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ADHD and Self-Esteem

Helping the child with ADHD to grow up with a balanced sense of self‑worth requires care and effort by all who impact on his life. At every turn the child is met with situations that tend to tear down and warp the self‑image. Among these are the following:

 

1. From an early age, he finds himself in constant conflict with the limits placed on him by parents, teachers, and other authority figures. Since much of the behavior producing this conflict is not purposeful disobedience on his part, he is confused and frustrated. He gets the message, “There must be something wrong with me. I can’t do anything right!”

2. Lack of achievement in school reinforces the sense of being abnormal and inferior. A child who sees himself getting further and further behind his peers in achievement easily loses his self‑confidence. If this continues long enough, he may come to say, “Why try, I’m no good anyway.”

3. The child who is uneven in his development and who has significant discrepancies in his abilities may be confused by the contrast between what he can do easily and that which requires an inordinate amount of effort for rather minimal achievement. He may be puzzled as he tries to understand what his capacities really are. The amount of study, including testing, that is needed in the diagnosis of a learning disability also can create worry about himself. The child and his parents may be the victims of professionals disagreeing about diagnosis and treatment.

4. The child may be jealous of other children and siblings for whom achievement comes easily. There may be problems around school work at home; particularly if his brothers and sisters degrade him in any way for his less than perfect work. He may hear from school personnel or family the fallacy, “If you just work harder, you can do better.” The child may be upset by the kinds of work that he must do because of his disability: for example, a fourth‑grade boy cried because he was doing the same kind of work his first‑grade sister was doing.

5. Poor coordination resulting in unsuccessful performance on the playground is also detrimental to the self‑image. Other children often ridicule the one who is poorly coordinated. And ridicule from a peer burns deeply.

How to Help

While it can be difficult to overcome these problems, parents and professionals have some practical strategies to help the child retain a balanced sense of self‑worth in spite of the odds:

1. When the child breaks the rules or oversteps the limits, we should discipline firmly but kindly. We should aim the punishment at the offense and not at the child or his personality.

The child should not be told, “Would you stop? You’re nothing but trouble.” Instead we might say, “Johnny, your jumping around is really bugging me. I think you should go to your room for 15 minutes and see if you can stop.” We then send him immediately to his room. If he doesn’t go willingly and quickly, we take him by the shoulder and lead him to his room.

Rather than say, “Don’t be stupid. I’ve told you that a hundred times,” we should say something like, “I’ve explained that rule before. Please do what I asked.”

Everyone should remember that one can discipline firmly without attacking the person or worth of the child.

2. We should not punish the child for things he really cannot help such as fidgeting or being clumsy.

3. As much as possible we should positively reinforce appropriate and desired behavior. “Catch them being good and tell them so” is a healthy working motto. Always be on the lookout for the opportunity to honestly say something affirmative.

4. If we suspect the child of having a behavior or learning problem, we should seek help as soon as possible so that the proper diagnosis and treatment may be instituted. Often such early intervention can circumvent much of the stress and conflict that blocks their success.

5. We must seek an educational environment which treats the child as an individual, recognizes his strengths and weaknesses, and helps him learn in his own way at a pace appropriate for his skills.

6. We should help the child to discover his good qualities and superior skills. All of us, even those with special problems, do have some good points and superior abilities. We all have a deep psychological need to excel in some area of life. Your child’s hidden talent may be an isolated academic skill, a sport, a hobby, or music ability.

For instance, many children with ADHD are not very good at the traditional sports such as football, basketball, and track because of their lack of coordination. But often these children are quite well coordinated in water and are excellent swimmers. Thus swimming for fun and competition can be pursued as their area of excellence. One boy was a very poor reader but had perfect pitch and became a good musician in spite of his inability to read well.

7. We should not use language that attacks the child’s dignity or personal worth. Children who are belittled as youngsters are likely to grow up with a poor self‑image. They literally continue to belittle themselves throughout life. Such belittling adjectives as “rude”, “ugly”, “stupid”, or “clumsy” should not be used to describe children. Rude, stupid, ugly, etc. may be used to describe actions, if necessary, but they should not be used against the child himself. The danger is that the child may accept such an evaluation and make it a part of his  self‑image. If he thinks himself as rude, ugly, or stupid, he is likely, in the end, to behave that way: it is only natural for a rude boy to behave rudely.

Such precautions do not imply parents should not correct a child or criticize his behavior. There is, however, a big difference between criticizing the behavior and criticizing the child.

Rather than say “You are a rude boy,” a parent can say, “That was a rude thing to do. Apologize and go to your room.” Such a statement is not an attack on the child’s personality but  does show disapproval of his behavior.

