Managing the Child with ADHD

What is Attention-Deficit Hyperactivity Disorder (ADHD)?

Attention-deficit hyperactivity disorder (ADHD) is the name for a group of behaviors found in many children and adults. People with ADHD have a pattern of inattention (lack of attention or regard) or hyperactivity (excessive activity) that is worse and more frequent than what is considered usual for their age group. Many children with ADHD are both inattentive and hyperactive/impulsive. It is a common disorder that affects one in every 20 children, and it is more common in boys than in girls.

Symptoms of ADHD

The child with ADHD who is inattentive will have six or more of the following symptoms:

  • Has difficulty following instructions
  • Has difficulty keeping attention on work or play activities at school and at home
  • Loses things needed for activities at school and at home
  • Appears not to listen
  • Doesn't pay close attention to details
  • Seems disorganized
  • Has trouble with tasks that require planning ahead
  • Forgets
  • Is easily distracted

The child with ADHD who is hyperactive/impulsive will have at least six of the following symptoms:

  • Fidgety
  • Is always on the go
  • Can't stay in seat
  • Blurts out answers
  • Runs or climbs inappropriately
  • Has trouble waiting his or her turn
  • Talks too much
  • Interrupts people
  • Can't play quietly

What causes ADHD?

People used to think that ADHD was the result of some type of brain damage. We now know that the brain structure of children with ADHD is normal, but the chemistry in the brain isn't normal. This may be a genetic problem. Children with ADHD do not make enough chemicals in key areas in the brain that are responsible for organizing. Without enough of these chemicals, the organizing centers of the brain don't work well. This causes the symptoms seen in children with ADHD.

ADHD isn't caused by bad parenting, but a disorganized home life and school environment can make the symptoms worse. ADHD isn't caused by a diet that contains too much sugar, too little sugar or aspartame (Nutrasweet). It isn't caused by food additives, food colorings, food allergies or other allergies, or a lack of vitamins. It also isn't caused by too much television, fluorescent lighting or video games.

What can I do to help my child with ADHD?

A team effort, with parents, school officials and doctors working together, is the best way to help your child. Medicine helps many children, and some children may need counseling. Ask your doctor what treatment he or she recommends.

How can I help my child at home?

Children with ADHD may be difficult to parent. They may have trouble understanding important directions. Children with ADHD are usually in a constant state of activity. This can be a challenge to adults. You may need to change your home life a bit to help your child. Here are some things you can do to help:

Organize your schedule at home. Set specific times for waking up, eating, playing, doing homework, doing chores, watching TV, playing video games and going to bed. Write the schedule on a blackboard or a piece of paper and hang it where your child will always see it. If your child can't read yet, use drawings or symbols to show the activities of each day. Explain any changes in routine in advance. Make sure your child understands the changes.

Set up house rules. Make the rules of behavior for the family simple, clear and short. Rules should be explained clearly. It's important to explain what will happen when the rules are obeyed and when they are broken. Write down the rules and the consequences of not following them. Hang this list next to the schedule. The punishment for breaking rules should be fair, quick and consistent.

Be positive. Tell your child what you want rather than what you don't want. Reward your child regularly for any good behavior, even little things such as getting dressed and closing doors quietly. Children with ADHD often spend most of their day being told what they are doing wrong. They need to be praised for what they do correctly.

Make sure your directions are understood. First, get your child's attention. Look directly into his or her eyes. Then tell your child in a clear, calm voice specifically just what you want. Ask your child to repeat the directions back to you. It's usually better to keep directions simple and short. For difficult tasks, give only one or two directions at a time. Then congratulate your child when he or she completes each step.

Be consistent. Only promise what you will deliver. Do what you say you are going to do. Repeating directions and requests many times doesn't work well. When your child breaks the rules, warn only once in a quiet voice. If the warning does not work, follow through with the punishment that you promised.

Make sure someone watches your child all the time. Because they are impulsive, children with ADHD need more adult supervision than other children their age. Make sure your child is supervised by adults all day.
Watch your child around his or her friends. It's hard for children with ADHD to learn social skills and social rules. Be careful to select playmates for your child with similar language and physical skills. Invite only one or two friends at a time at first. Watch them closely while they play. Reward good play behaviors often. Most of all, don't allow hitting, pushing and yelling in your house or yard.

