Parents often feel guilt and anger over child’s bad behavior

This could be subtitled: How to handle anger and frustration caused by ADHD behavior, but ADHD is not the only behavior disorder that might lead to despair, frustration, guilt and anger.

Almost ninety percent of parents of children with behavior disorders that come to my office for ADHD diagnosis feel guilt and anger over their child’s misbehavior and will ask: What did I do wrong? Did I cause his (her) bad behavior?

Nick’s mom Sarah was no exception. On Nick’s first office visit for ADHD evaluation, Sarah explained the “real reason” for her visit. It wasn’t because her 11 year-old son Nick had bad grades or was in trouble with the law. It wasn’t even because she was sure he had ADHD. It was because she had just reached the end of her rope-her patience was gone and nerves were shot and she felt guilty and angry.

She told me Nick’s behavior was terrible regardless of where he went. He talked back to teachers, smarted off to everyone who tried to befriend him, lost his temper at the drop of a hat, and had absolutely no respect for anyone-especially elders and those in authority.

His usual saving grace at school was he made “straight A’s” in all subjects and teachers usually gave him a lot of leeway because of his intelligence. They often just considered him to be “eccentric.” However, this time, his grades didn’t save him when he “blew-up” in class and threatened a teacher. He was expelled for a week and couldn’t return until his behavior problem was “checked-out and fixed.”

As a result of his behavior, Sarah and her husband were getting complaints from everyone who encountered Nick-even before the episode at school. Not only was it frustrating that they had no control over his behavior and that nothing they did seemed to change it, but they felt guilty-very guilty over the possibility they had done something to cause his behavior. Now, that guilt had now turned to anger-lots of anger. (We’ll discuss Nick’s behavior disorder in our next article-hint-it is not ADHD!)

Why do children like Nick make parents feel guilty and angry?

It’s because most parents of behavior problem children:
• Feel out of control because they really don’t understand what is going on in their son’s or daughter’s brain,
• Are frustrated because nothing they do or have done seems to work to fix things or even make them the slightest bit better,
• Become embarrassed about their child’s terrible behavior around friends, family or even strangers-they can’t take them anywhere,
• Begin to believe things are hopeless and their child will never change-will never grow up-may never leave home as an adult,
• Start to doubt their parenting skills and believe they are bad parents or that they actually did something that caused the bad behavior,
• Worry there is something wrong with their genetics or that they have an inheritable disease they passed down to their child
• Become angry as all of these things come to a head.

Knowing what happens to cause parents of behavior disordered children to feel guilty gives us an edge in understanding how to handle those feelings. So, here goes…

1. First and foremost, you must assess your feelings about your child’s behavior and how it makes you feel. Doing so frees your emotions so you can deal with them and get them out of the way.
2. Make a list describing what you don’t like about your child’s behavior; followed by suggestions on how to change or improve his or her bad habits.
3. List all of your child’s good behaviors and make notes about what you can do to get him or her to continue these behaviors and develop new ones.

Tips on learning to deal with your child’s misbehavior and your own emotions

If you’re angry, you should ask this question; did your child really make you angry or did you allow the anger to occur?

Keep in mind that most behavior disordered kids are excellent at manipulation and know which buttons to push to get a rise out of someone. Why? Because by doing so, they are in control of the immediate situation. Children and teens with ADHD and other behavior disorders often feel insecure and not in control, so they do whatever they can to get control of their immediate situation.

When it comes to losing one’s temper; my grandfather always said “He who loses his temper first; loses the argument.” As adults, we should avoid losing our temper and control of parenting situations.

To help solve anger issues; make a list of exactly what behavior(s) made you angry, what you did about the anger at the time and how you plan handle it in the future.

Actively ignore little behaviors. I advise parents to pick a behavior-any little annoying irritating behavior and promise yourself that you’ll just ignore it. With my teenage daughters, I chose to ignore the words whatever and Duh!

Do not reinforce repetitive behaviors such as use of the word duh or silly little hand or facial gestures. When you react or overreact to these behaviors you’re actually fulfilling one of your child’s needs-the need for attention and his or her ability to get it immediately. Instead, act and don’t react. Have a plan formulated in advance about what you’ll do when a specific behavior occurs.

Be honest with your feelings and reassess them from time to time. Anger, frustration and hopelessness can be emotionally draining, can sap your energy, and can cause sleepless nights, stomach ulcers, depression and anxiety. It’s like any emotion in order to get a handle on them you must first admit their existence.

Take time for yourself- that’s time away from your child. You can’t handle your own feelings if you have to deal with your child’s emotional and behavior roller coaster at the same time.

Ask for professional help-get help from a behavior specialist or counselor coach. Trying to go it alone with a misbehaving child is like trying to learn how to build a computer without ever having read a book on computers or taking a class in the subject. Kids don’t come with owner’s manuals, instructions for assembly, or tips for rearing.

With little effort you might use the tips we’ve discussed to handle guilt, frustration and anger caused by dealing with children with behavior disorders.

Next time we’ll discuss Nick’s real behavior problem.

Happy parenting!
Frank Barnhill, MD

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New Liquid Medication available for ADHD Treatment

Many parents have asked countless times if their child’s ADHD medications came in liquid or chewable form. Usually, they asked because their kids had a problem swallowing the pills or capsules because they were either too big or tasted terrible.

