On Behavior Therapy for ADHD

Patricia Quinn, MD, director of the National Center for Gender Issues and ADHD, was online Tuesday, May 2, at 11 a.m. ET to field questions and comments about behavior therapy as a means of treatment for attention-deficit hyperactivity disorder.

Quinn is a developmental pediatrician in the Washington, D.C. area. A graduate of the Georgetown University Medical School, she specializes in child development and psychopharmacology. Quinn has worked for more than 30 years in the areas of AD/HD and learning disabilities. She gives workshops nationwide and has published widely in these fields. Quinn is the author of several books on AD/HD and the director of the National Center for Gender Issues and ADHD.

From The Post:

Going the Behavior Route (May 2)

The transcript follows.

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Patricia Quinn, MD: Good morning! I'm pleased to be invited to respond to your questions in this forum. My hope is that this will be an informative discussion for you all.

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Los Angeles, Calif.: Dr. Quinn, While psychopharmogolical options have been the favored method of treatment for ADD/ADHD over the past decade, how does psychotherapy compare to drugs as far as efficacy and efficiency? Thank you

Patricia Quinn, MD: Psychotherapy has not been found to be an effective treatment for ADHD. While it does address some of the related issues such as poor self-esteem, depression and relationship issues, it does not get to the core symptoms of inattention and impulsivity that the medications address. Recently, therapists have been using cognitive-behavioral therapy for those with ADHD and this seems to be working.

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Potomac, Md.: If you believe your child could have ADHD what is the best course of action to take and who is the best person to go to for testing?

Patricia Quinn, MD: I would start by discussing your child's behavior with his or her classroom teacher and then contacting your pediatrician. Even if the teacher doesn't see any problems in class, I would still seek and evaluation if you are concerned about behaviors at home as that is usually the first place ADD reveals itself.

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Washington D.C.: This session is good timing for me! I have been taking Methylin for about 18 months for my ADD. This is the first prolonged treatment I've used. In the last 6 months, I've had a recurrence of depression and anxiety that I've experienced on and off for years. My therapist is wondering if the Methylin is exacerbating my depression and anxiety? I have been experiencing obsessive negative thoughts and a severe general sadness. I guess there may be an anti-depressant that would address the depression and the ADD, but I am wary of other meds and like the Methylin because it it out of my system in 8 hours. Is the Methylin causing or intensifying my depression? Should I stop or switch to something else?

Thank you!

Patricia Quinn, MD: Stimulants may make anxiety and depression worse. However, we also see these other disorders frequently coexisting with ADHD. It is important that you discuss this with your physician as these other disorders may need to be treated in addition to your ADHD.

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Washington, D.C.: I'm seeing a psychiatrist for anxiety disorder. My doctor told me I should get fully tested for ADHD, but my mind wanders and I do something else instead. That's a joke. My real question is, is behavioral therapy better for anxiety patients than drugs which can make you rather wired.

Patricia Quinn, MD: When a large study of medication effectiveness looked at this issue it found that patients with ADHD and anxiety were the most responsive to behavioral interventions. It is important to get both your anxiety and ADHD treated. Stimulants to treat your ADHD may increase your anxiety unless it is also being treated. Discuss treated both your anxiety and ADHD with your physician.

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Rockville, Md.: Hi, I have been diagnosed with mild adult ADD. Doesn't seem bad enough to be medicated and while I know exercise can help, are there other things I can do to stay focused without meds?

Thanks!

Patricia Quinn, MD: A coach may be just the answer. ADD coaching has now been employed to help those with ADHD function better for some years now. It helps you set goals and work on achieving them. You may work with a coach daily or as needed to stay on task and get things done. Also keep up the exercise!

