by changing the questions?
Changing the questions
As we need to be asking questions about the family we need to be clear here: our purpose is not to attribute blame to the parents or anyone else. Our purpose is to be open to numerous possibilities that together may have a cumulative impact upon the child’s moods and behaviour. This is an enquiry, not an inquiry. By enquiry, I mean a wish to discover more about the child’s circumstances (family included) without seeking to blame; hence, it is not an inquiry, which in legal terms seeks to apportion blame. So here are some different questions that we might be asking.
- Does the child have little exercise and stay indoors a lot?
- Are there severe tensions between the parents?
- Is there violence or abuse at home or at school (including bullying)?
- Is this child particularly sensitive to what goes on (so that what some children can tolerate is intolerable for this child) in his/her life?
- How does the child get on with his/her siblings?
- Does the child have too little sleep?
- Has the child experienced some particular trauma?
- Does the child have a high sugar diet and eat foods and drinks high in colourings and preservatives that the child might be sensitive to?
- Is the child a fussy eater (and vegan/vegetarian) and possibly deficient of essential nutrients?
- Has someone in the family died quite recently?
- If someone has died, what was the child’s attachment to that person like?
- Are there inconsistencies or the giving of mixed messages in parenting? (Such as “no you can’t” changes to “yes you can” in response to pestering).
- Has the child had a serious sports head injury?
- Does the child find it difficult to make friends?
- Is the child struggling over the parent’s separation/divorce?
- How does the child think and feel about him/herself?
- If the child has stopped listening to the parent/s: reconsider, what is being said and how is it being said?
Don’t miss the obvious
In the search for answers, it is perhaps too easy to miss the significance of the basic building blocks necessary for the child to have an emotionally healthy life: a safe and secure upbringing without extreme emotions of anger and violence; a nutritious and balanced diet; adequate routine sleep; loving care and attention; in a home when the parent has clear, fair and consistent boundaries; plenty of physical exercise and an outdoor life too.
A study, not specifically focussing on ADHD-type behaviours as such, sought to reduce the likelihood of later (in late adolescence and early adulthood) psychosis and antisocial behaviour. This preventative programme working with 3-5 year olds demonstrated the importance of some of the basic elements of a more balanced life. These included: good nutrition, attention to health care, physical exercise – including walking and field trips, and educational activities ensuring the child developed necessary verbal and conceptual skills 1. There’s something refreshingly commonsense about these findings.
ADHD treatments focus, in the main, on medication and/or cognitive and behaviourist techniques. With regard to drug treatments, we have seen here that the risks are considerable; furthermore, causing (through side-effects) a child/young person to become aggressive, paranoid, depressed, lethargic and even hyper isn’t much of a cure. Whilst techniques can be helpful, families are complex and varied, and any techniques need to be tailored to each particular family and it's dynamics. It can be more beneficial for families to gain greater insight and understanding about themselves so that they can begin to trust their own resources and intuition. Sometimes this process includes restoring relationships and an openness to respecting one another in a new way.
All too often people conclude that if ADHD behaviours can’t be attributed to genetics then the parent’s must surely be to blame. This is neither true nor helpful. As we have seen, there are many possible contributing factors that affect mood and behaviour, and parenting is just one of these. In looking for the big solutions we can so easily miss these essentials which can also be part of the bigger picture. Families tend to discover what suits them best when it comes to parenting, but here in this website are some of my preferences as a basis for nurturing children - not just with children with ADHD-type behaviours - and could be seen as some ways to reduce the likelihood of these behaviours with some children. These are not intended as specific guidelines for responding to extreme behaviours.
Ruling in or out any physiological factors
Based on current research it would seem that physiological causes are perhaps some of the least common reasons: here I am referring to viral infections, brain damage due to a sports injury, rare genetic disorders, hormonal disorders, for example, that we looked at here (under the heading: Physiological factors...). A doctor or neurologist should be able to rule these in or out as possible causes if a parent has reasons to believe these might be applicable.
Changing diet to change mood and behaviour
I think the impact of food and drink on mood and behaviour is far too easily disregarded. I cover dietary factors in more detail here; including the impact of high sugar and high refined carbohydrate diets, vitamin and mineral deficiencies, and food additives (some of the E numbers). For some people food sensitivity and allergies, including the possibility of gluten sensitivity and/or intolerance, may be worth checking out. I mention these in more detail on this page here. This paper (2) gives an overview of food allergies: it shows physiological rather than behavioural symptoms, but can be helpful in recognising food sensitivities. I recognise that some people (see BMJ article here) are more sceptical when it comes to the science behind food intolerances; understandably, the market for related products is also big business.
It is true that links between food and hyperactivity are hotly disputed by some researchers, however, on the basis of the Southampton 3 and similar studies, Dr Alison Schonwald, concludes: “For the child without a medical, emotional, or environmental etiology of ADHD behaviours, a trial of a preservative-free, food coloring-free diet is a reasonable intervention.”
Although many youngsters appear to get away with high sugar and high refined carbohydrate diets some are clearly more sensitive to this and suffer extreme moods as well as hyperactivity. I respect that youngsters are often reluctant to change what they eat, so it is not always easy making changes. But if the reasons are carefully explained in an interesting and meaningful way I find they can be willing to give it a try.
