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ADHD and Handwriting

Even in this day of thumb-driven Twitter shorthand, handwriting continues to be a critical and needed skill. Legible, coherent handwriting is a signal measure of academic success and still plays an important role in formal and informal communication.

 

Educators and other professionals working with children with Attention Deficit Hyperactivity Disorder (ADHD) have observed that many of these children have significant problems with handwriting.

 

A recent study coming out of the Centers for Disease Control and Prevention (CDC) documents the relevance of these observations. This research, led by Slavica Katusic of the Mayo Clinic was published in Pediatrics (September, 2011). The study included 6,000 children—all those born in Rochester Minnesota between 1976 and 1982 and who was still living there after age 5.

 

Katusic and her co-workers evaluated school and medical records to see which children showed signs of ADHD, as well as how well they performed on writing, reading and general intelligence tests over their school career. A total of 379 children fit the criteria for ADHD. About 800 children scored poorly on tests of writing abilities, and most with writing problems had reading difficulties as well.

 

Writing problems were much more common in both boys and girls with ADHD, with close to two-thirds of boys with ADHD having problems with writing. That compared to one in six of their peers without ADHD. In girls, 57 percent with ADHD had a writing problem, compared to less than 10 percent without ADHD.

 

There are several reasons why children with ADHD may have problems in writing. Handwriting is a very complex task that involves cognitive activity and motor activity at the same time. A high level of mental coordination and sequencing is required—tasks that individuals with ADHD have difficulty with. Also, memory and planning problems may affect the writing process. The impairment in sustained attention experienced by children with ADHD causes them to loose track of what they are doing and they will tend to make careless errors and get confused about what is to come next in the phrase or sentence.t is my observation that when kids with ADHD are appropriately treated with medication, improvement in handwriting can be dramatic. In fact, improvement in handwriting can be one of the more objective, observable markers of effective treatment.

 

Kids who have problems with handwriting sufficient to interfere with their ability to express what they are learning can be allowed, even encouraged, to use other means of communicating what they are learning. For instance, a student may be allowed to give a report orally rather than in writing. Certainly in middle and high school the student can be encouraged to develop word processing skills and permitted to prepare homework and even classwork using the word processer. At the same time the student will need ongoing instruction and practice in handwriting. For some ADHD students, their handwriting will never be optimal but should be functional by high school.

At the same time, intentional instruction in handwriting skills is needed. The ADHD child may not develop perfect handwriting but writing skills can be enhanced with intervention. It is appropriate to help them be the best they an be in this area while compensating in other subjects. For instance their grade in science or math should not be knocked down due to messy or slow handwriting.

 

Long term observation does suggest that the writing problems do get a little better with increasing m

Conditions That Complicate Management

Attention deficit/hyperactivity disorder is a specific developmental condition with a defined set of characteristics. Although a varied spectrum of severity exists, children with ADHD demonstrate a consistent and typical pattern of behavior and neurological function.

 
However, this “pure”@ picture is often complicated by the presence of other developmental or emotional dysfunctions. Several co-morbid conditions are described by professionals working with A DHD children.

 
Common Co-Morbid Conditions
Let’s look at some of the more common co-morbid conditions which may exist with ADHD:

 
Language-based learning disabilities. Central language processing disorders can mimic, and certainly complicate, the expression of attention disorders. For decades clinicians and educators have observed a significant overlap between children with ADHD and various language-based learning disabilities. As recently as two decades ago, professionals in the field tended to lump children with these related developmental disabilities together into the diagnostic category of minimal brain dysfunction. Attention, hyperactivity, and language-processing disorders were thought to be different ends of the continuum within this diagnosis. Recently the trend is to define the various diagnostic categories more precisely.

 
While many children with ADHD have no evidence of language-based learning disability, there are many children in which ADHD and a learning disability co-exist. I have seen children who have gone for years without treatment for their ADHD because all their academic problems were blamed on their language dysfunction. The attention problems and poor organization were thought to be secondary. On the other hand, I know of children who have not received serious evaluation of their reading and spelling under-achievement because their poor grades were blamed on their attention deficit disorder. When a child has been diagnosed with either ADHD or language processing dysfunction, the child should be carefully observe for evidence of the other condition.

 
Oppositional Defiant Disorder. While children with ADHD may disobey and at times seems to resist discipline, they are not typically defiant. Their lack of compliance is most likely due to impulsiveness and failure to think before they act. They also have difficulty associating their behaviors with consequences. But they want to please and tend to be unhappy with their failure to live up to expectations.

