ADHD

A letter to #MyYoungerSelf

A letter to #MyYoungerSelf

The Child Mind Institute has launched the #MyYoungerSelf campaign during Mental Health Month to counter the stigma for the 1 in 5 children struggling with these disorders. This May actors, athletes, social influencers, business people and others are sending a message of hope about their experiences growing up with a mental health or learning disorder. Here's a letter from the leader of our ministry team to an eleventh grade boy who was going through a difficult time.

When Kids Become Aggressive at Church

When Kids Become Aggressive at Church

Let’s get to work in exploring how we can do a better job of including kids vulnerable to aggression into our ministry environments while maintaining the safety of those environments for all kids, staff, and volunteers.

FDA takes action on "bad" versions of generic Concerta

FDA takes action on "bad" versions of generic Concerta

The FDA announced plans to rescind the approval of generic versions of Concerta manufactured by Kremers Urban Pharmaceuticals and Mallinckrodt Pharmaceuticals. The drug companies have until mid-November to file a request for a hearing to appeal the decision. Thanks to all of our readers who contacted the FDA to share their experiences with these products.

ADHD, Suicide, African-American Boys…and How Churches Might Help

ADHD, Suicide, African-American Boys…and How Churches Might Help

Is the stigma against treatment of mental illness generally, and treatment of ADHD specifically a contributing factor to the difference in rates of completed suicide among African-American children and other ethnic groups? 

Dr. Oren Mason - Wondering what a pill will do to me?

Dr. Oren Mason - Wondering what a pill will do to me?

People who don’t have ADHD probably never imagine how much effort goes into the smallest task, the simplest morning routine, nor do they know how frustrating it is to spend that much effort and still do it badly.

What keeps kids with ADHD out of church?

Since we’re filming a training this weekend on the impact of ADHD on spiritual development, I thought today might be a good time to review some of the impediments to kids and adults with ADHD becoming involved and staying involved at church.

Let’s start by looking at this issue from the perspective of the parent. In all probability, the kids aren’t coming to church if the parent doesn’t bring them to church.

By the weekend, many parents of kids with ADHD are very tired. Kids with ADHD often have a very difficult time getting through their morning routine. They need constant reminders to get out of bed, get dressed, eat breakfast and are easily distracted by the TV, the dog, just about anything. If kids are taking medication, the stuff does take a little while to kick in, so that mornings often become a great source of frustration to parents.

If the parent(s) can get their child up and ready in a reasonable time, the next challenge is the car ride to church. Compared to kids without ADHD, the child with ADHD is more likely to be angry about going to church, more likely to be screaming, yelling or crying because of some perceived grievance about their sibling’s behavior, and the family as a whole is less likely to arrive in a worshipful mood.

A major obstacle is the perception of many parents that they’ll be placed in a situation where they’ll be expected to explain their child’s behavior to others, or where they’ll bejudged by others. Like it or not, there’s a stigma associated with many of the hidden disabilities (while this study from the American Journal of Psychiatry doesn’t address ADHD, it does reinforce the point). I was at a worship service in our church a number of years ago for Disability Sunday at which a couple got up to share their story of what it was like looking for a church with two young boys with ADHD. The mother’s words illustrated the expectations parents of kids with ADHD and other hidden disabilities bring to church:

“People in the church believe they can tell when a disability ends and bad parenting begins.”

Another common complaint I hear from parents whose experience of church has been in denominations or traditions in which children and parents are expected to attend worship services together is that they can’t get anything out of the experience if their primary focus is monitoring their child’s behavior during the service. We’re seeing a growing trend among Catholic churches we serve to offer (at least periodically) separate worship experiences for kids and adults as a strategy for addressing this problem. I’m admittedly apprehensive about the well-intentioned efforts of some in the family ministry movement to discontinue separate worship experiences for kids because I suspect we’d lose many of the families of kids with ADHD who have difficulty with self-control.

