Ever since our country established a system of universal compulsory education, educators and clinicians have begun to notice students with ADHD-like symptoms. It has gone by many names and has been addressed in many different ways.
Accepting the Diagnosis
Many families go through a period of uncertainty during the time leading up to the eventual diagnosis. Sometimes, but not always, school problems trigger the ADHD diagnostic work up. The experience of “getting diagnosed” is powerful and can either be a blessed relief or a crushing blow. Many parents experience this as a loss and need to go through a process of mourning so that they can eventually accept their child as he or she is. The classic stages of mourning, denial, anger, grief and acceptance all apply here. Parents and teachers may have different perspectives on this phase of the process of acceptance. The professionals need to be patient with parents as they come to terms with their child’s condition. They should not be too quick to pathologize parents who become emotional or angry in meetings. Some of the nicest, most conscientious parents may become angry and tearful in meetings. Parents and children may go through repeated episodes of mourning as they experience the effects of the ADHD in different settings and at different ages.
Parents need to listen carefully to teachers’ observations. However, they must remember that teachers and schools do not make medical diagnoses. The classic symptoms of ADHD, inattention, impulsivity, and and sometimes hyperactivity, can be due to a variety of causes. A parent might request that a specialist observe the child in class or go to observe the class himself. Conferences with teachers and guidance counselors are useful ways of gathering and sharing information. Finally, a thorough diagnostic work up is crucial. It is not a good idea to diagnose and medicate a child based on a few checklists and a brief office visit. The psychiatrist or other clinician should take a complete individual and family history, interview the child, and review data from the school. The clinician should assess the child for the presence of depression, anxiety disorders and learning disabilities. These disorders are over represented in ADHD children. The clinician should discuss a comprehensive program for addressing the child’s difficulties. Although there are a few children who seem “cured” when they are on the right medication regimen, most need other interventions too.
Medication is often an important part of the comprehensive treatment of an individual with ADHD. Ritalin is the most commonly prescribed medication for ADHD. It is important to remember that it is a short-acting drug and only lasts 2.5 to 4 hours. Often children are given a morning dose at 7AM before leaving home and do not get their second dose until Noon. If this is how your child’s medication is scheduled, check to make sure that he is doing well in the two hours before lunch. Some children may experience a rebound effect as the medication wears off. If there is a problem during this period, talk to your child’s doctor about adjusting the timing of the medication doses or switching to a different medication. Sometimes a small change in the timing of Ritalin dosing can make a big difference. Since teachers and some clinicians may not understand the short -acting nature of this medication, they may interpret the rebound irritability as deliberate acting out. When teachers note difficult behavior in a child on Ritalin, be sure to find out whether it is occurring at a specific time of day. There are now several good longer-acting forms of Ritalin and other stimulants. There are also other medications that can be helpful for ADHD if the stimulants are not sufficient. If the current regimen is not adequate, a comprehensive psychiatric evaluation may clarify the roles of both medication and other interventions.
Part of dealing with medication is dealing with the issue of stigma. Some children may think that only the “bad” kids go to the nurse to get stimulants. Other children enjoy their daily visits to the nurse. When students line up to see the nurse, the students sometimes figure out who is getting the Ritalin. For some sensitive children, this may be a reason to consider other medications. In other cases, some general classroom education about ADHD and medications may suffice.
Community and Extended Family Support
Community support is important during and after the time of the initial diagnosis. It is easy for a family to become overworked or overwhelmed. At such a point, the family might be tempted to withdraw into itself just when support is most needed. Extended family can be an important source of support, but can sometimes also be a source of tension. Parents often feel that extended family members do not understand the situation. Educating grandparents and extended family can take time.
Confidentiality and Disclosure
Whom do you tell about the diagnosis and condition? This is a judgement call. Often it is best to consult the child about this. Many times, it is better to allow friends and their parents to get to know your child before telling them. That way, they know your child as a person before they can stereotype him.
How much do you tell your child’s school? (before and after admission) This, too is a judgement call. Generally it is a good idea to let the school know if your child has any special needs. However, this can be a particularly thorny issue if your child is applying to a competitive private school. Some schools are more understanding about ADHD than others. If 100 children are applying for ten slots, a few schools might not spend the time to understand your child’s unique situation. Talk to other parents and get a feel for how the school personnel deal with these issues. If you know the parent of an ADHD child who attends the school, they might be able to give you advice. If your child is currently attending a particular school, one should be sure to tell the school nurse about any medications, even if they are given at home. Children do have accidents at school and the information should be available for emergencies.
Advocating for Your Child’s Educational Needs
Often simple interventions can make a big difference for a child with a short attention span. The teacher can place him near the front of the class and work out secret cues to remind him to stay on task. The parent should suggest more frequent telephone or face-to-face contact to monitor and coordinate school and home progress. The parent and teacher should work out a system of helping keep the child accountable for work.