Help with school activities. School mornings may be difficult for children with ADHD. Get ready the night before. Lay out school clothes and get the book bag ready. Allow enough time for your child to get dressed and eat a good breakfast. If your child is really slow in the mornings, it's important to make enough time to dress and eat.
Set up a homework routine. Pick a regular place for doing homework. This place should be away from distractions such as other people, television and video games. Break homework time into small parts and have breaks. For example, give your child a snack after school and then let him or her play for a few minutes. Then start homework time. Stop frequently for short "fun breaks" that allow your child to do something enjoyable. Give your child lots of encouragement, but let your child do the school work.

Focus on effort, not grades. Reward your child when he or she tries to finish school work, not just for good grades. You can give extra rewards for earning better grades. Talk with your child's teachers. Find out how your child is doing at school. In class, at playtime, at lunchtime. Ask for daily or weekly progress notes from the teacher. These notes should include positive and negative behaviors. Consider getting an extra set of schoolbooks for home. Learn the teacher's lesson plans in advance so you can work with your child at home.

Will my child outgrow ADHD?

Many children with ADHD get better at managing their diagnosis as they grow older because they have learned to adjust for their problems. Hyperactivity usually stops in the late teenage years. But about half of children with ADHD continue to be easily distracted, with wide mood swings, hot tempers and an inability to complete tasks. Children with loving, supportive parents who work together with school staff, mental health specialists and their doctor have the best chance of becoming well-adjusted adults.

This information provides a general overview on attention-deficit hyperactivity disorder and may not apply in each individual case. Consult your physician to determine whether this information can be applied to your personal situation and to obtain additional information.

Visit the AAFP Web site at http://www.aafp.org/healthinfo for more useful information.

Parenting Children with ADHD

Parenting a child (or children) with ADHD can be an overwhelming experience! For many parents, managing the behavior of these children can be frustrating and exhausting. Even though you may have raised other children without problems, these children require a lot of attention and need much more consistent discipline. For some pointers, please see The National Deficit Disorder Association (www.add.org) for tips on living with ADHD. The best way you can learn to do this is to learn all that you can about ADHD and how it impacts your child.

If there were ever children that needed good, consistent parenting and educated family support, these children are it! Dr. Robert Brooks conducted a research study in which his research assistants shadowed children with ADHD through a typical day. The results of this study showed that 80% of the interactions these children had with other people in their environments (parents, siblings, bus drivers, teachers, community people, and peers) were negative interactions. When the study was repeated with children that did not have ADHD, 80% of a child's interactions with others were positive. Please think about this simple, yet profound study for a moment. How would you feel if four out of five people you had contact with during the day were negative contacts? Is it any wonder that children with ADHD have poor self-esteem and often give up?

Our most important job as a parent is to help keep this child's self-esteem intact; to build upon their strengths, and to build resiliency within the child.

 

Some Tips on Living with ADHD

If there are concerns that you or someone in your family might have ADHD, the first crucial step is to have a proper evaluation done by a qualified health care professional. The person may be a psychologist, psychiatrist, neurologist, pediatrician, clinical social worker, professional counselor, or other type of professional. The most important concern is that the person should be someone who is well informed about ADHD and knows how to perform a comprehensive evaluation. It is perfectly fine -- even wise -- to ask questions about the person's level of expertise and experience in working with people with ADHD.

Second, it is important to keep in mind that ADHD is not something that can be "cured" and usually it does not "just go away" -- think of it as something which will need to be managed and treated over time, probably for many years, and possibly over the person's entire lifetime.

Third, seek the treatment methods and support which works best for YOU. Many (but not all) people with ADHD can benefit greatly from medication -- but it needs to be the medication which works for THEM, at the dosage which is most effective.

Fourth, become very well informed about ADHD -- read books, talk to others, join support groups, join a national organization such as ADDA or CHADD. There is an extensive reading list of books about ADHD which is posted in the Books and Webs area of this website, along with a list of ADHD related websites and organizations.

Fifth, find and use whatever sources of support provide you with what you need. That may involve working with a therapist on modifying behaviors and learning new coping skills, as well as dealing with emotional issues, managing stress, etc. Many adults work with an ADHD Coach. CHADD sponsors a nationwide network of support groups for parents, and more recently some adult groups as well. ADDA is developing a nationwide network of support groups for adults with ADHD.

Myths about ADD/ADHD

MYTHS ABOUT ADHD (www.add.org/content/abc/myths.htm)
by Becky Booth, Wilma Fellman, LPC, Judy Greenbaum, Ph.D., Terry Matlen, ACSW, Geraldine Markel, Ph.D., Howard Morris, Arthur L. Robin, Ph.D., Angela Tzelepis, Ph.D.

