Dr. Steven Ritchfield on how to help your ADHD child with school skills and social skills.

Helping Your ADHD Child with School Skills, Social Skills

One of the many challenges faced by teachers, counselors, and parents when coaching emotional and social skills to children is how to foster the use of tools at the point when they are most needed, i.e., the point of performance. Many children can learn new skills when they are presented in a neutral environment, free of environmental pressures. But when the pressure heats up in the form of teasing classmates, teachers who ignore their raised hand, and temptations to misbehave, it can be hard for these children to summon the internal language needed to bring the skills "on-line."

In addressing the classroom issues, I will focus upon how to coach "anticipation skills" so that children can prepare themselves to respond skillfully to environmental pressures and demands. This begins with an explanation by the "coach" (teacher, counselor, or parent) about the importance of anticipation. For the sake of practicality, narrative examples will illustrate a variety of ways that coaches can translate the coaching model into classroom application. (Classroom coaching is not necessarily conducted by a teacher, but only assumes that the instruction is being delivered to a large number of children.) In this first illustration, a teacher offers a framework for introducing anticipation skills:

"Imagine that you are driving to a vacation with your family. It's going to take a few hours to get there, and none of you have been there before. Your parents have directions, but they need more to get to where you all want to go. Think about it. What else makes it possible for people to drive places they have never been before, and actually arrive there without getting lost? (pause for answers)"

" Those of you who were thinking about road signs are right. Road signs help drivers because they direct us to our destinations. In order to do that, they give helpful information about how many miles it will take, how fast we should go, and just as important, what we should look out for along the way. Signs do that by telling us about upcoming twists and turns in the road, traffic lights ahead, and exits that we need to prepare for so that we can slow down and turn off where we need to."

This opening example uses metaphor to introduce the subject. Driving serves as a useful analogy because it requires practice, skill, and many relevant issues (laws, accidents, penalties, etc.) have counterparts in the interpersonal world of children (rules, conflict, consequences, etc.) Thus, classroom coaches may find it helpful to refer to the driving metaphor during coaching discussions. Next, I return to the narrative, with the teacher demonstrating how driving a car and being a kid have similarities:

"Signs allow us to anticipate what is down the road, so that when we get there we won't be too surprised. For instance, exit signs tell drivers to get ready to slow down and change lanes so that when it is time to turn it can be done safely. Anticipation means the ability to prepare ourselves for what's ahead of us, whether it be driving or anything else. Why is this important to kids?" (pause for answers)

"Just like speed limits that change depending upon where we drive, kids go from place-to-place, and must deal with different rules in different places. In school, the rules change a little depending upon whether you're at recess, lunch, in the library, free time in class, or group lesson time at your desk. In each one of these places, the rules are a little different, whether it be talking, walking around, running around, raising your hand, and so on. Kids who anticipate what the rules are in these different places don't get into trouble as much and do a better job at steering themselves."

"Sometimes the rules in different places are posted on the walls, just like road signs. But most times, the rules are not posted and kids may not use their anticipation skills to keep themselves within the rules."

Once the classroom coach has brought the discussion to this point, it's time to explain how kids can improve their ability to anticipate what skills will be needed, and how to "hold them in mind" in order to be accessed when necessary. This latter concept refers to the ability to use mental scripts, or self-talk messages, that can be matched to the specific demands of the environment. The goal is for children to retrieve the right "mental road sign" for their present place, but this requires varying degrees of coaching assistance depending upon needs of each child:

"Let's go back to driving for a minute. Even though drivers use signs to get to where they want to go, there are many rules that do not appear on signs. So how do drivers know what to do?" (pause for answers)

"If it starts to rain, there's no sign that tells them to turn on their windshield wipers. If there's a car pulled over on the side of the road, there's no sign that says slow down because somebody might need help. The rain and the car on the roadside are clues that drivers look out for. Drivers need to watch carefully for clues to anticipate what to do. And as clues appear, drivers give themselves directions about what to do. Inside their minds, drivers think about what they should do as they keep their eyes on the road."

"Most kids do the same thing. They learn how to look out for clues that help them stay within the rules. Clues help kids anticipate the rules. But if kids don't notice the clues, they can't use them to anticipate what to do. For instance, if a kid is clowning around and walks backward into the classroom, he won't see the teacher motioning for everyone to be quiet as they enter. Let's say he's laughing out loud about something he heard at recess, retelling the joke, and wham - he slams right into the teacher! Now, there's a kid in for a bumpy ride."

"But what if the kid had been looking out for clues as he walked back into the school building from recess? Most kids use walking-back-into-the-building as the clue to change behavior from clowning around to straightening out. If this boy had picked up that clue, he could use it to anticipate what to do. Maybe he could have directed himself, 'I'm back in school now. I've got to stop laughing and acting silly. I'll find a good time later to tell my friends about this joke.'"

"When kids pick up clues they are much better at figuring out what to do. Walking into school is only one clue. Who knows other school clues that tell kids to give themselves directions?" (pause for answers)

At this juncture, coaches can offer a list of clues that help reinforce observation skills.

Children are taught how clues may be auditory, visual, kinesthetic, or a combination. Auditory clues include verbal instruction, ringing of the school bell, singing of others, etc. Visual clues include facial expression, body posture, hand gestures, etc. Kinesthetic clues include walking into school, opening doors, etc. Depending upon the age of the group, others may be added to this list. Next, comes a discussion of the need for self-instruction:

"Once kids have picked up the important clues around them, it's important to know what to do. This can also be tricky for some kids who are not used to giving themselves the right kind of directions. Let's go back to our backwards walking friend for a moment: he first told himself, 'I've got to tell all my friends this incredibly funny joke, no matter what.' We all know that was the wrong direction to give himself because it didn't anticipate that he was going to crash right into the teacher and her rules.

"Giving yourself the right directions is kind of like figuring out the road signs that fit the place you are in at any given time. Sometimes the road signs are simple to figure out, such as "BE QUIET" or "SAY THANK YOU" or "RAISE YOUR HAND BEFORE YOU SPEAK." But sometimes the road signs are a lot harder to figure out and you need to pay much closer attention to the clues. For instance, "RESPECT THEIR PRIVACY" or "ACCEPT NO FOR AN ANSWER" or "I CAN'T ALWAYS EXPECT TO BE CALLED ON EVEN IF I KNOW THE RIGHT ANSWERS."

"These road signs are harder to figure out for a lot of kids. They require that kids carefully look out for clues. Some clues come from watching the people around you and thinking about what keeps things going smoothly for them. Other clues come from thinking about what happened the last time you were dealing with this kind of situation. The way things did or did not work out in the past gives kids clues about what they should direct themselves to do the next time around."

Coaches can proceed from this point with a discussion of typical self-instruction messages that children can employ for improved social and emotional functioning.

The text from Parent Coaching Cards can be used as examples and/or as a springboards for coaching sessions targeting specific skill areas. Once the coach has chosen a finite number (between 5-10) to begin with, children can be made aware of which self-instruction messages fit with which situations. Increased reinforcement will also come from teachers encouraging children to figure out in advance of transitions, which skills need to be brought to mind. Social and emotional skills can also be woven into discussions within subject areas (social studies, reading, science. etc.) that reflect the skills in question, i.e., teachers can ask children which skills were displayed by Thomas Edison, Martin Luther King, etc.

About the author: Dr. Steven Richfield is a child psychologist and father of two. He is also the creator of Parent Coaching Cards. His articles focus on helping your child with school-related skills.

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If your child with ADHD has learning difficulties, here are some inside tips about Individualized Education Plans (IEP).

IEPs (Individualized Education Plans) can be intimidating, especially if there is tension or conflict between you and the school. Here are some of the things I've learned along the way that I hope might help you.

