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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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