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Rockville, Md.: I have 4 children. Their ages 10, 7, 5 and 18 months. I've noticed that my 5 year old is very active. He is so active that he is always hurting himself. He doesn't listen to me sometimes. Going to the mall is terrible. He'll start running around the store, doing cart-wheels. He ends up hurting himself most of the time. I don't know what to do. His teacher mentioned that I should get him tested for ADHD. I don't know where to begin. I went to a place called WATS in Silver Spring. I was not satisfied. Could you recommend places where I could have him tested?

Patricia Quinn, MD: I would suggest that you discuss your child's behavior with his pediatrician or family practitioner. Children with ADHD and hyperactivity are very accident prone and can have lots of problems both in school and relating to others. It is in your child's best interest to get him evaluated as soon as possible before he has a serious injury.

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Richmond, Va.: Thank you for your work and taking our questions.

I am very concerned about the over-diagnosis of ADD/ADHD. In 5th grade my daughter's teachers/school counselor told me she had ADD and it was possible she would have to repeat the grade.(Or "probably" had it and I should get her tested/treated.) I frankly didn't buy it and first worked it as a study skills and confidence issue. The next year she was a honor roll student. Thank God I didn't listen to the school! And thank God I didn't get her pumped full of meds she didn't need. My question: How significant is false diagnosis of ADD? Also, who is the most qualified person (professional) to diagnose ADD.

Patricia Quinn, MD: Your questions are good one and aren't you fortunate that your daughter didn't have ADHD. In most instances ADHD is overlooked in girls and that your daughter's teacher thought about ADHD is very lucky. If your daughter did have ADHD her problems would have continued and she would have had to deal with it for many years to come as this is a lifelong disorder. Pediatricians, child psychiatrists, and other mental health professional are the most qualified to diagnose ADHD. However, many of them are not familiar with how ADHD presents in females.

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Mendham, N.J.: Our child was diagnosed late (age 17) with ADHD and is not taking meds. What can our son do to help himself when he starts college far away on his own? He frequently forgets assignments in high school and it has affected his grades (interestingly, he gets A's in courses such as science courses, where he writes up the lab in class and therefore has no homework). Thank you.

Patricia Quinn, MD: If your son has a formal diagnosis, he can contact the learning disabilities specialist or special student services office on campus. They should be able to help him develop a program on campus. You also might look for an ADD coach in the area to help him stay on task and succeed.

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Colorado Springs, Colo.: Where do I find a reputable coach for AD/HD?

Patricia Quinn, MD: There are several in the area, but coaching can be done online and by phone. Online look on www.americoach.org, www.addresources.org or www.addconsults.com list coaches.

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Chantilly, Va.: Dr. Quinn,

I have an 8-year-old daughter in the 3rd grade in Fairfax County who has recently been diagnosed with ADHD by our pediatrician and school. She is taking both Adderall and Stratera with with minimal to satisfactory results (it varies depending on the week). While her academics are great (mostly "A" equivalents) her social behavior and impulsiveness need much improvement. She's defiant and although she has a very sweet side the teachers at school tell me she is callous toward the other students and adults. I'm starting to feel a little helpless. Are we taking the right medications? Besides medication what should I be doing to address these issues? If there are recommendations you can make for resources in my area that would be much appreciated. Thanks much.

Patricia Quinn, MD: Your daughter's medications may still need to be adjusted (sometimes methylphenidate works better), but she also needs to work on her social skills which are often problems for children with ADHD. Social skills training groups are held in Virginia at Stepping Stones run by Cathi Cohen. LCSW. Jewish Social Services in Rockville also has social skills groups for children.

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Central New York: Is ADHD an organic condition (i.e. caused by some chemical or neurobiological deficit) or merely a behavioral problem? If it is the former, how can it ever be fully treated without medication to make up for the deficits?

Patricia Quinn, MD: It is a neurobiochemical condition (resulting from problems with the dopamine system in the brain)and needs both medication and behavior therapy. In addition, many people need help with organizational skills, social skills and therapy for coexisting conditions.