 
Oppositional defiant disorder (ODD) is characterized by a pattern of negative, hostile, and defiant behavior. Children with this disorder easily lose their temper, purposely annoy others, openly defy authority, refuse to comply with rules, and argue often. They may be resentful, angry, spiteful, and vindictive. ODD is defined by a pattern of such behavior over a long period which is not due to temporary stresses or provocations. Oppositional defiant disorder is more common in males. Over time ODD is likely to be associated with low self-esteem, low frustration tolerance, temper outbursts, poor peer relationships, and school underachievement.

 
Conduct Disorder. Children with conduct disorder exhibit a basic disregard for the rights of others and ignore age-appropriate norms of behavior. They may be cruel to other people and animals, fail to respect others rights (i.e., steal, misuse property), and ignore common rules of conduct. This pattern of behavior exists over a long period of time. It significantly disrupts the child’s relationships and adjustments to common life situations such as home and school.

 
Poor school performance, a greater frequency of school suspensions, and incidence of substance abuse are seen in children and adolescents with conduct disorders. These dysfunctional behaviors may begin in middle childhood but become more prominent in adolescence.

 
! Tourette’s Syndrome. Tourette’s syndrome (or Tourette’s disorder as it is sometimes called today) is characterized by the onset during childhood of multiple tics of various kinds (both motor tics and vocal tics) which may fluctuate in severity. The currently accepted essential diagnostic criteria include onset before the age of 21 years, multiple involuntary motor tics, one or more vocal tics, the waxing and waning of the tics, the gradual replacement of old tics with new ones, the absence of other medical explanations for the tics, and the presence of tics for more than one year.

 
Along with the tics, there may be obsessive compulsive tendencies, excessive anxiety, sleep disorders, learning difficulties, and impulsive behaviors. A variety of behavior/emotional problems have been identified in children with Tourette’s syndrome. Whether these behavioral problems are related to tic severity, a direct consequence of having a stigmatizing condition or an underlying part of the developmental condition is not clearly delineated.
ADHD has been reported to occur in 35% to 65% of children with Tourette’s syndrome. The treatment of children with attention deficit/hyperactivity disorder with co-morbid Tourette’s syndrome is controversial. The major confounding factor is that stimulant medications may provoke or intensify the tics. The stimulants do not cause the tics but if a child is predisposed to tics, the use of the stimulants may hasten the expression of tics, or aggravate them when they are present. While the stimulants may help the child with ADHD and Tourette’s, they should be used with caution.

 
If behavior and educational approaches are not successful for the child with Tourette’s and ADHD, then a trial with other types of medication should be considered.

 
Depression. It is well know that psychological depression is the most common emotional disorder affecting adults. The fact that depression is also very common in children and adolescents is less well known. Pre-teens and adolescents are particularly vulnerable to some degree of depression even under the best of circumstances. The child living with the stresses of ADHD are even more vulnerable. The frustration due to having to work harder to keep up academically, the constant negative feedback that is all too common and the difficulty getting along with peers sets the child up for depression. The usual low self-esteem experienced by many children with ADHD underlies their vulnerability.

 
Signs that suggest depression are a sudden drop in grades and performance in other activities such as sports or music. The depressed child or adolescent will tend to be moody and easily frustrated. They seem sad and have more trouble enjoying things they have enjoyed in the past. They often will withdraw and be less able to cope socially.

 
Depression in children and adolescents is likely to be a reaction to circumstances and come on over a short period of time. Chronic, long-term depression is less common.

 
This reactive depression is probably the most common co-morbid condition seen in children with ADHD. Fortunately, depression is also the most effectively treated of all the co-morbid conditions. Recognition, counseling, and sometimes short-term antidepressant medication will usually overcome the depression fairly quickly.

 
These are some of the more common co-morbid disorders. If is important to look for such conditions as a child is evaluated for ADHD. When they exist, success depends on managing the ADHD and co-morbid condition together.

ADHD and Prevalence of Depression

Attention Deficit in early childhood predisposes to adolescent depression according to research published  October 2010  in the Archives of General Psychiatry. This risk of depression in young children with ADHD is greater in girls, in those with associated conduct disorder, and in those whose mothers were depressed according to the study.

The Researchers evaluated 125 children age 4 to 6 who met the criteria for ADHD and 123 matched controls without any sign of ADHD. These subjects were followed for up to 14 years. All of the children in the study lived with their biological mothers.

