The problem with ADHD

My younger son has always been a daredevil. At age four, he’d run up the slide at the playground only to fling himself over the top and dangle from his fingertips. When it came to sliding down a pole, fireman style, he’d linger a bit too long with his toes over the platform ledge, as if preparing to jump. Even now, at six, he’s in constant motion, bouncing from one activity to the next. I often wonder why he can’t sit still, how come he never tires out. “He’s a boy,” offered one friend recently. “Aren’t they all a little ADHD?”

She was mostly kidding, yet her comment is telling. These days, the label is tossed around to describe any child who’s very active or seemingly in his own little world. But attention deficit hyperactivity disorder (ADHD) is a complex neurological disorder that affects five to 12 percent of school-aged children, according to the Canadian ADHD Resource Alliance, with boys around three times more likely to have it. The Diagnostic and Statistical Manual of Mental Disorders (better known as DSM-5) characterizes ADHD by three main symptoms: inattention, hyperactivity and impulsivity. Though doctors are unsure of precisely what causes it, research has shown that genes (it often runs in families) and brain size may be involved. Outside the medical world though, many are inclined to think of ADHD as a behavioural issue. Typical kid stuff—losing toys, fidgeting during circle time, inability to follow directions—leaves many parents wondering if their child has it.

If only a diagnosis were simple. Unlike, say, diabetes or a bacterial infection, there’s no blood test for ADHD. It’s up to a family doctor, psychologist or psychiatrist to make the call. And that system is far from foolproof. As L. Alan Sroufe, a long-time researcher in the fields of behavioural and emotional problems, and professor emeritus of psychology at the University of Minnesota’s Institute of Child Development, explains, “If you meet X number of Y symptoms, then you have the disorder. If you meet X minus one, you don’t. That’s one problem. The other is that almost every diagnosis in the DSM-5 lists difficulty concentrating [as]. A definitive diagnosis is hard—it’s always going to be ambiguous.”

While some kids very clearly have ADHD—a diagnosis is certainly a lifesaver for those families—some experts worry we’re too quick to label and then medicate out of convenience, without first looking at the bigger picture, which might include a learning disability, anxiety or depression that looks like ADHD. Research shows teachers in particular tend to oversuggest it; in one US study, nearly 24 percent of students were viewed by teachers as having ADHD—well above the prevalence rate.

In Back to Normal, psychologist and a leading ADHD researcher Enrico Gnaulati explores why what he calls ordinary childhood behaviour is often mistaken for ADHD. “All children, to varying degrees, are impulsive, forgetful, have trouble waiting their turn and have difficulty keeping their bodies still. These are all symptoms of ADHD but also very quintessential childhood tendencies,” he explains. “The general protocol these days is: Teacher sounds alarm bells, parents get anxious, parents go to paediatrician. The average appointment lasts 15 minutes, and only a tiny minority of paediatricians have a background in mental health. So because of the time crunch, there’s a focus on symptoms and not on more deeply understanding the child.”

When experts can’t even agree, it can be tough for parents to determine the best way to treat their kid, who may or may not have ADHD—there’s no one-size-fits-all approach. Usually, it takes a lot of trial and error, research, advocacy and, above all, patience. Here are three families who have taken very different paths to treatment, proving an open mind may be the best prescription of all.

For some parents, the ADHD label itself is a questionable one—at least when it comes to treating their child. Both of Eva Solan’s* sons, ages seven and 13, have an ADHD diagnosis, though the kids’ symptoms (and personalities) are extremely different. Over the past five years, Solan has taken her boys to a slew of tutors, psychotherapists, occupational therapists (OTs) and, at one point, a psychiatrist. Medication worked wonders for her younger son, Ryder*, who has impulsivity issues. “He felt like someone gave him the bicycle brakes he never had—he could finally slow down,” she recalls. But for her eldest, Jordan*, who struggles with anxiety and low self-esteem, the medication’s benefits did not outweigh the side effects. “He became this perfect student but was zombie-like. He stopped eating because he was never hungry. As a parent, you walk around with a pit in your stomach that you’re drugging your child.”

Solan has since taken both kids off medication—Ryder had reached a good place without it, while Jordan required more attention for ADHD symptoms she believes are a by-product of his anxiety. “My kids are such polar opposites socially, in the way they approach school, in how they see the world—and yet they’re both called ADHD,” she says. “People with ADHD have anxiety—how could you not? But with Jordan, I really believe his anxiety comes first.”

