חריגות, טראומה ואמפטיה כולנו חריגים בעיניו

Uniqueness, Trauma and Empathy — We are all Unique in His Eyes

Translated from Hebrew by Claude AI. The original Hebrew text is preserved on the same page. Originally published in Hebrew in 'Horim Choshvim' (parenting magazine), Vol. 9, pp. 13-16, 1995.

The woman sitting across from me had come to the meeting with her newborn baby girl, to talk about the difficulties of her eldest son. When I said "Mazal Tov" to her on the birth of the baby, she burst into tears and the conversation took on a different character, turning to a different subject — her miscarriages. She had gone through more than eight miscarriages over the past ten years and, Baruch HaShem, she has three healthy children. "But all I do is cry, all the time. I try not to cry outside, but inside I cannot stop. The whole family around me is happy about the baby's birth, but all I do is cry. How can they ignore everything that happened before this daughter was born?"

She sat across from me, a polite nine‑year‑old girl. Her appearance was unremarkable except for the fact that she was wearing a wig. In a whisper she told me, "Nobody talks to me about it, and it's very strange that a nine‑year‑old girl is wearing a wig and how can they not see it — it's hard not to recognize that it's a wig." She had undergone "treatments" for an illness and her hair had fallen out. "Not one of my friends visited me in the hospital, but I thought that when I came back somebody would say something about the wig."

"Isn't it true that no one is perfect?" asked the girl sitting across from me. "Isn't it true that everyone has something? I have a leg and a hand that don't quite work — but is that a reason not to invite me on a trip to the zoo?"

These three conversations, which took place many years ago, taught me an important lesson. "Being different" is a synonym for "being isolated." People who have been through hard situations feel alone, as though waiting for us to say something, to draw closer to them. We were taught — and we teach our children — "don't stare at someone who is different." In conversations with friends, and in the bosom of the family, we do not bring up subjects that are "not pretty."

The conversations described above attest to the loneliness of people who feel themselves to be different, because of the various circumstances that brought them to their state. In their differentness, they feel isolated from society.

How should we behave with "different" families — families that have been through, or are currently going through, trauma, bad news or some other catastrophe?

A child who falls comes to his mother bitterly crying, with a bleeding knee or some other injury on his body, and she says, "Oh, it hurts you a lot; I'll give you a kiss and it will pass." His mother saw the source of the crying / pain, identified it, and let the child understand that his pain has a cause and that she is "with him" in his suffering. Another mother, perhaps less empathic, might have said, "Nothing happened, everything is fine." In the end, both children will recover from their pain — but one will recover with the feeling that his mother respects his sensation and will feel less isolated, while the second child is liable to be left with the view that the world is a cold place and that every person is alone in his sorrow as in his joy, something that will make it more difficult, in the future, for him to be empathic and sensitive.

The story is well‑known of the Rebbe (Rabbi Yehudah HaNasi) who felt the need to "enter into" someone else's pain in order to be able to pray for him. In other terms this is called — empathy, as opposed to sympathy. Someone who radiates sympathy, as it were, gives the other person the feeling that he understands his message that he is in pain.

Empathy, on the other hand, is to truly enter into the feeling, as if to feel that same pain oneself: "Once I too fell and the exact same thing happened to me; I know how much it hurts and burns."

Empathy is to feel that you are in his situation, in "his shoes," of someone else. In the Mishnah, in Pirkei Avot, the meaning of the word "empathy" is expressed in the sentence "Do not judge your fellow until you reach his place."

With empathy, we come to visit the person who is in pain; we are with him in his sorrow — he is not alone and isolated.

Perhaps the question now arises in your minds — how do the concepts of "empathy" and "sympathy" connect to the subject of people who are different? Whether they have a wound or whether it is an inner pain that is not visible, or a different condition, the fact is that we ignore it because it is hard for us to identify with the situation, or because we have learned from our environment that one does not speak about such situations.

Without responses from those around them, the child, the man, the woman, or the entire family (which is going through the difficult experience associated with a "different child") will feel — isolated.

What is the dynamic (psychological/emotional process) we go through when, God forbid, we hear bad news?

Anyone to whom hard news is delivered passes through stages similar to mourning.