Finally, we have the issue of parents who themselves have ADHD. They’re more likely to have difficulty following through on good intentions. They may want to come to church, they may know it’s important for their kids to be involved at church, but they have a hard time pulling things together to make it to church. They’re more likely to suffer from insomnia, or be “night owls” themselves, and struggle to get themselves up in the morning, much less their kids. They have more difficulty with establishing priorities and managing time. I can spot the families affected by ADHD in our church parking lot ten minutes after the start of the last service with Mom hopping across the parking lot putting her shoes on with three kids in tow.

For parents who themselves may have ADHD, the ease and clarity with which a church communicates where to go and what to do when you arrive is especially important. They tend to be easily frustrated looking for parking. They have a very difficult time remembering directions, resulting in the need for signage that is highly visible and processes for checking in and checking out kids that are as simple as possible.

Here’s one more issue to consider: Unlike families in which a child has an autism spectrum disorder, in which divorce rates are no higher than in the general populationthe divorce rate nearly doubles in marriages where there’s a child under the age of eight with ADHD. Kids with ADHD are more likely to be alternating from household to household on the weekend, making establishment of a consistent routine of church attendance more difficult.

What about the experience of church from the perspective of the child or teen with ADHD?

Kids with ADHD are often capable of intense focus when they’re engaged in activities they find interesting. In fact, the vast preponderance of the time kids come into my office with a history of wetting themselves during the daytime, their “accidents” occurred while playing a video game or outside in the middle of play with their friends. In many ways, ADHD should be thought of as an attention dysregulation as opposed to an attention deficit…kids with ADHD pay attention to too much stuff, much of which is unimportant, at the expense of what they need to pay attention to.

Kids with ADHD don’t do well in situations when they perceive the activity or the topic as boring or irrelevant, and unfortunately that’s the case in too many churches. I’ve said on many occasions that I believe it’s a sin to bore kids with the Gospel. And that’s exactly what happens when kids are required to sit through worship services designed for adults, especially kids with ADHD.

For many kids with ADHD, especially those with the “H” component, the mental energy required to maintain self-control for an extended period of time takes away from their ability to get the desired “take away” from their church experience. They don’t like sitting for extended periods of time. Many educators are starting to catch on to the importance of movement and exercise on learning.

As kids with ADHD get older, rates of insomnia increase. Many of these kids are “night owls”…they stay up very late because they have a hard time slowing down their brains to settle enough to fall asleep. The problem is compounded when they have to get up very early (6:00 AM in the case of our tenth grader) on school days. By the weekend, getting up and out of bed may be more of a challenge for the teen with ADHD than their friends. One of the wiser moves the leadership made at the church our daughter attends was moving high school worship service from 9:00 AM to 6:06 PM on Sundays. Let’s just say there weren’t a whole lot of kids with ADHD responding to invites from their friends to check out 9:00 AM church!

Here’s another consideration… there are a lot of kids with ADHD who need to take medication to have a successful school experience during the week who don’t have that option available to them on the weekend because of concerns their treating physician or parents have about the effects of medication on appetite and growth. Think about this: If many kids with ADHD require medication for school during the week despite accommodation plans and assistance from teachers with special training, how do you think they’re going to do at church on the weekend without medication and a volunteer leader who lacks a teaching degree?

One of the main points my former ministry colleague Katie Wetherbee makes when training church staff and volunteers is that kids want to be successful. My kids with ADHD often get very frustrated and discouraged and start to see themselves as a disappointment to parents and teachers. Put that kid in an environment in which the behaviors resulting from their inability to maintain self-control may be labeled as sin and see how excited they’ll be about coming back next week!

One final word on the issue of environments…there is such a thing as too much stimulation for kids with ADHD. When kids are struggling with sensory overload…too noisy, too many kids talking, lighting is too bright-they don’t learn and may experience the environment as unpleasant or aversive. Let me share an example…

We’ll call my friend Jake. Jake has ADHD along with auditory processing difficulties. When several people are talking at once, Jake’s experience is like listening to a radio with lots of static. Because of his ADHD, he notices all the different sounds in his environment. One day, I was hanging around in the lobby of the church about five minutes after the start of our second service and Jake comes up to say hello:

Jake: Hi, Dr. Steve

SG: Hi Jake. How you doing?