Sroufe says anxiety can absolutely be masked as ADHD. “For some kids, anxiety is really at the root of it all. Of course you can’t stay focused—you’re so worried about things. For other kids, they’re angry and hugely upset, and that can look like ADHD, too, especially the impulsivity part,” he explains. The list of issues that can cause what looks like ADHD is long; it includes hormonal imbalance, sleep deprivation and learning disabilities such as dyslexia or auditory processing disorder (up to half of kids with ADHD have a learning disability). Even some of the world’s leading experts have conflicting opinions. “I think Jordan has anxiety,” says Solan. “The psychiatrist said no, it’s ADHD. The OT said no, it’s sensory integration issues. There are so many different schools of thought on why these symptoms are manifesting themselves.”

These days, Jordan no longer sees a therapist because, as Solan explains, they have yet to find the right fit. “He’s so anxious that even the idea of needing or getting help causes anxiety—acknowledging that he’s different is a real trigger. It’s a bit of a Catch-22,” she says. Instead, she uses her own training in mindfulness and some role-playing to help her son deal with his anxiety. For instance, Jordan will often RSVP excitedly to friends’ birthday parties but then become more and more anxious as the day approaches. In these cases, Solan will role-play with him, pretending the party is tomorrow (even when it’s still weeks away) and asking him how he feels. Together they’ll come up with ways to deal with the inevitable panic, acknowledging the anxiety and contemplating worst-case scenarios. Just talking it through has helped Jordan to cope better, Solan says.

When Kaelin Britton’s son, Liam, now 11, was diagnosed with ADHD in grade three, it came as a surprise. “I was completely oblivious to the concept,” recalls Britton, a respite care worker at the Canadian Mental Health Association (CMHA) in Guelph, Ont. “I just thought, sure, he’s a bit busy and functioning at high speed most of the time. But ADHD didn’t cross my mind until we had a conversation with his teacher, who said he’s constantly in motion.” Britton and Liam’s mother (from whom Britton is separated) booked an appointment with a paediatrician, who walked into the room to see Liam climbing from a chair onto the window frame, according to Britton. “You must be here to discuss ADHD with me,” he said. After a 15-minute chat with all of them, including Liam, he recommended they consider starting him on Concerta.

The paediatrician also recommended an independent assessment, typically done by a psychologist, because Britton suspected Liam might have a literacy-related learning disability as well—but the $2,500 price tag was too hefty. Liam eventually qualified for an assessment through the school board, though it took a lot of wrangling from his parents as well as from the school’s support team. As Britton explains, an ADHD diagnosis alone wasn’t enough to qualify Liam for an assessment, but once a board-appointed consultant determined Liam also likely had a learning disability—mostly in the areas of spelling and comprehension—he was selected as one of two students at his school to receive an assessment from the board’s own psychological team. Just as Britton had suspected, results confirmed the disability. “It had been causing Liam great anxiety, as he had trouble following instructions and understanding what was being asked of him in terms of projects or class participation,” says Britton. “He was also afraid to read out loud and pretty much began hating having to read or write at all.”

Though Britton was wary of starting his son on medication, he gave it a try because his ex felt strongly that it was the right move, and he eventually agreed. The side effects were terrible—emotional outbursts, loss of appetite and stomach pains—so they tried a different class of drugs, with no success. Britton says he felt confused and, at times, overwhelmed. Ultimately, after a lot of research about ADHD, they stopped the meds to take a more holistic approach.

“I couldn’t live with myself if I didn’t try everything that could possibly benefit Liam and help him achieve success. When one thing wasn’t working, we tried something new. Or we tried combinations,” says Britton. They enrolled Liam in sports as a means of keeping him active and burning off energy, as well as to boost his confidence and help him meet new friends. (Britton says exercise is the one thing recommended unanimously by doctors, parents and teachers alike.) They also visited a naturopath, who suggested that his day-to-day behaviour might change if he either cut back on or altogether eliminated gluten, dairy and refined sugar . Some doctors believe there’s a connection between diet and neurological and psychiatric conditions, including ADHD.

Beyond these daily strategies, Britton reached out for extra support. The whole family (Liam, Britton and his partner, and Liam’s mother) started seeing a psychologist at the CMHA, but more recently, Liam has been meeting the therapist on his own. The family also attended seminars at CMHA—for the parents to share what they were going through, and for the kids to socialize and make new friends (as Britton explains, that’s not always easy to do at school, when these kids are singled out or always in trouble for one reason or another). At school, they met with teachers to develop an individualized education program, including one-on-one time with an educational assistant, who supported Liam with homework and helped him get back on track if he was losing focus. And at home they created “choice boards”—Velcro boards with removable images, such as a toothbrush and pyjamas, which can help kids with schedules and organization.

They’ve also introduced occasional massage treatments to help Liam relax, as well as yoga and vitamin supplements such as fish oil, and vitamins D and C. Because routines and consistency are so important for a child who struggles with focus, Britton ensures they have strong routines that are supported at school (and vice versa).