Sufficient and regular sleep
One quick way to create an imbalance for children (and adults too) that affects moods and behaviour is too little sleep. With TVs in bedrooms and computers and mobile phones youngsters have more than enough late night distractions; these can also stimulate the brain and make falling asleep more difficult. Going to bed late is seen as being more grown up - but youngsters need considerably more sleep than adults. I take a look at sleep problems here. Addressing sleep imbalance can be an important step towards improving a child’s moods and behaviour.
Attending to social and emotional issues
In looking at possible causes of ADHD-type behaviours we touched on the importance of social and emotional issues in this website here. Children who are distressed often do not speak about this, but this inevitably affects not only how they feel but shows in their behaviour. The source of distress could be, for example, the loss of a close grandparent, the death of a family pet, changing to a new school or having difficulty making friends. More extreme forms of childhood adversity such as emotional, mental, physical and/or sexual abuse and other trauma and ill-treatment are likely to lead to more pronounced responses. School bullying can also be devastating for the child and be kept from the parents.
It is not difficult to see that a distressed child may be deeply agitated, restless, and unable to focus properly or concentrate. They may well become restless and hyperactive – possibly with mood swings. A traumatised child is also likely to have difficulty regulating emotion and may become overly-reactive 4 and thus be prone to angry and/or sad outbursts. It is also important to bear in mind that neglect can also be experienced as traumatic and lead to similar emotional and behavioural responses. It is sometimes said 5 that a traumatised child will likely respond by either (sometimes a mixture of the two) “hyperarousal” (on edge ready to defend against the next attack) or “dissociation” (in a withdrawn, defeated, and detached state). It is easy to see how these responses to pain and pent-up emotions can be miss-diagnosed as so-called ADHD. It is therefore important to be open to the possibility of personal trauma and distress in exploring possible causes for ADHD-type behaviours.
Are there likely environmental factors?
We touched on some possible environmental factors here. These are more likely in certain circumstances and locations. Opinions vary as to how significant a cause these are with ADHD-type behaviours. Clearly, if there are specific reasons for concern these can be followed up.
There are medication-free programmes designed to help with parenting and ADHD-type behaviours, such as this one here (6), which you may find of some interest. There are also computer programmes marketed to help with concentration problems, but I am not sure how helpful these are (maybe youngsters learn similar skills form PC games anyway).
The importance of physical exercise
Formalised sports may be helpful as an outlet for a seemingly endless flow of energy. Team sports can introduce new skills for self-control. Peer pressure in this more controlled setting can be character forming too as they learn to function as part of a team. Exercise not only helps burn off excess energy, it relieves physically and emotionally-felt residues of distress, can be great fun, and also helps lift their mood too. Adventure sports (when affordable) can be not only perceived as “cool” and something to boast about at school - but practically help with concentration, self-regulation, and are a channel for excess energy too. Some youngsters may benefit for martial arts. Boxing can be a helpful discipline and an outlet for inner tensions and anger.
The benefits of relaxation and mindfulness
Trauma, stress and distress can lead to physiological changes that affect mood and behaviour. One aspect of this is in triggering various hormonal responses (including the release of adrenalin, cortisol and noradrenaline). In the short-term these chemicals can be helpful in facing threats and crises, but with excessive and continued trauma and abuse, homeostasis is disrupted. This can lead to increased anxiety, becoming over-reactive and angry, difficulty sleeping, and being over-active. It may therefore help to consider a range of possibilities that help calm the central nervous system responses that we have just described. Essentially, anything that is relaxing (and helps set in motion a parasympathetic central nervous system response) could be helpful, such as yoga, massage, meditation, mindfulness, listening to some types of music, art, drama. Tai Chi can also be relaxing and help with self-control and self-regulation.
My intention here has been to show that there can be numerous reasons leading to ADHD-type behaviours, and, very often there is a cumulative impact from a number of causative factors. These are not intended as the only possible factors; rather, it is my hope that anyone struggling with a child's moods and behaviours will find appropriate support (from family, friends, others with direct experience of similar concerns, and professionals too) with understanding and regain hope.
References - Bibliography - Further reading
1 Raine, A. et al. (2003) Effects of Environmental Enrichment at Ages 3–5 Years on Schizotypal Personality and Antisocial Behavior. Am J Psychiatry 160:1627–1635. Available here.
2 Mansoor, D. & Sharma, H. (2011) Clinical Presentations of Food Allergy. Pediatr Clin N Am 58 (2011) 315–326. Full paper here.
3 McCann, D. et al. (2007) Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomised, double-blinded, placebo-controlled trial. The Lancet, Volume 370, Issue 9598, Pages 1560 – 1567. Abstract here.
4 Perry, D. & Pollard, R. (1998) Homeostasis, stress, trauma, and adaptation. Child & adolescent psychiatric clinics of North America. Vol. 7 No. 1. Available here.
5 Read, J. et al (2001) The contribution of early traumatic events to schizophrenia in some patients: A traumagenic neurodevelopmental model. Psychiatry 64(4). Available here.
6 Stein, D. (1999) A Medication-free Parent Management Program for Children Diagnosed as ADHD. Ethical Human Sciences and Services Vol 1, No 1.