When a child with a difference is born, or when another trouble lands on the family that isolates them, or if, God forbid, someone has received bad news about his health — they mourn. They mourn the healthy child who was not born; the loss of one's own health, which is considered the norm; they mourn the "order" in our world which has suddenly been disrupted.

When visiting a shiva, we have rules, signposts, of how to behave: in the first three days of the shiva, we let the mourner initiate the topic of conversation, and when those first days have ended, the visitors initiate the conversation — we come towards the mourners.

In contrast, we have no rules instructing us how to behave in the unusual situations described above as traumatic situations.

Understanding the processes of this special "mourning" will perhaps teach us what the "different" family is going through, and will help us to communicate with them and draw close to them, in order to remove them from the loneliness in which they are immersed.

A person under trauma goes through processes described in the psychological literature, namely:

1. Psychological shock
2. Preoccupation (re‑living the trauma over and over in thought)
3. Anger
4. Guilt
5. Depression
6. Social and familial pressure
7. "After the fact"

1. Psychological shock:

The very fact of the "news" shakes the psychological/emotional "balance" of the person hearing it. Sometimes, the reaction is a feeling that he feels nothing at all. The person, as it were, distances himself from the life going on around him. People describe this as "feeling like a log" — a general fatigue and behaving like a "robot."

On the other hand, this distancing acts as a defense and gives the sufferer time to digest what is happening, while he is "as though" functioning and living "as usual."

2. Preoccupation

For a long time, even for years after a traumatic event, that same fateful moment occurs over and over in the thoughts of the person suffering from the trauma. Nightmares at night and waking nightmares, like a script that repeats itself again and again. As though re‑enacting — playing out the whole script and trying to change the outcomes.

The therapeutic value that arises here is the attempt to gain control over the shocking situation. Trauma shakes a person's trust in his own ability to control situations in general; "preoccupation" allows him to process the matter anew, to arrive, as it were, at a different path, to "change" the outcome, and by this means to once again take control of his life.

3. Anger

A feeling of very strong anger. Anger toward oneself, even though there is no place at all to feel guilty. Anger toward others who are not suffering as he is, who can continue to live "as usual." Anger toward those who delivered the bitter news, and anger toward the injury itself or toward the child who was born "not okay."

The positive side of anger is expressed in the fact that it constitutes an important factor that gives a person the strength to act. All of us, almost certainly, have personally experienced situations in which we were angry, and the anger was the "fuel" that brought us to act one way or another.

4. Guilt

Parents feel guilt that they were born "okay" and could not "absorb" or receive the defect themselves, instead of "letting" the child experience it. This guilt resembles survivors' guilt (guilt over the fact that they were saved from a disaster and did not suffer or die, like the others). Or guilt — why didn't I do more to prevent the situation? The feeling of guilt arises specifically in situations that are unavoidable — for example, in an earthquake or other natural disaster, people feel that perhaps it was in their power to prevent the catastrophe. Here too there is a positive contribution to the feeling of guilt. In situations in which a person has no control at all over what is happening, the feeling of guilt gives him the ability to feel that he did in fact have power/control, and he alone is to blame for not having exercised the control that was in his hands.

On the other hand, if the one suffering from guilt does not give expression to this feeling, does not process it, examine it, and allow it to pass, the guilt turns into shame. Shame is a more draining feeling, which, instead of granting a person strength and control, absorbs the strength, weakens him, and does not allow him to work through healthier processes.

5. Depression

Depression is connected to loss. (The "finality" — the end of relationships that had been expected.) Parents who have received bad news feel the "death," the loss of a part of themselves, of who they were before the bad news. Once, a mother described to me how she continues to live, but there is a "room" in her heart that is forever dark. A part of her has died, because she will never again be what she was before.

6. Social and familial pressure

People whose disaster is expressed in death can turn to family or community for help. There is a burial, there is the week of shiva, and all the familiar customs of mourning. However, in a situation in which the parents have been informed of their child's difference, they cannot receive this kind of "care." They are alone in their sorrow. There is no one to prepare food for them in the first week, when they are as if in shock — like "a log." Especially in our circles — the close family sometimes does not know; that is, the parents do not tell their parents and siblings the bitter news they have received. All the more so do friends and neighbors not know, and therefore are also not able to help — to be present physically or emotionally with the sufferers.

