Parenting Huckleberry Finn

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Journal of Moral Education

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Parenting Huckleberry Finn

Russell Hanford; John R. Snarey

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RUSSELL HANFORD & JOHN R. SNAREY

Dr. Larry Silver’s Advice to Parents on Attention Decit Hyperactivity Disorder

LARRYB. SILVER, 1999

New York, Times Books, Random House

316 pp., $15.00 paperback, ISBN 0 8129 3052 5

ADHD in the Young Child: driven to redirection

CATHYREIMERS & BRUCEBRUNGER, 1999

Plantation, Florida, Specialty Press

A Dad’s Nuts and Bolts Guide to Understanding Attention Decit Disorder

MARKJACOB, 1999

Seaford, VA, People with Attentional and Developmental Disabilities Association (PADDA)

There is a bit of Huckleberry Finn in all of us and, of course, Mark Twain’s Huck was a truly wonderful character. But when we look at Huck’s behaviour from the perspective of Widow Douglass, who took Huck for a son, we quickly realise that his inability to concentrate in the classroom, bouncing-off-walls restlessness and auto-matic opposition to adult authorities made Huck’s life difcult at both home and school. Huck’s behaviour reects hallmark features of attention-decit hyperactivity disorder (ADHD): inattention, hyperactivity and impulsivity. We all exhibit these traits to a greater or lesser degree but ADHD, when properly diagnosed, denotes cases in which these characteristics are so chronic, severe and pervasive that they become debilitating. Although Huck was a boy of his times, his “uncivilised” behaviour stood out even then.

ADHD is diagnosed according to very specic criteria outlined by the American Psychiatric Association (Barkley, 1998). Nevertheless, the perception remains among many that the disorder is overdiagnosed and, perhaps more troubling, that psychostimulant medications such as Ritalin are overprescribed, particularly in school-aged children, in an attempt to manage the problematic symptoms (Diller, 1998; Leo, 2000). The Ritalin debate, in particular, has become a moral debate. Do ADHD children have an attention decit or a moral decit? Is their biology or their environment to blame? Might a dysfunctional family or an overcrowded classroom be the more likely cause of their symptoms? Perhaps some parents are overly eager

ISSN 0305-7240 print; ISSN 1465-3877 online/01/030293-05

Ó_{2001 Journal of Moral Education Ltd}

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294 R. Hanford & J. R. Snarey

to have their child diagnosed with ADHD as an excuse for their child’s embarrassing behaviour. Others, it is feared, might be tempted to try to “buy” a diagnosis so their child will qualify for special education services (e.g. psychological services, speech/ language therapy) or accommodations (e.g. extended time on tests). Managed care organisations and the pharmaceutical companies making Ritalin and other stimulant medications do not escape indictment either. For insurance companies, it may be more economical to medicate a child than pay for a behavioural intervention. Although medication may be less expensive than therapy, the manufacturers of the medications are assumed to be making more than a fair prot, creating an unhealthy incentive to diagnose and medicate more children.

Given the complexity of the situation, what is the parent of a child suspected of having ADHD to do? Many publications are available to help frustrated and worried parents navigate the rough waters of ADHD evaluation and treatment, ranging from professional booklets suitable to pass on to a child’s teacher (Nadeau et al., 1993) to personal stories by parents who learned how to help their child cope with ADHD (Kilcarr & Quinn, 1997) to monthly magazines (e.g. Attention!) for families and adults with ADHD. Three new books deserve particular recognition for cutting though the politics and offering sound, helpful advice: Dr. Larry Silver’s Advice to

Parents on Attention Decit Hyperactivity Disorder; ADHD in the Young Child: driven

to redirectio nby Cathy Reimers and Bruce Brunger; andA Dad’s Nuts and Bolts Guide

to Understanding Attention Decit Disorderby Mark Jacob. All three books are written

in a parent-friendly style.