Now, the long awaited solution to one of the few problems of stimulant-type ADHD drug dosing-especially in younger children with ADHD is finally here…

Yesterday, Pfizer pharmaceutical announced it was releasing an extended-release methylphenidate in oral suspension for treatment of attention deficit hyperactivity disorder. “Quillivant XR”, this first-ever liquid alternative to ADHD pills will be available in January 2013.

Apparently, Quillivant has the very same effects and side-effects as pill or capsule form methylphenidate and a child who is currently being treated for ADHD using this drug would probably experience no changes with regard to changing from the pill to liquid formulation.

I think the biggest concerns a parent and physician should have about using any liquid-suspension drug are:

• Since the drug comes in powder form and must be mixed with sterile water at the pharmacy, it is essential that it be mixed properly to avoid over-dosage or under-dosing.
• Whoever measures the medication must do so carefully before giving the ADHD drug to a child. In the case of liquid medications, one teaspoon means 5 ccs. If a child accidentally gets one and one-fourth teaspoons, that amount is 6.5 ccs and could cause significant side-effects.
• We probably won’t know the realities of how taking this drug with food or liquid will work for at least a year…so watch closely for side-effects and treatment failure.

We have long needed a liquid extended release ADHD drug and now it appears we finally have one in the form of a suspension.  Should you and your doctor decide to start your ADHD child on Quillivant, watch carefully for worsening of behavior, mood, and signs of depression or anxiety and if noticed, call your doctor right away.

As more information on the use and effects of liquid methylphenidate becomes available, I’ll pass it on.

Frank Barnhill, MD

Here are a few links to articles about Quillivant:

FDA OKs Extended Release Liquid ADHD Medication, Quillivant

http://psychcentral.com/news/2012/10/03/fda-oks-extended-release-liquid-adhd-medication-quillivant/45469.html

Drug information on line

http://www.quillivantxr.com/

http://www.drugs.com/cons/quillivant-xr.html

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Foods that cause ADHD Behavior

A child’s diet often determines whether or not they show signs and symptoms of ADHD.

Many parents have noticed their child’s behavior to be more impulsive or more hyperactive after eating certain foods. This increase in ADHD behavior is particularly more common during times of the year when children and teens tend to eat or drink more foods that contain sugar, dyes, caffeine, and preservatives.

Christmas is one such time of the year, as it’s not uncommon for children to be bombarded by offers of candy, cookies, cakes, sweetened flavored drinks and other high calorie foods. It just seems we all tend to err on the side of over-eating for the holidays. This habit probably comes from the common misbelief that in order to have a great Christmas or holiday season and be happy-during a time of the year we want everyone to be happy-that we must be well-fed, over-stuffed and jolly like Santa.

Unfortunately, overfeeding children with ADHD or feeding them the wrong foods can make their ADHD behavior much worse. This is especially true of ADHD hyperactivity and impulsivity. To further confuse things, as many as 25% of children and teens who do not have ADHD, will show signs and symptoms of attention deficit hyperactivity disorder when eating the above mentioned foods.

Suggestions for avoiding or improving ADHD behavior during the holidays include limiting or eliminating certain foods from an ADHD child’s diet.

I suggest limiting these things in any child with a behavior problem-ADHD-like behavior:

1. Fast foods-these tend to be high in calorie loaded carbohydrates and preservatives-our brains need protein and simple glucose to help us concentrate.
2. Highly caffeinated drinks and foods-this includes power and high energy drinks; excessive coffee, tea, and sodas; as well as some chocolate containing drinks and candies.
3. Candy and foods that are high in red, yellow, and purple dyes-many parents continue to tell me their children display ADHD behaviors after eating large amounts of these dyes. I must point out that there has never been a study that conclusively has shown that these dyes cause ADHD behavior. However, it’s hard for me to believe all of the parents who report these things could be wrong.
4. Alcohol or alcohol containing foods and drinks-Remember that special Christmas cake Aunt Em always made for Sunday’s reunion? You know, the one saturated with wine or bourbon? Well, don’t be surprised if little Jonny’s ADHD behavior worsens about an hour after eating just a small slice. In fact, it would surprise most parents to learn of just how many foods and drinks do contain small amounts of alcohol.
5. Any food or drink you have noticed caused worsening of your child’s impulsivity, distractibility, hyperactivity, or mouthiness in the past.  Once again, I realize every parent feels guilty when they restrict their child’s diet. But, look at the this way-you’re actually helping your child learn to control his or her ADHD symptoms which helps them build social skills and self-esteem-and after all; would it be worth putting up with terrible behavior for 4 to 12 hours just so your child can eat what he or she should not?

It’s important to remind each of you that every child’s metabolism is different. For example, I’ve known a few kids that could eat bags of candy and drink gallons of caffeine containing beverages, yet show no signs of ADHD.  However, it’s the many others who may only ingest very small amounts of red candies, sugary drinks, or caffeinated beverages and literally be “bouncing off-the-walls” within an hour that we all think of when the hyperactive-misbehaving child comes to mind.

