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SUSAN ASCHOFFA Tampa program uses play therapy to teach children with Attention Deficit Disorder how to focus and make friends.
TAMPA - Eight-year-old Conrad slouches in his chair and examines the tip of each finger inches from his face. He is oblivious to the other children seated at the table.
The others are talking about Brent and Alexis, who just play-acted at the front of the room. Brent and Alexis practiced having a conversation. They acted the opposite of Conrad: They focused. They listened. They did not fidget. They smiled at each other.
"Each person got to talk about the same amount, and they remembered to ask each other the questions back," psychologist Jonathan Greenstein says. He gives their practice chat a thumbs-up. (There are no thumbs-down here, only up or sideways.)
Greenstein is pleased. The 8- to 10-year-olds who meet in a group with him and several other specialists are having a good day. They come to the Child Development Center of Tampa Children's Hospital, in a bank building on Armenia Avenue, every Saturday morning for 15 weeks of group behavioral therapy. This is week No. 12.
Most in the group of 13 have been diagnosed with Attention Deficit Disorder, or ADD. Some are depressed, others anxious. About three-fourths take medication such as Ritalin. They struggle in school, though many have higher-than-average intelligence. They have difficulty concentrating and sitting still.
An estimated 5 percent of children ages 3 to 17 in the United States suffer from ADD, more recently referred to as Attention Deficit Hyperactivity Disorder, or ADHD. Two to three times more boys than girls are affected. Prescriptions for Ritalin have risen fivefold in a decade, statistics show. Critics contend that we are a nation guilty of overmedicating our children.
In his 1999 book Ritalin Nation, Richard DeGrandpre, Ph.D., says that the real problem is a "rapid-fire culture" overloading children and parents. ADHD, he contends, is a developmental, not chemical, shortcoming solved by destressing our children's lives.
Greenstein and many others counter that ADD is a very real neurological disorder. He is not seeking compliant children, he says, but happy ones.
He is teaching them how to get, and keep, a friend.
"What breaks my heart is that they're so innocent about it. They don't see that what they do contributes to not having any friends," says Greenstein, who at 6 feet 2 towers over his charges but is a gentle giant in plaid shirt and athletic shoes. He has worked with children in group therapy for almost 10 years.
"I'm not trying to teach them a pat set of manners, not just what to say. It's much more complicated than that," Greenstein says. "They don't have awareness that they're irritating other kids."
They barge into a room. They interrupt. They may be quick to anger. Or are overly sensitive.
They fail to read the social cues that others learn instinctively.
The child ostracized on the playground may be unable to pay attention in math class, Greenstein says. "You get a note if their grades are slipping or if they're misbehaving, but no one tells you they're sitting alone at lunch. There's no note for that," he says.
Instead, medication may be increased and a child disciplined for his poor academic performance, ignoring the social ineptness that is causing the problem.
So for 90 minutes on Saturdays, children ages 5 to 15 who have been split into different groups according to age or maturity work on their social skills.
They role-play on keeping a conversation going or joining one in progress.
They practice making eye contact and smiling when they say hello.
They cheer others in a game of finding matching cards placed face down on the table.
"Did anyone get a chance to be a social detective this week?" Goldstein asks at the beginning of the 8- to 10-year-old group session. (The St. Petersburg Times agreed not to identify the children.)
"I saw (a girl) had a toy, and I asked them if they got it at the carnival," says Maria, who is wearing blue velvet and is one of five girls in the class of 13.
One of the boys is beyond exchanging pleasantries.
"A bunch of third-graders who are on the soccer field are treating us second-graders like garbage!" he says.
Greenstein asks the group members if they have ideas on what to do.
"Ignore them," Ashlyn says.
"You could walk away," Andrew says.
"You could just tell them they're not being nice," Alexis says.
Greenstein, harking back to a previous lesson, wants to know what kind of statement is made when a person tells someone what they think.
"Brave talk!" says Conrad, now tuning in.
Another pair play-acts another conversation, this one about Easter, and Conrad is lost again. He uses his leg to bump the empty chair beside his into the table as the boy and girl describe decorating eggs and "boiling water in little cups of dye."
Greenstein likes the details. "Elaboration" is part of a good conversation, he says.