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Anonymous: Beginning about 2 years ago, my daughter's therapist has voiced concerns that my daughter, who is now 14, has a mild or moderate form of ADD. However, I have been unable to persuade my ex-husband to permit my daughter undergo educational testing, even though my daughter has gradually come around to the idea (he is worried that it will stigmatize her). The experts in educational testing that I have spoken with say that need both parents' consent in a situation of joint custody. Would you recommend that I speak with my daughter's pediatrician about medication even if she has not gone through a formal diagnosis?

Patricia Quinn, MD: You certainly could start there and maybe he or she could evaluate your daughter and discuss the findings with your husband. In any case, it is important to pursue a diagnosis at all coats as untreated ADHD exposes teens to many at risk behaviors including substance abuse and increased auto accidents.

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Mclean, Va.: Hello Dr. Quinn, You mentioned previously that AD/HD is a life-long condition. Our 4 year old was recently diagnosed with AD/HD, and we have been using a modified diet and supplements to address some of the symptoms as opposed to medicating a 4yr old. We also have taken advantage of occupational therapy resources to help out with the "life skills" that are a source of frustration and exacerbate inattention and lack of focus. In your experience, have you seen AD/HD symptoms diminish or go away as the child grows up? That is, when our son reaches high school, could he have "grown out" of the AD/HD condition? Thanks very much.

Patricia Quinn, MD: The hyperactive components of ADHD seem to diminish over time particularly in males. However, about 70% of adolescents diagnosed in the earlier years continue to have symptoms that affect their functioning and about 50% continue to have problems as adults.

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Silver Spring, Md.: So, this may be a stupid question, but I have a son who was diagnosed with probable ADHD. However, he does have a moderate social imbalance with anxiety. So, I guess my question is which comes first, the chicken or the egg? Does the anxiety/social awkwardness lead to ADHD or vice versa? Does it matter?

Patricia Quinn, MD: ADHD is a neurobiologic condition. However, many with ADHD also have anxiety as a separate condition or as a result of the consequences of not having their ADHD diagnosed.

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Silver Spring, Md.: Is medication the only therapy for ADHD? My brother refuses medication but at 52 he is still unable to succeed in the workplace (or any other place for that matter).

Patricia Quinn, MD: Medication is the only therapy that addresses the biochemical imbalance and the basic symptoms of inattentiveness, distractibility and/or hyperactivity.

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Brussels, Belgium: Dear Dr. Quinn, We are Americans living in Brussels. My 18-year-old son has been diagnosed with ADHD. He also has auditory processing issues. (He goes to an American school, so language is not a problem.) He is a bright and popular kid who is getting ready to go off to college. He is not working up to his potential, but he is learning -- in fact, he retains an extraordinary amount of information in certain subjects. He just doesn't want to study much. We have chosen not to put him on medication even though it was recommended. I hesitate because ADHD meds seem to me to be one step away from speed or cocaine in what they do to the brain/body. My son is a football player and BIG: 6'3", 250 pounds. I feel stimulants would be a strain on his heart. He is able to concentrate for long periods of time, but only on what interests him. Aren't we medicating kids basically to make them work harder/act more as we want them to act? Yes, he's forgetful and disorganized and this does cause problems for him and for those who love him. But many teenaged boys are this way as well who have not been diagnosed with ADHD. So I'm torn: am I doing my kid a disservice by not trying meds, or am I doing him a service by not putting him on something for which the verdict (on long-term health and brain effects) is still out? I have also heard about kids who have ill effects even from just trying these meds, even if they didn't stay on them. Can this happen? Obviously we are also worried about how our son will handle the demands of college. I appreciate hearing your opinion. Many thanks for your time. --Francesca

Patricia Quinn, MD: If your son has no structural heart defects, stimulants only increase pulse and blood pressure minimally so that should not be a cause for concern. Stimulants have been used very safely and effectively for several decades (dexedrine was first used in 1937 and ritalin in 1956). Stimulants do not act like cocaine in the brain and have not been found to be gateway drugs to other drug use. To the contrary, adolescents with untreated ADHD have a greater risk of substance abuse.

