Monday, July 27, 2009

Parenting and ADHD

Dear Dr. Dan,
Is there anything you can add to the advice in your book when it comes to parenting a kid diagnosed with ADHD, after a divorce? I don’t remember if you say in the book whether or not you even believe in the diagnosis.

Good question. You’ve said you didn’t know if I ‘believed’ in ADHD or not, which could be the subject for another entire blog altogether. Our knowledge about ADHD is expanding almost exponentially, particularly with the advent of the Human Genome Project and a lot of good solid research coming out of various medical centers. And I have actually been working on a new book that I hope will help translate these exciting new findings into regular English. I’ll keep you posted.

You should know that, unlike much contemporary research, research into ADHD is not funded by drug companies. Most medications used to treat this disorder have been generic for a very long time, so there’s little money to be made by encouraging the diagnosis of ADHD. But as a result, the research is being conducted in university medical centers, and it is quite solid and credible.

In general, I would advise the following:
  • Don’t be afraid of medication treatment — which happens to be the only real treatment for ADHD. Despite what you may have heard, the stuff is pretty safe and it usually works.
  • As with everything else we say, learn as much as you can about ADHD. There’s new stuff coming out all the time, and the more you learn, the better able you will be to understand your child.
  • Take your newfound information directly to the school and educate them — we’ve done a lousy job of educating the lay public, and teachers are no exception. The more completely one understands this problem, the more tolerant one becomes, and the more tolerant one becomes, the more “understood” the child feels.
  • Physicians are accustomed to dealing with very well-informed parents, and normally they will welcome your input and your questions. Don’t hesitate to call the pediatrician to address your questions or concerns directly.
Research has shown pretty conclusively that medication treatment will result in demonstrable improvement in virtually all of the issues that stem directly from the underlying ADHD. This makes a trial of medication all the more useful, as it may then make it easier to identify other issues that may require intervention, such as learning disabilities, anxiety, depression, etc.

A second issue is more directly related to you. It has now been conclusively demonstrated that ADHD is a genetic disorder, and one that is not “outgrown”; quite the contrary, difficulties associated with ADHD persist throughout a lifetime. This means: (a) if your child has ADHD, there is an exceedingly high probability that someone very near him on the family tree has it as well, and (b) if that someone happens to be you ... well, if you’ve read my book, you know what to do. Get active. Learn as much as you can about the disorder and how you may be impacted by it; go get yourself a credible evaluation; and if you have it, treat it. It’s hard enough raising a kid with ADHD under the best of conditions. Trying to raise one when you’re a noncustodial father and you have ADHD as well is a real challenge.

A Word About “Executive Functioning”
ADHD is really more than simply an attentional problem. It’s fundamentally a problem of how well you are able to regulate yourself. We call these regulatory mechanisms ‘executive functions’, because they are all involved in how we do what we do. Executive functions are things like how well we’re able to manage time, how well we learn from from our own mistakes as well as from the mistakes of others, how well we anticipate social consequences, how efficiently we can plan, organize, and execute tasks, and how well developed our problem-solving abilities are.

Just a couple of examples:

Time Management
The teacher assigns a report on a topic. She provides an outline of what she expects, and indicates that the report will be due in two weeks. Every kid in the class, in some way or other, immediately starts laying out a picture of how they will structure the task — for example, ‘outline done by Friday, rough draft done by the next Monday, final report completed by Thursday night’ — except the kids with ADHD. They immediately think, “Hey, this is great, 13 days with nothing to do!”

The kid without ADHD discovers she forgot to write down her homework assignment. She calls a friend and gets the assignment. The kid with ADHD discovers she forgot to write down her homework. Guess what? No homework!

The kid without ADHD can’t find her shoes. She goes through a typical series of problem-solving steps — remembering the last time she wore them, retracing her steps, looking in all of the usual places, and ultimately she finds her shoes. The kid with ADHD can’t find her shoes. She (a) has a meltdown, (b) blames her brother, or (c) goes out with no shoes.

