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Dr. Bob is Robert Hsiung, MD,
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Posted by Donna Stolberg on September 7, 1999, at 4:53:03
I am hoping to get some suggestions. I am wondering if there is a medicine recommendation for an ADD 11 year old who responds well to Ritalin in terms of concentration with some behavioral improvement. Howvever, it seems that asking him to perform the slightest task, such as taking a bath or shower, turning off TV, etc, results in opposition and crying.Also, this child has always been pleagued with fears, lightening, insects, etc.
I would appreciate any help.
Thank you,
Donna
Posted by Yardena on September 7, 1999, at 6:22:23
In reply to Medication for ADD and Opposition, moodiness, posted by Donna Stolberg on September 7, 1999, at 4:53:03
Donna,
This is not "expert" advice, just some thoughts I had about your post. Only an in-person evaluation can truly help you assess what is going on with your son.
Anxious children are at risk for developing oppositional behavior patterns. I heard a presentation by John Walkup, MD, of Johns Hopkins, on this subject last year. He recommends a consistent cognitive/behvavioral approach which helps kids to develop routines and to build in logical/natural rewards for following routines as expected. Another thought--ask your child's doctor about "Ritalin rebound". Because ritalin has a short half life, the rebound from it (when it wears off) can produce depression, irritability, moodiness, etc.
Still more thoughts--kids with ADD are at risk for anxiety disorders because they have to struggle so hard to master their main environment, which is school (for many with ADD it affects a lot more than just school, too). Sometimes, the child with add has difficulty making predictions and thinking ahead. This can lead to feeling like he or she never knows what is coming next, which, of course, is highly anxiety producing. A parent can help his or her child learn to predict from "clues" when he/she will encounter things that were "unexpected" before. For example, as the early signs of a storm approach, they might have a relaxed conversation about the signs, asking him/her what he/she expects might happen next (lightning, thunder, rain, etc.), etc. as well as what helps to deal with the anxiety about lightning. This "game" of predicting can be played about anything to build up the skills of making predictions from clues. Also, doing research about the feared thing (insects, lighting, whatever) can help build a sense of control. This might involve going to the library and reading together, going online, watching videos, going to the museum (here in DC they have a great insect museum at the Smithsonian!)
The ability to anticipate what is going to happen next is especially important when a parent is giving a direction such as "turn off the tv". Often, it can help to work out a plan as to the time for tv. The parent and child can figure out how much warning he/she needs before telling him/her to turn it off, or they can work out a plan together about how to monitor the time independently (this can be hard--a lot of kids with ADD have distorted senses of time or no sense of time at all). Using concrete ways for self monitoring is often useful. For example, a timer or alarm clock set for just before the end of the shows might work. Many children with ADD also need a previously discussed plan about what to do when the timer rings, in concrete, small steps. According to John Walkup, rehearsing the entire plan helps the child to learn it well enough to carry out for real.
As for the bath or shower, it would help to find out if the opposition is to the shower itself or to the transition in what he was doing, etc. Giving a child some control over some aspects of the decision, but not at the moment of opposition, can be helpful to some children. The input in the decisions needs to be worked out when the child is calm and outside of the situation itself.
As for medication for moodiness and oppositionality, there are some antidepressants that are being used for some of these problems, but if I were making this decision about my child, I would try non-medical approaches first. As you can see from reading this board, medication is great but not simple--lots of complications from potential side effects, etc. And, medication alone doesn't build the skills needed to deal with a lot of what life brings. On the other hand, if my child were really depressed, I would take into account some of what I have been reading lately about research that shows that early treatment can prevent recurrent episodes.
Which brings me to the final point--get expert consultation on this. Who is prescribing his ritalin? Is it a pediatrician? A child psychiatrist? A developmental pediatrician? Is he getting any therapy or are you getting any child guidance from this doctor? You need to have someone who knows about ADD and anxiety disorders and oppositional disorders evaluate him and follow up with treatment, whether psychotherapeutic, behavioral, or pharmocological.
Good Luck.
Posted by Finch on September 8, 1999, at 13:19:33
In reply to Re: Medication for ADD and Opposition, moodiness, posted by Yardena on September 7, 1999, at 6:22:23
I'd suggest you consult his MD for med. changes. The addition of a bedtime dose of Clonidine might help. Or small morning dose of Prozac (10mg) or another SSRRI added to Ritalin might help reduce the opposition/reactivity.
Some slight changes should do the trick. There are so many alternatives available now.My best, Finch
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