The most comprehensive of the books, Dr. Larry Silver’s Advice to Parents on Attention Decit Hyperactivity Disorder, begins with a message especially relevant to parents concerned with their child’s moral formation: “Many children get up each school morning and promise their parents that they will try to be good in class that day. They do try. But because these children may be hyperactive, distractible, and/or impulsive, their behaviors disrupt class activities, annoy the teacher, and push their classmates away. Such children cannot help their behaviors. Yet, the message they hear is always the same: ‘Why can’t you be good?’ ” (p. xiii). Dr Silver, a former deputy director of the National Institute of Mental Health, believes that only the correct diagnosis and treatment can erase this painful and unfair message. Toward this aim, he organises his professional advice across a broad range of six topics: dening and understanding ADHD (Chapter 1–2), exploring the causes and diag-nosis of ADHD (Chapter 3–5), reviewing the associated neurological disorders (Chapter 6–7) and social–emotional disorders (Chapter 8–10), and treatment op-tions and school services (Chapter 11–17), before addressing adulthood ADHD and legal issues (Chapter 18–19).

The chapters on the causes and diagnosis of ADHD highlight how complicated it is. Silver strongly recommends a conservative approach. He argues that ADHD is

the leastlikely cause of symptoms such as inattention, hyperactivity and impulsivity.

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the parents—and child, if old enough. (Many parents recognise that their children have problems they struggled with during their own childhood, and most experts agree that hereditary factors account for a large percentage of the variance in ADHD symptoms in children). As the assessment continues, clinicians rely primarily on reports by multiple classroom teachers and on neuropsychological measures of attention, impulsivity and related cognitive functioning completed by the child. Such extensive care is taken because it is necessary to rule out other possible causes of the symptoms and to determine the extent to which other disorders co-exist (e.g. anxiety, depressive, conduct and oppositional deant disorders). The clinician must gather a careful history to avoid what can appear to be a chicken/egg dilemma. Does ADHD create symptoms of impulsivity, hyperactivity and/or inattention, which can then lead to social, emotional and family problems and then, ultimately, to co-occurring anxiety and/or depression? Or is the real source of the ADHD-like symptoms anxiety, depression or a learning disorder? When ADHD is the primary diagnosis, anxiety, depression or other social and family problems may also be present (and most likely are), but they are a consequence of the disorder, not the cause.

Dr Silver includes a particularly insightful chapter on the impact of ADHD on the family. Because a child with ADHD requires a great deal of time and attention, Dr Silver warns parents to be prepared for the ADHD child’s siblings to express feelings of anger, worry, jealousy, embarrassment, guilt and even revenge. Expecting these emotions to arise will help parents keep them in perspective when they do. He advises parents to avoid double standards to the greatest extent possible, to keep lines of communication open and to answer questions from family members as honestly as possible. ADHD is an explanation for a child’s behaviours; it is not an excuse. Children with ADHD must still be held accountable for their inappropriate behaviours.

Another particular strength of Dr Silver’s book is the detailed, but accessible, section on school procedures and services relevant to children with ADHD. Because of the controversial nature of ADHD, it is not included as one of the thirteen categories of disabilities specied in the Individuals with Disabilities Education Act (IDEA). Thus, securing special services such as psychological services, transporta-tion or speech/language therapy may prove difcult. He wisely refers parents of children with ADHD to another set of regulations, Section 504 of the Rehabilitation Act of 1973, which grants accommodations such as extended time on tests.

Cathy Reimers’ and Bruce Brunger’s book,ADHD in the Young Child: driven to

redirection, is unique in its focus on 2–5-year-olds. The authors suggest that early

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of medicating a 3-year-old with extreme symptoms, which are resulting in impaired functioning. Among many helpful appendices is a chart of medications used com-monly to treat ADHD with duration of effect, common side effects, benets and comments provided for each (p. 132).

Most of ADHD in the Young Child addresses behavioural interventions. The primary technique advocated is redirection: guiding a child engaged in problematic behaviour toward alternative appropriate behaviors. Problem behaviours are replaced rather than simply stopped, since achieving the latter intervention can be difcult, particularly with a child diagnosed with ADHD. Other recommendations include the following: establishing clear rules, rewards and consequences; offering verbal praise liberally when appropriate behaviour is observed; and using pre-established cues to identify problem behaviours before they escalate. These management tips are not new or unique; however, their presentation is. Brunger is an artist and the father of a son who has ADHD. Long before he thought of co-authoring a book, he drew a cartoon book with his son as the central character. Each cartoon panel showed a before-and-after scene with his son misbehaving on one side of a page and acting appropriately on the other side. The authors formalised and expanded the cartoon book to include situations commonly confronted at home (bedtime, teasing siblings), school (ghting, not staying on task) and outside home and school (car, grocery store). Helpful suggested remedies for each situation are provided.

