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Capital
Area Psychological Services, P.A.
(CAPSPA)
ADHD RECOMMENDATIONS
Introduction
If your child has been identified as having some attentional
difficulties, it is important for you as a parent to have some idea of
the types of interventions and modifications that are used with
children with attention deficit hyperactivity disorders (ADHD) so that
you can be a more informed parent, but, more importantly, so that you
can be an advocate for your child in the various settings in which he
may experience difficulties. There are many books on ADHD and
many more recommendations that are offered parents than can be put into
this short note. However, the patterns of interventions offered
are important to understand, and this addendum is meant to address the
types of interventions or modifications that can be given.
Currently, the official name for children with attention and/or
hyperactivity problems is attention deficit hyperactivity disorder
(ADHD). This title includes children whose problem is only
inattention and not hyperactivity. There are three types of
ADHD: ADHD-Inattention, ADHD-Impulsive, and ADHD-Combined.
The ADHD-Inattention category is for those children with attention
problems but not hyperactivity; the ADHD-Impulsive is for those with
hyperactivity but not inattention; the ADHD-Combined is, of course, for
those with both inattention and hyperactivity. Legally at this
time, there is no such identification as simple attention deficit
disorder (ADD).
There are four general areas for recommendations that are typically
given for ADHD children. These areas are behavioral, educational,
psychological, and medical. Each of them is important, and a
complete treatment plan for an ADHD child will likely include elements
of each. At the same time, treatment for ADHD children may not
include all aspects. For examples, many parents feel strongly
about not wanting their child to be treated with medication. As a
result, medical interventions may be limited.
Behavioral Interventions
There are many books available that speak to the behavioral control of
children. Several are listed in the bibliography that
follows. In addition to the specifics of behavior contracts,
positive and negative reinforcements, and rules and consequences, there
are general patterns that are of even more importance to the ADHD child
than to other children. The watchwords for these patterns are
three: structure, consistency, and supervision.
Structure.
ADHD children generally need structure more than most other
children. This means having a schedule, whether that be a daily
or a weekly schedule. Many of these children have a very
difficult time with transitions, moving from one task to another, and
they do not like surprises, even very pleasant ones. Some ADHD
children have thrown tantrums when told that they are to leave for
someone’s birthday party that they did not know about. Having
structure also means that children know what is going to happen in the
next hour, in the evening, or tomorrow. Many need warnings about
events that happen every day. For example, many need to be told
that in 20 minutes they need to get ready for bed, even though they go
to bed at the same time every night. Finally, having
structure means having very clear rules for your child, with them
pasted on the refrigerator if necessary. The general rule of
thumb is that a schedule can never be too clear or too obvious to an
ADHD child.
Structure also implies giving simpler directions to ADHD children than
one might consider appropriate for their age. A major trap for
parents of ADHD children is to say or even think, “You are x years old;
you should be able to do... without help.” Thus, ADHD children
may need help with figuring out how to clean their rooms, how to order
their homework so it gets done in a reasonable time, etc. Tasks
may need to be broken down into individual steps or simple single
directions may need to be given rather than two-, three-, or four-step
directions.
Consistency.
This means that similar happenings must be treated in similar
ways. If it is important to you that your child not slam the door
when he leaves the house, then do not punish him for slamming it one
day and ignore it the next. Rules that are important to you must
be enforced consistently. If you do not wish to enforce the rule
consistently, then change the rule. This is not to say that we
all do not “miss” sometimes. However, our goal is to be
consistent and we must not let our frustration or our “having a bad
day” keep us from being consistent. Needless to say, this is not
easy, but it is extremely important.
There is another element of consistency that is important.
Consistency does not mean that everyone must treat the child in the
exact same way. This is impossible! Parents are not alike,
nor are they exactly the same as the child’s teacher, the child’s
coach, or the child’s karate teacher. Everyone will treat the
child differently to a certain extent. What is meant by
consistency is that each is clear about his expectations for the child
and is consistent with those expectations. Of course, for basic
rules around the house (when and where the child does his homework,
what his chores are, etc.), parents should be consistent with one
another. One parent’s silent collusion with the child to avoid
another parent’s requirement is extremely destructive and undermines
both parents’ authority. If parents differ on expectations for
the child, they need to discuss and agree on what they will
require. Each must then follow the rule even if he or she does
not particularly agree with the expectation.
Supervision.
The issue of supervision revolves chiefly but not solely around
performance in school. Close communication between parents and
teacher is mandatory with the extent of contact dependent upon the
child’s performance. Some parents need to consult with the
teacher only every few weeks, some daily. Homework as well as
school behavior is involved. Parents need to know what the
child’s assignments are for the evening, when it is completed, and
whether the previous assignments have been turned in. The initial
difficulty is determining the nature of the problem. For homework
to be successful, the child must know the evening’s assignment,
complete it within an appropriate time frame, and hand it in at the
proper time. Difficulties can arise with each of these
areas. Dependent upon the problem, various interventions can be
implemented.
If the child is not writing down or in some way confirming to the
parent the nature of the evening’s assignment, several interventions
can be used. Teachers often suggest that the child write the
assignment in the assignment book and they will then sign it.