“Not one single entity worked wonders on its own, but all of them combined have definitely helped,” Britton says. “Liam is happier and healthier.” This type of multi-faceted approach is touted by ADHD experts as the best course of action. “Pills don’t teach skills,” says Doron Almagor, a child and adolescent psychiatrist, and director of The Possibilities Clinic in Toronto, which specializes in the diagnosis and treatment of ADHD. While Almagor will often prescribe medication, he says it should ideally be done in conjunction with other treatments, including cognitive behaviour therapy, mindfulness and ADHD coaching (for example, putting organization and time-management strategies into place), and school interventions (parents working with teachers to create an individual learning plan for their child). “There is a stigmatization of all mental health issues in our society, but avoiding the issue is not going to help,” says Almagor. “The most successful kids I’ve seen are those with parents who are active advocates for them.”

Melissa Tam* was first concerned about her son, William*, now age 10, four years ago when he was in grade one. She’d noticed some sensory issues (he’d constantly smell his fingers, for example, or chew on his T-shirt), and so William underwent a psychological assessment. Results didn’t reflect an ADHD diagnosis. She had him reassessed two years later, and this time the report came back with mild ADHD, along with a learning disability (slow processing speed, meaning it takes him longer than other kids the same age to make sense of the information he takes in) and issues with executive functioning (when the brain cannot organize and act on information, making it difficult to complete a project or keep track of time). Tam sent William to an OT, who noticed he had problems with tracking—that’s the ability for your eyes to move smoothly across text; if your eyes can’t track properly, it’s difficult to develop reading skills. The recommendation: William should undergo vision therapy to strengthen his eyes.

“I hadn’t heard of vision therapy before,” says Tam. “I never thought the fact that he couldn’t concentrate had anything to do with his eyes.” But as she began to research, she quickly learned there’s a correlation between ADHD and convergence insufficiency (the inability to keep the two eyes working together while trying to focus on a nearby object). Though his vision is 20/20, William was fitted with prism glasses, which help to artificially align the eyes. He also had weekly vision therapy sessions in which a therapist used tools like lenses, prisms and filters to “train” William’s visual system to correct itself.

While William’s teachers didn’t observe any changes in his behaviour, Tam noticed he stopped blinking all the time when trying to focus, and William said he didn’t get as tired while reading. Around three months into vision therapy, he started on ADHD medication. Tam was seeing results, but she wanted to add meds to the mix because she says there were still serious behavioural issues at home (for instance, he’d have multiple tantrums while getting ready for bed each night). “He held it all in at school; nobody would know he was struggling. But he’d just lose it when he got home,” says Tam. “Doing his homework, brushing his teeth, showering—every little transition was a battle.” Tam says the results have been life-altering; William is now excelling at school and is calmer at home. It’s difficult to tell if the change is a result of vision therapy or medication, but Tam feels it’s likely a combination of the two.

“Imagine that your child’s brain is a symphony orchestra made up of many musicians, each with a different role. Individually, these musicians are talented, but they need an organizational system to keep them on track—they need a conductor.” That’s how Ainslie Gray, medical director of Toronto’s Springboard Clinic (which helps families in the assessment and treatment of ADHD), explains the disorder. Of course, just who or what that “conductor” is will vary from child to child. For all parents, it’s a matter of researching treatment options, meeting with professionals, working with teachers, advocating for and checking in with their child (self-esteem is always a big indicator of how things are going). Most important, however, is going with your gut. “Nobody has the answer for you when it comes to what’s best for your child,” says Solan. “Your instinct has to guide you through this more than anything else—more than any teacher, friend, doctor, therapist. You’ll always second-guess it, but it’ll guide you.”

* Names have been changed

A note on ADHD meds

Medication for ADHD most often comes in the form of a stimulant (popular brands include Concerta, Ritalin and Adderall), which increases the ability to concentrate on tedious tasks and, in turn, can help regulate hyperactive and impulsive behaviour, and increase attention span. While it may seem counterintuitive to give an overactive child a stimulant, it works. These drugs increase the levels of certain chemicals in the brain, most notably dopamine (a neurotransmitter associated with pleasure, movement and attention), which causes an increase in heart rate and blood pressure that can actually have a calming effect; when dopamine levels are elevated, a kid may no longer have the need to self-stimulate by bouncing in his seat or blurting out answers in class, for instance. But because these meds often come with side effects, such a reduced appetite (resulting in weight loss), sleep problems, headaches or stomach aches and moodiness, many parents seek out alternative treatments hoping to find a long-term answer.

A version of this article appeared in our October 2015 issue with the headline, “The trouble with ADHD”, pp. 84-88.

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