A Dad’s Nuts and Bolts Guide to Understanding Attention Decit Disorderby Mark

Jacob is a personal account of one father’s struggle to deal with his son who was diagnosed with ADHD at age 7. The presentation is informal and humorous, although when reading about some of the situations described in the book one can sense the frustration, anger and hopelessness of the author. He chronicles the period from initial assessment through later treatment. He discusses his mixed emotions when a child psychologist gave his son the diagnosis: the sadness that his child was, in some sense, imperfect and the validation that his child truly was a challenge to manage for reasons beyond poor parenting skills. Jacob makes some sage observations on the basis of his son’s behaviour. He suggests that distractibility, not inattentive-ness, is the real problem for kids with ADHD. In fact, he suggests that “attention decit disorder” is a misnomer. He writes that the syndrome would better be named “attention surplus disorder” (p. 23). Jacob quotes Richard Lavoie (1994) who said, “The inattentive child pays attention to nothing … the distractible child pays attention to everything!” Jacob also highlights another very important lesson— ADHD children are not morally decient, they have an attention decit (p. 11). Jacob’s book is short and unsophisticated, yet it achieves its aim of helping parents to understand that attention decit disorder is real. Many parents unfamiliar with ADHD will benet from the story it tells and the information it provides.

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concern. Would I prescribe Ritalin for them, too?” Gladwell responds: “But this is just the point. Huck Finn and Tom Sawyer lived in an age where difcult children simply dropped out of school, or worked on farms, or drifted into poverty and violence.” Gladwell believes that it is “a strange inversion of moral responsibility” to “seek to make those parents and physicians trying to help children with ADHD feel guilty for doing so. The rise of ADHD is a consequence of what might otherwise be considered a good thing: that the world we live in increasingly values intellectual consideration and rationality—increasingly demands that we stop and focus. Modernity didn’t create ADHD. It revealed it” (p. 84). Parenting in a complex world is complicated. Parents are advised to seek a thorough evaluation by a psychologist or psychiatrist who takes a complete clinical history and consults with third-party, objective adults who know their child (e.g. teachers). If the child receives the ADHD diagnosis from a trusted professional, the parents should implement at home and school the well-documented behavioural interventions recommended in these books and others. Finally, the parents should consider a blind placebo-controlled medication trial. The physician can arrange for the child to receive the stimulant medication one week and the placebo the next without parents and teachers knowing which week is which. Behavioural rating scales completed each week by parents and teachers can lend objective support to the effectiveness of the medication.

There is much left to learn about ADHD, but its diagnosis and treatment are not the breeding ground of moral, political and economic corruption some profess. There are undoubtedly children on stimulants who need not be, just as there are children left untreated who should be. Well-informed and caring parents can help move our society toward a more perfect match between those children needing special services and those receiving them.

Correspondence: Dr Russell Hanford, Child Psychiatry, Children’s Hospital and

Regional Medical Center, 4800 Sand Point Way NE, PO Box 5371/CH-87, Seattle, WA 98105–0371, USA; e-mail: Russell@ss.emory.edu

Dr John R. Snarey, Professor of Human Development and Ethics, Emory Univer-sity, Pitts Library Suite 3, Atlanta, GA 30345, USA.

REFERENCES

BARKLEY, R.A. (1998)Attention-decit Hyperactivity Disorder: a handbook for diagnosis and treatment, 2nd edn (New York, Guilford Press).

DILLER, L.H. (1998)Running on Ritalin(New York, Bantam).

GLADWELL, M. (1999) Running from Ritalin,The New Yorker, pp. 80–84.

KILCARR, P. & QUINN, P. (1997) Voices from Fatherhood: fathers, sons, and ADHD (Bristol, PA, Brunner/Mazel Inc.).

LAVOIE, R. (1994)Last One Picked, First One Picked On: learning disabilities and social skills[video and viewing guide] (Washington, DC, PBS WETA Videos).

LEO, J. (2000) Attention decit disorder: good science or good marketing?Skeptic, 8, pp. 63–69. NADEAU, K., DIXON, E. & BIGGS, S. (1993)School Strategies for ADD Teens: guidelines for schools, parents,