This is a good technique, but, unfortunately, sometimes teachers
demand that the child take the initiative for getting the book
signed. If the child is unable or unwilling to take this
initiative, the technique fails. Other methods may prove more
effective. Some school provide daily homework assignments on
their web site. This is the most effective method. Also,
the teacher may assign the child a study buddy, a student who ensures
that the child has the assignment written down. Finally, the
parent may obtain from the teacher the name of another parent whom the
child’s parent can call to find the appropriate assignment. There
are ways to learn the day’s assignment, but some are more difficult to
do than others.
If the child does not hand in assignment, several interventions can be
implemented here also. Again, a study buddy can be assigned to
make sure the child hands in assignments. Other techniques that
have worked well in various circumstances include the teacher
specifically asking for the work, having the child hand in all
assignments at the beginning of the day, and having a specific place on
the teacher’s desk to place the assignment. Dependent on the
child and his particular issues, each of these can work well.
ADHD children are typically immature, some researchers saying that they
lag 30% in development. Thus, they will not do many tasks at the
same age as their peers. It is important for parents to realize
that their ADHD children need supervision for a longer time period than
do other children. Like with structure, parents here need to
avoid the trap of saying to themselves that the child is old enough to
do something for himself. If they fall into this trap, the parent
typically moves back into a system or reward and/or punishment, a
system that is not especially effective with ADHD children.
Educational Interventions
Many ADHD children do very well in school insofar as educational
achievement is concerned. Many of these same children, however,
do relatively poorly when grades are considered. The difficulty
is that the problems that ADHD children experience are not in the areas
of either cognitive ability or academic achievement. Instead,
they are in the area of executive functioning. Such problems as
organization, procrastination, processing speed, and inattention are
all difficulties that can be present concurrent with the child being
“smart.” Thus, despite having the ability, these children may do
poorly in the classroom. In addition, because of the large number
of children in the class, they may not receive the instruction they
need to improve in these areas. Extra academic instruction
becomes important for these children, not simply a restating of what
has previously been taught. The children often know this
material. Instead, they need instruction that also teaches them
ways to correct their specific weaknesses.
In seeking outside tutoring, two types of tutors are available, content
tutors and process tutors. Content tutors teach content to
individuals who do not understand what has been taught. If one
does not understand algebra, it is best to go to a content tutor who
will teach you algebra. Process tutors will teach content, much
as content tutors do, but they will also teach ways to improve
functions of executive processing. Generally, teachers with
experience in learning disabilities are more process oriented.
Classroom modifications are also common. Typically, these include
such things as extended time for certain tests, oral testing as
necessary, having a study buddy, and modification of certain
assignments. Since these children are not strong on detail,
writing should be proofread before a final grade, and separate grading
should be given for content and grammar. While no set
recommendations are automatic for every child, these recommendations
are typical for the kinds of interventions that are used in the
classroom with an ADHD child.
It is also possible that your child may be identified with the school
system as a child with special needs. Specifically, the area of
attention problems falls into the category of “other health impaired,”
the official legal designation for these children. Identifying
your child within the school system provides for the development of an
individual education plan (IEP), a plan that specifically identifies
the difficulties your child has and the interventions planned by the
school to help your child. Perhaps the most important part of the
IEP is that it requires your participation and your signature.
The IEP, in other words, allows you as a parent to be much more closely
involved in your child’s education. Identification of a child
within the school system is typically for a period of three years.
Psychological Interventions
Counseling is generally required for ADHD children who have additional
problems of anger control, excessive frustration, anxiety, or
disruptive behavior. By itself, however, counseling is usually
not sufficient to improve these difficulties. Simultaneous
behavior strategies are also very important, as are means of addressing
any educational deficiencies. Parent counseling is also very
important. Very seldom do parents instinctively know what is the
best way to work with an ADHD child. Consultation with a mental
health professional around specific situations is strongly recommended
so that parents can be secure in their approach to improving behavior.
Medical Interventions
The final general intervention is that of medication. There has
been much written about the proliferation of children on stimulant
medication in the past two decades. The fact remains, however,
that medication has proven to be an effective intervention for many
children. It is the duty of every parent whose child may be
considered for medication to learn as much as possible about the
various medications and their effects. Reading and study are
essential. Several books in the last few years have been
publicized and are very anti-medication. While these books are
sensationalized, they are, for the most part, out of the mainstream of
professional publications, and I do not recommend them. Nor do I
recommend the few books that present a one-sided positive view of
medication. Rather, I strongly recommend the greater quantity of
publications which take the position that medication can be a safe and
effective intervention for many children at the same time that
medications must be taken cautiously, they are serious interventions,
they are not candy, and parent must be knowledgeable about side effects
and possible consequences. Generally, anti-medication books can
be recognized by their titles: Say No to Ritalin, etc.
The most frequent medications used with ADHD children are
stimulants: ritalin, adderall, or concerta, as well as some
extended release forms of these medications. Ritalin is the
medication which has received the most coverage simply because it
has been prescribed for over 70 years. Within the last several
years, more extended release medications have become available
(concerta, ritalin sr, adderall xr), allowing children to take
medication without having to be singled out at school for taking
medication. Most recently, a new medication named strattera, a
non- stimulant, has been introduced. All of this has been
extremely helpful to children since they can now take medication only
in the morning. Some children may also take an additional dose
after school to help with organization and homework completion.
Some other medications are also prescribed for ADHD children,
particularly antidepressants. These are, however, typically not
used initially or are used in conjunction with other disorders:
depression, anxiety, oppositional behavior, etc. It is not
unusual for children to be on both stimulants and antidepressants.
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