How does your son feel about the effects ADHD has had in his life? He is the one with the disorder and I feel he should be heard at this age.

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Alexandria, Va.: Can you tell me what, exactly, the medications used to treat ADHD, do in the brain to control the neurobiologic imbalance that causes this condition?

Patricia Quinn, MD: In certain individuals with excess dopamine transporter protein (DAT receptors), stimulants block the reuptake of dopamine from the synapse back into the presynaptic neuron by these transporters, thus resulting in a relative increase of dopamine in the synapse.

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Washington, D.C.: I was diagnosed as ADD as a child, and went through tutors and medications. Now as I transition to the adult world I see my ADD effecting my life and work differently. What types of exercises do you go through in behavioral therapy? Which skill sets does therapy target? Thanks.

Patricia Quinn, MD: Behavioral therapy works best for children. Contracts and coaching works best for adults. A coach is a person that works with you on setting up and achieving both long- and short- term goals. Through a process of seeing what techniques work best for you, they help you become accountable for your actions.

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Vienna, Va.: I am very concerned about giving my teenager ADHD medication since the FDA has strengthened the warning labels on several ADHD drugs, yet doctors seem to be at ease in prescribing them. How safe are these drugs (adderall, stratera, concerta...)?

Patricia Quinn, MD: The medications used for ADHD are safe and effective but are contraindicated in certain conditions. These include: severe anxiety or depression, glacoma, know structural cadiac defects and psychotic conditions. The recent FDA warnings are there to make sure that we don't take medicating anyone lightly and practice due diligence in making sure that we inquire and are aware of a patient's history and other medical conditions.

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Springfield, Va.: Can you name some examples of behavioral therapy in children?

Patricia Quinn, MD: Behavioral therapies basically include two types - rewarding positive behaviors (token reinforcement, charts, etc.) and eliminating negative behaviors by time out, withholding of privileges or punishment. Most are in favor of the former. We all like to be rewarded and while negative reinforcement works it may not teach the behavior that we would like to see in place of the inappropriate one.

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Anonymous: I'm late joining this chat, but today's article opens with the statement that Ritalin is associated with vivid hallucinations often involving bugs. Where do I find more on this? My 19 year old son with ADHD has a severe fear of bees to the point he won't go outside if their present. He has been on Ritalin since first grade. Any connection?LB in Hughesville

Patricia Quinn, MD: Fear of bees is not a hallucination (seeing something that isn't there). Instead, your son exhibits symptoms of a phobia. This can be discussed with a mental health professional.

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Alexandria, Va.: I have a 17-year-old HS Junior who has been diagnosed with ADD, but who no longer takes medicine because it "makes him feel funny". He has a short attention span, is disorganized and forgets to do homework and/or turn it in. We hired a tutor, a special ed teacher, who came highly recommended. Although she has managed to help him somewhat, she has stated that unless he decides for himself that it's important to write down assignments or get organized, he won't do it.

My questions - (1)Is it ever "too late" to do behavioral therapy for a teenager? How can it be structured to provide respect for his age? (Rewarding with chips may seem juvenile to him.)

(2) Are there natural remedies such as a special diet or herbal therapy that may help somewhat? Are there homeopathic doctors that specialize in this?

Patricia Quinn, MD: As I stated in another reply, contracts work better with teens. It is important to realize, however, that if your son continues to have difficulty with distractibility and attention span that he is at risk while driving (for both accidents and speeding tickets). I would suggest that he discuss his symptoms and reasons for not taking medication with a professional who has expertise in the area of ADD.

Regarding your second question, there are those who specialize in alternative treatments of ADHD but few to date have been found to be successful.

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Chicago, Ill.: Can you recommend books that describe appropriate behavior therapies? Specifically, books that can help parents of young children.

