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ADHD Associated With Early Death

Individuals diagnosed with attention deficit disorder (ADHD) are at a higher risk of dying young, usually as the result of automobile crashes and other accidents. This is the conclusion from the largest study to date on the relationship of ADHD and mortality. This study, an analysis of nearly 2 million Danish medical records, The presence of related disorders such as drug abuse, or oppositional disorder the odds of early death. The study also noted that the risk of early death is even higher in those diagnosed after age 18.

 

While increased morbidity and mortality due to trauma has been known for many years, this new study gives a more precise picture of the risks due to its large size.

 
Most experts feel that this increase vulnerability is due to the impulsiveness and perceptual deficiencies along with general delayed maturity seen in individuals with ADHD

 
The findings of this study should not cause panic in parents and caretakers of children with ADHD, it does point out the importance of early diagnosis and effective treatment of children and teens with ADHD .

 
Other studies furnish evidence that treatment with behavioral intervention, academic support and medication has the highest rate of success. (Seem previous editions of this blog for management and treatment recommendations.)

The Importance Of Reinforcement In The Learning Process

(For parent or teacher, this is a timely reminder.)

 
We hear, see and feel things that are kept in our awareness for a short period of time and then forgotten. These things are not really learned. In order for a stimulus to be committed to the long term memory and, therefore, learned, reinforcement must occur. Reinforcement is the process by which our conscious and unconscious mind is given a reason, or motivation, for committing a stimulus, thought, or concept to long term memory.

 
Reinforcement is a complex and highly varied process. One of the most significant reinforcers for children is the internal, built in drive to learn so characteristic of all children. Children innately want to learn about their world. A high percentage of all stimuli impinging on their senses is assimilated and committed to long term memory, i.e. learned. This innate drive to learn persists in children until it is turned off by some negative reinforcement.

 
Negative reinforcement occurs when learning is made unrewarding, unpleasant, boring, or anxiety provoking. Under such circumstances a child may begin to lose his internal motivation. For instance, the young child eagerly wants to talk with his parents and others about all the exciting things he is learning that the tree is tall, the sky is blue, that bugs crawl. If his enthusiasm is met with continual indifference, he eventually will grow less interested himself in learning. The first grader is usually ready to learn to read. But if he finds the effort confusing and frustrating and finds he is not making progress, learning to read becomes unrewarding and he eventually will quit trying.

 
The human mind has fantastic potential for learning, for absorbing facts, and making leaps into new concepts. Each child has this innate drive to learn from the time his eyes begin to explore the environment, to his reaching for a rattle, taking his first step, saying that first word, to exploring the world of physics. This internal reinforcer, to remain strong, needs to be supplemented with external reinforcement for maximum learning to occur. This external reinforcement may take many forms. Certainly among the most powerful reinforcers are the social ones such as recognition, encouragement, and praise.

 
The knowledge that actions on his part will get him something he wants, such as more free time, treats, money, or participation in a special activity, is a strong reinforcer.

 
Rewards must be immediate and tangible to the child to be effective. We should reward each little step toward the right goal, not wait to give one big reward for total perfection. As learning is reinforced, the material becomes more and more indelibly imprinted on the conscious and subconscious mind of the child.

 
Thus it is important to plan the learning disabled child’s curriculum so that he or she has the opportunity to experience academic, personal, and social success.

 
Here are some healthy ways we can use positive reinforcement in molding the child’s behavior:

a. Recognition
Recognition from family, friends, teachers, and other important people serves as a strong motivator. This may be done in many ways:
“Billy, I am so pleased that you were able to put your pants on by yourself.”
“Wally, you tied your shoes by yourself.”
“Sean, you answered every question. I am pleased.”

b. Encouragement
We all, children and adults, need to be encouraged.
“You are trying very hard with your art. Good job.”
“I like the way you picked your colors for this picture so carefully.”

c. Praise
Genuine praise for a job well done or a good effort extended is one of the greatest motivators.
“I appreciate the good job you did in putting the toys away.”
“I was very pleased by the way you behaved while we were waiting in line…”

d. Sense of accomplishment
The knowledge that one has done a job well, or learned something significant is itself, a powerful motivating force.

e. Material gain
The chance of personal gain is a definite human motivating factor although it is not always the most important. There are times and places for tangible rewards. But they are not always appropriate and in general are not as powerful as the social reinforcers discussed above. However, the knowledge that desirable actions on her part will get her something she wants such as treats, money, or time can be a significant reinforcer for a particular child.