Think about what your child is eating and drinking over this holiday season and you just might save yourself a few gray hairs and it may please you more than any Christmas present when his or her ADHD behavior improves…

Parents can often control an ADHD child’s bad behavior during the holidays by reducing or eliminating excessive dietary caffeine, sugar, dyes, alcohol and preservatives

Frank Barnhill, MD

Here are a few previous articles and news briefs you might enjoy reading-watching:

‘Healthy’ Diet Best for ADHD Kids-abc News

http://abcnews.go.com/Health/w_ParentingResource/healthy-diet-best-adhd-kids/story?id=15320571

ADHD Diets/WebMD

http://www.webmd.com/add-adhd/guide/adhd-diets

Energy and Sports Drinks may cause ADHD Symptoms

http://www.mistakenforadhd.com/2011/07/energy-and-sports-drinks-may-cause-adhd-symptoms/

Elimination Diets and ADHD Behavior

http://www.mistakenforadhd.com/2011/03/elimination-diets-and-adhd-behavior/

Energy Drinks may make ADHD Worse

http://www.mistakenforadhd.com/2011/03/energy-drinks-may-make-adhd-worse/

Restricting Certain Foods May Help ADHD Behavior

http://www.mistakenforadhd.com/2011/02/restricting-certain-foods-may-help-adhd-behavior-2/

Study: Diet May Help ADHD Kids More Than Drugs

http://www.npr.org/2011/03/12/134456594/study-diet-may-help-adhd-kids-more-than-drugs

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Christmas Shopping with the ADHD Child

This article could also be titled “How to avoid the stress of Christmas shopping with a child with ADHD and behavior problems.”

I bet you have a horror story about shopping with a son or daughter who made your trip to the mall so bad that you swore you’d never take them back again. If that’s the case, then you’ll be able to empathize with this mom.

Christopher had been successfully treated for ADHD for two years.

You could hear him screaming from halfway across the store. The louder he got, the louder his mom got in a shouting match that was stopping passersby’s and had to be terribly embarrassing for the mom.

“I want this airplane now. I don’t want to wait for Christmas. I ‘m not going to wait for Santa to bring it. I want it now!” He was throwing items out of her shopping cart as he screamed and threatened; “And if you don’t buy it….I’ll….I’ll”

She responded loudly; “If you don’t shut-up and behave yourself, you won’t get anything for Christmas….much less this airplane. Now, put it back on the shelf.”

I was shopping for Christmas presents at a local variety store. Looking down the aisle where all the commotion was unfolding, I quickly recognize the mom and her son. I had evaluated Christopher a couple of years earlier for ADHD and started him on ADHD medications. His mom thought his ADHD treatment was effective, because she had noticed at least a 75% decrease in outbursts (impulsive behavior), hyper-ness, and a definite improvement in Christopher’s grades and social skills.

Unfortunately, Christopher’s mom and dad went through a nasty divorce over the next two years and just like in so many other broken families, his father refused to let him take the ADHD medications or go to counseling.

Within weeks of stopping the drugs, the boy was back to his old behaviors; interrupting, manipulating, disrupting class and his grades were dropping like a rock. Despite his mom’s insistence that his ADHD behavior was terrible and he needed to be back on his ADHD medications, his father absolutely refused to let him start the drugs again.

This is one case in which I’m absolutely sure the father was ADHD before age 7. I think he felt guilty that he was ADHD and the child might have gotten it from him. As a result of denial, he refused to believe his son could have attention deficit hyperactivity disorder.

As fate would have it, I never saw the two of them again, until that day in the toy store.
(I was shopping for Christmas presents for my grandkids and knew better than to bring them along. They can’t keep a secret.)

So…How do you go Christmas shopping with an ADHD child and not suffer a nervous breakdown or end up in jail for beating the misbehaving child half to death?

Here are a few quick tips to help lessen ADHD behavior problems while Christmas shopping:

In advance, promise your ADHD child you will let him or her buy an inexpensive prize for good behavior after you finish shopping. Be sure to outline exactly what you consider good behavior and how much you’ll invest in this open bribe.

Let them help you find some of the presents on your list if old enough to do so without your help. This works particularly well for hyperactive teens and preteens and of course keeps them busy.

Plan your trip in advance with attention to the fact that loud noises, crowds, flashing lights and excessive music may cause your child’s hyperactivity and inattentive behaviors to suddenly worsen. Many an ADHD kid has gotten lost at the mall, because he or she didn’t pay attention to where they were going. In most cases, they were distracted by flashing lights, vibrant colors, excessive noise, and the excitement of so many shoppers.

Carry snacks with you or take frequent snack breaks. ADHD kids often show their worst behavior when hungry.

Allow them to take a toy or video game with them to help when they are bored. You just can’t occupy their every minute with behavior modifying actions, distractions, and tasks. Trying to do so would lead you to frustration and exhaustion.

Ask them to put together a shopping list for friends and family and decide in advance how much to spend on each item. (This is the way my mom kept me busy while she shopped. She showed me how to budget my gift giving when I was 10 years old and off to Woolworth’s we went.)

Let them buy items for the needy. This will not only keep them busy, but will give them a chance to earn respect and self-esteem in helping the less fortunate.

Break shopping up into 45-60 minute spurts since ADHD kids have a hard time focusing much longer. Use the breaks for snacks, meals or a visit to Santa or the video arcade.

Let them be in charge of choosing colors or styles. ADHDers love to be in charge-they love to push the buggy and letting them help in making decisions about what to buy actually helps build confidence.

Before we finish, please let me remind you of a few key points about shopping with ADHD children and teenagers:

• Crowds overwhelm some ADHDers
• ADHD children will become angry when they don’t know what to do or expect
• Noise, flashing lights, and fast-moving crowds can cause confusion and worsen hyperactivity, impulsivity and distractibility.

