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It was 9:58 one recent morning and already Barbara Lucchetti had had to set a time limit for her 10-year-old daughter, Katie, who was giddily distracted from doing her morning chores.
For this Pacifica, CA. mother and daughter, it was the umpteenth contest of the day.
Katie, who awoke shortly after 8 a.m., had already resisted taking a shower ("I hate this, I hate this, I hate this"), spilled her Corn Pops and debated with her mother over which pair of pants to wear.
 Katie jumps on her brother David Lucchetti, 14. Her family is using behavioral therapy rather than drugs to treat her attention deficit hyperactivity disorder. |
It was a typical midsummer morning in the Lucchetti household.
Many parents can relate to having to ask a child to do something half a dozen times. The difference with Katie, her mother said, is that instructions never seem to sink in unless there's a threat of having one of her favorite activities withheld.
Katie has attention deficit hyperactivity disorder, an inherited developmental disability affecting 5 to 10 percent of school-age children. Like many kids with ADHD, Katie has problems with impulse control, attention and interacting with people.
Unlike many children with ADHD, however, Katie's parents have opted not to put her on Ritalin, the controversial stimulant drug commonly used to treat children with ADHD. Katie's father, Douglas, also has ADHD and had a negative experience taking Ritalin as a teenager. The Lucchettis say they want to exhaust all other options before they consider putting Katie on medication, and they have found help through a counseling program in San Francisco.
Ritalin, which has been prescribed for ADHD since the 1950s, speeds up part of the brain and enables kids with ADHD to focus better. Kids with ADHD are not mentally retarded. In fact, many experts say they excel in school once they are medicated. Many others succeed in the arts and leadership. Without medication, they have difficulty focusing and completing homework. They get in trouble with teachers and have trouble making and keeping friends.
More and more children's conditions are being diagnosed as ADHD, and although experts aren't sure what's driving the surge in cases, they suspect that it may be due to greater awareness of the disorder and the effectiveness of newer treatments.
Barbara has to be vigilant about watching her daughter's every move; working from home offers advantages that other parents of ADHD children don't have. On this particular morning, she tackled computer work for the family's cabinet-making business while keeping an eye on Katie. "Katie you're distracted again," Barbara said, the patience in her voice noticeably waning.
"I don't care," Katie replied.
"Katie, you have a time limit," Barbara said sternly. "If you're not done with your chores by 10:30, there will be consequences."
An all-too-familiar refrain in the Lucchetti household, the threat of consequences often gets Katie back on task. That, or its polar opposite: the promise of a reward.
"Nooo!" shrieked Katie from the other room. She begins to dart from room to room, hurriedly trying to beat the clock.
Even though some families of children with ADHD choose not to put their kids on medication, health experts say the benefits of Ritalin and similar stimulants are well established. The drug, they say, is perfectly safe when prescribed and closely monitored by a doctor.
Critics of the drug, however, argue that it is being overprescribed to children who don't need it, for the sake of convenience and cost. A bill passed overwhelmingly by the House earlier this year prohibits schools from forcing parents to medicate children with ADHD.
Dr. Peter Breggin, a psychiatrist in New York and a staunch critic of Ritalin, said under no circumstances should parents put their children on stimulant medication for what he considers a discipline problem.
"We're not even talking about a disorder here," Breggin said in a phone interview from his home in Ithaca, N.Y. "It's nothing more than a list of behaviors that annoy teachers. I don't think the answer is drugging our kids. Instead, we should be figuring out what their problem is. There's no substitute for caring enough."
The preliminary results of one small ADHD study in San Francisco seem to bolster one argument against Ritalin -- that kids with the disorder don't necessarily need medication and could benefit from more structure and discipline from parents and teachers.
The pilot study, led by Dr. Linda Pfiffner, a UCSF psychologist and professor whose research has focused on non-drug treatments for ADHD, showed that inattention in 13 children with ADHD was reduced by half after children were exposed to a series of classes covering independence and social skills.
Katie and her family participated in the study. In clinic classes, Katie learned how to be more patient, practiced tools to tune out distractions at school and learned about sharing and good sportsmanship. For good behavior, her mom now gives her coupons for cuddle time or computer time. For misbehaving or not completing homework or chores, she must pick a task from a job jar.
 Cuddling with her mother is a reward for good behavior. |
Barbara Lucchetti said she knew Katie, her youngest daughter, was different from her other children early in her development but attributed it to her being the last born. She was hard to reason with and easily distracted. When she didn't get her way, Katie would slam doors, run away or cry.