 

As discussed previously, rewards, to be effective, must be immediate and tangible to the child. It does little good to tell a third grader that if she makes straight “A”s she will get a bicycle at the end of the year or that she will get a dollar for every “A” she has on her report card. Such a goal is too distant and intangible for most children.

 
More appropriately we could say, “Susan, complete the first five problems of your homework now then you can take a break and have a cookie and juice.” You give a small, immediate reward for one small step in the right direction and then repeat this process until the task is completed.
We should reward each little step toward the right goal, not wait to give one big reward for total perfection. As learning is reinforced, the material becomes more and more indelibly imprinted on the conscious and subconscious mind of the child.

 
What is most rewarding, or reinforcing, to a given child, will depend a great deal on what that child has learned to like. We should remember that the strongest reinforcer of all is success. Success breeds success. As the child is able to accomplish tasks and sense personal fulfillment, he wants to repeat this pleasant experience. Success reinforced by genuine appreciation and honest attention is powerful in molding behavior and learning.

Beware of the Help!

As a parent of a child with ADHD you are bombarded with advice and suggested help from every direction. As the prevalence of ADHD has become more known, a hoard of individuals and organizations has flooded the market with their own brand of “help.” Many of these ideas come from reputable and experienced sources. However, much of this advice and help come from groups pushing their own agenda.

So it is important for parents to carefully evaluate the advice and interventions they see on the internet, hear from friends or read in the mass media.

I would suggest that parents be wary of the following:

1. Any one offering a complete or, quick, cure. So far I have not found any “quick fix” for the developmental problems of kids with ADHD. Help is certainly available but it involves time, effort, and cooperation of many people. When fad treatments are latched onto, time as well as the family’s money, is often wasted.

2. Anyone pushing a method of treatment not known to the school personnel, your physician and other professionals in the community. You can be sure that your child’s teacher, principal and counselor as well as your pediatrician are interested in what the community has to offer. If there is someone or some program around which can help, one of these people you trust is likely to be aware of its existence. They are not likely to recommend a program that is worthless and expensive.

3. Anyone who pushes just one form of therapy. The strengths and weaknesses of each underachieving child are unique. No one treatment is a panacea for each of them. Most children will benefit from a variety of interventions—through special education, behavioral management, and maybe medical treatment. Most competent professionals will be open to any possibly effective technique.

As with all parenting advice, consider the source as well as the open and hidden expense of any suggested help you receive.

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.

Encouraging Responsibility In Teens

“I can’t decide if my eighth grade son is normal or not,” a mother reported.” At times he acts so irresponsibly. But, then, at other times, he can be so mature. I do want him to assume more responsibility for himself. But he does have to prove to me that he can make right decisions consistently.”

One of our major tasks as parents is to help our teens grow into more responsible, mature thinking and behavior.

One of the problems common to children with ADHD, however, is their apparent lack of responsibility. Their lack of organization and impulsive control often results in behaviors and attitudes that exaggerate the lack of responsibility and maturity.

In order for us who are parents of teens to maintain our own emotional balance, we need to be reminded of some basic facts. The rate at which teens mature varies greatly from person to person and from year to year. One fourteen-year-old may seem vastly more responsible than his peers, another much less so. Typically, a teen may get “hung-up” for a while at some stage and make little progress toward being responsible for chores, school work, or emotional control. As hard as it is for us at such times, we need to be patient, accepting our teen where he or she is emotionally and give him or her time to develop. We should set reasonable rules while not getting overly distraught over these plateaus in our teen’s development.

I remember one fifteen-year-old boy who was notoriously irresponsible about his chores and homework. He was casual about his music lessons and he was not interested in assuming responsibility in the youth group or other activities. His parents were concerned but did not panic. They consistently set rules on his behavior and outlined specifically what chores he was to do and told him exactly what would happen it the chores were not done—and, most importantly, what “good things” would happen if the chores were done without complaint. At the end of his fifteenth year he attended a camping program sponsored by his church. He participated in the activities, listened attentively to the camp leaders. On returning home, his whole attitude changed. He began to do his homework without being pushed and took more responsibility for his chores. Now a college student, his parents are rightly proud of him.

