ADD ADHD and Tourette Syndrome.

Dear Bob,

How about a follow-up to your column on ADD/ADHD -- one that deals with attention deficit disorder in staff. Some of the new information out on ADD in adults may have ramifications for working with staff as well as for directors. Learning about this new information opened my eyes to some of the coping mechanisms that might be helpful to others.

Lisa Duffell, Massachusetts

Dear Lisa,

Thank you for the opportunity to share some new information about attention deficit disorder in adults with readers. Since it is now understood that about 70% of children with attention deficit disorder will have some of their symptoms persist into adulthood, knowing some of the signs can help directors identify the syndrome in themselves and in staff, as well as develop creative ways of adapting to camp.

The statistic mentioned above, which makes it clear that many children with ADD/ADHD do have symptoms that extend well into their adult life, contradicts the belief commonly held just a few years ago that children out-grew the disorder during puberty. Unfortunately, many adolescents who don't get help with their ADHD often engage in troublesome activities that are actually attempts to control the constant "buzzing" they experience. One such behavior is drug abuse, which for some youngsters with ADHD is an attempt to "self-medicate." Another is engaging in high risk behavior, which is one way ADHD kids "calm the noise inside" -- they simply match it with adrenaline bursts from their high-risk activities.

One question I hear frequently from directors is, what happened to ADHD folks before we knew about it? One answer is that such people gravitated toward jobs or careers where their energy could be utilized constructively, such as on the frontier, in the circus or theater, in highly active jobs, and so on. There were more open spaces and more opportunities for "hands-on" work that could occupy some people with ADHD. Either that or they ended up in jail. Indeed, many experts believe that the prison population in the United States has an inordinately high percentage of people with ADHD -- folks who simply could not-make sense out of their world or whose risk-taking "adaptations" got them into trouble.

Thom Hartmann, author of the book, ADD: A different perspective, argues that attention deficit disorder is really an adaptive trait and not a disorder. He suggests, for example, that adults with what is now called ADHD would have been the ones who did the hunting in pre-modern days. These are folks whose bursts of energy and propensity toward action would have been well-suited to hunting, while they would have been bored and ill-suited for the routines of farming, gathering, or more settled tribal life.

My experience with adults at camp who have had ADHD but who have not had it diagnosed is that they have been able to survive at camp by developing various coping mechanisms to compensate for their disability. One way counselors with ADHD might adapt at camp, assuming they were able to function reasonably well in the community, would be to run special activities or special events -- activities that require creativity, familiarity with chaos, and a lot of movement and excitement. It would be deadly for such a person to have a position that required tracking a lot of mundane detail or being tied to a routine that did not change.

Signs of ADD/ADHD

What are some signs to look for if you as an adult think you might have some form of ADD/ADHD? The following is a partial list of traits to look for:

* fails to finish projects/assignments

* acts before thinking

* always on the go

* sensitive to criticism

* thinks negatively, even after exciting or positive experience

* has difficulty when reading

* has difficulty being and staying organized

* has trouble managing a check book

* tends to be a poor planner

* has trouble prioritizing

* outspoken and/or impatient with group process

* prefers to work solo as opposed to on a committee

* has difficulty giving or receiving soothing and holding (except, perhaps, with children)

* tends to be great at identifying children with ADHD!

For more information on ADHD in adults, read Attention Deficit Disorder in Adults by Lynn Weiss, 1992, Taylor publishing.

Dear Bob,

We have just discovered that we have enrolled a youngster with Tourette Syndrome. Can you tell us a little about it, including what we can expect from this young fellow and what special challenges he might pose to our staff?. Any ideas about where we can get information on the subject would also be helpful.

Concerned in California

Dear Concerned,

Tourette Syndrome (often referred to as "TS" by educators and mental health workers) is an inherited neurobiological disorder that usually first appears in children in their early elementary school years. There are four characteristic features of TS, the most commonly observed of which is involuntary multiple motor tics -- things like sudden jerking of the head or shoulders; rolling or blinking of the eyes; tapping or repetitive touching; and so on.

The second feature is something called "vocal tics." These involuntary noises can include throat clearing, growling, repeated coughing or a variety of other sounds or utterances. Some children with TS display echolalia (repeating what others have just said), while others may blurt out socially inappropriate words (technically known as "coproialia"). While very few children with TS actually manifest this last trait, it has become one of the most notorious and best known of those associated with TS.

The third characteristic of TS is that there are times when the symptoms can be very intense, and others when the symptoms virtually disappear. Also, some children with TS can, with extraordinary effort, suppress some of their behaviors for various amounts of time. Thus, a child with vocal tics might be able to be quiet during vespers or some other camp assembly, but experience a greater intensity of tics back at the cabin at bedtime. This may at first appear manipulative on the part of some children, so it is best to educate staff about TS if they will have contact with such a child.

The fourth characteristic of TS is that symptoms change over time. One year a child may exhibit eye blinks and head movements, while the next year he or she may display clicking noises with the tongue, and shoulder shrugs.

The most severe consequence for children with TS may be low self-esteem due to shame they may feel about their behavior. Some children with TS have a "short fuse," and lose tempers quickly. Others are sensitive to criticism and hold back from making friends. Though most cases of TS are mild, you should talk with the parents about their child (how the child has adjusted, what works, etc.), as well as with any physician who might be involved. Many children with TS are on medication to control the tics. The most common is Catapres, used in adults to control blood pressure. Catapres seems effective only in 50% of the cases. More recently, pediatric neurologists have been using small doses of Risperdal with remarkably good success.

Many children with TS usually also have ADHD, but because of the underlying tic disorder, these children cannot take Ritalin. In this case, the discussion needs to focus on how to help the child manage him or herself in the social and learning settings at camp. Just as with other children with ADHD, camp directors need to establish with parents what the social skill level is of any TS child, with or without ADHD. This will help determine whether a child is ready for the social community that camp is. For more information on TS, contact:

Tourette Syndrome Association 42-40 Bell Boulevard Bayside, New York 11361-2874 718/224-2999

Bob Ditter is a licensed clinical social worker specializing in child and adolescent treatment. Camp directors are invited to write to Bob at Bob Ditter, "In the Trenches," 93 Union St., Ste. 307, Newton, MA 02159. Letters should be signed, although requests for confidentiality will be honored. "In the Trenches" is sponsored by American Income Life Insurance.