In closing, I taught my kids that Christmas shopping should be an adventure-an adventure in buying things so they could give to others with love. And, I emphasized the whole thing should make them feel all warm and fuzzy on the inside…dreaming of silver bells and sugarplums all through the night.

You can survive Christmas shopping with your ADHD child by planning ahead and anticipating and spotting problems before they erupt in bad behavior.

Frank Barnhill, MD

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Young ADHD children at Risk for Nonsuicidal Self-Injury

Young children with ADHD are probably more likely to engage in nonsuicidal self-injury than children who are not ADHD.

Children with ADHD as a group are of course much more impulsive than children without ADHD. As most parents and teachers know, it’s that increased impulsivity that forms one of the core symptoms of ADHD and makes an accurate diagnosis of ADHD more likely.

Increased impulsive behavior in ADHD is felt to be caused by inefficient executive brain processing of sensory input and the subsequent lack of an ADHD child’s or adult’s ability to delay gratification. It’s often this tendency to act before thinking through the consequences of doing something that gets the ADHD child, teen or adult in trouble.

As I’ve previously pointed out, excessive and off-the-spur of the moment tattoos and body piercings tend to be good examples of impulsive ADHD nonsuicidal self-injury behavior (NSSI). However, quite a few parents would argue even one body piercing or tattoo was excessive and impulsive, but we won’t debate that opinion here.

ADHD experts have realized over the past few years that adolescents with ADHD suffered higher rates of self-injury not related to suicidal gestures or thoughts. In some cases, these ADHD teens were looking for attention. In other cases, they may have been trying to improve their self-image or fit in with a particular group. Whatever the reason, it’s been my experience that teenagers with ADHD are much more prone to self-harm than teens who are not ADHD.

Imagine my surprise when a community-based study of children as young as 7 years from central New Jersey and Denver showed that 8% of kids interviewed from grades 3, 6, and 9 reported at least one episode of self-harm behavior. Of those, about one-third admitted self-harm multiple times. Most of us just never suspected such a high rate of this behavior problem existed in kids as young as 7 years.

In this study, Benjamin L. Hankin, PhD states “girls in the 9^th grade appeared to be at greatest risk of engaging in NSSI, hurting themselves 3 times more often than their male peers.”

Reported self-injury behaviors in both boys and girls included:

• hitting themselves (55% in boys),
• cutting or carving skin (63% in girls),
• biting themselves,
• pulling their hair to cause pain,
• throwing themselves into walls or sharp objects.

These self-harm behaviors were much worse in 9^th graders where skin carving was reported at the unbelievable rate of 70%. It appears the closer a child is to becoming a teenager, the more likely self-harm occurs.

Obviously, as advocates for our children, we must be diligent in spotting these behaviors and seeking help for affected children as soon as possible. While children with nonsuicidal self-injury behavior don’t really intend to seriously and permanently injure themselves, they often don’t think about the consequences of their behavior before acting.

As a result, many times, they will be ashamed what they’ve done or scared they will be punished and will hide all traces of their behavior in hopes to avoid further pain and suffering. So, it’s rare that they will tell you when they’ve done something painful or disfiguring that they didn’t mean to do.

Here are a few things I’ve noticed in similar kids that caused suspicion of self-harm behavior and things that parents of children who self-harm have shared with me:

Kids who prone to self-injury tend:

• to suddenly wear long sleeves to hide scars, fresh wounds and sores or self-applied tattoos
• put their long hair up so as to hide areas where hair has been pulled from their scalp or areas of redness or sores
• to want to eat in their room and spend more time away from parents and close family
• keep unusual objects (knives, rope, rocks) in their room or backpack
• lose their “good friends” and attract more “bad friends”
• to become more irritable and moody for no reason (this always makes me suspicious of ADHD misdiagnosis).

As parents, teachers and healthcare providers, we need to keep our eyes open for signs of self-harm in our children. The earlier we detect and treat this type of impulsive and dangerous behavior, the more likely the child will avoid similar risk in the future.

A word of caution: not only are young children with ADHD more likely to engage in nonsuicidal self-injury, but adults with ADHD are probably at increased risk of self-harm as well. If your spouse has ADHD, you might want to discuss this topic.

Frank Barnhill, MD

Here’s a previous article dealing with self-harm you might find interesting:

Children with ADHD at Risk for Bullying and Self Harm
http://www.mistakenforadhd.com/2012/05/children-with-adhd-at-risk-for-bullying-and-self-harm/#more-1595

ADHD Impulsive Behavior and Risk of the Choking Game
http://www.mistakenforadhd.com/2012/04/adhd-impulsive-behavior-and-risk-of-the-choking-game/

Why ADHD Kids Get Tattoos and Piercings
http://www.mistakenforadhd.com/2010/10/hey-adhd-kids-get-tatoos-and-piercings/

Reference:
Young Children Engaging in Nonsuicidal Self-Injury
http://www.medscape.com/viewarticle/766097

P.S. Please share this article with friends and family who might have the same concerns.

www.adhdbehavior.com

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Helping ADHD College Students make better Grades

This article should probably be titled How to help your college student with ADHD survive and make better grades. But…that title is way too long.

By now, probably all students who are going back to college are back “in the grind.”  And if your ADHD teenager is one of those, you’re probably already worried about how he or she will cope with a new school, deal with returning to the same school or how you can help so they will study harder and make better grades.

