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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.

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.

Successful Coping Strategies

Successful Coping Strategies

Adults with attention-deficit hyperactivity disorder who have attained higher educational and professional status use a variety of strategies to cope with their disorder, a new study shows. The study was conducted by Robert D. Wells, Ph.D. and reported at the annual meeting of the Developmental and Behavioral Pediatrics Society.

 

Thirty-one adults who responded to a newspaper advertisement seeking people with ADHD filled out several symptom, behavioral, and intelligence measures. They were interview about their compensatory strategies. The group aged 23 to 71, included 22 women. They could be considered highly motivated for completing the study and may represent a skewed sample, the researcher noted.
Those who were relatively more successful in their education and career were more likely to do the following:

 

Set up rituals to get through repetitive tasks.
Use lists to retain large amounts of information
Control impulsive behaviors by writing down their thoughts and talking them over with someone.
Choose jobs which have a variety of different tasks each day and that allow them to be in charge of themselves and their time but that still have structure and quotas.
Learn to delegate.

 

Some of the individuals listened to “white noise” in the background to help them concentrate. “One guy had the rule of three: He only allowed himself to work on three things at once,” said Dr. Wells, Director of Pediatric Research at Valley Children’s Hospital in Fresno, California.
Many of the less successful subjects could not identify any strategies they used to avoid distractions, to retain information, or to make themselves feel successful. Only nine per cent of the variability in success could be attributed to differences in intelligence, Dr. Wells added.
Ongoing studies of junior high students and prison populations should help determine how much of the difference in success is due to skills that might be taught and how much may be due to temperament and personality.

 

Most people with ADHD do not outgrow their ADHD. But as this study shows, they can learn compensatory tools. The subjects of this study point to the way in which successful people do compensate.

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.

Classroom Strategies: Assisting the Child with ADHD

The Teacher’s Challenge

I have great admiration for the dedicated teacher. And most teachers I know are teaching because they love children and like being around them. They have a sense of satisfaction when they see their students learn, grow and succeed.

On the other hand, they are frustrated and personally defeated when one of their students fails to achieve and succeed. Thus the presence of a learning-disabled or hyperactive student in a class tends to stir up a mixture of reactions in a conscientious teacher. He or she wants to help, but are thwarted by lack of time, too many students or a lack of materials or training. This easily leads to frustration and hopelessness.

One fourth-grade teacher spoke not only for herself, but also many colleagues, when she discussed a learning-disabled child in her class. “Jimmy is a puzzle. I want to help him but I’ve been frustrated at every turn.”

This brief article cannot offer solutions to all the problems involved in teaching the learning-disabled child. The information presented here is a potpourri of tried and proven techniques which have been gleaned from experienced teachers. Hopefully, they will make the job of teaching the child with ADHD or learning disabilities a little less frustrating and more rewarding for you and the children in your class.

From long experience, we know that children with hyperactivity and attention deficits function much better in an organized, structured atmosphere. Not only does such an atmosphere allow the child to function more efficiently in the present, it also encourages him to internalize this imposed organization so that, in time, the child becomes more self-controlled.

The following suggestions regarding classroom management have been derived from the available literature, current research findings, and clinical observations. The goal of these strategies is to help the child internalize control of attention, impulsiveness, and activity, thus improving work habits and general behavior. The methods are designed to help the child develop more conscious control. Each teacher will not, and should not, employ each and every technique presented. This is simply a sampling of practical techniques which can help with certain problem behaviors. The teacher can pick those he or she thinks may work for him or her with the child in question.

Classroom Strategies Useful With ADHD Children

Seat the student near the teacher’s desk in a reassuring non-threatening way.

Call the student’s name before addressing him or asking him to recite.

Stand near the child when giving instructions so as to capture his focus.

Reduce the visual stimuli in the child’s visual field (place construction paper over windows, eliminate posters, pictures, etc.) Lighting should be of medium intensity, no flickering or bright lights.

A child with ADHD will often have difficulty finishing work. Give shorter assignments with immediate feedback of results. Multiple short assignments work better than one long assignment.

Work from small units to larger units in the quantity of work required, the complexity of the task, and time required to complete tasks. Shorten assignments.
Start with easily accomplished tasks. Build assignments in terms of length and complexity.

Break assignments and experiences into smaller units. Gradually increase quantity and complexity of timed units.

Use a multi-sensory approach to allow rehearsal of the material such as speaking orally, writing down key words, drawing pictures, etc. Have a child repeat orally the material to be committed to long.

Provide an opportunity to express motor restlessness in appropriate ways such as when appropriate allow the child to work standing or moving about .

Adequate physical education that allows for gross body movement without involving competitive sports can be helpful.

Summary

Yes, there are no easy answers to treating and teaching children with attention deficits. These children are often lovable and attractive, while at the same time frustrating and exhausting to the teacher. One or two such children in a regular classroom without help for the teacher can be stressful for everyone. Open, free communication between teacher, parent, physician, and educational diagnostician is of critical importance if success is to be realized.

While the institution of a well-structured, organized environment at home and school will allow many hyperactive children to function reasonably well, others will need additional modes of therapy such as medication or a prescribed behavior modification plan. However, the teacher is always a key member of the management team.

 

(Additional teaching strategies is found in the book, ADHD Strategies for Success by Dr. Grant(

ADHD Can Persist Into Adulthood

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

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

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

Several take home lesions from this study:

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

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

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

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

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.

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