Observing this young man’s progress reminded me that most teens will make it to maturity, albeit at their own pace, if we give them guidelines but also allow room to grow. One way we help our teens learn responsibility is to give them increasing freedom to make decisions for themselves as they show the ability to handle such responsibility.

Some teens will need more supervision and guidance than others and for a longer period of time. It is imperative for parents to continue to be present in their teen’s life, to model appropriate attitudes and actions, and to set appropriate limits. (Yes, limits are still needed during the teen years.)

The teen, however, should be given small doses of freedom which are increased as his actions permit. For example, the teen can, within limits, be allowed to buy his or her own clothes and other basic necessities, to make some choices about friends, entertainment, and what to do with his or her free time.

One father started giving his fifteen-year-old daughter an allowance sufficient for her to buy her clothes and other needs such as make-up and accessories. She was allowed to make her own decisions as to what to buy. If she were imprudent and spent her allowance before the end of the month, she might have to go without something she really wanted for a while. This particular girl handled her responsibility well and is now working to help pay her way through college.

Some teens could not handle this degree of autonomy at 15 or 16 but maybe could respond to a smaller dose of independence. We need to realize that our teens will make mistakes and will make some wrong decisions. But that is not all bad. As it was with us, they will learn some of their best lessons from their mistakes. If we do not give them an opportunity to fail, they will have difficulty learning how to succeed. Periodically, we should re-evaluate the rules that we set for our teen. We should talk with them about their progress, or lack of it. We should praise them when and where we can.

Although we may need to revise the rules from time to time, we should always be firm but gentle. In discussing rules it is helpful to review these points:

1. We should give our teens reasons why a given rule is necessary.

2. We should give them a chance to openly discuss rules that they agree or disagree with.
3. We should discuss which rules should be discarded and why.

4. We should decide what new rules should be made and why.

5. We should discuss which existing rules should be changed and why.

6. Most of all, we parents need to trust our teens. They need to know that we believe in them and that we trust them. We also need to clearly let them know what the rules are and what the consequences of irresponsible behavior will be. But we also let them know that we believe that they are capable of thinking and acting responsibly.

Teens, like everyone else, become what they believe others think of them. We, then, can expect the best.

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 maturity. Individual education plans that address some of those related difficulties can help especially if they’re started early.

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.

Medication in the Summer

A mom asks, “What should we do about medication in the summer-time? I have heard from some parents that they always discontinue their child’s medication during the summer. I asked my doctor what we should do and he said we could do whatever we wanted. So I am not sure. My child is active and disorganized all the time. I worry about him becoming frustrated. What do you recommend?”

This is a good question for this time of the year. Summer is right around the corner and many parents are wondering about the same issues your raise. At one time, it was assumed that the child would take stimulant mediation for attention problems and hyperactivity only during the school year. It was felt that the medication was primarily given to help with school.

The Physicians’ Desk Reference carries a recommendation that the child taking stimulants be given a “vacation” from his medication periodically. But does this mean that all children should interrupt their medical therapy for the summer?

The goal of the total treatment program for ADHD is to provide the framework in which an individual can perform up to his or her fullest potential. Medication, environmental structure, and behavioral management all play a part in maximizing a child’s function in any given situation.

The role of medication in this process varies with each individual. Thus, the answer about summertime medication must be evaluated individually. In this process, we should look at three major skill areas—academic, social, and behavioral.

An important reason for using medication is to promote focus and concentration in the learning environment. Studies have shown that children with ADHD learn better when taking their medication. Medical treatment also enhances the ability to use skills that have been learned. Therefore, the use of medication helps individuals function more appropriately in the many areas where they are continuing to practice and master skills, i.e., family, school, playgrounds, sports, reading, organization.

If, then, the child will be involved in activities during the summer which put demands on his need for concentration or organization (summer school, sports, special camps, etc.), medication may be helpful.

Special circumstances need to be considered. For instance, adolescents often take driver’s education during the summer. Teenagers with ADHD have a higher rate of moving traffic violations primarily due to being easily distracted and the longer time necessary to acquire skills. Teens with ADD may need more prolonged driving practice with their medication before they become safe and proficient drivers.

Building social skills is extremely important for the child with ADHD. “Summer involves more socializing and self-planning than does the school year,” the author points out. There is much more free time, much less adult supervision, and fewer structured settings to provide the usual external controls.