7. "After the fact"

As stated above, in the traumatic situation of receiving bad news, there is no "burial" as there is in death and other loss. The wound remains, as it were, open forever. Sometimes one can see only a scar, but with every passage or other injury, the wound opens again and oozes blood/pain.

Especially in our community, there is a void in the ability to continue as before. Even when one continues to live a "normal" life, there is a "scar" in the belief that everything is going well. As though a disturbance in the certainty that after the sun sets it will rise again. The world and the belief in "order" have been disrupted forever.

In the psychological literature there are well‑known stages of mourning. The processes that a bereaved person goes through resemble what is described above in sections 1 through 6. The stage that differs is stage 7, the stage of "after the fact." In bereavement, in mourning, the final stage is the stage of "acceptance." The mourner mourns for a reasonable period of time (about a year) until he reaches the stage of "acceptance." He accepts — digests reality — and continues onward with his life.

Among people who have experienced a trauma such as receiving bad news about their child's differentness, there is no "acceptance" — and moving forward — in the same sense as there is with "death" or with mourning.

Acceptance in this case is that life has changed forever, and that there is indeed a kind of return of the strength to take charge of the new life, but life will always be different. The wound will not scar over and will not become a scar that never opens again.

The parents must go through a process of "acceptance." To accept the reality that the healthy child they had, or whose birth they had anticipated, will not be. The degree to which they are able to accept themselves as being different from who they were before they received the bad news, and their ability to accept their current child as he is, with his strengths and his unique personality in every sense — this is what will testify to their ability to succeed, to live, and to continue on to "after the fact."

Understanding the stages and processes that parents of a "different" child go through is the point at which we — the broader community and the family — can help them, and by means of that same information enrich our own lives as well.

What is the way to help people who have suffered trauma, as described in the psychological literature:

1. Give empathy and support to the capacity for adjustment (the opposite of helplessness). To return the strength to cope to the person.
2. Acceptance of unusual situations as normal, routine situations — for "differentness" is in fact a feature that exists in normal life. If we, as a community, will make an effort to change our attitude and stance toward what we feel to be different, we will be capable of assisting and easing the burden on those families in the community in accepting the situation of the "different" person.
3. Prevent the families from their desire to disconnect from "regular" society. Teach our children (and ourselves) how to behave in the presence of any kind of differentness.
4. Grant them a sense of being able to take control of what is happening, instead of a feeling of helplessness. Perhaps ask for help from parents who have personally experienced some disaster or who have a child who is different — how to cope in difficult situations — because, in the end, such people, who continue to live among us after such a trauma or another, are possessed of tremendous strength, and we have much to learn from them.

If we use the example of the shiva, when we visit we say that we are "with them in their sorrow," "may HaMakom comfort you among the other mourners of Zion," and "may you be comforted from heaven." The essential difference is that the mourners allow us — to "enter into" their sorrow and to allow them to feel and to express their sorrow on the matter; these are our empathy and our sympathy for their situation. In cases of trauma, and especially upon being informed of "differentness," the family, as a rule, does not allow us to be with them — and therefore, here, the communal work must be done. The community must change its approach to children with differences and to their families, in order to enable families to come out of their loneliness, and to allow them to move on to the next stage in the process of mourning or trauma, the stage of "after the fact."

"All of Israel are responsible one for another" — this is empathy — empathy demands openness on both sides. The one suffering from the trauma must be "open," must take the risk of revealing the pain; and the wider community must be "open" to receive the information and to "enter into the shoes" of the sufferer in order to understand him properly. Only in this way will each of us help the other.

Language: terms we use

The labels we apply to human beings often pull along with them an attitude that matches that label, and the main sufferers are those very people who have a certain difference. The guide that follows is drawn from the book Handicapping Language — A Guide for Journalists and the Public, and is intended to improve the way we relate to these people.

People with "disabilities"

"Disabled" is a word with a negative connotation for most people. Therefore they should be referred to as "people with disabilities." "Disability" describes a situation or barrier caused by society or the environment. That is: "She is limited in her ability to use transportation," or "Stairs are an obstacle for him."