Planning and Execution
The kid without ADHD is told to go clean his room. He goes to the room and automatically understands how to structure the task, for example, first getting the underwear off the floor, then getting the tuna sandwich out from under the bed, etc. Whether he knows it or not, he uses a systematic, efficient set of strategies, and pretty soon the job is done. The kid with ADHD goes into the room, looks around, has no idea where to start, looks around again, spots the Ninja Turtles over in the corner. An hour later you come into the room and he’s sitting in the corner playing and you’re pulling your hair out.

Working Memory
The kid without ADHD, even if he’s not exceptionally bright, is given a set of instructions: “Go upstairs to your room, get your hat and coat, and on the way to meet me at the car, give the dog some water.” Within two to three minutes he’s at the car, and you’re on your way. The kid with ADHD, even if he’s absolutely brilliant, is given the same set of instructions. You may not see him again until next week. Because he was unable to ‘hold’ the information well enough to get the job done.

The importance of understanding these things is that it leads directly to helpful interventions. Once we understand the child’s deficits in self-regulation and executive functioning, we can set about putting in place our own ‘regulators’ to assist in getting the job done.

For example:
  • If she doesn’t yet have the working memory capacity to ‘hold’ multiple-step instructions, give her one at a time. Have her come back when she’s done the first one, and then give her the next one. Repeat as necessary until the job is done.
  • If he’s unable to effectively plan and organize a task, do it for him (the planning, that is). “First, go get the clothes off the floor, then come back and see me.” “Now, go get the tuna sandwich from under the bed ... ” Again, repeat as necessary until the task is done.
  • Adopt a ‘Problem-Solving Mind Set’ for everything the child faces; work with them on everything as a problem-solving situation. Even something as simple as going out for fast food. “Here's the deal. We’re hungry, we need to eat. What are our options?” (Wendy's, Taco Bell, etc.) “Which one is the best solution to this problem? Why do you suppose this solution is better than the others?” (closer, cheaper, better-tasting, etc.) Or, Homework: “The problem is that the school has these outrageous demands on your time and energy, and they will do bad things to you (poor grades) if you don’t meet these demands. How can we solve this?” If you think about it, just about everything is, at its core, a problem-solving situation.
  • “Externalize” the regulators. If your child has no sense of time, get a kitchen timer. Have her compete against it to get work done quickly; have her guess about how long a particular task will take, and set the timer. Use the timer as a reminder to take a break, to get back to work after a break, etc. If your child has lousy working memory, use lists. Put them on Post-Its. Put them on the refrigerator. If he needs to remember to flush the toilet, put a BIG sign right above it as a reminder. If she's impulsive and doesn’t anticipate consequences well, work on the “30-second rule.” Help her train herself to delay for a count of 30 — this gives her a chance to “cool down,” if necessary, to decide if what she’s going to say really needs to be said at all, or if it will result in a negative consequence.
The possibilities are endless. But they all require work and vigilance on your part — yet another reason to manage your own ADHD well, if this applies. More importantly, however, it also requires a different mind-set of parenting. The reason these kids have executive functioning deficits has to do with (we think) delays in the development of the prefrontal cortex of the brain, the structure that houses these abilities. This has nothing to do with intelligence or any other attribute — simply and specifically with executive functioning.

What this tells us is that if the child with ADHD doesn’t get his homework written down on a consistent basis, we need to step in and help manage this problem until he is capable of doing it on his own. Our experience tells us that when these kids become able to perform certain functions, they do. Until then, however, they need our help. Not once. Not twice. But every single time they have to perform the task. With other kids you can simply walk them through a task two or three times, and then leave them to perform it on their own. With the ADHD kid, on the other hand, you must do it every time, or it simply won’t get done.

Issues related to parenting youngsters with ADHD and other childhood disorders could fill libraries. In this limited space I hope I have been able to cover some of the highlights, and I hope that this has been responsive to your question. Keep those cards and letters coming!

Dan McClure