ADHD at 4 to 6 years resulted in increased risk of major depression during the teen years by more than 15 times. Girls with ADHD had twice the risk of later depression than boys. Maternal depression increased the chance of depression in the children with ADHD by more than 7 times.

Comment: This study documents what many clinicians working with children and families have observed informally. The reasons for this increased risk of depression and mood disorders in teens who are diagnosed with ADHD are not yet clear. There may be biological factors common to both disorders. It is also likely that the stress of trying to live with the symptoms of ADHD would predispose one to depression. The very fact that the person with ADHD experiences the frustration of not being able to perform at the level they know they are capable of is, in itself, a significant stress.

Proper management of the ADHD as outlined in the book, ADHD Strategies for Success, will help minimize the stresses of living and learning for children with ADHD.

Certainly, parents and professionals working with children with ADHD, especially adolescents, should be diligent is watching for signs of depression and follow up on such signs when noted.

Teens with ADHD and Driving

It goes with the territory. All adolescents are at some increased risk of distracted driving. Those with ADHD are especially vulnerable. This fact was reinforced by a study published in the JAMA Pediatrics recently. “ADHD appears to impact specific driving behaviors,” according of Cincinnati Children’s Hospital researcher, Megan Narad, one of the authors of this study. “Both maintaining a consistent speed and central, consistent lane position require constant attention to the road and one’s surroundings,’ she added.

 

Such sustained attention is difficult for the person with ADHD.
The study involved adolescents aged 16 and 17 years with or without ADHD participating in a simulated driving class which monitored driving under various conditions. In conclusion, the study clearly demonstrated that both ADHD and texting while driving present serious risks to driving performance of teens.

 
Other studies have pointed out that teen drivers with ADHD are 8 times more likely to lose their license, 4 times more likely to be involved in a collision, 3 times more likely to sustain a serious injury and 2 to 4 times more likely to receive a moving vehicle violation. These risks are not surprising considering that the core symptoms of ADHD are inattention, impulsivity, and hyperactivity—all conditions that affect focus and concentration.

 

One encouraging finding in other studies is that treatment with stimulant medication at optimum levels improve driving performance of teens with ADHD in a significant way. Thus teens with ADHD who are driving should take their prescribed medication on a regular basis without holidays.

 

Other suggestions that can help the teen drive more safely are the following commonsense precautions:

 
Always wear a seatbelt
Never drink and drive
Never drive while sleepy
No cell phone use while driving
Pay attention to surroundings—be aware if traffic is slowing, etc.
Select a radio station or recording device (CD or MP3 player) before starting the trip
Know ahead of time the directions to your destination
No speeding, follow all traffic signs
Minimize night time driving
No tailgating
Inform parents of your destination and return time.

 
Other studies suggest that teens with ADHD may need more intense driver education. Also with many teens with ADHD, delaying driving for a year or two thus allowing more time for maturity to develop would be wise.

Diagnostic Device Approved by FDA for Evaluating ADHD

The Federal Drug Administration recently approved a new device for assessing ADHD. This is the first medical device approved for the diagnosis of this common condition of childhood.

 
The technique, called the Neuropsychiatric EEG-Based Assessment Aid (NEBA) System, relies on deciphering encephalogram (EEG) waves. Taking 15 to 20 minutes, this non-invasive test uses computer functions to calculate the ratio of beta and theta brain wave frequencies. Previous research has shown that theta and beta ratios are higher in children and adolescents with ADHD compared to non-ADHD subjects.

 
Although officially approved, significant uncertainty exists among experts as to the NEBA technology’s value in the overall diagnosis and management of ADHD. Currently the evaluation of ADHD is a complex process utilizing observation, behavior analysis, and psychological testing. Whether the NEBA adds significant help in this process is uncertain. One concern is how much does the use of this technology add to the overall cost of an evaluation.

 
Of course, time will reveal the usefulness of this new technology. Stay tuned. We will keep you informed as additional research data comes in.

ADHD Can Persist Into Adulthood

Investigators in Rochester, Minnesota studied a large group of children born between 1976 and 1982. This group was followed from early childhood into adulthood (mean age 27 years at time of study). In this group, 232 subjects had been diagnosed with childhood ADHD. These 232 children were compared with 335 children without ADHD who served as controls. At the time of the study, the now adults were administered a variety of standardized neuro-psychiatric tests and interviews.