The following myths - and factual responses - have been collected from rebuttals to recent media articles about ADD/ADHD. The rebuttals were written by MAAAN (Metro Area Adult ADHD Network, based in the Detroit area).

Myth #1: ADHD is a "phantom disorder".

FACT: The existence of a neurobiological disorder is not an issue to be decided by the media through public debate, but rather as a matter of scientific research. Scientific studies spanning 95 years summarized in the professional writings of Dr. Russell Barkley, Dr. Sam Goldstein, and others have consistently identified a group of individuals who have trouble with concentration, impulse control, and in some cases, hyperactivity. Although the name given to this group of individuals, our understanding of them, and the estimated prevalence of this group has changed a number of times over the past six decades, the symptoms have consistently been found to cluster together. Currently called Attention Deficit Hyperactivity Disorder, this syndrome has been recognized as a disability by the courts, the United States Department of Education, the Office for Civil Rights, the United States Congress, the National Institutes of Health, and all major professional medical, psychiatric, psychological, and educational associations.

Myth #2: Ritalin is like cocaine and the failure to give youngsters drug holidays from Ritalin causes them to develop psychosis.

FACT: Methylphenidate (Ritalin) is a medically prescribed stimulant medication that is chemically different from cocaine. The therapeutic use of methylphenidate does NOT CAUSE addiction or dependence and does not lead to psychosis. Some children have such severe ADHD symptoms that it can be dangerous for them to have a medication holiday. For example, a child who is so hyper and impulsive he'll run into traffic withoug stopping to look first. Hallucinations are an extremely rare side-effect of methylphenidate and their occurrence has nothing to do with the presence or absence of medication holidays. Individuals with ADHD who are properly treated with stimulant medication such as Ritalin have a lower risk of developing problems with alcohol and other drugs than the general population. More importantly, fifty years of research has repeatedly shown that children, adolescents, and adults with ADHD safely benefit from treatment with methylphenidate.

Myth #3: No study has ever demonstrated that taking stimulant medications can cause any lasting behavioral or educational benefit to ADHD children.

FACT: Research has repeatedly shown that children, adolescents and adults with ADHD benefit from therapeutic treatment with stimulant medications, which have been used safely and studied for more than 50 years. Readers interested in more studies on the effectiveness of medication with ADHD should consult the professional writings of Dr. Russell Barkley, Drs. Gabrielle Weiss and Lily Hechtman, and Dr. Joseph Biederman.

Myth #4: ADHD kids are learning to make excuses, rather than take responsibility for their actions.

FACT: Therapists, educators, and physicians routinely teach children that ADHD is a challenge, not an excuse. Medication corrects their underlying chemical imbalance, giving them a fair chance of facing the challenges of growing up to become productive citizens. Accommodations for the disabled, as mandated by federal and state laws, are not ways of excusing them from meeting society's responsibilities, but rather make it possible for them to compete on a leveled playing field.

Myth #5: ADHD is basically due to bad parenting and lack of discipline, and all that ADHD children really need is old-fashioned discipline, not any of these phony therapies.

FACT: There are still some parent-bashers around who believe the century-old anachronism that child misbehavior is always a moral problem of the "bad child." Under this model, the treatment has been to "beat the Devil out of the child." Fortunately, most of us are more enlightened today. A body of family interaction research conducted by Dr. Russell Barkley and others has unequivocally demonstrated that simply providing more discipline without any other interventions worsens rather than improves the behavior of children with ADHD. One can't make a paraplegic walk by applying discipline. Similarly, one can't make a child with a biologically-based lack of self-control act better by simply applying discipline alone.

Myth #6: Ritalin is unsafe, causing serious weight loss, mood swings, Tourette's syndrome, and sudden, unexplained deaths.

FACT: Research has repeatedly shown that children, adolescents, and adults with ADHD benefit from treatment with Ritalin (also known as methylphenidate), which has been safely used for approximately 50 years. There are NO published cases of deaths from overdoses of Ritalin; if you take too much Ritalin, you will feel terrible and act strange for a few hours, but you will not die. The unexplained deaths cited in some articles are from a combination of Ritalin and other drugs, not from Ritalin alone. Further investigation of those cases has revealed that most of the children had unusual medical problems which contributed to their deaths. It is true that many children experience appetite loss and some moodiness or "rebound effect" when Ritalin wears off. A very small number of children may show some temporary tics, but these do not become permanent. Ritalin does not permanently alter growth and usually does not result in weight loss. Ritalin does not cause Tourette's syndrome, rather many youngsters with Tourette's also have ADHD. In some cases, Ritalin even leads to an improvement of the tics in children who have ADHD and Tourette's.