1. I always ask for a copy of all the test results prior to the meeting date. This gives me a chance to read over what they found and, if needed, get input from my child's pediatrician or therapist. It also allows me to absorb what I've learned before I sit down and ask for services for my son.
2. Feel free to take a support person with you. Not only can they help calm you and keep you focused on the task at hand, but they make excellent witnesses if you should ever need one. A support person can be anyone-- family member, friend or even your child's counselor or therapist. Counselors and therapists come in handy when there are some issues concerning services. They can be more persuasive given their education and medical training when it comes to accessing services the school is reluctant to give.
3. You do not have to sign any papers at the IEP meeting. You are not obligated to sign any papers at the IEP meeting. You may want to take the papers home, review them with your child's therapist or doctor or even get input and feedback from a relative. You might just want to think about and absorb everything that transpired at the meeting. Don't feel pressured into signing an IEP, especially if you do not agree with it.
4. Remember... School personnel cannot start services, change services or stop services unless you sign an IEP stating so. If the school is asking that you make changes that you do not agree with, do not sign the IEP papers.
5. One thing that worked really well for me was taking my manual of Special Education Rights and Responsibilities with me to the IEP. I made sure it was in plain view but did not flash it around. The principal asked me about the book and I explained what it was. I was treated differently once they knew that I was aware of my rights. Once they realized that I was a fully informed parent and that I was aware of what they could do and what they couldn't, I seemed to have a much easier time getting the things I asked for.

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Insights into how to deal with teachers and school districts in helping your ADHD child.

My Two Cents on Schools and Districts

Here is my two cents worth on what I've learned dealing with the schools over the years in trying to get help for my son who has severe ADHD. While I realize that not all school districts and teachers are out to avoid providing educational services to your ADHD child, the fact is that many are.

If you happen to have a school staff that is not working with you, here are some things I have learned. Remembering that I am not a professional, just a mom who's been there and done that. Here is my best advice:

• It's extremely important that if you want to advocate successfully for your ADHD child that you remain polite and in control at all times. Losing your temper does not get you anywhere. You do not have to be rude or obnoxious to be aggressive. The same goes for letters you might write. Remember that strangers not associated with your case may be reading your letters and you do not want to offend or alienate them.

• Write everything down!! If your child is having problems in school and you are not getting the cooperation that you think you should be, start a journal. Get names, dates and times and any facts regarding any issues or incidents. Make sure you have copies of documents, notes, letters, a log of phone calls, etc. You may never need this information, but if you do, you'll have it.

• Know your chain-of-command and use it. If you find yourself in the position of not getting your calls returned, go up the chain-of-command. If excuses such as "Mr. Brown is out of the office. He's in a meeting. He's on another line," etc. are growing old, then take action.

  If Mr. Brown is away from his desk or on another line, ask to hold. If he continually is not in, get his supervisor, and if he or she is out, get their supervisor. I don't stop until I find somebody who can talk to me even if it means going to the state or county boards of education.

• Don't make empty threats. While there are times when you really, really wish you could sue the school district, and they deserve to be sued, the facts are, the threats of lawyers and lawsuits don't even make them flinch. Unless there is cause for large sums of money, in the way of damages through injury, death, etc., lawyers do not like to take on the school districts because taxpayer-funded pockets run deep.

  Very few of us have the means to pay for such suits out of our pockets and lawyers are unwilling to front the costs themselves. For the same reasons, school districts know that lawsuits are unlikely and if taken to court, can be dragged out and tied up forever.

• The chain-of-command works both ways. I have found that when there is a possibility of trouble, ranks close. The principal protects the teacher and the district protects the principal, and the school board protects the district.

• Because lawsuits are costly and because school staff never hestitate to make my son take responsiblity for his behavior/actions, I have started filing written complaints against school staff that mistreat my child, endanger his health/welfare/or safety, (including self-esteem) or who I feel need to be held accountable for their conduct. I also cross-file the complaint with the Special Education office if the action warrants it.

  Each district has certain rules they follow concerning written complaints, but the great part about these types of actions is that they become a permanent part of that employee's record. A superintendant once told me that written complaints are often the only way they find out that an employee has problems. When their file is reviewed, or an employee is up for promotion, this is when the complaints will be found and taken into consideration.

• While school districts may laugh at the mere mention of courtrooms and lawyers, they do not appreciate publicity. If you are suffering through some real injustices, do not hesitate to notify your local paper, t.v. station or reporter. They might get action where you haven't been able to.

• Question Authority! I realize it's not the 70's, but the same holds true even for today. I believe that a lot of schools and districts depend on parents taking their word as gospel. Why not? They are educated professionals with lots of training. Why would a parent question a trained professional? If you don't ask questions, or know your rights, how can you be sure that you are being treated fairly and that you are being made aware of all your options?

  Some educators depend on the fact that you don't know your rights and that you won't question their recommendations or actions. That's the best reason there is to question everything and make sure that you are indeed being given all the facts and options.

• Last, but not least, KNOW YOUR RIGHTS! I can't stress this enough. I can't say it enough and I can't impress upon you enough, how important this is. Some schools do not volunteer information, especially when it's going to cost them money in the way of services and accomodations.

  You can be sure that these types of districts are not going to advertise what your child is entitled to and the only way to find out is to KNOW YOUR RIGHTS!

  My son suffered because I didn't know my rights. Don't let this happen to you!

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Figuring out which ADHD medication works best and the proper dosage for your ADHD child may involve a process of trial and error.

"What guidelines should be used to determine the ADHD medications your child should be taking? And which guidelines are used to let parents and teachers know if the ADHD medications are working properly?"

These are really important questions because although there is considerable research evidence that medication is quite helpful for the vast majority of children with ADHD, it is frequently prescribed and monitored in such a way that prevents children from getting the maximum benefit possible.

In regards to the first question raised above, there is simply no way to predict in advance which of several medications will be most helpful for a child with ADHD, nor the optimal dose will be. Physicians generally start with Ritalin, which is certainly reasonable since it is the most extensively researched. A child who does not respond well to Ritalin, however, may do very well on other stimulants (e.g. Adderall, Concerta, Dexedrine). Similarly, a child who does not do well on the initial doses tried may do very well on a different dose. In some cases, side-effects that are prominent with one medicine may be absent with another.

The bottom line is that because there is no way to know in advance what ADHD medication will be best for an individual child, the child's response needs to be monitored very carefully. One very useful procedure is to begin a child on medication using a careful trial in which a child is tried on different doses during different weeks, and is also put on a placebo for one or more weeks during the trial. The child's teacher is asked to complete weekly ratings of the child's behavior and academic performance, and side effects forms are completed by both parents and teachers.

Why have a child receive a placebo during the trial? This is important because no matter how good one's intentions are, it is very difficult to be objective about a child's behavior when one know the child is on medication. Thus, one study found that when children with ADHD were given a placebo, the child's teacher reported significant improvement over half the time. This is probably because teachers expect the child to do better which can color what they see. Also, when children believe they are on meds they actually may do a bit better, at least for a period of time.

By using the placebo procedure outline above, the information obtained is less likely to be effected by such potential biases because the teacher does not know when the child is getting medicine and when he or she is not.

By comparing the teacher's ratings for the different medication weeks with the placebo week, one has a more objective basis for deciding if the medicine really helped, whether it helped enough to be worth continuing, what dose produced the greatest benefits, whether there were adverse side effects, and what problems may remain to be addressed even if the medicine was helpful.

Compare this type of careful trial with what is often done: the doctor prescribes medication and asks the parent to let him know what happened. Parents ask the teacher for feedback about how their child did on medication for ADHD, and passes this along to the physician who then decides whether to continue, try a different dose, or try a different medication. Here are possibilities that are much more likely to occur with this procedure:

1. Because of the "placebo" effect, medication may be reported to have been helpful even though no real benefit was produced. The child then continues to take medicine even though he or she is not really benefiting.

2. Because a systematic comparison of different doses is not made, the child is maintained on a non-optimal dose, and thus fails to get al the benefits that are possible.

3. Medication is discontinued because of "side-effects" that actually had nothing to do with the medication (see below).

4. Because a careful assessment was not made of how the child did on medicine, problems that may have remained even though the medicine was helpful are not targeted for adjunctive forms of treatment.