Person first:

The person comes before the disability. We are speaking of "a person with a disability," not a "disabled person." A person with "cerebral palsy," not "a cerebral‑palsied person."

Avoid pity:

People with disabilities are not "victims." A woman in a wheelchair is not a "victim." Her victims are those whom she runs into with her chair in the supermarket. Likewise, they are not particularly brave or "inspirational" because of it.

Descriptions are not names:

One should describe the disability and not label the person or the group with a name. That is: "people who have a disability" and not "the disabled." "A person suffering from epilepsy" and not "the epileptic."

Avoid being too "nice":

Terms such as "physically challenged," "special," and "differently abled" give off a whiff of condescension. If there is need to note that a person has a physical, sensory, or intellectual disability — then say so, and that's that.

Relevance:

People with disabilities should be related to like anyone else. Just as you would not mention the physical condition of a person who is not disabled unless it is relevant to the conversation, so too, if the condition of the disability is not relevant, do not mention it.

Contact with people with disabilities:

When you are introduced to a person with a disability, it would be polite to shake hands. Even someone who is limited in the use of his hands will usually be able to do so. If you are not sure — let him take the first step.

Relate to an adult as you would to any adult. The presence of a physical disability does not indicate an intellectual disability. Relate to the person with a disability with the same respect with which you relate to others. Speak to him directly and not to his companion, and leave childish speech for children.

Speech impairments:

Ask questions that can be answered briefly or with a nod of the head. Don't pretend you have understood when you have not. Repeat what you think you heard, and if you did not succeed — use writing.

Deaf or hard of hearing:

Focus his attention on you, touch him gently, wave your hands or use some other physical sign. If there is an interpreter, turn your face toward the hard‑of‑hearing person and not toward the interpreter. If the person reads lips, look straight at him, speak slowly and clearly, do not exaggerate the movements of your lips, and especially do not shout. Speak with expression, because the person will use your expressions, your movements, and your body language in order to understand. Do not stand with a bright light behind you, and keep your hands, cigarettes, and food away from your mouth when speaking. If there is still difficulty in communication, do not hesitate to use writing. Even the very best lip‑reader manages to read less than half of the words that you use.

Visually impaired:

When you meet a person who suffers from a severe visual impairment, identify yourself to him and introduce to him everyone who is present in the surroundings. Before you shake his hand, say something like, "Shall we shake hands?" or extend your hand toward his outstretched hand. When you sit down in your places, make sure that his hand is on the armrest of the chair.

When walking from place to place, offer him your arm for support, and inform him of obstacles such as stairs, curbs. At a meal, do not feel embarrassed about directing the person to the location of the utensils or other objects on the table. Let the person know when you are leaving.

People in wheelchairs or on crutches:

The chair is a part of the person. It is not polite to lean on or touch the chair unless you have received explicit permission to do so. Never pat a person in a wheelchair on the head. When you speak to a person in a wheelchair or on crutches for more than a few minutes, position yourself at eye level. Let people who use a wheelchair or crutches be within their own reach.

Make sure that the meeting place is reachable in terms of parking, restrooms, an elevator or ramp, and other essential things. If there is a problem, inform him about it; make sure he can arrange a suitable accommodation.

Cognitive (perceptual) disabilities:

Speak in short, clear sentences and maintain eye contact. Ask open‑ended questions and not yes‑or‑no questions or multiple‑choice questions.

Don't be frustrated if it is hard for you to make contact. Be patient and pleasant. Sometimes it will help you if there is alongside you a person who is familiar to him, to calm him, and who can also translate for him.

Not this — but this

Attention deficit with hyperactivity — ADHD (Attention Deficit Hyperactivity Disorder)

• The syndrome
• Description of the disorder at different ages
• The causes of the disorder
• The treatment and rehabilitation of these children

Moshe came home from school early again. The Rebbe spoke with his father and told him that Moshe is not focused in class. The Rebbe said: "He has a problem with concentration, he is 'impulsive,' 'mischievous,' and in other words he is 'hyperactive.'" Moshe's father felt great anger. (He was angry at the Rebbe for not succeeding in controlling Moshe. He was angry at his wife, because he felt that Moshe's maladaptive behavior in class is a sign that she is not fulfilling her role as a mother and "educator" of the children.) And in the end he was angry at Moshe. All the other children in the cheder are behaving properly and only his son is acting "deliberately" (out of line).

