Is it really ADHD or is it something else?
I think parents would like their pediatrician to answer for them if the symptoms they see in their child are being caused by ADHD or by some other issue. Of the kids we see who are brought in with a question of ADHD, a lot of them have other problems that are causing their attentional problems, and if we are able to treat the other problems, we don’t have to go down the road of treating their attentional problems, because we’ve treated the real problems.
Leonard Rappaport, MD, MS,Director, Developmental Medicine Center
Will my kid grow out of it?
Parents also want to know what is going to happen to their child over time. They want to know if their child is going to grow out of having ADHD, or if he or she is not going to grow out of it. If you look at the data, somewhere between 30 and 50 percent of kids who have ADHD grow out of their symptoms in the sense that they no longer need or necessarily benefit from medication as they get older. So I can tell parents that the data suggest that people do grow out of their symptoms of attentional problems. In addition, as a child gets further in school the world becomes a much bigger place. His or her attentional problems aren’t as big of a deal when there is ample time to handle situations in college or if he or she gets a job that makes the most of his or her energy and creativity. Some of the characteristics that were a burden for a kid in kindergarten, or elementary school, or middle school, or even high school become assets for him or her as he or she gets older.
Leonard Rappaport, MD, MS, Director, Developmental Medicine Center
Will my kid be OK?
Parents want to know if their kids are going to be okay, if they are going to be able to succeed in life with the symptoms that they have. Fortunately, ADHD is a very treatable disorder and the majority of the children can be okay. Obviously if they have multiple co morbid disorders the cards are more stacked against them. But for the children with ADHD who receive good treatment and have the supports of the family, their parents’ question about if their child will succeed can be answered pretty confidently with a yes.
Stuart Goldman, MD, Senior Associate in Psychiatry, Child and Adolescent Psychiatrist
A positive future
When I see a family whose child has ADHD, I always start by articulating the family’s as well as the child’s strengths. I point out that kids who have ADHD are and can be quite bright, because often parents have the misconception that their kids can never go to college and are not bright. Kids with ADHD have as much cognitive ability as kids without ADHD and can function at school, home, play sports, be involved in extracuriclaur activities, excel in multiple areas post high school and do wonderful and creative things just like other children.
Marcus Cherry, PhD, Child and Pediatric Psychologist
Misconceptions parents have
One of the biggest misconceptions parents have is they don’t think of ADHD as a medical illness. They think it is something that a child can willfully turn on and off. I think the reason for this perception is that kids will get into mal adaptive coping strategies and so it feels to the parent like it is a behavioral issue and not really a medical problem. So I share with them that there have been studies done and that there are areas in the brain that are targeted for all ADHD. Even though we don’t totally understand what the medical and chemical processes are we have a lot more information about it than we used to. I talk about it in terms of a medical illness.
Frances Johnson, Advanced Practice Nurse
Multi-modal interventions
On all cases, we evaluate multiple areas where children function: home, school, and anyplace else the child goes. The interventions are usually multi modal. Usually I intervene with the school by talking to teachers and guidance counselors and trying to make modifications in the classroom and in the child’s workload, if needed. Sometimes, depending on current child/parent interactions, there are modifications in the home, too. We help parents make their home ADHD friendly which may require parents to respond differently to their child, alter the structure of routines, increase opportunities for praise and positive child/parent interactions, and problem solving to complete some tasks. The goal is to create a home and school environment that is ADHD friendly which has some structure, some basic rules, some basic guidance, opportunities to learn skills and immediate feedback about positive and not so positive behaviors and appropriate consequences. As with all children, Kids with ADHD benefit from feedback and direct praise.
Marcus Cherry, PhD, Child and Pediatric Psychologist
Situational behavior
Many parents have difficulty understanding situational variability of ADHD. One of the hallmarks of ADHD is that the behaviors shift to the environment. Kids can look perfectly fine out on the playground. Parents tell me about how their kid loves video games and can sit and play them for a long time. One of the things I try and do is explain that the symptoms and their severity can be different in different contexts. When they play a video game they are focused on one thing and they are doing something they like to do. During morning routines when kids have to adhere to their parents’ rules and structure, kids tend to struggle. Children diagnosed with ADHD can also struggle with transitions, homework and boring repetitive tasks. I am always thinking about and explaining that the symptoms are exhibited in different levels at different places.
Marcus Cherry, PhD, Child and Pediatric Psychologist
Working with families with different income levels
It is very satisfying to work the underprivileged population. Very often parents are worried about having enough financial resources just to make it. Often that’s the first priority; it’s almost a survival thing. Sometimes there is a higher no show rate for those families because they run into difficulty with transportation or some kind of crisis happened at home and so they don’t get to the appointment. That interferes with structuring the environment, possibly the parent being able to get to the school and talk with the school as frequently as they need to. Sometimes schools don’t take parents very seriously because of cultural barriers. So sometimes we have to step in and advocate for the parent, to help them with that process. There are situations where we are actually advocating for other resources. So for example, if a parent is required to work, working to find an after school program that the child can go to that’s fairly structured. And what in fact parent’s rights are as far as having extra help for kids who have special needs in school.