Let me say something about side-effects of ADHD medications. I do these type of trials all the time and often find that what would otherwise be assumed to be side-effects of medication actually occur during the placebo week! Several carefully controlled studies have reported similar findings, as well as the fact that problems presumed to be side-effects of medicine are often present prior to starting medication.

Suppose a good trial has been done and the proper dose selected - now what?

After this has been done, it is VERY important to monitor how the child is doing on a regular basis. In fact, guidelines published by the American Academy of Child and Adolescent Psychiatry, recommend that at least weekly ratings from teachers be obtained. This is because a child's response to ADHD stimulant medication can change over time, so what starts out as being very helpful may become less helpful over time. Some of you may have already had the unfortunate experience of believing that things were going along pretty well, and then finding out at report card time that this was not the case. With regular, systematic feedback from teachers about how well a child's ADHD symptoms are being managed, the quality of work being completed, peer relations, etc., this type of unpleasant surprise does not need to occur. This is not difficult to do, but in my experience, is rarely done.

Allow me to put in a plug for procedures I have developed and use regularly to help parents with these important issues. If you visit my site www.help4add.com, you'll find overviews of a medication trial program to assist with initial medication trials and a monitoring system to carefully follow how a child is doing. I use these programs all the time and know how useful they are. Please consider giving them a try if you are considering the use of medication for your child or have a child who is already on medication.

Dr. David Rabiner Ph.D

Dr. Dave Rabiner received his Ph.D in clinical psychology from Duke University in 1987 where he also completed a one-year internship in child psychology at Duke University Medical Center. From 1987-1998, he was a professor in the psychology department at the University of North Carolina at Greensboro. During this time, he maintained a part-time private practice where he worked primarily with children diagnosed with ADHD (Attention Deficit Hyperactivity Disorder). In addition to this direct clinical work, he has consulted with numerous pediatricians and family physicians in North Carolina to assist them in evaluating and treating children with ADHD.

Dr. Rabiner has also published a number of papers on children's social development in peer-reviewed journals and presented his work at professional conferences. He's also served as a consultant on two federally funded grants to study ADHD.

Currently, Dr. Rabiner is teaching and conducting research on ADHD at Duke University in Durham, NC.

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Information for parents planning to coach their ADHD child. Are you a helicopter parent or one who will help your child achieve autonomy?

To Coach or Not to Coach: The Fine Line Between Helping and Hindering

Parents planning to coach their ADHD children to social and emotional success need more than tools, such as Parent Coaching Cards, to get the job done. Along with the virtues of patience, determination and insight, is the need for an often overlooked, but key coaching ingredient: support for autonomy. In this context, I define autonomy as the child's capacity to independently achieve healthy and desirable goals in life. Among these goals include completion of homework, satisfactory resolution of a peer problem, or choosing a sensible course of action from a variety of options. The ability to attain these goals without parental involvement allows children with ADHD to take complete ownership of the pride that flows from them. This pride translates into fuel for the developing sense of autonomy, a critical building block to self-esteem.

The dilemma for many parents begins with the fact that children's path towards autonomy doesn't take place without our help. As we strive to guide our children towards independence we must provide some of the necessary "scaffolding" within which they can grow. Some of these external supports include rules, expectations, consequences for misbehavior, and so on. Coaching is also included within this framework since it helps children develop self-management skills. Each parent shares a similar goal: for their child to develop the skills to be self-sufficient in a challenging and unpredictable world. Yet, the goal is much clearer that the individual steps we must take in assisting children in reaching this destination. As we provide "parent coaching" we must be mindful of the need to step back and allow our children the chance to venture forth on their own.

The delicate balance between coaching skills and supporting autonomy was recently epitomized by the mother of Kenny, a seventeen-year-old boy with AD/HD (Attention Deficit Hyperactivity Disorder), "There's a real fine line between coaching and not coaching. My husband and I are not sure which side to be on. Sometimes we get it right and Kenny accepts our help, but a lot of times he rejects it. This confuses us because we're not aware of doing anything different each time; it's more like he's the one who feels differently about receiving our help. And when we blow it, and try to force our help upon him, it's liable to backfire." This astute mother's comments highlight several issues that parents are wise to consider when approaching their child with coaching help: children's mood, parents' presentation, and the potential for coaching backfires.

Is Your Child in the Right Mood to Accept Help?

Mood acts as a filtering mechanism, coloring a child's internal experience of external events. Therefore, it plays a pivotal role in how children interpret help. If a child's mood is on a downturn due to a recent disappointment, or even on an upswing after a success, a parent's help may be perceived more like a hindrance than a help. For the parent, the child's rejection of help is confusing and frustrating, emotions that don't peacefully combine with the child's fragile mood. In the exchange of verbal crossfire, parents may get easily sucked into the role of attempting to enforce "help" upon the unwilling child. This coaching backfire results in distance and distrust between parent and child, leaving both feeling wary of offering or asking for help.

To minimize these backfires, I recommend that parents "take their kid's emotional temperature" before being generous with help. This means asking open-ended questions or making non-threatening observations to find out how receptive the child may be towards help. Comments such as "Maybe we could talk about that since I think we could both learn a thing or two," doesn't present the parent as the one with all the answers. Instead, it places parent and child in the same role of learning from events.

Of course, some kids don't offer a lot about what's happening in their lives, but they may demonstrate how they're feeling about those events. Angry expressions, attempts to discredit parents' help, and/or rampant justifications for why they don't need help, suggest that the coaching bridge between parent and child may be closed for the time being. Parents are wise to back off in the face of these barriers to help, but they should stress that help remains available should the child be ready at some other point.

The importance of how parents present their offers of coaching cannot be overestimated. It's much easier to send a child reeling away from our offers than it is to establish a safe dialogue within which to receive it. Comments such as, "I want to give you some help with that," or even "Let's talk about that," can quickly send a child into a defensive mode. Some children are so sensitive to having their autonomy threatened that they experience a parent's coaching as the imposition of control.

When the child sounds off with protests such as "You're pressuring me!" or "Stop pushing so hard!" this signals the need for some preliminary groundwork. The groundwork can be likened to preparing soil for cultivation; don't expect a child's self-management skills to grow and flourish without the proper environment. The proper environment for coaching considers the whole child, not just their areas of need. A forthcoming article addresses the many concerns inherent in the "whole child" concept. For the purposes of this column I will continue to confine my comments to autonomy.

A Little Humor Goes A Long Way

Cultivating acceptance of coaching in a child whose feelings of autonomy are easily threatened is a daunting task. One of the first steps is to establish a dialogue wherein the two of you can safely discuss what coaching is supposed to be and what it isn't supposed to be. It may even be helpful to write down two headings, such as "good coaching" and "bad coaching" and then start placing examples under each heading.

A little self-effacing humor on the part of the parent can go a long way towards helping to cultivate a more receptive mood in your child. Humor can also effectively set the stage for parent and child to reflect upon some of the coaching backfires in the past, and unearth what went wrong and why. For instance, in the "bad coaching" example, it provides the parent with the opportunity to suggest that in her zeal to help, she actually made the child feel controlled by her approach.

Another important step in "coaching cultivation" is to talk about every child's need for autonomy. Many children experience relief to hear parents say something like the following: "Being a kid who needs help every once in a while but also wants to be able to do without it, is not an easy position to be in. And sometimes when you need help the most, you want it the least! That's because a lot of kids reject help when they're feeling touchy about not knowing something as well as they think they should." These words convey a parent's empathic understanding of the Catch-22 that kids find themselves in.

Once a child acknowledges that this is true of them, parents might follow with a comment such as this one: "Maybe you could tell me a way that I could let you know that I've got some help to offer without you feeling like I'm trying to take control away from you?"

Such a comment diminishes the child's feelings of being controlled by placing them in the advice-giving role. Apart from the various factors that parents can weigh in considering their "coach approach," there is the option of not offering help. Sometimes this choice is made by default because circumstances require it, while other times it can be voluntarily determined by parent and child.