It was observed that ADHD persisted into adulthood in 29.3% of the individuals who had been diagnosed with childhood ADHD.

The participants who had childhood ADHD were more likely than controls (56% compared to 29%) to have one or more psychiatric disorders as adults. The most common co-morbid condition was alcohol dependence/abuse (26%). Additional diagnoses were other substance dependence/abuse conditions, anxiety disorders, mood disorders, and major depression. Those with ADHD persisting into adulthood were much more likely to have one or more psychiatric disorder (80% vs. 47%).

Several take home lesions from this study:

First of all, most children with ADHD will have resolution by adulthood.

However, ADHD does persist in a significant number of individuals (30%).

ADHD does leave significant emotional scars in a high percentage of individuals who were diagnosed with childhood ADHD. This points out the need for those diagnosed with ADHD to have ongoing mental health care into adulthood with special attention paid to potential psychiatric disorders.

Those adults with persistent ADHD (30% of those with childhood ADHD) will need to have ongoing ADHD treatment and monitoring as adults for other mental health needs.

Affirming Creativity in Children

The seeds of creativity are planted in the child from creation. But these seeds must be watered and nurtured if they are to grow to their full potential. Creativity can be enhanced or discouraged depending on the way we as parents and teachers react to the child’s initiatives.

So give some of the ideas listed below a try. These easily implements actions will help foster creative thinking and nurture a love of learning on the part of the child. Once you get started, you can add to this list out of your own experience.
1. Help the child chose a topic to write about. Suggest a word length and make it short so as to stay within the child’s attention span. You don’t want to discourage or frustrate him or her. This exercise develops the ability to follow directions. Consider dressing the writing up as a magazine article by encouraging the child to choose pictures he or she can cut out and paste illustrating the narrative.

2. Using a recorder to develop a story. You can start telling the story. Make it up as you go. It doesn’t have to be perfect. At an exciting point stop and ask the child to pick up the narrative and add to the story. At this point you add more to the story line but quickly give the child a chance to jump back in. Later replay the tape and discuss the story.

3. Explore the backyard or school grounds with a magnifying glass. Have the child make a list of what he finds. Assist him or her in looking up the discovered items in an encyclopedia or on the internet.

4. When the child asks you a question, don’t automatically give an answer. Respond with, “What do you think?” Treat the answers with respect even when you may add or correct information.

5. While driving, begin a “What if?” game. Start with a sentence such as, “What if you went to school one day, and the teacher said you were all going on a trip in a submarine?” Let the child continue adding all the “what ifs” she can imagine. Once the story gets going, prompt the child for more details. Ask why, how, who, when, etc?

6. Don’t belittle or treat lightly any question. As Lucy said to Charlie Brown, “There are no dumb questions, only dumb answers.” For some questions you will have no answer. A good response is simply, “I don’t know. What do you think?” And then add, “Let’s look it up. Where do you think we might find an answer to that question?”

7. Have the child color, draw, or paint any picture he or she wants. Then tell a story about it.

8. Introduce your child to the computer. De-emphasize games; rather, show him or her how to use the computer to accomplish tasks. For instance, help the child to learn basic word processing and encourage them to write stories. Help them to use the thesaurus and spell check. Realizing that there is more than one way to say something is liberating.

You will note that running through all of these examples is the encouragement of the child to use language and especially practice the art of story. The goal in all of this is to stimulate your child to exercise his or her brain in a variety of ways. You want to encourage active problem solving rather than passive data acquisition.

Sleep-Disordered Breathing and ADHD

Sleep-Disordered Breathing and ADHD

A large, population-based study demonstrated that early in life sleep-disordered breathing symptoms had a strong relationship to behavior in children later in life. Children with sleep-disordered breathing developed more behavioral difficulties such as hyperactivity and aggressiveness, as well as emotional symptoms and difficulty with peer relationships when compared with children without sleep-disordered breathing. Findings suggest that children with sleep-disordered breathing symptoms may require treatment as young as one year of age to prevent increased tendency for behavior problems.
“This is the strongest evidence to date that snoring, mouth breathing and apnea can have serious behavioral and social emotional consequences for children,” reported Karen Bonuck, PhD, one of the researchers and professor in the Family and Social Medicine Department at Albert Einstein College of Medicine.
In the study, parents completed surveys reporting on children’s snoring, mouth breathing and witnessed apnea at ages 6, 18, 30, 42, 57, and 69 months of age. More than 11,000 children were followed for more than 6 years. Parents then completed the Strengths and Difficulties Questionnaire when the children reached 4 and 7 years of age. The questionnaire has five scales: inattention/ hyperactivity; emotional symptoms (anxiety and depression); peer problems; conduct problems (aggressiveness and rule breaking); and a social scale (sharing, helpfulness and other factors). Researchers controlled for 15 potential confounders, such as socioeconomic status, maternal smoking during the first trimester of pregnancy and low birth weight.
Researchers found that children with sleep-disordered breathing were 40% to 100% more likely to develop neurobehavioral problems by age 7 years, compared with children without breathing problems. The worst symptoms were associated with the worst behavioral outcomes, and hyperactivity was most affected among the neurobehavioral domains examined, according to the researchers. “The biggest increase was in hyperactivity, but we saw significant increases across all five behavioral measures,” said Bonuck. Bonuck K.