Myth #7: Teachers around the country routinely push pills on any students who are even a little inattentive or overactive.

FACT: Teachers are well-meaning individuals who have the best interests of their students in mind. When they see students who are struggling to pay attention and concentrate, it is their responsibility to bring this to parents' attention so parents can take appropriate action. The majority of teachers do not simply push pills- they provide information so that parents can seek out appropriate diagnostic help. We do agree with the position that teachers should not diagnose ADHD. However, being on the front lines with children, they collect information, raise the suspicion of ADHD, and bring the information to the attention of parents, who then need to have a full evaluation conducted outside the school. The symptoms of ADHD must be present in school and at home before a diagnosis is made; teachers do not have access to sufficient information about the child's functioning to make a diagnosis of ADHD or for that matter to make any kind of medical diagnosis.

Myth #8: Efforts by teachers to help children who have attentional problems can make more of a difference than medications such as Ritalin.

FACT: It would be nice if these were true, but recent scientific evidence from the multi-modal treatment trials sponsored by the National Institute of Mental Health suggests it is a myth. In these studies, stimulant medication alone was compared to stimulant medication plus a multi-modal psychological and educational treatment, as treatments for children with ADHD. The scientists found that the multi-modal treatment plus the medication was not much better than the medication alone. Teachers and therapists need to continue to do everything they can to help individuals with ADHD, but we need to realize that if we don't also alter the biological factors that affect ADHD, we won't see much change.

Myth #9: CH.A.D.D. is supported by drug companies and, along with many professionals, is simply in this field to make a quick buck on ADHD.

FACT: Thousands of parents and professionals volunteer countless hours daily to over 600 chapters of CH.A.D.D. around the U.S. and Canada on behalf of individuals with ADHD. CH.A.D.D. is very open about disclosing any contributions from drug companies. These contributions only support the organization's national conference, which consists of a series of educational presentations, 95% of which are on topics other than medications. None of the local chapters receive any of this money. It is a disgrace to impugn the honesty and efforts of all of these dedicated volunteers. CH.A.D.D. supports all known effective treatments for ADHD, including medication, and takes positions against unproven and costly remedies.

Myth #10: It is not possible to accurately diagnose ADHD in children or adults.

FACT: Although scientists have not yet developed a single medical test for diagnosing ADHD, clear-cut clinical diagnostic criteria have been developed, researched, and refined over several decades. The current generally accepted diagnostic criteria for ADHD are listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) published by the American Psychiatric Association (1995). Using these criteria and multiple methods to collect comprehensive information from multiple informants, ADHD can be reliably diagnosed in children and adults.

Myth #11: Children outgrow ADHD.

FACT: ADHD is not found just in children. We have learned from a number of excellent follow-up studies conducted over the past few decades that ADHD often lasts a lifetime. Over 70% of children diagnosed as having ADHD will continue to manifest the full clinical syndrome in adolescence, and 15-50% will continue to manifest the full clinical syndrome in adulthood. If untreated, individuals with ADHD may develop a variety of secondary problems as they move through life, including depression, anxiety, substance abuse, academic failure, vocational problems, marital discord, and emotional distress. If properly treated, most individuals with ADHD live productive lives and cope reasonably well with their symptoms.

Myth #12: Methylphenidate prescriptions in the U.S. have increased 600%.

FACT: The production quotas for methylphenidate increased 6-fold; however that DEA production quota is a gross estimate based on a number of factors, including FDA estimates of need, drug inventories at hand, EXPORTS, and industry sales expectations. One cannot conclude that a 6-fold increase in production quotas translates to a 6-fold increase in the use of methylphenidate among U.S. children any more than one should conclude that Americans eat 6 times more bread because U.S. wheat production increased 6-fold even though much of the grain is stored for future use and export to countries that have no wheat production. Further, of the approximately 3.5 million children who meet the criteria for ADHD, only about 50% of them are diagnosed and have stimulant medication included in their treatment plan. The estimated number of children taking methylphenidate for ADD suggested in some media stories fails to note that methylphenidate is also prescribed for adults who have ADHD, people with narcolepsy, and geriatric patients who receive considerable benefit from it for certain conditions associated with old age such as memory functioning. (see Pediatrics, December 1996, Vol. 98, No. 6)