If a particular situation arises that lends itself to a child "going solo," parents can highlight that perhaps this time the child might want to handle things on their own from start to finish. For instance, in the case of a child who has always relied on the parent to format a study plan for upcoming tests, the parent might suggest that this time they do it alone and give themselves the directions that they have relied upon the parent to give them in the past. In fact, the expression, "Give Yourself The Directions," may be the only coaching advice the parent offers in those situations that lend themselves to such tests of autonomous functioning.

Much more can be said about supporting our children's needs for autonomy. As Kenny's mother put it, parents must walk that "real fine line" that tends to keep moving as the child's mood and surrounding circumstances shift it's position. Parents are advised to pay particular attention to the balance between coaching and supporting autonomy by not emphasizing one side to the exclusion of the other. Many factors will help you stay abreast of where the line is, especially an open communication channel between you and your child.

About the author: Dr. Steven Richfield is a child psychologist and father of two. He is also the creator of Parent Coaching Cards. His articles focus on helping your child with school-related skills.

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Children with ADHD often cause classroom disturbances or other behavioral problems. Here are ideas on how to control that.

Exercising Control

Often when ADHD (Attention Deficit Hyperactivity Disorder) people are forced to think fast on their feet, make multiple decisions or are backed into a corner, they will try to self-medicate through confrontation. By causing a situation to escalate, they are boosting their adrenaline in an attempt to gain control. It is common for ADHD children to push buttons and create classroom disturbances in order to gain a sense of control and stability. This can get them into much trouble and can become a self-destructive coping technique. Soft, controlled responses and time-outs work well to de-escalate when they are becoming confrontational.

Athletic coaches and military drill sergeants have known for years that one of the best ways to get someone to be more receptive to training is to have them run a few laps or "drop and give them twenty".

Physical exertion is a very positive way to increase the adrenaline and therefore the dopamine levels in the brain. Many of our best athletes have ADHD. They have used activity to self-medicate. Not only does the ADHD athlete gain from the increased dopamine, but the fitness also aids in a more efficient use of the body's resources.

For ADHD Child, More Exercise is Better

However, when an ADHD child is having difficulty in school or with behavior, one of the first ways both schools and parents try to deal with the problem is to take away athletics. I would suggest more physical activity as a method of helping the student, not less. However, I know that some sports can be so demanding on time and energy, that this may be the only reasonable solution. Be careful, because that sport might be the only way this child gets success and might be the only reason to keep trying in school.

I know a teacher who gets permission from parents to use physical exercises like push ups for disciplinary purposes. The students respond well to this method.

I had an ADHD student who had such a difficult time sitting still during an assembly that I had him and me run around the school twice before we went back in and sat down. This type of immediate approach also allows the student time away from the stimulus that caused the problem, thus reducing the need for the additional neurotransmitters.

In Modesto, California, a physical education teacher came to me during a break at an in-service I was giving at his school. He said that he has had problems with certain students who purposely confronted him, the other coaches and players. He had heard me say that the best thing to do when a student is becoming confrontational is to find ways to de-escalate by backing off, softening your voice, and providing space to calm down. He expressed concern that if he backed down from the student, that the student would use confrontation to manipulate every situation. I impressed on him that it would be wrong to back down, but letting the situation cool before administering discipline will help the student learn from the situation and learn that confrontation does not work. Eventually, confrontations should decrease because he is not achieving the goal of boosting the neurotransmitters and thus he does not gain control using this method.

Taking a Time-Out

Time-outs are definitely one of the best ways to achieve calm in a classroom. The best discipline for an ADHD child is one that is immediate, does not allow for increase of tension and allows the emotions of all involved to subside. However, time outs should not be long in duration. Five minutes is usually enough. The real correction occurs at the moment of being separated from the rest of the class.

One time, one of my students refused to go outside for time-out. I sent the rest of the students outside for a five-minute time-out. He did not like the isolation and tried to come out with the class. He never tried that again!

Another approach to de-escalating a situation involves providing specific options or choices. Since ADHD children, have a difficult time thinking and acting especially in stressful moments, providing limited choices helps them think while allowing them to keep a sense of control. For example, if a child is not doing his work properly, a teacher could give her the option to work right or take a time-out. The choices do not have to be equally good. In fact, it is best to make the right choice obvious and the wrong choice distasteful. However, be willing to let the child choose the wrong one. Otherwise, it would not be a choice at all.

By keeping in mind that ADHD people are seeking balance and control, we can learn to respond positively and provide options which can help them achieve balance without self-destructing. It is my greatest hope that no person give up on success.

------------------------------

I wanted to share this idea that was brought up in ADDtalk. I think it's great and I want To thank Carylin for giving me permission to share this:

On cleaning their rooms- what I mean by 'visual pics' is this: I cut out actual pictures from ads or magazines of a neatly made bed, dresser with closed drawers, books on shelves, shoes in a row etc. and stick them on index cards (so I can add or change them when needed).

When room cleaning time comes instead of a long list or one at a time verbal instructions that I continually have to repeat or check up on I just select the cards I need and stick them on the wall or a poster board for them to refer to. Then they can bring each card or all of them to me to check if they are done and how they compare to the picture.

This works for the bathroom too. They especially like the cards I've made with the big NOT sign on them- you know, the circle with the slash in it. Like the no smoking signs. Since on of mine is dyslexic and can't read he really grabs on to these. We have one with the cap off the toothpaste and the stuff all smooshed out &NOT. And even one with chewing gum on the bedpost & Not These actually make it fun-more like a detective game to figure out. (the last is really a reminder to wear his orthodontic headgear at night!)

We use this at the grocery store too. It beats list making to take coupons with and send them on a"special mission" to find and identify such and such a cereal. Although we don't always use the exact coupon item- it always helps us not to forget the spaghetti sauce or peanut butter!

About Rick Pierce: The Hyperactive Teacher

Rick has Attention Deficit Disorder. He had a very difficult time in school and in previous careers. Rick discovered his ADD (Attention Deficit Disorder) while attending teacher training and eventually was clinically diagnosed. Life's many lessons have taught Rick to successfully cope with ADD.

During his tenure as a sixth-grade teacher, he has searched for methods to be successful with ADD for both himself and the students that he so closely understood. He has also experienced the skepticism or lack of knowledge about ADD among teachers and parents alike and is now committed to help train teachers and parents to work together for the ultimate success of these students.

Rick has a California Teaching Credential and Bachelors Degree in Business Marketing. He has worked as a sixth-grade teacher, supervisor, salesman, retail store manager, marketing director, and is currently running his own business.

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What is social phobia? Learn about the symptoms, causes and treatments of social phobia - extreme shyness.

Many people get a minor case of the jitters before performing in public. For some, this mild anxiety actually enhances their performance. However, this anxious reaction is massively exaggerated in the individual with social phobia. While mild normal anxiety can actually enhance performance, excessive anxiety can severely impair performance.

An anxious episode may be associated with some or all of the symptoms of a panic attack. These might include sweaty palms, palpitations, rapid breathing, tremulousness and a sense of impending doom. Some individuals, particularly those with generalized social phobia may have chronic anxiety symptoms. Individuals with social phobia may turn down accelerated classes and after school activities because of their fears that these situations will lead to increased public scrutiny.

The individual with a specific social phobia feels anxious during the feared social situation and also when anticipating it. Some individuals may deal with their fear by arranging their lives so that they do not have to be in the feared situation. If the individual is successful at this, he or she does not appear to be impaired. Types of discrete social phobia may include:

• Fear of public speaking - by far the most common. This seems to have a more benign course and outcome.
• Fear of interacting socially at informal gatherings (making small talk at a party)
• Fear of eating or drinking in public
• Fear of writing in public
• Fear of using public washrooms (bashful bladder) Some students may only urinate or defecate at home.