This report published in the Journal, Pediatrics, points to one specific condition that can cause, or at least worsen, symptoms of ADHD. In evaluating a child for ADHD, the examiner should look for signs of sleep-disordered breathing with the medical history and physical exam. Causes of sleep-disordered breathing can be allergic rhinitis, large tonsils and adenoids, or congenital abnormalities of the upper airway. Essentially all of these are treatable with surgery or proper medication.
Sleep-disordered breathing is certainly not the cause of ADHD but one of many factors that can affect the expression of this common developmental problem in children.

Redemptive Features of ADHD

Children with ADHD have very real challenges. The disruptiveness of the child’s behavior and the struggles in learning can make life difficult. These dysfunctions tend to drive professionals as well as parents to focus largely on the negative connotations of attention deficits. But redeeming features do exist, even though they may be difficult to see. However, this positive side to ADHD often begins to show itself in adolescence and young adulthood if we look for it.

—The inattention to detail that is so frustrating to student and teacher alike can lead to strengths in conceptual ability. A result can be an enhanced ability to see the big picture. Such individuals can become adept at global problem solving and may be an asset in leadership roles.

—The inability to be easily satisfied can be associated with ambition and initiative. Could this be one reason why so many individuals with attention deficits have been successful in a wide variety of fields?

—Distractibility is intimately linked to creativity. A student who notices things no one else sees is in a position to detect meaningful interrelationships that elude more disciplined minds.

—A student who is highly impulsive may ultimately evolve into an adult with a strong bent for closure, a person who accomplishes a great deal during the working day.

—It is not unusual to encounter adolescents with attention deficits who have superb sense of humor, appealing personalities, true leadership skills, and striking individuality.

Yes, the struggles that children with ADHD face are real. It is important to intervene and provide healthy management such as academic accommodations, medical treatment, counseling when needed. In doing so we can avoid some of the unhealthy consequences such as poor self-esteem and discouragement.

However, we should have an optimistic anticipation of the ultimate success of the child with ADHD. We should be looking for ways to help the teen discover his or her strengths and help them see that they can turn a weakness into an asset.

 

ADHD in the Pre-school Child

Bobby’s parents were concerned. Following his fourth birthday in the summer he had been enrolled in preschool three months ago. The teacher had already requested several conferences with the parents regarding Bobby=s work and play habits as well as his behavior in the classroom.

His mother brought along a note his teacher had recently sent home: Bobby has trouble sitting for more than two minutes before he is up and running about the classroom. He is restless at circle time and wanders around the room. He disrupts the other children who are trying to work. He cannot concentrate for more than a minute or two on a task because he  is so easily distracted.

 Bobby’s Story

I learned that Bobby was the first child in his family. His mother reported that he had always been difficult to manage at home. Always active and restless, he had difficulty staying at the table through a meal and getting to sleep at night. He acted without thinking and was repeatedly in trouble for things like jumping on the furniture or getting into places that were off limits.

When his cousin of the same age visited, he pushed and shoved and was over-excited. But he was not angry and seemed genuinely sorrowful when confronted about what he had done.

His mother had noted these behaviors but did not know what to make of them since Bobby was here first child. AI thought maybe it was because he was a boy.

Once he began to have persistent trouble at preschool the parents suspected that something was not right. The teacher suggested that he might be hyperactive, the father volunteered.

But I thought he was too young. Doesn’t that problem only occur in older kids?@ his mom asked.

In fact, most children with attention problems and hyperactivity are not recognized until early elementary school.