A large percentage of individuals with ADHD have difficulty acquiring and applying social skills. This is often seen as difficulty with peers and siblings when they are not taking medication. Some children will have much more difficulty dealing with these social situations without the medication due to persistence of impulsiveness and over-reactivity.

So in making a decision about taking a break from ADHD medication during the summer, consider these factors:

•Does the child find medication to be helpful in managing a routine day at home with family and friends?

•Without medication, are there many more negative social interactions leading to social failure, discipline problems, and lower self-esteem?

•Does the continuation of medication during the summer allow the family to successfully participate in activities together, such as going out to dinner, attending religious services as a family, or joining large family gatherings?

If the answers to these questions suggest that medication could be helpful during the summer, it would be wise to give it all summer.

But, then, there are certain reasons to consider a medication vacation:

If the child is experiencing significant loss of appetite with slow weight gain, a vacation from medication is in order. A few individuals on stimulant medications will have difficulty maintaining growth during the school year. In the vast majority of these children, this means poor weight gain. If there is concern about a child’s growth, the time to discontinue medication to allow necessary ‘catch up’ growth is during the summer. Most children will regain weight quickly.”

The second reason for taking a “medication vacation” is if the family and physician decide that during the summer, medication is truly not needed. Many individuals with ADHD can discontinue their medication in the non-academic setting, such as summer vacation, holidays, and weekends. But still find it necessary for the extremely intense focus required for the hours of concentration on school and studies.

I am often asked by parents about medication during the summertime. As we see, the answer to this question must be individualized for each child. I point out to parents that what happens in school is important for the child. But as far as his success and happiness in life is concerned, what happens at home and on the playground is even more important. Thus if the child is having problems in his social and family relationships, continuation of medication is probably helpful. Actually, there are several optional courses of action: continue the medication on the same schedule as during the school year, stop the medication all together, or consider a reduced medication schedule.

When there is some question as to how the child will do off medication, I suggest giving a break for the first two weeks of summer. If the child does well, then it is appropriate to continue without medication for the remainder of the summer. If the child has trouble coping with the ordinary activities of his summer during this trial period, then restart the medication.

ADHD: Overcoming–Rather Than Being Overcome

ADHD: Overcoming–Rather Than Being Overcome

Day-to-day experience as well as scientific observation attests to the fact that different children exposed to the same degree of stress or frustration are not affected in the same manner. Some are stymied and squelched by the obstacles in their path. Others thrive as if the obstacles were more of a stimulus than a roadblock. Many observers have asked why.

Several years ago Peter Wyman, Ph.D. and associates studied this question. They looked at demographically comparable groups of children exposed to major life-stress. They interviewed both stress-resilient and stress-affected children assessing perceptions of their care giving environments, peer relationships, and themselves. A functions analysis identified four variables that correctly classified 74% of the children in one or the other group. Stress-resilient children, compared to the stress-affected children, reported more:

 positive relationships with primary caregivers (i.e., parents)

 stable family environments

 consistent family discipline practices

 positive expectations for their futures.

These findings support the view that caregiver-child relationships play a key role in moderating children’s developmental outcomes under conditions of high stress. (J. Am Acad Child Adolescent Psychiatry, 1992:; 31 (5):904-910)

Editor’s Note: This study points out again the extreme importance of a positive parent-child relationship in helping a child overcome obstacles. Children with ADHD and learning disabilities do have plenty of reasons to be stressed. Many will grow into healthy, well-adjusted adults in spite of their difficulties. Stable families, applying consistent, loving discipline in an affirming spirit greatly enhance the chances of success for the child.
Now, read the next article.

Because of My Problems!

“Wendell Wilkie said, ‘What a man needs to get ahead is a powerful enemy.’ Edmund Burke said, ‘Our antagonist is our helper. He that wrestles with us strengthens our muscles and sharpens our skill.’ Apparently human nature must have something to push against and something to wrestle with. I suppose this is the hopeful thing about handicaps…Handicaps are the hard things we wrestle with and push against.

Dr. Marie Ray, a psychiatrist of some note, after making a wide study of the relations between handicaps and achievements, and going down the list of notable men and women, came up with this conclusion, that most of the shining lights of history were made so by their struggles with either some disability or some responsibility that seemed too great for their powers. And then she put down this definite rule as the result of her research, ‘No one succeeds without handicap. No one succeeds in spite of a handicap. When anyone succeeds, it is because of a handicap.'”

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