Individuals with generalized social phobia are characterized as extremely shy. They often wish that they could be more socially active, but their anxiety prevents this. They often have insight into their difficulties. They often report that they have been shy most of their lives. They are sensitive to even minor perceived social rejection. Because they become so social isolated, they have greater academic, work and social impairment. They may crystallize into an avoidant personality disorder.

Social phobia is the third most common psychiatric disorder. (Depression 17.1% Alcoholism 14.1% Social phobia 13.3%.) (Kessler et al 1994.) Onset is usually in childhood or adolescence. It tends to become chronic. It is often associated with depression, substance abuse and other anxiety disorders. The individual usually seeks treatment for one of the other disorders. Individuals with SP alone are less likely to seek treatment than people with no psychiatric disorder (Schneier et al 1992) Social phobia is vastly under-diagnosed. It is not as likely to be noticed in a classroom setting because these children are often quiet and generally do not manifest behavior problems. Children with SP often show up with physical complaints such as headaches and stomach aches. Parents may not noticed the anxiety if it is specific to situations outside the home. Additionally, since anxiety disorders often run in families, the parents may see the behavior as normal because they are the same way themselves. On the other hand, if the parent has some insight into his of her own childhood anxieties, he or she may bring the child into treatment so that the child will not have to experience the pain the parent experienced as a child.

Treatment of Social Phobia:

Psychotherapy: There is the most evidence for cognitive-behavioral psychotherapy. Since the child or adolescent is more dependent on his parents than an adult, the parents should have some adjunctive family therapy.

Both individual and group therapy are useful. The basic premise is that faulty assumptions contribute to the anxiety. The therapist helps the individual identify these thoughts and restructure them.

• Identifying out automatic thoughts: If I sound nervous when I present my paper, my teacher and classmates will ridicule me. The patient then identifies his physiological and verbal responses to the thoughts. Finally he identifies the mood associated with the thoughts.
• Irrational beliefs that underlie automatic thoughts:
  Emotional reasoning: "If I am nervous, then I must be performing terribly."
  All or nothing: Absolute statements that do not admit any partial success of gray areas. "I am a failure unless I make an A."
  Overgeneralization: One unfortunate event becomes evidence that nothing will go well. Should thoughts: Insisting that an unchangeable reality must change in order for one to succeed.
  Drawing unwarranted conclusions: Making connections between ideas that have no logical connection.
  Catastrophizing: Taking a relatively small negative event to illogically drastic hypothetical conclusions.
  Personalization: Believing that an event has special negative relationship to oneself. ("The whole group got a bad grade because my hands trembled during my part of the presentation".) Selective negative focus: Only seeing the negative parts of an event and negating any positive ones.
• Challenge negative beliefs: Once the patient and therapist have identified and characterized the negative thoughts, the therapist should help the patient examine the lack of data supporting the beliefs and look for other explanations of what the patient sees.

Exposure: Create a hierarchy of feared situations and start to allow one to experience them. One starts with situations that only elicit a little anxiety and then gradually move up to more intense experiences. This must be done in reality, not just as visualization in the office.

Group therapy: This can be a powerful modality for individuals with social phobia. A patient may need to use individual therapy to prepare for group therapy. In the group patients can encourage each other and can try out new behaviors within the safety of the group. They can get immediate feedback that may refute their fears. Patients should not be forced to participate more actively than they wish.

Medications Used to Treat Social Phobia:

Recent studies have shown that some of the SSRI medications can be helpful in the reatment of Social Phobia. Paroxetine (Paxil) have been approved by the FDA for treatment of Social Phobia. Other medications that may be useful include: blockers (propranolol, atenolol) Benzodiazepines, MAO inhibitors (Parna (lorazepam, clonazepam) buspirone, and Nardil.) MAO Inhibitors are only rarely used in children and adolescents because one must go on dietary restrictions while taking them.

References:

Kessler R.C. McGonagle, K.A. Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen, H.U., and Kendler, K.S.(1994) Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Archives of General Psychiatry, 51, 8-19.

Kessler, R.C., Stein, M.B., Berglund, P. (1998) Social Phobia Subtypes in the National Comorbidity Survey. American Journal of Psychiatry, 155:5.

Murray, B., Chartier, M.J., Hazen, A.L., Kozak, M.V.Tancer, M.E., Lander, S., Furer, P., Chutbaty, D., Walker, J.R. A Direct Interview Family Study of Generalized Social Phobia. American Journal of Psychiatry, (1998) 155: 1.

Pollack, M.H., Otto, M.W.Sabatino, S., Majcher, D., Worthington, J.J. McArdle, E.T., Rosenbaum, J.F. Relationship of Childhood Anxiety to Adult Panic Disorder: Correlates and Influence on Course. American Journal of Psychiatry. 153: 3.

Schneier, F.R., Johnson, J., Hornig, C.., Liebowitz, M.R. and Weissman, M.M. (1992) Social Phobia: Comorbidity and morbidity in a epidemiologic sample. Archives of General Psychiatry, 49, 282-288

About the author: Carol E. Watkins, MD is board-certified in child, adolescent and adult psychiatry and is based in Baltimore, MD.

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Article on managing bipolar disorder in women who want to become pregnant or have an unplanned pregnancy.

Because bipolar disorder (manic-depressive illness) is a common and highly recurrent disorder requiring lifelong treatment, many women of childbearing age are maintained on mood stabilizers, usually lithium and the anticonvulsant Depakote (valproic acid).

Both drugs are teratogenic, so women with bipolar disease have typically been counseled to defer childbearing or abruptly stop their medications when they get pregnant. However, the discontinuation of lithium is associated with a high risk of relapse, and pregnancy does not protect women from relapsing. In a recent study, 52% of pregnant women and 58% of non-pregnant women had recurrences during the 40 weeks after stopping lithium (Am. J. Psychiatry, 157[2]:179-84, 2000).

There are no contraindications to lithium or Depakote use during the second and third trimesters. First-trimester exposure to Depakote is associated with a 5% risk of neural tube defects. Prenatal exposure to lithium in the first trimester is associated with an increased risk for cardiovascular malformations.

Although lithium is clearly teratogenic, the degree of risk has been previously overestimated. The report from the International Registry of Lithium- Exposed Babies almost 35 years ago estimated that the risk of cardiovascular malformations, most notably Ebstein's anomaly, associated with first-trimester exposure was increased by about 20-fold. But six later studies show that the risk is increased no more than 10-fold (JAMA 271[2]:146-50, 1994).

Because Ebstein's anomaly is so rare in the general population (about 1 in 20,000 births), the absolute risk of having a child with this malformation after first-trimester exposure to lithium is only about 1 in 1,000 to 1 in 2,000.

Managing Bipolar Disorder During Pregnancy

So how do you manage bipolar disease in women who want to become pregnant or have an unplanned pregnancy? Clinicians should not arbitrarily stop or continue mood stabilizers in these patients. The decision should be driven by both the severity of the illness and the patient's wishes; this requires a careful discussion with the patient about the relative risks of relapse and fetal exposure.

A reasonable approach in patients with a milder form of the illness, who may have had one episode in the distant past, is to discontinue the mood stabilizer while they are trying to get pregnant or when they become pregnant. They can resume the medication if they begin to show signs of clinical deterioration during pregnancy. This approach can pose a problem in women who take more than a few months to conceive, since the risk of relapse increases the longer a patient is off medication.

The best-case scenario in women with milder illness is to stay on the mood stabilizer while trying to get pregnant and to stop treatment as soon as they know they are pregnant. Women must be aware of their cycle pattern so they can stop the drug soon enough to avoid exposure during a critical time of organ development.

Going off medication maybe harder for those with a history of multiple episodes of cycling. We explain to such patients that it may be reasonable to stay on the mood stabilizer and assume a small risk to the fetus. If a woman on lithium decides to continue treatment, she should have a level II ultrasound at about 17 or 18 weeks' gestation to evaluate the fetal cardiac anatomy.