"I think they could have done a lot more topics," Ashlyn says. "They kinda stayed on eggs a lot."
The pair gets thumbs-up for big smiles, thumbs-sideways for kicky legs.
One of the adults in the room keeps a sheet on each child for ongoing evaluation, reports to parents and, at the end of class, points to be redeemed for prizes. Parents, and sometimes teachers and guidance counselors, are informed about a child's current issues and which areas of behavior are the focus week to week.
In the waiting area down the hall, a mother from Bradenton says that she brought her 10-year-old son to the group because he is painfully shy, a result of dealing with Tourette's Syndrome, a brain disorder characterized by tics that can accompanying ADHD. She hopes to prepare him for the social challenges of middle school.
"The other day, out of the blue, he told his father, "I'm really learning a lot"' in the group meetings, she says with relief.
Greenstein says that he is often saddened by what he observes at a school.
"I just did not expect the cliquishness. The boys tend to wear their hearts on their sleeve; the girls are more sneaky" in inflicting emotional comeuppances in the social maelstrom that is childhood, he says.
Although ADHD is the most heavily researched condition in child psychiatry, much about it remains unknown and controversial. No one is certain what causes it or exactly how to define it. The most common behaviors fall into three categories: inattention, hyperactivity and impulsivity, according to the National Institute of Mental Health.
Many still question how a disorder no one heard of 20 years ago now affects millions of children. Critics say that society and the medical community are simply trying to make all children into round pegs to fit into education's round holes. Others counter that the disorder has always been present but undiagnosed. In the past, its sufferers were shrugged off as wild boys, spacey girls, adrift adults.
More recent research suggests that ADHD tends to run in families and is caused by abnormal function of neurotransmitters in the brain.
"We are seeing a definite increase in anxiety disorders and depression in children," Greenstein says. "I think there's a lot of stress on them."
Untreated, those with ADHD and other behavioral issues can suffer low self-esteem, impaired relationships, academic or employment failure and may even impulsively commit criminal acts or engage in injurious behavior.
ADHD is treated with stimulant drugs such as Ritalin, Adderall, Concerta and Metadate. Paradoxically, stimulants improve short-term concentration and reduce impulsiveness in about three-fourths of children, likely by making more of the brain chemical dopamine available.
Unwanted side effects include insomnia, loss of appetite and, in some cases, body tics.
No one is certain about the long-term impact of putting children on "speed."
Many welcomed the arrival in January of the first nonstimulant drug approved by the Food and Drug Administration to treat ADHD. Called atomoxetine, it is marketed under the brand name Strattera by drugmaker Eli Lilly and Co.
"Strattera doesn't go to the part of the brain that causes tics, and it doesn't seem to aggravate anxiety," says Dr. Nancy Carnevale, also at St. Joseph's Child Development Center. Her specialty is developmental pediatrics. "It's a nice new alternative, and since it's a nonstimulant, you don't have to worry about addiction."
Strattera also is a noncontrolled medicine, meaning that prescriptions can be refilled by phone. The 12- to 24-hour capsule is simpler than the 4- to 12- hour doses of some drugs, easing the logistics involved when a child takes medication at school and proving a lifesaver for parents whose children fall apart at bedtime or in the morning, when a dose may be running out, Carnevale says.
With Saturday's session almost over, Greenstein tells the children that he wants to try something new, quieting an increasing amount of twisting, tugging and waving arms. They are going to talk about something on which they disagree.
"I think you've lost your marbles," Andrew says.
But others say there are times when people don't feel the same and they need to deal with it. They will discuss school uniforms, pro and con.
"It's a free country. We should be able to wear what we want," says Andrew, after first raising his hand for permission to speak.
"If a class goes on a field trip," Claire says, "they should at least wear T-shirts" that match so they can stay together and be safe.
"Uniforms are itchy," another says.
No feelings are hurt, and one of the adults rates their effort an eight on a scale of 1 to 10.
The room is beginning to sound like a muffled stampede, many feet banging against chair and table legs. It has been 90 minutes in a room with a closed door.
Increasingly, mental health experts think that behavioral therapy and medication combined promise the best results for people with ADHD. A five-year study to test combination approaches is under way at the National Institute of Mental Health.
Greenstein and his patients already know that as potent as any pill is the power to make, and be, a friend.