Raphael sits in the room more or less quietly. The Rebbe does not complain. When he comes home his mother describes a different picture. It is impossible to calm him. He is angry, throws objects, cries that he is hungry and does not want to eat. At night it is hard to put him to bed. When he sleeps he is not calm. He often wets the bed. The rest of the children in the family complain about him all the time, and his mother is helpless as to what can be done.

"I am not going to take him to pray anymore," so began Shmuel's father at the meeting with the psychologist. "He made a fool of me. He did not sit quietly, he made noises and even threw the candies that someone had given him. At home he is quieter, especially when he is left alone. But there are days when he is simply unable to get dressed, that is to say, I give up trying to dress him. He is already seven years old, you know. When he is alone with his mother and there is a certain daily order — he behaves like an angel. In the cheder he has a Rebbe who keeps watch and Shmuel behaves properly. What can be done? Is there a medication or something that can be given to us to help him — and me — to calm down?" the father asks.

Rivki is a nine‑year‑old girl. Her parents describe a child who has no friends. She succeeds in her studies up to a certain limit, but all her teachers say they are convinced that she could have achieved more if she were more focused. In class she gets up, walks around, answers questions without permission, and even pesters the other girls during recess. Today no one wants to sit next to her. With tears in her eyes the mother reveals that she understands the girls in the class — because she herself does not enjoy being in her daughter's company. "She does not have the kind of manners that my other children acquired at home; perhaps there is some medication that can help her?"

These are a summary of a number of referrals for evaluation at the pediatric‑neuropsychology clinic at Shaare Zedek Hospital.

At the conclusion of a thorough evaluation, only one of these children was diagnosed as "hyperactive" — on the basis of the results of neurological and neuropsychological examinations. For the other children, recommendations were given for behavioral treatment, guidance for the parents, and specific recommendations for the educators, tutoring lessons, occupational therapy, and more.

Attention and concentration disorders include lack of focus, impulsivity, and sometimes hyperactivity (ADHD, ADD). Hyperactivity in itself is a very common disorder, between 3% and 5% in children aged 5 to 13 years, and much more common in boys than in girls. It is not known why this is so. There are hypotheses that boys are indeed "built" differently from girls (surprise?!), and there are those who say that in our culture we expect more of boys than we expect of girls and that this hidden pressure causes this difference. To this day there is no explanation agreed upon by all the professional sources.

Description of the syndrome of ADHD (attention deficit with hyperactivity)

Primary symptoms:

• Difficulties in attention
• Impulsivity
• Hyperactivity

Secondary symptoms:

• Low academic achievement or learning disabilities
• Physical and verbal aggression
• Low self‑image
• Poor interpersonal and social relations

Developmental changes in the symptoms:

1. Infancy:

These children may have a history of difficulties during the pregnancy and during the birth. As infants they tend to be more active, restless, and there is a notable lack of consistency in eating and sleeping patterns — but this is not always the case.

2. Early childhood:

During the daycare and kindergarten years, these children are more active and exploratory than is customary. They respond less than others to the discipline methods accepted for children at this age, and they tend to engage in dangerous behaviors as a result of impulsivity.

3. School age:

As the demands for self‑control, focus, and perseverance become more demanding, the child's difficulties also increase, and the differences between him and the rest of his peers grow. These children appear to lack the ability to regulate attention and activity, and to adapt to the demands of the environment. At this stage, specific learning disabilities and difficulties in social relationships with peers may appear, which may form a basis for the development of a low self‑image.

4. Adolescence:

Difficulties in focus, impulsivity, and restlessness are likely to continue, but the hyperactivity may be in decline. The secondary difficulties mentioned above may become prominent.

5. Adulthood:

Current studies show that difficulties in focus continue, and there may also be emotional and behavioral difficulties.