It's a more delicate situation when such a patient is stabilized on Depakote. Lithium is less teratogenic, so we often switch a woman on Depakote to lithium before she gets pregnant. That doesn't mean we never use Depakote during pregnancy. But when we do, we prescribe 4 mg of folate per day for about 3 months before they try to conceive and then throughout the first trimester because of data suggesting that this may minimize the risk of neural tube defects.

We don't discontinue or lower the dose of lithium or Depakote near the end of pregnancy or during labor and delivery because the incidence of any type of neonatal toxicity associated with peripartum exposure to these drugs is low--and bipolar women are at a five-fold increased risk of relapse in the postpartum period. This is why we also resume medication in women who have been off medication at about 36 weeks' gestation or 24-72 hours post partum.

Typically, bipolar women on lithium are counseled to defer breast-feeding because this drug is secreted into breast milk and there are a few anecdotal reports of neonatal toxicity associated with exposure to lithium in breast milk. Anticonvulsants are not contraindicated during lactation. Since sleep deprivation is one of the strongest precipitants of clinical deterioration in bipolar patients, we suggest that bipolar women defer breast-feeding, unless there is a clearly established plan to ensure she gets enough sleep.

About the author: Dr. Lee Cohen is a psychiatrist and director of the perinatal psychiatry program at Massachusetts General Hospital, Boston.

Source: Family Pratice News, Oct. 2000

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Researchers conclude that lithium maintenance provides a sustained protective effect against suicidal behavior in manic-depressive disorders, a benefit that has not been shown with any other medical treatment.

Can timely diagnosis and treatment of depression reduce the risk of suicide? Studies of treatment effects on mortality in major mood disorders remain rare and are widely considered difficult to carry out ethically. Despite close associations of suicide with major affective disorders and related comorbidity, the available evidence is inconclusive regarding for sustained reductions of suicide risk by most mood-altering treatments, including antidepressants. Studies designed to evaluate clinical benefits of mood-stabilizing treatments in bipolar disorders, however, provide comparisons of suicidal rates with and without treatment or under different treatment conditions. This emerging body of research provides consistent evidence of reduced rates of suicides and attempts during long-term treatment with lithium. This effect may not generalize to proposed alternatives, particularly carbamazepine. Our recent international collaborative studies found compelling evidence for prolonged reduction of suicidal risks during treatment with lithium, as well as sharp increases soon after its discontinuation, all in close association with depressive recurrences. Depression was markedly reduced, and suicide attempts were less frequent, when lithium was discontinued gradually. These findings indicate that studies of the effects of long-term treatment on suicide risk are feasible and that more timely diagnosis and treatment for all forms of major depression, but particularly for bipolar depression, should further reduce suicide risk.

INTRODUCTION

Risk of premature mortality significantly increases in bipolar manic-depressive disorders.(1-12) Mortal risk arises from very high rates of suicide in all major affective disorders, which are at least as great in bipolar illness as in recurrent major depression.(1, 2, 13-16) A review of 30 studies of bipolar disorder patients found that 19% of deaths (range in studies from 6% to 60%) were due to suicide.(2) Rates may be lower in never-hospitalized patients, however.(6, 11, 12) In addition to suicide, mortality is probably also increased due to comorbid, stress-related, medical disorders, including cardiovascular and pulmonary diseases. (3-5, 7, 10) High rates of comorbid substance use disorders contribute further to both medical mortality and to suicidal risk (11, 17), especially in young persons (18), in whom violence and suicide are leading causes of death.(11, 12, 19)

Suicide is strongly associated with concurrent depression in all forms of the common major affective disorders.(2, 9, 20, 21) Lifetime morbid risk for major depression may be as high as 10%, and lifetime prevalence of bipolar disorders probably exceeds 2% of the general population if cases of type II bipolar syndrome (depression with hypomania) are included. (2, 22, 23) Remarkably, however, only a minority of persons affected with these highly prevalent, often lethal, but usually treatable major affective disorders receive appropriate diagnosis and treatment, and often only after years of delay or partial treatment. (8 ,9, 22, 24-28) Despite grave clinical, social, and economic effects of suicide, and its very common association with mood disorders, specific studies on the effects of mood-altering treatments on suicidal risk remain remarkably uncommon and inadequate to guide either rational clinical practice or sound public health policy.(7, 8, 11, 12, 22, 29, 30)

In view of the clinical and public health importance of suicide in manic-depressive disorders, and the rarity of evidence proving that modern mood-altering treatments reduce suicide rates, an emerging body of research has been reviewed. It indicates a significant, sustained, and possibly unique reduction of suicidal behavior during long-term treatment with lithium salts. These important effects have not been demonstrated with other mood-altering treatments.

THERAPEUTICS RESEARCH IN SUICIDE

Despite broad clinical use and intensive study of antidepressants for four decades, evidence that they specifically alter suicidal behavior or reduce long-term suicidal risk remains meager and inconclusive.(9, 11, 17, 31-37) The introduction of selective serotonin reuptake inhibitors (SSRIs) and other modern antidepressants that are much less toxic on acute overdose than older drugs appears not to have been associated with a decrease in suicide rates.(34, 38) Instead, their introduction may have been associated with a shift toward more lethal means of self-destruction.(39) We found only one report of a significantly lower rate of suicide in depressed patients treated with antidepressants compared to placebo (0.65% vs 2.78% per year), with an even lower rate with an SSRI than with other antidepressants (0.50% vs 1.38% per year).(37) Nevertheless, suicide rates during antidepressant treatment in that study were far greater than the general population rate of 0.010% to 0.015% per year, uncorrected for persons with mood disorders and other illnesses associated with increased suicide rates.(40)

Bipolar depression accounts for much or most of the time one is stricken with bipolar disorder (24) and can be disabling or fatal.(2, 7, 11, 12) Remarkably, however, the treatment of this syndrome remains much less studied than depressive to manic, agitated or psychotic unipolar major depression.(24, 38, 41) Indeed, bipolarity is typically a criterion for exclusion from studies of antidepressant treatment, apparently to avoid risks of switching from depressive to manic, agitated or psychotic phases when patients are not protected with lithium or another mood-stabilizing agent.(38)

Reasons for the rarity of studies of the effects of modern psychiatric treatments on suicide rates are not entirely clear. Therapeutic research on suicide is appropriately constrained ethically when fatality is a potential outcome, and particularly when discontinuation of ongoing treatment is required in a research protocol. Treatment discontinuation is increasingly recognized as being followed by at least temporary, sharp increases in morbidity that may exceed the morbid risk associated with untreated illness. This evidently iatrogenic phenomenon has been associated with discontinuation of maintenance treatment with lithium (42-46), anti-depressants (47), and other psychotropic agents.(44, 48) Mortality can also increase following treatment discontinuation. (9, 11, 21, 22) Such reactions can complicate clinical management. Moreover, they may also confound many research findings in that typically reported "drug vs. placebo" comparisons may not represent straightforward contrasts of treated vs untreated subjects when placebo conditions represent discontinuation of an ongoing treatment.

Avoiding such risks, most studies of treatment effects on suicide have been naturalistic or have examined suicidal behavior post-hoc as an unintended outcome of controlled treatment trials. Such studies have provided evidence that maintenance treatment with lithium is associated with a strong, and possibly unique, protective effect against suicidal behavior in major affective disorders, and particularly in bipolar syndromes. (6, 8, 11, 12, 21, 22, 49-56) Moreover, lithium's protective effect may extend more broadly to all causes of mortality in these disorders, although this possibility remains much less studied. (2, 3, 5, 7)

SUICIDE RATES ON AND OFF LITHIUM

We recently evaluated all available studies of lithium and suicide since the emergence of long-term lithium maintenance treatment in manic depressive disorders in the early 1970s. Studies were identified by computerized literature searches and cross-referencing from publications on the topic, as well as by discussing the aims of the study with colleagues who have conducted research on lithium treatment or who may have had access to unpublished data on suicide rates in bipolar disorder patients. We sought data permitting estimates of rates of attempted or completed suicides in bipolar patients or mixed samples of patients with major affective disorders that included bipolar manic-depressives. Suicide rates during maintenance lithium treatment were compared with rates after discontinuation of lithium or in similar untreated samples when such data were available.