There is hope…there really are ways you can help your ADHD college student survive his or her first year and each subsequent year of academic life.  With that ray of sunshine in mind, please let me share a few of the more than 50 tips on dealing with ADHD in college that I’ve collected from parents of college students and from students with ADHD themselves over the past few years. Here goes….

• Do not keep your child’s ADHD diagnosis a secret from everyone at college. A mom told me several years ago that she and her husband thought it best to protect their son from ADHD bias by making him keep his ADHD a secret. No one knew about Jason’s ADHD in his freshman year. So, since he had no one to turn to when things went bad, he failed almost all of his subjects.

  What Jason’s mom advised was to tell all professors, all tutors, the school nurse, advisors and school administration that dealt with special needs students-to tell “Almost” everyone about your child’s ADHD and ask for their help. She also advised each person be asked to keep the diagnosis private in hopes that doing so would help avoid student-student bias and bullying and problems with others wanting to borrow pills. Sounds reasonable-doesn’t it?

• Help your ADHD student find a mentor-a person they can turn to when they have questions, concerns, need advice, feel frustrated or overwhelmed. Preferably this person needs to be older and have dealt with ADHD on a personal basis or helped others with behavior problems in the past. Life coaches work really well in providing not only emotional and social support, but help keep your ADHD child from being embarrassed from having to call you all the time. No one wants to be tied to the proverbial apron strings all the time. After all, you want them to grow-up and part of growing up is recognizing when you need to ask others for help.
• Hire a graduate student, an interested teacher, or retired professor to act as a tutor in your son’s or daughter’s most challenging classes/subjects. Just two or three hours a week may make all the difference in the world when it comes to improved studying, better test taking and of course a boost in self-esteem that goes with improved grades.
• Do not isolate your behavior challenged child. I’ve had several moms and dads tell me about how they moved their ADHD teenager “off-campus” in their second year of college in hopes that their behavior would improve if they lived alone or didn’t have to share a bath or living areas. Later, these same parents returned desperately seeking help, because their ADHD college student had become so isolated living alone or with just one other person, that his or her social skills and study habits had deteriorated to the point they were an emotional wreck, not capable of interacting with others, had lost all friends and were making failing grades.

  It’s important to realize that just like all other levels of learning-whether in the classroom or not-students learn from each other, not just from books and teachers. They learn how to study, pick up little nuances about what is and what is not acceptable behavior, observe social skills that allow for making friends and dating and mature into adulthood as a group.

  By forcing an ADHD child to live off-campus, parents deprive their college student of most of the benefits of college life. It’s almost impossible to replace these experiences later and usually these students will mature at a slower pace than those who integrate well and develop great social and interact skills.

As you can see, parenting the college student with ADHD is an on-going learning experience that involves a lot of trial and error. Just like ADHD kids, college students with ADHD don’t come with an instruction manual. Each child is unique and of course any treatment plan must be individualized to match not only their weaknesses, but their strengths.

Parenting the ADHD college student is often scary, frustrating, time-consuming and heart-breaking, but with a little help from those who have walked the rocky road before you…you can successfully help your college student with ADHD survive college and make better grades.

Frank Barnhill, MD

Here are a couple of article you might want to take a look at….

Heading to college with ADHD brings extra challenges

http://usatoday30.usatoday.com/news/nation/story/2012/09/22/when-students-with-adhd-go-to-college-they-may-flounder-parents-can-help-them-succeed/57825092/1

College Student Abuse of ADHD Drugs Causes ADHD Misdiagnosis

http://www.mistakenforadhd.com/2010/12/college-student-abuse-of-adhd-drugs-causes-adhd-misdiagnosis/

College Students Misuse ADHD Drugs to Improve Grades

http://www.mistakenforadhd.com/2011/08/college-students-misuse-adhd-drugs-to-improve-grades/

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Adult ADHD and Anger

When ADHD and anger are combined, the destruction to a person’s life is multiplied many times.

At least 40% and as many as 60% of children with ADHD will still have symptoms of ADHD well into adult life. Of these Adults with ADHD, probably at least 50% will have problems with anger. ADHD experts feel that anger issues in ADHD adults often take two forms- problems controlling anger toward others or anger directed inwards-toward themselves.

As many of us now realize, just being ADHD causes frustration and the doom of impending failure. Teachers often tell me of how ADHD kids just seem to give up when they appear overwhelmed and frustrated.  It’s often this frustration that causes ADHD children to fail at whatever they are doing. These failures just help perpetuate a cycle of frustration-failure-loss of confidence that further damages already fragile egos and self-esteem.

Adults with ADHD suffer many of the very same behavior problems they had as children-poor concentration to detail, impulsivity, inattentiveness, but rarely show all of the elements of hyperactivity. Usually by age 25 to 30 most will have learned coping mechanisms that help control or suppress their outright hyperactivity.

It’s often anger that gets the adult with ADHD in trouble. Anger usually clouds a person’s judgment and impulsivity is then quick to follow. Let me tell you about one of my 29 year-old patients and you’ll get a clearer picture of how anger makes adult ADHD worse.

Robert had a pretty good job as a machine operator in a local plastics manufacturing plant. He had been ADHD since his was able to walk according to his mother and had taken multiple ADHD medications all the way through technical college. Unfortunately, at age 24, Robert decided he had outgrown his ADHD, because he was able to date and get married, had a steady job and wasn’t hyperactive.