A. The disorder appears for at least six months, and eight out of the following fourteen points are present:

1. Tends to restlessness and to nervously moving hands and feet in his chair. (In adolescents this behavior is more subjective: feelings of unrest and restlessness.)
2. Has difficulty sitting in a chair when he is required to do so.
3. Is easily distracted by external or peripheral stimuli.
4. Has difficulty waiting his turn in games or in group social situations.
5. Tends to speak without permission in class and to blurt out answers to questions before the teacher finishes asking.
6. Has difficulty following the instructions of others. (Not because of oppositional behavior or difficulty understanding the task), for example: he does not succeed in finishing work.
7. Shows difficulty persisting in or attending for prolonged periods to tasks or games.
8. Tends to move from one task or unfinished activity to another.
9. Has difficulty playing quietly.
10. Tends to talk excessively.
11. Tends to interrupt the speech of others or to disturb the games of other children, and tends to intrude into the personal space of others.
12. Tends not to pay attention to what is said to him.
13. Tends to lose objects essential to tasks or activities at school or at home: games, pencils, school supplies.
14. Tends to engage in physically dangerous activities, without considering the consequences, for example: running into the road after a ball without looking.

B. The beginning of the behavioral phenomena before the age of 7.

Etiology (the causes of the disorder):

An effective approach in understanding the syndrome of attention, concentration, and hyperactivity (ADHD) is an approach that includes the following areas:

Genetics:

There is a hypothesis that there are "unusual" genes that explain the existence of this syndrome, especially in families in which there is a father or an uncle with the same problem in the family.

Neurophysiology:

There exists a mild brain injury (MBD — Minimal Brain Damage), which today is not considered the sole cause of this syndrome.

Biochemical factors:

A mother who drinks alcohol or smokes during pregnancy, smoking by the father in the home, and/or by the melamed in the child's classroom (second‑hand smoke inhalation), are considered primary factors in problems of attention and concentration. (In the secular population smoking is in decline, while in the charedi society smoking is still on the rise. Who has not seen children smoking on Purim?!)

Psycho‑social factors:

Including familial, developmental, social, and emotional factors. Family and social factors do not create this syndrome in a child, but they do influence the development of a child suffering from ADHD. (For example, it is harder for a child with slow motor‑emotional development to succeed in acquiring reading at age three than it is for the same child in a society in which they teach him to read at age six. These three years are important and vital in the development of this child!!)

Within these families are included families in which the mother suffers from depression, and families in which there are difficulties in setting clear boundaries in the area of behavior.

Neuro‑biological factors:

In laboratories today, many studies are being conducted on the subject of the chemical and biological metabolism in the body, and especially in the nerve cells of the brain, from which behaviors stem.

Factors of maturation and arousal:

Questions concerning impairments in the mechanisms responsible for arousal in the brain. Scientists are testing the hypotheses that the difficulties of children with the ADHD syndrome in "calming down," in working slowly, and in focus and concentration, are connected to a defect in the nervous system at the place where the regulatory center of alertness is located (there is over‑alertness to the environment, or there is not enough alertness to stimuli in the environment).

Neuro‑anatomical factors:

Scientists in this field have a hypothesis that the structure of certain regions in the brain, of children with this syndrome, is different from the structure of other regions that are normal. These hypotheses are built on these children's difficulties in planning, difficulties in social judgment, increased emotional arousal, impulsivity, emotional volatility (mood swings), and more.

Toxic factors (TOXIC):

There are children who have the syndrome PICA. These children eat paper or chalk, and things that contain lead (LEAD) in a high quantity, which may cause cognitive impairments.

Nutritional factors:

In 1975 Dr. Feingold (USA) raised the hypothesis that there are substances (colorings and food preservatives) that cause hyperactivity in children. Over the years this hypothesis and other hypotheses have been examined, and today the scientific literature is of the opinion that for a very small percentage of hyperactive children, drastic changes in nutrition will be helpful. The vast majority of hyperactive children are not influenced by the presence or absence of these substances in the various diets.

What recurs in the studies is that there are hyperactive children who are helped by a portion of protein in their breakfast; other hyperactive children are helped by sugar in their diet, while other hyperactive children become more hyperactive when they are given an addition of sugar in their diet. So it appears that each case must be examined on its own merits.