Jake: Just great

SG: How’s school?

Jake: Really good this year. (Hesitation) Dr. Steve, Can I ask you a question?

SG: Of course

Jake: When I go into my church service, there are too many kids yelling and screaming and talking and pushing…I can’t concentrate on what’s going on. Do you have any suggestions for what I can do?

Jake just had too much trouble tolerating the level of stimulation in the large group worship area that was present at the time. He liked the discussions when he broke out into his small group, so his parents and leaders came up with a great solution. Jake was given an orange vest and made a part of the parking team between services. We had people who drove around the lot looking for Jake on Sunday morning because of his friendly demeanor. He’d finish directing traffic about the time his large group worship was winding down and the kids were getting ready for their breakout groups.

Fitting in at church as person with Asperger's

Editor’s Note:  “Sydney” sent me this e-mail last week and gave me permission to share with our readers. Her e-mail is a wonderful, first-person description of attending church as a person with Asperger’s Disorder.

Church is one place where there ought to be a place for everyone. We’ve had two very similar conversations in the last few weeks…one with a man who, like “Sydney” has autism, the other with a woman with bipolar disorder and PTSD. We share in the hope that the church will listen and learn from “Sydney’s” perspective…

I have aspergers, ADD, depression, and anxiety. I am a student who recently moved to do more studies. I am very nervous about joining a new church because of the experiences I have had in church before. I so find the loud rock concert type services completely overwhelming. However, the social aspects at the quieter services are just as overwhelming as some very perky person pounces in on me. Although I typically like structure and routine, I do enjoy contemporary (less high services) for connecting with god. In addition, there is all that small talk around swarms of people wearing all sorts of perfume who do not understand when I talk loudly, change topics, or suddenly get distracted.

Coordinating getting myself to church and then balancing a cup while talking to people is a challenge. When I finally do get the courage to introduce myself to someone, it turns out that I met the person the week before but did not remember his or her face. I am never on time for church and it is a good day when I remembered both my money and kindle bible. (Real Bibles are too distracting as the smooth pages are too much fun to feel!) I feel left out as others display their feelings and get emotional during worship. I never know where to sit and always leave belongings behind after church.

I have managed to alienate everyone at my old church–apparently through breaking countless social rules (though I am not sure which ones). It is hard to know what I do wrong since no one communicates with me and I cannot read body language. Even when I try to send update emails, I get no response. It is so is hard for me to initiate conversations. Therefore, I even sent an email with pictures from Corinth and Ephesus to initiate a conversation. However, no one from church ever emailed me back. Many people when dealing with me say, “There’s Sydney. And I hadn’t even asked God for patience when I met her.” I have taken all of these “find your spiritual gifts” and “find your ministry” quizzes. All of them say that since I care about social issues and kids that I must want to do all these social activities. I like people as an abstract concept and I like helping them indirectly. I would rather hang out with the kids since I feel as immature as they are. In addition, my attention span matches theirs.

I do not want to join a small group in a new church because I am so afraid of belong alienated again. My old pastor told me I just needed to get more antidepressants and more friends—if only it was that easy. In my old church, I tried doing alpha at the church but I never felt like I was part of the fellowship. I enjoyed watching the alpha videos online more. I am currently learning from Christian courses.com and biblicaltraining.com in the meantime. When I have autistic meltdowns, worries, or compulsions, I am just admonished for not giving things to god and that I have not asked for enough healing. If I speak about issues such as modesty, they admonish me for being too shy introverted or antisocial. In discussions in admonished for always being too off topic. Do not even get me started sitting still for quiet time with god. Clear sermons with pictures and outlines are such a blessing (though church with so much socializing can be tiring!)

I do not even know how to approach joining a church now since it is so evident that no one at my old church in my old city wants anything to do with me. For all the talk on forgiveness, I am apparently too eccentric and egocentric to be forgiven and to be accepted. Moreover, if not even loving Christians can put up with me, the rest of the world seems scary. I once volunteered at a Christian youth centre, but I was told I had to leave after a few days for being too clumsy. I applied to several Christian schools, but I have found them to be the least accepting of my disabilities. I have this vision that if I ever get married, it will be an empty church (not that I want to be the centre of attention making small talk and hugging others). I was told once during a healing session that I was to remember that I was a princess in God’s kingdom; however, what I also remember is the person who described me as the “pre-princess” from The Princess Diaries.