As a result of Robert’s self-evaluation, he didn’t return for follow-up and wasn’t seen in my office for four years. During that time, he had two speeding tickets; had not been arrested, but came close while arguing with an officer about speeding; was passed over for promotion and raises three times; and was experiencing problems in his marriage.

When he finally showed back up in my office, he had just been placed on 30-day probation at work and was told he would be fired if he had any more outbursts. Robert had blamed others at work every time he experienced a failure and had become angry with those he thought caused his problems.

When he and I finally got deep into his social and work relationships, it was very obvious he still had a “flaming case of ADHD”. He eventually admitted he just got tired of taking medications and was “hiding his ADHD” from everyone else.

What had “set him off” in his latest meltdown was a co-worker getting away with something Robert thought wasn’t fair. Apparently, another machine operator took an extra 15 minute smoke break and got away without a reprimand. When Robert complained to his shift foreman, his complaint fell on deaf ears because as Robert put it: “They are best friends anyhow and smoke together all the time.”

The foreman’s indifference “set Robert off” and he started fussing and hollering at both his co-worker and boss. The whole fiasco ended with Robert in the “big boss’s” office getting a reprimand for causing such a commotion. After cooling off, Robert admitted he should have avoided losing his temper and now realized he had significant anger issues.

How did we help Robert deal with his anger issues?

First of all, I started him back on the very ADHD drug he had used and had worked so well for over ten years-Focalin. Why? Since Robert was about to lose his job we didn’t have time to try counseling, behavior training, relaxation techniques, or lifestyle changes. All of these interventions take 60 to 90 days or even more to implement. We needed to make a dramatic change in his behavior-one that would save his job.

Don’t get me wrong, we did make changes in his diet, sleeping habits, and schedule behavior counseling as soon as possible. Once again-even though diagnosed as ADHD in the past-I put Robert through another head to toe evaluation to make sure he was not the victim of ADHD misdiagnosis.

In Robert’s age group the common things that can look just like and mimic ADHD causing misdiagnosis of ADHD include:

• Obstructive sleep apnea
• Depression
• Anxiety disorders
• Thyroid disease
• Alcohol and drug abuse
• Caffeine and stimulant addiction.

After all was said and done, Robert’s tests came back normal and that essentially confirmed he had Adult persistent ADHD.  The good news? Robert has control of his emotions and behavior 98% of the time, still has his job, his marriage is no longer on the rocks and he’s going back to school to learn another trade. His life is no longer full of the ups and downs of petty jealousy, unreasonable rivalry and threats and of course he is a lot happier.

Obviously, ADHD and anger seem to go hand-in-hand with about 50% of teens who have ADHD persisting into adulthood. In these persons, the inability to control anger actually stems from problems in executive thought processing and not recognizing little social and interpersonal clues that allow a person to get along well with others.

As I pointed out to Robert, while it really isn’t fair for a coworker to be treated differently, an extra 15 minute break isn’t something worth fighting for or losing his job over.

Frank Barnhill, MD

P.S. I just finished reading one of the best books on dealing with adult anger I’ve read in the past three years. In “The Cow in the Parking Lot”,  Leonard Scheff and Susan Edmiston explore the emotions and behaviors related to anger and offer insights and training techniques that should allow any angry adult to deal with the largest part of their destructive behavior.  Their book should be required reading for all teens and adults with ADHD.

You might also want to take a look at these previous articles:

Helping ADHD teenagers and adults handle anger producing situations

http://www.mistakenforadhd.com/2009/02/helping-adhd-teenagers-and-adults-handle-anger-producing-situations/

Problems sleeping cause ADHD Behavior in Children and Adults

http://www.mistakenforadhd.com/2012/06/problems-sleeping-cause-adhd-behavior-in-children-and-adults/

Anger issues can be part of ADHD

http://www.mistakenforadhd.com/2012/05/anger-issues-can-be-part-of-adhd/

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Changing an ADHD Child’s Behavior

How to improve behavior in a child with ADHD

As kids return to school to start the new academic year, more and more parents are asking for ways to change their ADHD child’s behavior. This usually means their ADHD child has poor behavior, has bad habits, or displays misbehavior and they want help in fixing it-the behavior.

Common complaints about the behavior of a child with ADHD include:

• He doesn’t listen to me (pay attention to what I am saying or ignores me)
• She interrupts when I’m speaking (has to get the last word in)
• He won’t sit still in class (fidgets all the time-disrupts the class)
• She refuses to do her homework (I can’t get her to do her homework)
• He talks back to me all the time (has a smart mouth-is mouthy)
• She argues over everything or acts like she knows everything.

As I’m sure you have noticed, all of these ADHD symptoms are really just typical behaviors or habits normally seen in ADHD kids and teens. They include the core symptoms used to make the diagnosis of ADHD-inattentiveness, impulsivity, and hyperactivity.

Daniel was the perfect example of an ADHD child’s behavior problem

Daniel’s mom was about to lose her job-not because she was a poor worker or wasn’t at work on time every day she was scheduled-but because of Daniel’s bad behavior.

Daniel’s behavior during thye first two weeks of school was so bad, that Patti had to leave her job 7 out of 10 days to pick him up at school between 10 and 11 am. On each of those days, his teacher called telling her his mouthiness and constant fidgeting and interrupting were so disruptive to the class as a whole, that someone had to come and get him. Since Daniel’s father worked out of town for days at a time and no one else was available, Patti had to leave work to get him.