Lucchetti said that at times she was so distressed by Katie's behavior that she was in near tears herself. Douglas, Katie's father, said he recognized Katie's behavior as being similar to how he acted in his childhood but assumed she would grow out of it.
"We were very frustrated," Barbara said. "We didn't know why she was different. It never dawned on us she might have ADHD. You'd think we'd be embarrassed to have a kid who is 'handicapped,' but it was just the opposite. When we found out from the doctors it was ADHD, it was like a big lightbulb went off. We were happy we were able to figure out what it is."
Experts say it is not uncommon for families of children with ADHD to feel as if they are grasping in the dark for answers.
"Putting everyone on the same page is what makes it work," said Pfiffner, director of the HALP (Hyperactivity, Attention and Learning Problems) Clinic at UCSF. "We've seen improvement across the board, from academic competence to life skills."
The carrot-and-stick approach involves teaching parents and teachers how to give praise for good behavior and consequences for bad behavior, as well as involving children in setting their own goals. When kids in the program received praise for their accomplishments and were able to see the fruits of their labor, they felt better about themselves, Pfiffner said.
"I don't want to discount the benefits of medication," Pfiffner said, "but it's hard to argue with the improvements we're seeing in the kids in our study.
People don't use behavioral intervention as much as they ought to -- maybe because it's harder to do and families and schools don't have the resources.
"I'm not so concerned about children being overmedicated as I am about children with ADHD who are not managed as closely as we might hope," said Pfiffner, who got a grant from the National Institute of Mental Health to pay for the pilot study and is raising money to expand the program.
"I worry more about untreated kids and the consequences that result from that, from higher dropout rates to drug use later in life, conflicts in relationships, not to mention the toll it takes on their self-esteems."
There are children with severe ADHD symptoms whom Pfiffner said she would never stand in the way of medicating.
The Smiths of Livermore (who asked that their real names not be used to protect their son's identity) went to great lengths to cope with their son's ADHD before deciding two years ago that medication was the best option.
Colton Smith, who was 8 when his parents first suspected two years ago that he might have a problem, was receiving "red zones" for poor performance at school. Eventually, a seasoned teacher suggested that the Smiths have their son evaluated by a psychologist. It was at about this time that Colton took a razor blade and sliced an easy chair at home. Another time, he took a permanent marker to his father's favorite desk.
They found a Walnut Creek behavioral pediatrician who met with them several times before recommending that they put their son on Metadate and Ritalin, two stimulants.
"Before medication, our house was in constant turmoil," said Rochelle Smith,
a stay-at-home mom. "Our two daughters were caught in the cross fire. We'd ask (Colton) to clean his plate and he'd do 15 things between the table and sink.
"It's hard not to take it personally," she said. "It's difficult to step back and remember it's the disease. He's not intentionally rebelling."
Rochelle has more patience than her husband, who works long hours as a general contractor.
"Some days I'd just like to come home and put up my feet," Charles Smith said. "But my day doesn't end until the kids go to bed. You can't play catch with him because after three or four tosses of the ball, he's off picking dandelions or doing other goofy things. Sometimes I stand back and think, 'Who are you and what did you do with my son?' It's brutal. The medication is a big help."
The Smiths' doctor, Lawrence Diller, who has written two books about Ritalin, has been waving a flag of caution about the drug for nearly a decade, since children with mild symptoms began flooding his clinic in the affluent suburb of Walnut Creek in the early 1990s.
"My objection to Ritalin isn't that it doesn't work or that it's dangerous, " said Diller, who has been prescribing Ritalin for 25 years. "It does work and it is safe, but it works so well we forget it's not a moral substitute for developing better parenting. It isn't the best thing since white bread.
"My colleagues in the mainstream would say, given that (ADHD) is a neurobiological condition and that is primarily genetic, that parenting has nothing to do with it. Their first line of treatment is stimulant medication. There's a wide gray area with this disease, and not all children with ADHD necessarily need pills. The problem is non-drug interventions are less available, more costly and don't have a corporate sponsor."
To that end, Diller, like Pfiffner at UCSF, promotes a "less-talk, more- immediacy type of action" approach to raising children with ADHD. "Discipline is a large part of it," Diller said, "but you can't ignore the importance of positive reinforcement." Parents and teachers can learn to tap children's "internal motivators."
Lodi elementary-school teacher Julie Jensen said she has one or two children with ADHD in her class every year. She believes it's unrealistic to expect teachers to play child therapist or coddle misbehaving kids.
