Last month, we reported on a National Institutes of Health conference, where the nation's experts concluded that Attention Deficit Disorder/Attention Hyperactivity Deficit Disorder (ADHD) is a serious and growing problem. But how to treat it? These same experts remain perplexed.
This month, in one of the best articles we've seen written on the subject for parents, a local expert lays out the facts about the disorder and offers suggestions for ADHD families ... Once again, a note arrived home from Richard's teacher: "Richard has potential, but he refuses to use it. He'd rather be playing around in class or his mind is just somewhere else. Please speak to him, because I can't get through to him."
Well-meaning family and friends had no shortage of suggestions as how to make Richard "get his act together", to which his mother, for the most part, kept her reactions private. "He is the kind of kid who will respond only if you punish him," they told her, but Cheryl thought: "I do punish him... and punish him, and it only makes him angry, me frustrated, and the problems keep happening."
"Richard has bad self-esteem - make him feel good about himself, then he will do better," they said, but Cheryl knew: "I love him and try to remember to tell him how great he is, but the rest of the world expects results... Come to think of it, so do I. Besides, how can he ever feel good about himself when the only feedback he seems to get is that he blew it?"
What is Attention Deficit/Hyperactivity Disorder (ADHD)? The bottom line for children with ADHD is the significant and recurring difficulty sticking with activities for as long as other kids would. It is a neuro-developmental disorder of self-control. The four main qualities that are typically seen in a child with ADHD are:
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What can be done to help a child who does have ADHD?
A helpful thought to guide parents of an ADHD child is: "You may not be able to change the wind, but you can adjust the sails." Certain methods, approaches and rules of thumb are valuable to learn and use in adapting to the unique needs of your child, your parenting style and your family. But parents, fortunately, do not have to reinvent the wheel - there is much good scientific research that has had an enormous impact on the lives of families with ADHD kids. What is challenging, though, is the creative act of adapting general principles to the uniqueness of your child. One thing that professionals have learned is that a "cookie cutter, one size fits all" approach does not work with ADHD kids. Often, children with ADHD possess some of the most valuable characteristics humans can have: insatiable curiosity, spontaneity and risk-taking, intense concentration on something of interest to the exclusion of all else, and rapid thought processes (think Robin Williams!).
Some principles that can be adapted to your unique child and your child's unique parent.
Immediate and frequent consequences. These work best with ADHD kids. They need more frequent feedback about their behavior, and it works best if it's a mix of corrective messages ("The rule is we have to eat at the table") and positive messages ("I am so impressed that you remembered to put your plate away when you finished eating"). Positive consequences work better than punishment, although punishment often feels better at the moment. For about 95 percent of kids, punishment seems to work just fine to change future behavior. For ADHD kids, it seems to stop some behavior at the moment and relieve some frustration for parent or teacher, but the problem behavior typically returns, at times before the punishment is even over. This has to do with the way ADHD kids seem to process information and experiences in their brains. Shifting to a positive consequence role model sometimes "goes against the grain" of what seems necessary to many adults. Yet the creative and careful use of a reward or incentive system can be one of the most essential parts of your child's success. Working for a prize seems to interrupt or delay some of the impulsive behaviors. Use Grandma's rule ("When...then") more than Grandma does. Grandma's rule is the infinite possible variations on "When you finish your vegetables, then you can have dessert." By the age of three, most kids grasp the concept of consequences. Children always want immediate gratification (come to think of it, so do adults), and this little structuring activity can be helpful in teaching how events are sequenced and how actions have consequences. You can make this a riddle game with young kids and have them predict the consequences of others as well. It is best to start with all positive outcomes ("When you finish cleaning up the toys, then we will watch the video"), then introduce occasional negative scenes ("When you drop food on the floor, then you have to clean it up before you can go play."). Play Beat the Clock. The noted ADHD expert, Dr. Russell Barkley, notes that "ADHD results in time blindness and temporal myopia... the future is its nemesis." What this implies is that ADHD is a disorder of performance, not a lack of skill; a disorder of when, not how. A simple kitchen timer is quite useful in helping to structure time. For example: "You have three minutes to finish using the crayons and put them back in the box. If you beat the clock you get to pick a treat." This is a way to avoid power struggles over time - and the timer becomes a referee. Honor transitions. As you have no doubt noticed, transition from one activity or place to another can trigger a strong negative reaction. Transitions are more successful when you build "bridges" - events to ease change. Here the timer is helpful ("Two minute- warning, then we turn off the video and clean up for dinner"), or the use of some transition routine like a singing a song, turning on music, changing lights, putting on hats, or some other playful but consistent activity. Try watching a program for a few minutes with your child, and then direct him to turn off the TV during a break or scene change. Predict problems - not in a pessimistic way, but with the realization that ADHD kids tend to have trouble in the same situations again and again. You can come to anticipate the settings that will be problematic. Just before such a situation (e.g., food shopping), a) review two to three rules and have the child repeat them back; b) set up a small, immediate reward if the rules are followed, and have the child repeat this several times during the trip; c) give ongoing feedback and praise for successful rule-following; and d) deliver consequences immediately. Maintain a sense of priorities. In other words, pick your battles. What are the most important one or two goals you are striving to accomplish with your child? Focus on these for a month or so, and do not get pulled into more trivial misbehaviors or rule violations. Act, don't yack. As hard as it is to accept sometimes, ADHD is not due to a failure of knowledge or reasoning. The more you talk, the longer you postpone more effective consequences. Use feedback, rewards, and small removal of privileges quickly and often. Strive to reduce repeating rules, commands, reasons and reprimands. Connect before you direct. Get down to eye level, and engage in eye to eye, hand to shoulder contact. Practice and reinforce "Jean, I need your eyes," praising your child for returning eye contact. A wide, inviting smile is a good message that "I like it when you find my eyes." It is more likely that directions will be heard and complied with if positive connection occurs first. Calm yourself, then your child. While ADHD kids are not quick to hear directions, they are often as swift as other kids to pick up on parents' feelings like "emotional radar". Use whatever works - breathing deeply, counting to 10, repeating a calming word (e.g., "quiet", "love"). Your agitation will initiate a "flight or fight" response in your child. Your calm response to him will be less provocative, and can be a model for how to bring feelings into check to result in better actions. Tie it to "When... Then": "When I take deep breaths, then I can speak softly and get my job done easily." Have your child practice this with you in non-problem situations to prepare for its use in more difficult times.
ADHD kids - like all kids - require love, forgiveness, and a healthy dose of humor to smooth the inevitable bumps in growing up. These ideas can be used successfully with all children, but there are many areas in which "special handling" is critical in the care and raising of kids with attentional disorders. Get an accurate diagnosis; find out what your child's strengths and weaknesses are; and learn from other professionals, other parents and other adults who seem to have "a way" with your child and other kids. You may not be able to change the wind, but you can always learn better and better ways of adjusting the sails.
DR. DANIEL GRIFFIN is director of the Attention and Learning Solutions Program at the Minuchin Center for the Family, 114 East 32nd Street. The program provides psychological assessment for attentional and learning problems, and a 10-week program for parents and children affected by ADHD. School consultation and staff training are also available. Dr. Griffin can be contacted at (212) 213-9202.