Once Patti arrived at the school, Daniel calmed down and appeared to act as if nothing had happened. Patti and her husband tried threats, punishment, promises of rewards for good behavior, but nothing worked, and in fact; his behavior worsened instead of improving.

At first, Patti’s boss was very understanding and let her take sick leave to handle the problem. But…the previous day was different-he told Patti he would have to replace her if something wasn’t done and he meant like yesterday.

So, what was Daniel’s problem? Why was his behavior so different from the previous school year? What happened over the summer that had changed this child?

Here’s what I discovered about Daniel’s ADHD behavior: Daniel

• Was starting first grade
• Was starting first grade in a new school
• Was starting first grade in a new school in a new town
• Had never had a school problem before
• Had a stressful summer filled with his parent’s money problems, having to live with a grandmother until a new house was ready, and then had to deal with moving the twenty miles to our town
• Had not attended school orientation like the other kids, because no one could take him.

I suspected Daniel was suffering school transition disorder with anger, frustration and fear as a result of being thrown into a new and poorly controlled setting and environment.

What could have been done to prevent or at least lessen the likelihood of Daniel’s behavior?

The best ways to change or improve an ADHD child’s behavior

• Try to anticipate things that will disrupt your child’s life-whether large or small
• Introduce changes slowly
• Avoid springing things on your child abruptly
• Target one behavior at a time
• Set definite and clearly understood goals (end points)
• Avoid setting unrealistic goals and time schedules
• Go slowly
• Avoid being judgmental or accusing
• Reward each change toward good behavior-no matter how small
• Set up ways to maintain the behavior once the goal is met
• Allow your ADHD child maximum input into everything done-if he or she doesn’t buy into the game plan-guess what? It will not work.

While it is often difficult for a parent to behavior train an ADHD child without professional help, it’s not impossible. In my next article, we’ll discuss simple things you can do to start behavior training at home while waiting on that all important doctor’s visit to re-evaluate your child’s behavior problem.

Twice yearly re-evaluation of your child’s behavior disorder is the best way to make sure he or she is truly suffering from ADHD and not one of the more than 100 things that can look just like ADHD causing misdiagnosis of attention deficit hyperactivity disorder.

Frank Barnhill, MD

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Diagnosing Sleep Apnea in Young Children Suspected of ADHD

More and more children ages 3 to 17 in the United States, as well as other countries, are being diagnosed with ADHD each year. US Statistics show a huge increase in kids under age 7 years being diagnosed and treated for attention deficit hyperactivity disorder particularly in the past three years.

Just in the U.S. alone, the number of kids ages 3 to 17 diagnosed with ADHD has skyrocketed to in excess of 10,000,000 ( Yes…that’s ten million) and that number is expected to increase by 15 to 20 percent over the next year.   Likewise, during this same period, as many as 4 million or 40 percent of those children ages 3 to 17 years, will have been misdiagnosed with ADHD.

Obviously, it’s very important that we diagnose ADHD and other behavior problems carefully and accurately in order to avoid wrongfully labeling a child with ADHD when indeed he or she is not ADHD.

Currently, there are in excess of 95 medical, social, and environmental things that can cause ADHD-like behavior, confusing the diagnosis; causing misdiagnosis of ADHD. One of the most common seen in kids under age 7 years is sleep disordered breathing or sleep apnea.

When a child suffers sleep apnea, their breathing becomes shallow or periodical ceases causing inadequate amounts of oxygen to be delivered to the brain. And of course, our brains do not work well without oxygen, even when we are asleep.

During these shallow breathing episodes (hypopneas) or total cessation of breathing (apneas), partial or complete awakening will occur as the body tries to correct the disordered breathing. Near awakening or what experts call partial arousal episodes cause as much disruption in a child’s sleep pattern as total awakening or complete arousal.

It’s these awakening events that cause the basic problem that leads a child to display ADHD-like behaviors-inattentiveness, restlessness, poor concentration, irritability and mixed hyperactivity. As the old saying goes, if you don’t rest well at night, then you’re wasted the next morning. I know of many adults who discovered this truth the hard way as the stayed out all night long at parties, sporting events or tried to get the last minute of a vacation at 4 am, yet still had to be at work at 7:30 am.

Obviously, lack of sleep and poor sleep quality produce the same hang-over effects for a child. They just can’t function normally after tossing, turning and awakening all night long. These are the kids who will suffer inattentiveness and learning problems and will often fall asleep in class the next day. Once awakened, they sometimes become very hyper and impulsive leading teachers to believe they have ADHD. It’s often then, that they are misdiagnosed as ADHD.

The earlier we suspect, detect and treat breathing- sleep disorders, the more likely we can prevent a child from developing the symptoms of ADHD in the first place and of course, the more likely we avoid the misdiagnosis of ADHD.

With that goal clearly in mind, let’s discuss the things you might observe in your child that would lead you to suspect his or her behavior was being caused by sleep apnea or disordered breathing sleep.

