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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.

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.

When the ADHD Medication Does Not Seem To Be Working

Most children and adults with ADHD have a positive response with few side effects to stimulant medication. It is estimated that up to 85 to 90% of properly diagnosed children with ADHD experience significant improvement in most areas of function with the stimulants. But there are times when the physician or therapist will hear the complaint that the “Medicine is just not working!”

Dr. David Rettew, associate professor of psychiatry and pediatrics at University of Vermont, responds to this concern of medication failure in an article published in Pediatric News. In the article Dr Rettew reviews several reasons why medication may seem to be not working. Some potential causes are listed below in order of there frequency of occurrence:

1. The dose is too low. There is caution on the part of parents and clinicians when prescribing the stimulants. They wisely start off with a modest dose and push it up slowly or not at all. In fact the dose required for optimum effect varies from person to person. If the patient does not have side effects at the low dose, the dose can be increased gradually to the recommended range per weight. Many doctors and parents give up on a specific medicine before the appropriate dose is reached.

2. The medication is working but wears off early. Again, when the dose is too low, the meds might have an early beneficial effect but this positive response wears off by noon or early afternoon. This does not mean that the medicine is ineffective. It means that the doctor, parent, and patient need to modify the dose and method of taking it. First of all, it is important to make sure that the dose is at the optimal level. If the dose is adequate but the medicine effect still wears off early, it probably means that the patient metabolizes the medication more rapidly than the average person. One way of dealing with this is to have the patient take a small dose of short-acting meds after lunch.

3. Symptoms are caused by some condition other than ADHD. If the medicine is given at the proper dose with the proper timing and the patient still does not have improvement, it could mean that some other condition is causing the ADHD-like symptoms. Such conditions could be chronic sleep problems, anxiety, or other mental health disorder.

4. There is psychiatric co-morbidity. Conditions like anxiety disorder, oppositional disorder, or bipolar disorder can mimic ADHD or accompany ADHD. In this case, a thorough evaluation by a psychiatrist and/or psychologist is in order.

5. There is non-compliance. If the medicine is not working, it is important to consider that the patient is not taking the medicine as prescribed. This is often an issue with teens who are given the responsibility of taking their meds on their own without supervision.

6. There is substance abuse. If other psychoactive drugs are being abused by the patient, the benefit of the ADHD medication may be compromised.

7. The expectations of medication are too great. Some parents, even some therapists, expect the medication to be a miracle worker solving all the patient’s, and the family’s problems. While medication can at times be highly effect, it is never sufficient by itself. Issues like learning disability, anxiety, and low self-esteem will need ongoing attention to help the child reach his full potential. Although medication is helping a given patient, counseling for parents and the patient is highly recommended.

Successful medical treatment for ADHD requires openness and honesty and clear communication between parent, patient, and clinician in order to evaluate and deal with these complicating issues.

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.

Can Exercise Help the Child with ADHD?

A recent study suggests that as little as twenty minutes of exercise a day may help kids with attention-deficit hyperactivity disorder (ADHD) function better. The study, to be published in the Journal of Pediatrics (2012), evaluated 40 eight- to ten-year-olds by looking at the short-term effects of exercise. The study compared 20 children with ADHD and 20 without signs of ADHD. All of the children took a standard test of their ability to ignore distractions and stay focused on a simple task at hand. The kids also took standard tests of reading, spelling, and math skills. Each child took the tests after either 20 minutes of treadmill exercise or 20 minutes of quiet reading on separate days.

 
Overall, the study found both groups of children performed better after exercise than after reading. On the test of focusing ability, the ADHD group was correct on about 80% of responses after reading, versus about 84% after exercise. Kids without ADHD performed better, reaching about a 90% correct rate after exercise. Both groups of kids scored higher on their reading and math tests after exercise than after the reading period.

 
The researchers noted that the effect of exercise on adults’ thinking and memory had been studied extensively, particularly older adults’. But little is known about kids, even though some parents, teachers, and doctors have subjectively seen positive effects of exercise.

 
The scientists reporting on the study state that it’s hard to say what the higher one-time scores could mean in real life. “One of the big questions is whether regular exercise would have lasting effects on kids’ ability to focus and their school performance,” they stated.

 
“We’re not suggesting that exercise is a replacement, or that parents should pull their kids off of their medication,” the scientist went on to say.

 
  This research, while preliminary, reflects the experience of parents, teachers, and others working with kids with ADHD. Since most of these kids have a drive to be active, most observers believe that facilitating active exercise during the day, especially the school day, allows the child to “run off” some of his excessive energy. Future studies in this area will be welcome.

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.

 

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