Suicide rates during long-term lithium treatment were determined for each study, and, when available, rates for patients discontinued from lithium or for comparable patients not treated with a mood stabilizer were also determined. Suicide rates during lithium treatment were not significantly greater with larger numbers of subjects or longer follow-up. However, many of the available reports were flawed in one or more respects. Limitations included: (1) a common lack of control over treatments other than lithium; (2) incomplete separation by diagnosis or provision of separate rates for suicide attempts and completions in some studies; (3) a lack of comparisons of treated and untreated periods within subjects or between groups; (4) study of fewer than 50 subjects/treatment conditions despite the relatively low frequency of suicide; (5) inconsistent or imprecise reporting of time-at-risk (the amount of time the patient was absent); and (6) selection of patients with previous suicide attempts that may show bias toward increased suicide rates in some studies. Some of these deficiencies were resolved by contacting authors directly. Despite their limitations, we believe that the available data are of sufficient quality and importance to encourage further evaluation.

Table 1 summarizes available data concerning rates of suicides and attempts among manic-depressive patients on or off lithium, based on previously reported (6) and new, unpublished meta-analyses. The results indicate an overall reduction of risk by nearly seven fold, from 1.78 to 0.26 suicide attempts and suicides per 100 patient-years at risk (or percent of persons/year). In another more recent, quantitative meta-analysis (L.T., unpublished, 1999), we evaluated fatality rates ascribed to suicide in the same studies as well as in additional previously unreported data kindly provided by international collaborators. In the latter analysis, based on results from 18 studies and more than 5,900 manic-depressive subjects, we found a similar reduction of risk from a suicide rate averaging 1.83 ± 0.26 suicides per 100 patient-years in patients not treated with lithium (either after discontinuing or in parallel groups not given lithium) to 0.26 ± 0.11 suicides per 100 patient-years in patients on lithium.

IMPLICATIONS OF FINDINGS

The present findings derived from the research literature on lithium and suicide risk indicate substantial protection against suicide attempts and fatalities during long-term lithium treatment in patients with bipolar manic-depressive disorders, or in mixed groups of major affective disorder subjects that included bipolar patients. While this evidence is strong and consistent overall, the relative infrequency of suicide and limited size of many studies required pooling of data to observe statistically significant effect that was not found in several individual studies. Large samples and lengthy times-at-risk, or pooling of data across studies, are likely to be required in future studies of treatment effects on suicide rates.

It is also important to emphasize that the observed, pooled, residual risk of suicides while on lithium, though much lower than without lithium treatment, is still large, and greatly exceeds general population rates. The average suicide rate during lithium maintenance treatment, at 0.26% per year (Table 1), is more than 20 times greater than the annual general population rate of about 0.010% to 0.015%, which also includes suicides associated with psychiatric illnesses.(11, 40) The evidently incomplete protection against suicide associated with lithium treatment may reflect limitations in the effectiveness of the treatment itself and, very likely, potential noncompliance to long-term maintenance therapy.

Since suicidal behavior is closely associated with concurrent depressive or dysphoric mixed states in bipolar disorder patients (9, 11, 20), it is likely that residual risk for suicide is associated with incomplete protection against recurrences of bipolar depressive or mixed mood states. Lithium has traditionally been considered to provide better protection against mania than against bipolar depression.(27, 38) In a recent study of more than 300 bipolar I and II subjects, we found that depressive morbidity was reduced from 0.85 to 0.41 episodes per year (a 52% improvement) and time ill was reduced from 24.3% to 10.6% (a 56% reduction) before vs during lithium maintenance treatment.(23) Improvements in mania or hypomania were somewhat larger, at 70% for episode rates and 66% for percentage of time manic, with even greater improvement in hypomania in type 11 cases (84% fewer episodes and 80% less time hypomanic). Corresponding suicide rates fell from 2.3 to 0.36 suicide attempts per 100 patient-years (an 85% improvement) during vs before lithium maintenance treatment. (9, 20) The present findings indicate an 85% to crude sparing of completed suicides and attempts (1.78 to 0.26% per year; see Table 1). These comparisons suggest that protective effects of lithium rank: suicide attempts or suicides ³ hypomania>mania>bipolar depression. Since suicide is closely associated with depression (11, 20), it follows that better protection against bipolar depression must be a key to limiting suicidal risk in bipolar disorders.

It is not clear whether reduction of suicide rates during lithium maintenance reflects simply the mood-stabilizing effect of lithium, or if other properties of lithium also contribute. In addition to protection from recurrences of bipolar depressive and mixed-mood states closely associated with suicidal behavior, important associated benefits of lithium treatment possibly also contribute to reduction of suicide risk. These may include improvements in overall emotional stability, interpersonal relationships and sustained clinical follow-up, vocational functioning, self-esteem, and perhaps reduced comorbid substance abuse.

An alternative possibility is that lithium may have a distinct psychobiological action on suicidal and perhaps other aggressive behaviors, possibly reflecting serotonin-enhancing actions of lithium in limbic forebrain. (38, 57) This hypothesis accords with growing evidence of an association between cerebral deficiency of serotonin functioning and suicidal or other aggressive behaviors. (58-59) If lithium protects against suicide through its central serotonergic activity, then proposed alternatives to lithium with dissimilar pharmacodynamics may not be equally protective against suicide. Specifically, mood-stabilizing agents that lack serotonin enhancing properties, including most anti-convulsants (27, 38), might not protect against suicide as well as lithium. It would be unwise clinically to assume that all putative mood-stabilizing agents provide similar protection against suicide or other impulsive or dangerous behaviors.

For example, findings from recent reports from a multicenter European collaborative study challenge the assumption that all effective mood-altering treatments have a similar impact on suicide rates. This study found no suicidal acts among bipolar and schizoaffective disorder patients maintained on lithium, whereas carbamazepine treatment was associated with a significantly higher rate of suicides and suicide attempts in 1% to 2% of subjects per year-at-risk. (60, 61) Patients assigned to carbamazepine had not been discontinued from lithium (B. Müller-Oerlinghausen, written communication, May 1997), which might otherwise have increased risk iatrogerically. (8, 42-46) A similar rate of suicide attempts to that found with carbamazepine in bipolar patients was also found among patients with recurrent unipolar depression who were maintained long-term on amitriptyline, with or without a neuroleptic. (60, 61) These provocative observations regarding carbamazepine and amitriptyline indicate the need for specific assessments of other proposed alternatives to lithium for their potential long-term protection against suicidal risk in bipolar disorder patients.

Several drugs are used empirically to treat bipolar disorder patients, although they remain largely untested for long-term, mood-stabilizing effectiveness. In addition to carbamazepine, these include the anticonvulsants valproic acid, gabapentin, lamotrigine, and topiramate. Sometimes calcium channel-blockers, such as verapamil, nifedipine, and nimodipine, are employed, and newer, atypical antipsychotic agents including clozapine and olanzapine are increasingly used to treat bipolar disorder patients, encouraged in part by an assumption that risk of tardive dyskinesia is low. The potential antisuicide effectiveness of these agents remains unexamined. An exception to this pattern is clozapine, for which there is some evidence of antisuicidal and perhaps other antiaggressive effects, at least in patients diagnosed with schizophrenia. (62) Clozapine is sometimes used, and may be effective, in patients with otherwise treatment-unresponsive major affective or schizoaffective disorders (63, 64), but its antisuicidal effects in bipolar disorder patients have yet to be investigated. Contrary to the hypothesis that serotonergic activity may contribute to antisuicidal effects, clozapine has prominent antiserotonin activity, particularly at 5-HT2A receptors (65, 66), suggesting that other mechanisms may contribute to its reported antisuicidal effects.