Patricia Quinn, MD: 1-2-3 Magic by Dr Thomas Phalen is an excellent book on behavior management techniques for use in children 2-12 years.

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Bethesda, Md.: In response to one of your earlier answers, how does ADHD present itself in young girls?

Thank you.

Patricia Quinn, MD: Girls with ADHD may not have the disruptive behaviors exhibited in young males. They tend to be less hyperactive and more inattentive and disorganized.

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Temple Hills, Md.: Is ADDHD genetic, does family history play a role, and is it possible to out-grow.

Patricia Quinn, MD: ADHD is a highly genetically inherited disorder. It is a lifelong disorder and one usually does not outgrow the symptoms although one can learn to manage them with good choices and life decisions.

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Bowie, Md.: You said "Keep up the exercise" to an adult reader. Could you comment on the influence of physical activity on ADHD behavior in children? In my admittedly limited experience, ADHD seems much less prevalent in children whose lives, including their school setup, include more opportunities for physical activity.

This might also help explain why ADHD doesn't seem to have been a noticeable problem in previous generations, when people were more physically active.

Patricia Quinn, MD: All individuals with ADHD (regardless of age) do better when they can engage in daily physical activity. One recent study also showed that being in touch with nature (green spaces) also helped.

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Alexandria, Va.: What is the impact of puberty on children with ADHD? Our daughter was diagnosed in 2nd grade, has been on medication since then and was doing fine. Since she became a teen, however, it sometimes seems as though we have returned to the old days. Is there any way to tell how much of her behavior is simply normal teen behavior?

Patricia Quinn, MD: Symptoms of ADHD seem to worsen in puberty especially for females. Hormonal influences are also noted. You can read more about this on our Web sites www.addvance.com and www.ncgiadd.org and in our book, Understanding Girls with ADHD.

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Kansas City, Mo.: My son was diagnosed at 4 with ADHD. He is currently using Ritalin. I see the benefits of him taking the medicine. My concerns is with all of the press about the future ramifications of the drugs on him. I have seen differences in his anxiety level. Having a bad dream affects him for weeks. How do we manage today while keeping an eye to his future?

Patricia Quinn, MD: Your son's anxiety and bad dreams are probably developmental and have nothing to do with his medications or ADHD. Your concern, support, and love will certainly see him through.

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Washington, D.C.: I do not have ADHD but take the same medicines that are typically prescribed for ADHD patients for narcolepsy. Should I be concerned that I might have the same kind of heart problems identified as dangerous side effects for ADHD patients? Are you familiar with the use of these drugs (Ritalin, Concerta, etc) for narcolepsy?

Patricia Quinn, MD: Your physician should be able to rule out any structural heart defects or other heart related conditions.

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Arlington, Va.: I have a very bright, sociable 9-year-old son who loves to read and is very inquisitive. He is also very active, easily distracted, (at times) and bothered by loud noises. What is the difference between "normal boy" behavior and ADHD? Friends and I are of the opinion that local schools are far too fast to label boys ADHD and suggest the parents drug their child rather than deal with boys as boys. Thoughts?

Patricia Quinn, MD: The difference between overactivity and hyperactivity may lie in the purposefullness of the activity. In addition, in order to be labeled ADHD, one must be impaired by the symptoms.

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Washington, D.C.: Is there any new information on causes of ADHD such as environmental factors or prenatal exposures? How strong is the link to tobacco and alcohol?

Patricia Quinn, MD: In addition to genetics, ADHD can also be caused by maternal cigarette smoking during pregnancy, exposure to lead, head trauma, brain infections, malnutrition, and extreme prematurity.

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Patricia Quinn, MD: That's all the time we have today to answer your questions. I thank you for this opportunity and for your excellent questions. For more general information on ADHD and its treatments, you can go to www.chadd.org, the National organization for ADD information and the National Resource Center for ADD at www.help4adhd.org

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