Frances Johnson, Advanced Practice Nurse
Cultural issues
Some cultures do not like the idea of medication at all and then there are others who are looking for the pill to do all the work and to change the behavior totally. There’s a lot of education around that. I like to target to symptoms because then we can measure whether there is a decrease in symptoms, but then we have to stress that there are other kinds of things that are important. For example, with ADHD having a time schedule for when the homework gets done, breaking it up in smaller amounts, keeping things in the same place, and maybe organizing things the night before so that the morning is not so chaotic, different things like that.
Frances Johnson, Advanced Practice Nurse
Not bad parenting!
All families come with their specific set of issues and understanding about ADHD, or misunderstanding about ADHD. A lot of times parents come in thinking that their parenting has caused ADHD. That is not the case at all; bad parenting does not cause ADHD. What usually happens is that over the course of time, parents do everything to try to help their child do the things they ask them to do like following directions, getting dressed in the morning, and getting ready for bed in the evening. By the time they have struggled with everything they usually end up having some very dysfunctional parenting skills. They are functioning only on the negative and are not giving praise to their child.
Marcus Cherry, PhD, Child and Pediatric Psychologist
Powerful praise
With younger kids I usually focus on the parents in terms of creating an environment where they start to provide more praise. We reframe their parenting to meet the needs of their child’s behavior and symptoms of ADHD. That process can take quite some time because you have to understand the makeup of the home. If it is a two parent home, both parents need to be on the same page, and sometimes that’s not the case if there is differences in parenting styles or understandings about the child’s difficulties, severe family conflict or other factors. We try to work on ways to provide the child with positive and immediate feedback by adjusting the goals to meet abilities of the child and the parents at any given time. One way could be to have the child earn rewards for different behaviors like getting homework done, putting books away, getting through each part the evening routine etc.. The kid then gets immediate positive feedback and is moving towards a privilege.
Marcus Cherry, PhD, Child and Pediatric Psychologist
Teaching, collaboration, and psychoeducation
I do lots of teaching, collaboration, and psycho education with parents of kids who have ADHD. I try to have parents understand the situations that their children are having the most difficulty in and either try to have them reduce the demands of those things or to choose another time for their children to learn those things. By reducing the demands on the child, kids won’t get as stuck and there won’t be as many temper tantrums. We also try to have parents focus on increasing opportunities for praise but also on appropriate and consistent consequences and limit setting for specific behaviors. We want the parents to help their child understand that there will be specific consequences for specific behaviors so that there are no surprises for the child. Also, we want parents pick their battles, to stop and think, “Is this situation worth blowing up over? No.” or “Is this behavior something we should really work on? Yes.”
Marcus Cherry, PhD, Child and Pediatric Psychologist
Shaping behaviors
When I work with parents, I like to begin with a great deal of psychoeducation around management of behavior, helping them understand what influences and impacts the behavior of their child. The role of praise and the role of positive attention for children are critical components. Subsequently, I actually teach parents how to try to use praise, attention, positive reinforcement to shape pro social behaviors in accordance with the rules at home.
Eugene D’Angelo, PhD, Chief, Division of Psychology
It’s a gamble
Parents are always concerned if their teens have ADHD that they will become dangerous drivers. This is a realistic worry; however, there are a range of possibilities. Some teens with ADHD have greater incidences of traffic accidents than other kids without it, but that doesn’t mean that the child with ADHD sitting in front of you is one of those people who will have accidents. It is something for parents to be aware of, however, not to over react about with their children.
Eugene D’Angelo, PhD, Chief, Division of Psychology
Concerns about driving
Driving requires that you be able to attend and focus and manage multiple things. It also requires you to follow rules, stop and think, and not be impulsive Adolescents who have ADHD may not move around as much as when they were kids, but they are hyper responsive. Their impulsivity may be in the choices that they make. They often struggle with taking their time to problem solve and thinking through questions and answers. Impulsivity and how that implicates choices when driving is a concern. If the adolescent is hyperactive, he or she is going to have a hard time attending and focusing while driving. Kids who have ADHD can have visual spatial issues, too, so it might be hard for them judging distances and spaces when driving. It’s really going to be a struggle for kids with ADHD to drive.
Most times parents of kids with ADHD are concerned already that their kids are going to struggle with driving. Most of it comes from parents’ concern that the kids can’t handle the responsibility of driving because they haven’t shown responsibility in other areas. Some parents negotiate with their adolescents about things they can do to ensure that they will have a responsible understanding of what it is to drive a car and then work step by step to do that– for example, going through a driving program and seeing how that goes. It’s also important to have them do other things in other places so that learning how to drive a car is a privilege that the adolescent has earned. Showing an increase in compliance with homework, with class work, with a job, and with whatever home rules an adolescent’s family has are all ways to demonstrate some of the responsibility that is needed for being able to drive a car.
Marcus Cherry, PhD, Child and Pediatric Psychologist