Many young kids with sleep apnea will:

• Appear to mouth breathe much of the time. This might be due to allergies-stuffy nose, enlarged tonsils or adenoids or may be caused by a growth in their nose or neck.
• Have poor appetite
• Toss and turn all night long, kicking covers off the bed or rolling out of bed
• Snore softly or loudly at night or when lying down to rest during the day
• Have sighing respirations when asleep
• Suffer nightmares or sleep-talking or sleep walking
• Wet the bed (enuresis)
• Are difficult to awaken or get out of bed
• Show early morning sleepiness and irritability that often gets better as the day goes on
• Complain of headache and being tired even though they “slept all night long” and might fall asleep in morning classes
• Suffer frequent leg cramps or as some call them…”growing pains”.

By now, I’m sure you’ve noticed all of these signs and symptoms of sleep disordered breathing share some common threads: they either interfere with the amount of sleep or interfere with the quality of sleep or affect the way a child feels the next day.

All sleep problems can cause poor concentration, difficulty with executive thought-decision processing, forgetfulness, inattentiveness, poor memory, an increase in irritability and hyper-ness and test taking abilities. These children often perform poorly on tests simply because they can’t focus on the task at hand.

As you can see, it’s terribly important to detect and treat a child’s sleep problems in hopes that doing so will prevent academic failure, poor self-image leading to depression and anxiety, and failure to grow into a mature adult capable of independent living.

Remember… the actual diagnosis of a sleep-breathing disorder requires testing by sleep study or polysomnography. However, knowing what you now know…you as a vigilant parent or teacher should be able to suspect the disorder simply by watching their children for the signs and symptoms of breathing disorder sleep.

Frank Barnhill, MD

Here’s a really good article on the topic by Jay D. Tarnow, MD.

ADHD and Sleep Disorders

www.adda-sr.org/reading/articles/tarnowadhdandsleepdisorders.htm

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Sleep Apnea Treatment may Prevent ADHD Behavior

Most ADHD experts agree obstructive sleep apnea can cause the core symptoms of attention deficit hyperactivity in children; inattentiveness, impulsivity and hyperactivity. It stands to reason the earlier we suspect, detect and treat obstructive sleep disorders, the more likely we can prevent the symptoms of ADHD in the first place and avoid the misdiagnosis of ADHD.

Approximately 2.5 to 4 million children ages 3 to 17 years are misdiagnosed with ADHD in the U.S. each year. Of these, several hundred thousand will suffer the terrible stigma and discrimination of being labeled as ADHD and the side effects of unneeded medications-sometimes for years-all because their sleep-time breathing disorder went undetected and untreated.

Much research is now being reported about the association of disorder breathing such as obstructive sleep apnea (OSA), and cognitive-learning problems and ADHD-like behavior disorders in children as young as age 3 years. A recent study presented at the Annual Meeting of the Associated Professional Sleep Societies showed nerve based abnormalities that affected cognition in brains of children with OSA were reversible with treatment of the OSA.

Studies had already shown a clear association between deficits in attention, executive brain function and cognition-learning; as well as problems with memory. In this study at the Children’s Hospital Colorado Sleep Center, children with OSA underwent neuropsychological testing and in some cases, magnetic resonance spectroscopy to detect neuronal abnormalities.

After appropriate treatment for their OSA, these children were restudied and found to have normal brain metabolites in both frontal lobes resulting in an improvement in attention span and verbal memory.

Most children with disordered sleep breathing problems such as central sleep apnea (CSA), obstructive sleep apnea (OSA) and upper airway resistance syndrome (UARS) go undiagnosed until age 10 to 12 years because few doctors and parents think or even imagine a child could have problems breathing at night unless they have asthma or are sick.

Many of these kids will suffer inattentiveness and learning problems as a result of not sleeping well and will often fall asleep in class the next day. When they awaken or are awakened, they sometimes become very hyper and impulsive leading teachers to believe they have ADHD. Unfortunately it seems most parents and teachers think any learning or attention span problem automatically means a diagnosis of attention deficit hyperactivity disorder.

While the actual diagnosis of a sleep-breathing disorder requires testing by sleep study, a parent or teacher should be able to suspect and request work-up for the disorder by watching their children for:

• Unexplained sudden behavior changes
• New onset of a learning disability that did not previously exist
• Frequent upper airway infections
• Falling asleep when least expected (while others are excited and wide-awake)
• New onset or worsened snoring
• Chronic mouth breathing
• Change in sleep pattern-new nightmares, restlessness, kicking covers off, rolling off into floor.

There are many more subtle signs and symptoms of disordered sleep breathing that occur in younger children (under age 5) that would help in making an accurate diagnosis. Many of these require close observation with a high level of suspicion and we’ll discuss them in our next article.

Frank Barnhill, MD

Here are a few links for interesting articles that deal with obstructive sleep apnea and ADHD or cognition. You might want to take a look and see if your child falls into one of these groups.

WELL; In Blur of A.D.H.D., Sleep Troubles May Be a Culprit

http://query.nytimes.com/gst/fullpage.html?res=9D01E5DA1430F934A25757C0A9649D8B63

Obstructive sleep apnea and ADHD in kids

http://www.psychologytoday.com/blog/sleeping-angels/200903/obstructive-sleep-apnea-and-adhd-in-kids

ADHD & Sleep Apnea: The Controversial Connection

http://doctorstevenpark.com/adhd-sleep-apnea-the-controversial-connection

References

Mistaken For ADHD-The book. How you can prevent mislabeling your child as a failure in life. March 2010 Chapter 8, Sleep Disorders. pp.118-130.

MaHoney, Diana. Family Practice News. Treating Child’s Apnea Boosts Brain Function. July 2012. Vol 42;12.pp25.

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