EFFECTS OF DISCONTINUING LITHIUM ON SUICIDE RISK

Another factor to consider in interpreting the findings pertaining to effects of lithium treatment on suicide rates is that most of the studies analyzed involved comparisons of suicide rates during vs after discontinuing long-term lithium treatment. In a recent international collaborative study, we found that clinical discontinuation of lithium maintenance treatment was associated with a sharp increase in suicidal risk in a large, retrospectively analyzed sample of bipolar I and II patients.(8, 9, 20, 21, 46) Rates of suicide attempts had decreased by more than six-fold during lithium maintenance treatment, compared to years between onset of illness and the start of sustained maintenance treatment (Table 2). In these patients, nearly 90% of life-threatening suicide attempts and suicides occurred during depressive or dysphoric mixed-mood states, and previous severe depression, prior suicide attempts, and younger age at onset of illness significantly predicted suicidal acts.

In striking contrast, after discontinuing lithium (typically at the patient's insistence following prolonged stability) rates of suicides and attempts increased 14-fold overall (Table 2). In the first year after discontinuing lithium, affective illness recurred in two thirds of patients, and rates of suicide attempts plus fatalities increased 20-fold. Suicides were nearly 13 times more frequent after discontinuing lithium (Table 2). Of note, at times later than the first year off lithium, suicide rates were virtually identical to those estimated for the years between onset of illness and the start of sustained lithium maintenance. These findings strongly suggest that lithium discontinuation carries added risk, not only of early recurrence of affective morbidity, but also of a sharp increase in suicidal behavior to levels well in excess of rates found before treatment, or at times later than a year after discontinuing treatment. These increased suicidal risks may be related to a stressful impact of treatment discontinuation itself that may have contributed to most of the contrasts shown in Table 1 between subjects treated with lithium vs subjects who discontinued lithium use.(8)

If stopping lithium is followed by added suicide risk associated with recurrence of bipolar depression or dysphoria, then slow discontinuation of treatment may reduce the incidence of suicide. Encouraging preliminary findings indicated that, after gradual discontinuation of lithium over several weeks, suicidal risk was reduced by half (Table 2).(9, 21) The median time to first recurring episodes of illness was increased an average of four times after gradual vs rapid or abrupt discontinuation of lithium and the median time to bipolar depression was delayed by about threefold. (8, 45, 46) The apparent protective effect of gradually discontinuing lithium against suicidal risk may reflect the highly significant benefits of gradual discontinuation against early recurrences of affective episodes as a key intervening variable.(8).

About the authors: Ross J. Baldessarini, M.D., Leonardo Tondo, M.D., and John Hennen, Ph.D., of the Bipolar & Psychotic Disorders Program of McLean Hospital, and the International Consortium for Bipolar Disorder Research. Dr. Baldessarini is also Professor of Psychiatry (Neuroscience) at Harvard Medical School and Director of the Laboratories for Psychiatric Research and the Psychopharmacology Program at McLean Hospital.

Source: Primary Psychiatry. 1999;6(9):51-56

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Researchers are working on a physical test to pin down diagnosis of ADHD.

Boston Life Sciences, Inc. released details of a human clinical study demonstrating that its diagnostic radioimaging agent, Altropane™, has detected an abnormal elevation in the number of dopamine transporters (DATs) in the brains of subjects with longstanding Attention Deficit Hyperactivity Disorder (ADHD). The study appears in the current issue of the prestigious British medical journal The Lancet.

Dr. Alan Fischman, senior author of The Lancet study, and Chief of Nuclear Medicine at the Massachusetts General Hospital stated, "the findings in this study are very significant, and demonstrate that Altropane potentially could be of great value in establishing the existence of an objective biological abnormality in ADHD."

Upon reviewing the study, psychiatrist Edward Hallowell, M.D, nationally recognized expert in ADHD and author of the book Driven to Distraction, stated, "Altropane is the most promising development I've seen in a long time in terms of our coming up with an actual physical test that could help us pin down the diagnosis of ADHD."

"There is currently great concern among parents, educators and health professionals regarding the accuracy of current psychosocial criteria used to diagnose ADHD, particularly in children, and the related problem of inappropriate use of potentially addictive stimulant medication for this poorly-defined condition. If the positive results obtained in our initial study in adults are further confirmed in children, we expect that Altropane will prove to be of immense value in helping health professionals and parents to deal with these important issues. Given its potential use to objectively diagnose ADHD in students as well as young adults who exhibit symptoms of inattentiveness and hyperactivity, Altropane can also provide a definitive basis for the use of medication in those patients who might otherwise be reluctant to initiate drug therapy," stated Marc Lanser, MD, Chief Scientific Officer of BLSI.

John Heavener, Chief Executive Officer of CHADD, the nation's leading advocacy organization dealing with ADHD stated, "Altropane is potentially a valuable tool in reinforcing the diagnosis of the ADHD, and in providing the public with proof the disorder exists. We receive 200 to 300 calls everyday asking about the diagnosis and treatment of ADHD and we are encouraged that Altropane may be a meaningful tool in advancing the science used to diagnose the disorder."

"To our knowledge, this is the first clinical study to demonstrate that there is a measurable biochemical abnormality in patients with ADHD. In this trial, adult patients with expertly-diagnosed, longstanding ADHD underwent Altropane-SPECT brain scans. In the scan, a Striatal Binding Potential (SBP) was calculated for each patient. The SBP is an indirect measure of the quantity of dopamine transporters (DATs) in the brain. Each and every ADHD patient had a SBP that was at least two standard deviations above the mean SBP of age-matched controls. These results demonstrated that abnormal levels of the DAT are directly associated with the clinical symptoms of ADHD in this patient group," added Dr. Lanser.

Altropane is a small molecule invented by researchers at Harvard and the Massachusetts General Hospital that binds with extremely high affinity and specificity to the DAT. Consequently, the amount of Altropane taken up by the brain is directly proportional to the number of DATs that are present in any given area of the brain. In Parkinson's Disease (PD), there is a marked decrease in the number of DATs in the striatal region of the brain. As a result, Altropane uptake is substantially diminished. This marked decrease in Altropane uptake in PD is the basis for BLSI's diagnostic test for early PD. For this application, Altropane is now in a Phase III trial and if successfully completed, will be submitted for marketing approval next year. Conversely, as now suggested by The Lancet study, ADHD appears to be associated with an excess number of DATs in this same region and thus Altropane has the potential to prove to be a powerful diagnostic for ADHD as well.

ADHD is the most commonly diagnosed behavioral disorder in children and is the fastest growing psychiatric disorder in adults. Since 1990, the total number of American children diagnosed with ADHD has risen from 900,000 to over 5.5 million, and the use of stimulant medication such as Ritalin" has increased 700% in the same period. ADHD is currently diagnosed according to a set of behavioral criteria defined in the Diagnostic and Statistical Manual (DSM) used by psychiatrists. However, it has not been possible to validate these criteria against an objective biological standard, since such a standard has never been established and does not currently exist. Consequently, the DSM criteria have generated widespread concern and, in the view of many critics, often are misapplied and misinterpreted. The lack of a clear-cut, demonstrated biological basis for ADHD has led to a great deal of confusion concerning the diagnosis of ADHD and has even provoked skepticism regarding the very existence of the disorder.

"With 5-10% of approximately 55 million school-age children currently diagnosed with some form of ADHD, roughly 1.5 million initial visits for ADHD per year, and with approximately 1.5 million adults diagnosed with ADHD, the Company believes that Altropane has the potential, if approved, to become one of the largest selling radio-pharmaceutical diagnostics ever developed. We hope to initiate Phase II/III testing for the diagnosis of ADHD early in 2000. The clinical protocol for the ADHD study is currently under review by radioimaging and ADHD experts at the Massachusetts General Hospital and Children's Hospital at the University of Pennsylvania," stated David Hillson, CEO of BLSI."

Source: Press Release from Boston Life Sciences Inc. Please visit their web site for more information.