How are kids and teens with ADHD different

Editor’s note: Out of the 700+ blog posts featured here since the middle of 2010, the post I’ve printed out and shared most frequently with parents coming through our office is this post on the differences in kids with ADHD. Here’s an updated version taking into account research developments since the original was written in 2010… 

ADHD is among the most commonly identified mental disorders in children and teens in the U.S. According to a 2011 study, 11% of youth between the ages of 4-17 have received a diagnosis of ADHD, and over 6% are actively being treated for the condition with prescription medication. Given the sheer number of  kids affected by the disorder, the need for the local church to serve, welcome and include them (and their families) has become too great a problem to ignore.

We need to understand the nature of the disability associated with ADHD if we’re to appreciate the challenges the condition presents for the church and for parents invested in their child’s spiritual development.

According to the DSM-5 criteria, children, teens and adults with ADHD have a developmentally inappropriate degree of inattentiveness, poor impulse control and in some (but not all) instances, hyperactivity.

Russell Barkley, Ph.D. is one of the world’s foremost experts in researching brain mechanisms in children and adults associated with ADHD. I had the honor of being his co-presenter at a day-long symposium on ADHD a number of years ago and was surprised to discover that he’d co-authored a paper with Dr. William Hathaway from Regent University entitledSelf-Regulation, ADHD and Child Religiousness(Journal of Psychology and Christianity, 2003; 22(2):101-114). Here’s a fascinating lecture on the nature, causes and treatment of ADHD that Dr. Barkley gave on February 13, 2008 at the U.C. Davis MIND Institute.

Dr. Barkley’s theories suggest that ADHD is a disorder not only of attention, but of executive functioning as well. Executive functioning describes a set of cognitive abilities involved in controlling and regulating other abilities and behaviors. Such functions are necessary in initiating goal-directed behavior, suppressing impulses arising from lower brain centers, and planning future behavior.

There are five key executive functions: Behavioral inhibition (critical to development of the other functions), non-verbal working memory, verbal working memory, emotional self-regulation and reconstitutionWe’ll describe in more detail the consequences of delays in the development of these functions.

Behavioral inhibition involves the ability to delay one’s response to an event (allowing time to think), interrupt a chain of responses to an event and the capacity to keep competing events from interfering with the initial response. Without this ability a person would be entirely focused on the immediate consequences of any action or behavior and would be unable to develop the capacity for self-control. Kids in whom the development of this capacity is delayed will be unable to suppress the publicly observable aspects of behavior.

Non-verbal working memory involves the capacity to maintain a picture of events in one’s mind. The ability to analyze situations for recurring patterns in order to predict future events is critical in anticipating consequences of behavior, managing relationships and planning complex, goal-directed behavior. Moral conduct and social cooperation are contingent upon this capacity as well the retention of events in sequence that allows one to estimate the time required to perform a task. Kids who experience delays in developing this capacity will have more difficulty remembering multi-step directions, more difficulty completing tasks (especially tasks that take a long time to complete), and will tend to underestimate the amount of time necessary to complete assigned tasks.

Verbal working memory involves the capacity to think in words. Internalization of speech allows kids to internalize social norms and rules, facilitating moral development. As kids develop this capacity, they’re able to hold a thought in their mind without having to actually say what they’re thinking. A classic example is the inability of little kids to pray silently.Kids with delays in development of verbal working memory would tend to talk excessively compared to peers, have more difficulty organizing and communicating thoughts, struggle more with use of proper grammar and experience more challenges in following rules and directions.