To the child who brings home a poor report card a parent can say something like this: “Cathy, this doesn’t look like you. I guess we will have to set up a regular homework time.” To say “I knew you were lazy, but I never expected this from a child of  mine!” is to whittle away at the child’s ego.

It is a hard lesson for us parents to remember but discipline should be directed toward the misdeed and  not toward the child’s personality. Even if the child’s personality leaves something to be desired, to attack it will only make it worse. Remember, we get a lot more out of a child, or anyone else, with positive reinforcement of good traits than we do by criticizing the undesirable traits.

 

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.

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.

ADHD–A Family Matter

One in every four children with ADHD has a biological parent who is similarly affected according to Dr. A.J. Zametkin of the National Institutes of Mental Health, Bethesda, Maryland. His excellent review of the family history of attention deficit disorder appeared several years ago in The Journal of the American Medical Association. Dr. Zametkin discussed a family in which 3 generations of males had significant symptoms of ADHD.
The youngest was diagnosed first and treated successfully with medication. On review, it was obvious that his father had attention and organization dysfunctions which continued to interfere with his life as an adult. He was also treated successfully with medication beginning in his forties. Further questioning suggested strongly that the paternal grandfather had symptoms of ADHD. (Zametkin A, JAMA 273:1871-1874, 1995)

Editor’s Note: This study, although from several years ago, points out the importance of discussing the family history when evaluating a child with attention problems or learning disabilities. Strong family patterns do exist. And this is not the first time a parent has learned of his or her own attention deficit after having had a child evaluated.


Over the decade and a half since this study was published, research into the cause of ADHD has shown that heredity is the most dominant factor determining the presence of ADHD. Those of us working with children with ADHD often see families in which the one or both parents will say, “You know when I was a child I was just like my son. I had the same problems. In fact I still have those problems to some degree.”

ADHD and Anxiety

Children of all ages with ADHD (Attention Deficit Hyperactivity Disorder) frequently suffer from varying degrees of anxiety. Anxiety may be provoked for many reasons in the child with ADHD: The frustration coming from having to work harder in order to keep up academically is a common and significant stressor. The incessant negative feedback that is all too common in the life of the child with ADHD creates a numbing pressure. Then the difficultly getting along with peers sets the child a part socially and fosters a sense of not belonging. All of these issues lead to low self-esteem which makes the child with ADHD even more vulnerable to stress.

A study reported recently at the American Neuropsychiatric Association meeting found that stimulants administered for ADHD also help relieve anxiety in the patients. In fact stimulants alone were as effective in treating anxiety as stimulant plus anti-psychotic medication.

The study evaluated 134 children and teens with a mean age of ten years. They were evaluated in terms of the change over time in anxiety scores on the parent-completed Child Behavior Checklist.

Eighty children were on stimulants only. Another 54 were on a stimulant plus antipsychotic drug. Twenty four of the patients had clinically significant anxiety, as determined by a baseline Achenbach anxiety score prior to starting medication. After four months of therapy with stimulant medication, 83% of the children had a reduction in their anxiety scores.

This study did not evaluate the reasons why anxiety was lessened with stimulant treatment. Two possible mechanisms, however, could be responsible. First, it is possible that stimulants have a direct anti-anxiety effect when used to treat ADHD. However, this is not proven. A more likely possibility is that with effective treatment of the ADHD behaviors, the patients experienced less conflict with his or her environment and, therefore, experienced a reduction in anxiety.

Those of us working with children with ADHD should remember that they are often dealing with significant stress and anxiety. We need to look for such complications and address them when needed. It is good to know that effective stimulant therapy, itself, has a measurable anti-anxiety effect.

The ADHD Child and Summer Camp

It is that time of year! Millions of kids across the country will be packing up their knapsacks, waving goodbye to mom and dad, and heading for the hills—literally. Yes, they will be off to summer camp.

What about camp for your ADHD child? Is camp good for him? Is she ready for camp? These are good questions. The answer, of course depends on a multitude of factors. The issues condense to two important areas:

Is your child With ADHD ready for camp?

Is camp ready for your child with ADHD?

Let’s look at the second question first. This question is really asking if the camp under consideration is one that is appropriate for a child with ADHD. Does the camp have a philosophy of inclusion in which they are interested and equipped to work with children with varying backgrounds and needs? Does the administration and staff have some knowledge about ADHD? Is the staff trained in the needed skills of reinforcement and behavioral management? If your child is taking medication, is the camp able to administer it properly.