The treatment of children suffering from ADHD

As you have understood from what has been said so far, there is still no certain conclusion regarding the source of ADHD (problems of attention, concentration, and hyperactivity). Likewise, there is no single treatment that "solves" this problem. Diagnosis and treatment of children with this syndrome must include cooperation among various parties: the child, parents, teachers, doctors, and psychologists.

Family treatment / parental guidance

Parents need support and reinforcement in their efforts to help their children. The perception that the child is a "bad child," "stubborn and rebellious," "acting deliberately," "not responsible for any of his deeds" — must undergo a change. The environment must adapt itself to the needs of a child with this syndrome. Too many stimuli in the room, classes that are too large, lack of organization or lack of consistency in the daily routine make things difficult for the child suffering from this syndrome. Times for eating and sleeping should be consistent. Likewise, one must set clear boundaries for the child.

Behavioral treatment

The child, the educational system, and the parents must be partners in a "contract." One must plan out the demands of the educational system, the needs of the child and his family, and build a relationship system that will help the child to change his self‑image. It is preferable that this "contract" be under the supervision of a psychologist, who will enable inter‑professional meetings and periodic follow‑ups in order to see how the parties to the "contract" are meeting their agreements.

Medication treatment

In the area of medication treatment, Dr. Varda Gross‑Tsur, pediatric neurologist in the pediatric neurology unit at Shaare Zedek Hospital, writes:

There are four types of medications:

1. Stimulants — Ritalin (Methylphenidate, Pemoline / Nitan)
2. Deprexan
3. MAO Inhibitors
4. Clonidine

Ritalin is the medication most widely used; 93% of children diagnosed as suffering from attention and concentration disorders and receiving medication treatment are treated with it. The use of Ritalin was first introduced by Charles Bradley in 1937, and the treatment is effective in about 80% of cases. The short‑term side effects are loss of appetite during the hours when the medication is active, difficulty falling asleep at night, and rarely stomachaches and headaches. In less than 1% of children, tics appear. These phenomena generally pass several weeks after taking the medication. There are no known long‑term side effects, as long as the medication is given in a controlled manner, and breaks are taken on Shabbat and on vacations.

The preparation of Ritalin in use in Israel is available in a dose of 10 mg and acts 30–45 minutes after taking the medication, with a range of action of 3–5 hours. The dose of the medication is 0.3–2.0 mg/kg, with the medication given 1–3 times per day. And one should raise the dose gradually according to the clinical response, since there are children who respond to even a small dose. The medication may be given to children from kindergarten age up to adulthood.

If Ritalin or other psychostimulants are not effective, or when there are contraindications to giving these medications, or in other special cases — treatment should be given with alternative medications such as Deprexan or Clonidine.

Effective medication treatment, given at an early time, leads to an increase in concentration, a decrease in hyperactivity and aggressiveness, and a secondary improvement in learning function. There is also improvement in social function and a long‑term improvement in attention and concentration disorders.

One should periodically consider the need to continue the medication treatment, where generally the average treatment lasts 2–3 years. Medication treatment in attention and concentration disorder is part of a treatment that also includes educational‑psychological treatment. A combined treatment of this sort leads, in most cases, to functional improvement in the academic plane, in the social plane, and in functioning at home.

It is highly recommended to perform a comprehensive examination by a neurologist who specializes in pediatric neurology, and not only an examination by a family doctor, before giving medication treatment, because there are a number of neurological diseases whose primary symptoms resemble hyperactivity and/or problems with focus of attention, and giving medication treatment without the above examination can harm the child instead of helping him.

In summary:

Treatment and rehabilitation of children with the ADHD syndrome

Early childhood:

• Medical assessment by a developmental pediatrician, pediatric neurologist, and a developmental neuropsychological evaluation.
• Treatment of language problems and/or motor problems.
• Parental guidance on how to organize and manage the treatment of their child both at school and at home.
• Evaluation and planning of the child's studies and learning environment.

School age:

• Planning for appropriate education that takes into account the child's cognitive state.
• Parental guidance on how to organize and manage the treatment of their child both at school and at home.
• Participation of the child in a group that will teach him social skills.
• Participation in clubs or groups such as: gymnastics, etc. and/or clubs in drawing, carpentry, etc.
• Medication treatment.

From Horim Choshvim, Issue No. 9.