Emotional self-regulation involves the ability to keep private one’s initial emotional response to an event or situation. This allows a child to modify their response to an event as well as the emotions that accompany the response. Capacity to sustain motivation for future-directed behavior is contingent on this ability. Kids who experience delays in acquiring this capacity will likely appear to overreact in response to minor provocation, have more difficulty appreciating the impact of their actions upon others, and have more difficulty summoning the drive or emotional states to overcome obstacles or complete goal-directed behaviors. Their response to initial frustration is usually to quit the activity or task.

Reconstitution involves the ability to use private visual imagery and language to represent language and actions. This allows us to mentally rehearse possible solutions to problems when attempting to overcome obstacles in order to complete a task or achieve a goal without physically having to carry out each and every solution. Kids with delays in acquiring this capacity will experience much more difficulty generating solutions to problems when they get frustrated or stuck.

The theory described above applies only to kids with the classic, combined type ADHD in which kids have difficulty with impulse control and hyperactivity. In general, they know what they should do, but lack the self control to do what they know is right. They also are challenged to generate work product, be it schoolwork or completion of chores at home. Kids with the inattentive subtype of ADHD have problems with focus, concentration and information retrieval. They are more likely to complete their work, but make careless mistakes in doing so.

Is Oppositional Defiant Disorder a description or a diagnosis?

Our current blog series… Dissecting the DSM-5… What it Means for Kids and Families, continues today with an examination of the recently updated diagnostic criteria for Oppositional Defiant Disorder.

Mental health professionals working with kids and families are often asked to intervene when children chronically exhibit angry or disrespectful behavior. The causes of this behavior are often complex, but typically are grounded in two very different biologic predispositions…referred to in the DSM-5 as disinhibition/constraint and negative emotionality.

My problem with the diagnosis of Oppositional Defiant Disorder (ODD) is that establishing the diagnosis doesn’t tell you anything about what to do to treat it. Consider it a “lite” version of Disruptive Mood Dysregulation Disorder without the severe, protracted tantrums or meltdowns.

In the DSM-5, the eight diagnostic criteria for ODD were regrouped into three categories: Angry/Irritable Mood (loses temper, touchy/easily annoyed, angry/disrespectful), Argumentative/Defiant Behavior (argues with authority figures/adults, defies/refuses to comply with rules/requests from authority figures, deliberately annoys others, blames others) and Vindictiveness. Kids are required to have four or more symptoms for at least six months for an ODD diagnosis, criteria have been included to emphasize that the behavior is beyond the norm for the child’s developmental age and specifiers for severity have been included. In addition, kids with ODD may now be diagnosed with Conduct Disorder as a comorbid condition.

Some kids are disrespectful and defiant because of issues with poor executive functioning. They roughly correspond to the angry/irritable group. One way of understanding their behavior is to view them as impulsively defiant…they argue with parents and authority figures without stopping to think about the issue that upsets them or why they’re upset. It’s not unreasonable to question whether this subtype of kids diagnosed with ODD would be better described as having ADHD, with the defiant behavior representing difficulties with emotional self-regulation caused by the executive functioning deficits central to our understanding of ADHD. In fact, one of the criticisms the folks from Shire Pharmaceuticals faced when they sought FDA approval of Adderall XR for ODD was the question of whether ODD was truly a stand-alone diagnosis-since 79% of the kids in their study were diagnosed with ADHD in addition to ODD.

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Other kids are disrespectful and struggle with transitions because of their inability to let go of their mental script of how a given interaction or situation should unfold. They correspond to the argumentative/defiant group in ODD. They perseverate or get “stuck” on a picture in their mind of how things should be and escalate when  adults violate their sense of control. The first subset of kids is defiant because they can’t stop and think. The second subset is defiant because they can’t tolerate the inner frustration when events unfold differently than they’ve pictured in their minds.  We know kids who “ruminate” or perseverate often experience problems with anxiety and/or depression as they get older.

What we do to help is contingent on our conceptualization of the cause of the defiant behavior. If they have difficulties with self-control related to ADHD, we’ll treat the ADHD. If they’re rigid, inflexible and perseverate, we might look at cognitive strategies or behavioral interventions to help. Use of the ODD label adds little to our understanding of how to best help address the behavior that led parents to seek professional help.

Updated January 24, 2016