"That's bogus," she said. "A lot of parents refuse the therapy approach and then the school is stuck trying to cope. When you're in a classroom of 30 kids and you have a couple with ADHD, somebody's daddy is in jail and somebody's mama is doing something, you don't have time to throw out M&Ms for Bobby who can't sit still."
Jensen said that in her 15 years of teaching, she's never known a child on Ritalin who didn't need it. "We deal with them all day long, every day," she said. "The doctors may know their pharmacological whatever, but we're the ones who spend the time with them. We have a more objective view. I see the kids who need to be treated and aren't. They perform so much better when they're properly medicated. Their self-esteem is so much better; they get along better with their peers. They're no longer the hyperactive kid whom no one wants to be around."
The Smiths couldn't have said it better.
Before they had their son on medication, some days they felt like throwing in the towel. They would ask Colton to feed the rabbits and he'd be out at the cage singing and the food dishes would remain empty. His room would never get cleaned.
"Since he's been on the medication, he's more compliant and focused," Rochelle Smith said. "We really had no other option. Putting him on medication would not have been our first choice. More than anything, we want him to be successful in school. With the medicine, he's able to hold it together, stay focused and on track."
Colton, who is 10, recognizes that he has a problem and sees the benefits of the medication. The only side effects from the medication, his mother said, are occasionally losing his appetite and biting his nails. He eats a normal breakfast and dinner but isn't hungry at lunchtime.
"When I don't have my pills, I'm wild," he told a reporter visiting the family one morning. "I just want to do what I want to do, watch "Sylvester & Tweety Mysteries" and "SpongeBob." When I have my pills, I don't get wild and excited. My pills help me focus on the teacher (in school), and that's good because I don't want to get in trouble."
Back in the Pacifica home of the Lucchettis, Katie was off-task again. The clock was fast approaching 10:30 a.m. and she was focused on removing the batteries from a toy cash register, grinning with a sense of accomplishment once she disabled the toy's voice.
She then fiddled with a necklace. In a rush to meet her deadline, she grabbed her clothes, which were strewn across her bedroom floor, and tossed them over the closet rail as opposed to putting them on hangers. She stuffed toys in a jam-packed closet and slammed the door.
Then she reported to her mother, who was in the family room working on the computer. Lucchetti gave her daughter a high five, and as a reward Katie was allowed to invite a friend over to play.
In spite of the need for constant reminders and time limits, Lucchetti said she is seeing improvement in Katie. She is learning to accept praise, and doing better in school and her music and art classes.
Lucchetti has also come to accept her daughter's condition as something she and her husband may have to cope with into Katie's adolescence and teen years.
She said the classes at the HALP Clinic in San Francisco helped a lot.
"We've gotten so far," Lucchetti said. "If we stick to the program, we do good. If not, we fall apart.
Study: Teachers Diagnosing ADD in 50% of Cases; Doctors Acting as "Rubber Stamp"
Some resources on medical management of attention deficit hyperactivity disorder:
-- National Institute of Mental Health, definitions of ADHD and basic information on treatment options: Office of Communications, 6001 Executive Blvd., Room 8184, MSC 9663, Bethesda, MD 20892-9663; (866) 615-6464. On the Web: www.nimh.nih.gov/publicat/adhdqa.cfm.
-- Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHAAD), Maryland-based nonprofit organization with chapters throughout the Bay Area, (800) 233-4050. For more information on Ritalin, go to the group's Web site at www.chadd.org, see Fact Sheet 3 -- "Medical Management of Children and Adults with Attention-Deficit/Hyperactivity Disorder."
-- Statement on Methylphenidate (Ritalin) for Children With ADHD (2000) by Steven E. Hyman, M.D., director, National Institute of Mental Health: www.hhs.gov/asl/testify/t000516c.html.
-- HALP (Hyperactivity, Attention and Learning Problems) Clinic, UCSF, Box 0984-CAS, 401 Parnassus Ave., San Francisco, CA 94143, (415) 476-7667.
-- Children's Hospital Oakland's Developmental and Behavioral Pediatrics Child Development Center, evaluation, treatment and referrals for families of children with developmental disabilities, 5220 Claremont Ave., Oakland, CA 94609, (510) 428-3351.
-- The Children's Health Council, pediatric and adolescent mental health clinic specializing in treatment of children with ADHD, 650 Clark Way, Palo Alto, CA 94304, (650) 688-3625 or www.chconline.org.
-- "Medicating Kids," a PBS Frontline special report on ADHD, Ritalin and the experience of several families: www.pbs.org/wgbh/pages/frontline/shows/medicating.
Source: S.F. Chronicle
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