Although few in number, camps for children with ADHD and/or other learning difficulties does exist. These camps are designed to present a general camping experience for the child while at the same time providing specific therapy and education relating to the ADHD. To find out about such camps in your area you might check with the local chapter of CH.A.D.D. or LDA (Leaning Disabilities Association). If you are unable to locate a local chapter, contact the national offices of these organizations.  Also, check with your school counselor. He or she might have a list of specialty summer camps.

Is your child ready for camp? The answer to this question is somewhat more complicated. Most importantly, the child’s attention deficit should be sufficiently controlled so that he will have a positive and helpful experience. His behavior should be at the point that undue re-direction or behavior modification will not be required.

While there is no sure way to know, there are a few points that indicate that your child is ready for the camp experience. Look for the following readiness cues: Does your child make friends easily? Does she adapt well to new situations? Does he respond well to adult supervision? Does she enjoy successful sleep-overs at the homes of her friends or relatives?”

If your child hasn’t experienced success in most of these areas, she or he probably is not ready for sleep-away camp. But she might be ready for a less socially demanding experience such as day camp. If day camp is too big a step, encourage your child to spend a few days with a favorite friend or relative. Then be sure to praise her success at being away from home.

In general, I would suggest that most children with ADHD are not ready for a week-long sleep away camp until ten or older. For many, this time will not come until their early teens. Of course there could be exceptions with the more mature child. Day camp could be a very good alternative for the child with ADHD.

What Are the Benefits of Camp?

Attending camp gives children an opportunity to learn many new skills—how to swim, ride a horse, sail a boat, hit a tennis ball, use a bow and arrow, tie a knot. It also gives them a chance to master important emotional, developmental, and social skills—how to get along with other people, establish peer relationships, tolerate differences, work as a team, and become more independent.  Camp also gives parents and kids a chance to practice the art of letting go. The experience lets children develop autonomy and a sense of self-respect. A successful camp experience can be a big boost to self-esteem. For parents, the separation allows them to take a break, care for some of their own needs, and recharge their parenting batteries. They also need to experience autonomy from their child—in preparation for what is to come in the very near future.

How To Prepare the Child for Camp?

Since children can be fearful of the unknown, it is a good idea to share as much information as possible about the camp. If the facility is within driving distance, you might plan a visit ahead of time. Such a visit allows the child to see the place as well as talk with some of the staff. Much of the mystique as well as the fear is thus removed.

If a personal visit is not possible, ask the camp for whatever information they may have: brochures, pictures, videos of the camp.

Above all, talk with the child about his hopes, dreams, and fears about camp. Listen to what he has to say. Discuss any concerns. Certainly, do not belittle the worries and fears. Let the child know that while you think the camp experience will be good for all of you, you will miss him and will look forward to his return. It also helps if the child is able to attend camp with a friend.

Association of ADHD to Obesity

A large of study of over 12,000 people in the U.S. has suggested an association of ADHD and obesity in children and young adults. In an analysis that controlled for age, sex, race, ethnicity, education, depression, alcohol use, smoking, and physical activity, survey participants with ADHD had a significant 63% increased risk of being obese compared with those without these symptoms. People with only inattention (ADD) had a smaller increase risk of 23%.  In the study, the more intense and widespread the symptoms of hyperactivity and impulsiveness, the worse the obesity risk.

The study did not evaluate the reasons for this association of ADHD and obesity. However, one of the characteristics of ADHD is impulsiveness. It is possible impulsive eating, maybe related to increased stress of coping with ADHD symptoms could contribute to the increased risk. Further study is needed to get a better picture of the cause of the obesity and how to prevent it. Also it would be of interest to know if optimum treatment with medication and cognitive behavior therapy would reduce this risk. I suspicion is that it would to the degree that intervention helped in the control of impulsiveness.

Rise in Prevalence of ADHD in Children

A new government study finds that nearly one in ten children has some form of ADHD. This is a significant increase from a few years ago. ADHD, or attention deficit hyperactivity disorder, makes it hard for kids to pay attention and control impulses and organize tasks.

The new estimate comes from a survey released by the Centers for Disease Control. The study found that there has been an increase of about 22% in ADHD since 2003. The researchers calculate that about 5.4 million children have ADHD.

The cause of this increase is uncertain although the researchers speculated that it may be due to better screening by schools and doctors—and just a general increase in awareness of ADHD by the general public. Whether these new estimates are accurate or not, they do point to the significance of ADHD. Over the years, repeated studies document that ADHD is the most common developmental disorder affecting children. Attention Deficit Disorder is a frequent reason why a child may under perform academically or be seen as having behavior problems.

Another important fact pointed out by this study: It is critical that children with ADHD be recognized and accurately diagnosed because, thankfully, there are reliable and effective methods of management and treatment. (See additional articles on this website.)

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