However, the characteristic symptoms of ADHD are typically present from early in life. Often parents as they present a detailed history of the older child recall that the one with ADHD was different from early in life. These difficult behaviors at the time were not clearly different form the typical toddler and preschool pattern. Because no one could put a finger on these differences, they were ignored, or at least tolerated, during the early years. Confusing the picture is the fact that toddlers and preschoolers are by nature active, impulsive, and easily distracted. So the child with developmental problems may be somewhat difficult to separate out at this age.

But, then, along comes a Bobby whose restlessness, impulsiveness, and pure motor hyperactivity cannot be ignored. Such a child has problems paying attention, following directions, and participating in cooperative play appropriate for their age. They are over stimulated easily in large groups or when excited. In a one-on-one situation they may be more attentive and cooperative but even here the short attention span is likely to be noticeable.

For instance, they may have difficulty sitting still at the table through a meal. They will want you to read to them but may listen for only a few minutes before they are up and running or asking for another book. They may hit, push, and shove impulsively, but yet, they are not angry or mean. One common symptom at this age is an incessant need to talk without any control.

 The Diagnosis

Indeed, Bobby did have attention deficit disorder.

After detailed observations were obtained from his parents and teachers, developmental tests were administered. He was cognitively advanced being particularly strong  in verbal skills. However, his motor skills were mildly delayed. The examiner noted that he had a very hard time keeping Bobby focused on the tasks.

Following this evaluation, Bobby was treated with a small dose of Methylphenidate. There was marked improvement in his activity level and degree of impulsiveness. He was much more controlled in school as well as in the home setting.

His teacher later wrote: Now Bobby is able to realize when he has done something wrong. He more often chooses positive options. He is able to sit and concentrate. He is choosing to ask for work which requires that he sit for 10-15 minutes at time. The amount of detail in his daily journal has changed tremendously. Before, he would draw just few lines with dark color in his interpretation was usually something violent and aggressive. This week, however he is taking his time and the colors and the details of his drawings are bright and clear.

 Management

The management of the young child with ADHD is certainly more difficult and complicated than with older children.

First, as we have discussed, it is not always easy to separate the attention behaviors from those behaviors which are typical of preschoolers. Not only is the initial diagnosis more confusing but it is also more difficult for parents to decide how to respond to a specific behavior.

Secondly, the preschooler is not sufficiently mature cognitively to understand the consequences of his disruptive behaviors. Thus verbal signals are often not well understood or received. Parents find themselves constantly interrupting and re-directing behaviors.

The excessive impulsiveness leads the preschooler to behaviors that can be dangerous to themselves and others. Parents must be on their guard for things like climbing to dangerous heights, playing with matches or fire, running into the street, etc. The children must be watched compulsively.

To complicate all of this, the preschooler’s response to stimulant medication is more erratic and unpredictable. Many physicians simply will not attempt to treat the young child with medication because they have had bad experiences with it or they are uncertain about how to administer it to this age child.

 The Use of Mediation With the Preschooler

Recent studies, however, have verified the fact that, indeed, preschoolers can be effectively and safely treated with stimulants with good response when the medication is managed appropriately for their age. The main problem is the narrow window between effective dose and side effects. However, by starting with a low dose and gradually moving upward, side effects can usually be avoided while finding that effective therapeutic window. While most stimulants are available in pill or capsule form only, there are some liquid form available. However, the liquids are all short-acting and require multiple doses during the day, however.

 Other Management Steps

In addition to medication when needed, other management steps are extremely important.

It is important for the home and school environment to be as calm and under-stimulating as possible while providing opportunities for learning. A consistent routine of living: eating, sleeping, play time, nap time, school, etc is essential.

An effective behavior modification plan is also important. Often behavioral counseling for the parents will be necessary to help them formulate discipline strategies and techniques to hand the specific bothersome behaviors of their preschooler. A developmental psychologist who understands preschoolers in a great help.

The preschooler with ADHD will often benefit from enrollment in a preschool at age three or four. The school should be quiet, structured, yet affirming in its atmosphere. Consistent behavioral management should be used.

Most of all, parents need relief. The supervision of the preschooler with ADHD is a very demanding, full-time job. This job can easily over-whelm the most energetic and well-meaning parents. Parents need to make good use of a competent preschool and mature sitters and relatives to get away and recharge their own batteries. Otherwise, they will collapse, emotionally, if not physically.

When confronted with the preschooler with ADHD we need to remember the natural tendency of ADHD to get better with chronological maturity. It we can provide right combinations of management at this early stage, we set the stage for more healthy growth later.

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