Sometimes, the parent feels that further educational intervention is needed. Educational funding is not plentiful, so then the parent may need to become a more active advocate. When advocating for your child, try to start off with a positive attitude. Be aware of your child’s educational and legal rights, but do not start off by quoting the law to staff. For children in the public schools, there is specific, legally mandated system to help determine the child’s educational needs. If you feel that your child needs educational testing or special education resources, ask for an official meeting to review your child’s educational plan. Often parents can assist the school in gathering information to determine whether the child needs testing or special help. If your child has a special educational plan (IEP), always review it carefully before the formal meeting. If possible, both parents should come to the meeting. If one parent is feeling angry or frustrated, try to have the calmer parent do the talking. If the special education process is confusing, you may seek out an educational advocate to come to the meeting with you. If the school does the testing, you do not have to pay for it. Try to meet with the school psychologist to go over the test results before the official school meeting. You may obtain outside evaluations, at your own expense, to bring to the school meeting.
If you have the time and energy, try to volunteer time for your child’s school. Volunteers can free up some of the teacher’s time. This may, indirectly, give her more time to focus on your child’s needs. This also gives the parent an opportunity to get to know the school environment and some of the child’s classmates. Having a good knowledge of the functioning of your child’s school can help clear up potential misunderstandings.
Some parents choose to arrange for private evaluations or tutoring. Speech therapy, occupational therapy and some other services may be covered by some insurance plans. Some companies have dependent medical care plans which allow the parent to put pre-tax money aside for medical and child care expenses. This can be used to cover certain kinds of assessments and treatments not covered by insurance or paid by the school. Check with your employer or tax specialist. Many private schools have arrangements with tutors and speech therapists. In these cases, the parents usually pay for the services. In some situations, a child in a private school may qualify for free services funded by the public schools. In this case, the parent usually has to drive the child to a public school to get the services there.
A child with a short attention span may have more difficulty sitting down, turning off the TV and doing homework on his own. It helps to have a specific time and place for the child to do homework. In some cases, supportive parental supervision can be valuable. This can be a positive opportunity for the parent to see what the child is doing academically. The parent can also go over concepts that the child may have missed when not paying attention. As the student enters middle and high school, the direct supervision of homework shifts more to a coaching model which I will discuss later.
Some students may need medication adjustment so that they can focus enough to do their homework. For some students, particularly those with learning disabilities, the standard amount of homework is just too much. They and their parents spend the entire evening struggling and arguing about getting it done. There is no enjoyable family time left before bedtime. If this is truly the case, the parent should talk to teachers about allowing shortened assignments or setting a time limit on homework. Conversely, some parents ask for extra assignments so that the student can work at home on assignments not finished during the day.
Among the first self-help groups to make extensive use of computers was the disability community. Physically challenged individuals could use computers and later the Internet as eyes, ears hands and legs. Individuals who learn to compensate for a deficit may, through their efforts, gain special skills Children, parents and adults affected by ADHD can benefit from computer technology. At this point, there are computer applications devoted to most types of interests and activities.
Computer-based educational software can help children learn academic subjects. The best programs provide immediate feedback and appealing, changing visual and auditory input. Many feature cartoon characters who function like an encouraging tutor. There are also entertaining programs such as “Geometry Blaster” that cover high school topics. Parents and teachers can sometimes use easily available commercial software for academic remediation and for enrichment. The newer educational software allows a parent to customize the program by changing the difficulty deleting voices, and changing the reward frequency. In other cases, educational specialists may use software designed to remediate a specific problem.
Many parents feel intimidated by computers and the Internet and allow their children free reign with software and Internet surfing. It is better to supervise and have ground rules. Some software programs and Internet sites contain over-stimulating graphic violent or sexual themes. Children with ADHD may be more vulnerable to the adverse effects of over-stimulation.
The use of a word processor or a voice recognition program can help individuals who have difficulty with getting their thoughts out on paper. There are a number of excellent typing and word processing programs for children and adolescents. The voice recognition programs are mostly aimed at adult professionals. A child might be able to use some of them but would need excellent reading skills and close adult supervision.
Social Skills at School
One of the most important skills, taught both at home and school, is how to get along with others. This may be the most important skill the ADHD child has to learn. Some ADHD individuals are naturally gregarious and popular. However, there are also a large number of individuals who have significant social deficits. Parents of younger students can help by encouraging constructive play dates. They can sometimes talk to the teacher about facilitating opportunities for socializing. If the student is not good at academics or athletics, he may have an interesting hobby such as fossil collecting. The student and parent might do a class presentation about the hobby or help the science class arrange a field trip connected with the hobby. The right marital arts class can instill a sense of confidence, help coordination and teach appropriate assertiveness.
Adolescents with ADHD are more likely to be impulsive. Thus parents might want to monitor peer relationships a bit more closely. Since individuals with ADHD are more likely to develop drug problems and sexual acting out, parents should begin education on drugs and sexuality early, and reinforce it often. If impulsivity is a problem after hours, consider a long acting stimulant. Teachers and guidance counselors may be the first to notice if an adolescent has changed peer groups or is hanging out with the “burnouts.”
It is always tricky to tell a parent when and how to gradually move from direct supervision of homework to more of a coaching role. For some adolescents, the parent must continue to supervise homework for more years than would the parent of a non-ADHD teen. Parents may accomplish this gradual pullback by the use of calendars, checklists, and Day Planners. Some adolescents are more motivated to use these than others. Regular contact with teachers can give the parent feedback on whether they need to be as directly involved in homework supervision.
Older elementary school children and adolescents should be educated about ADHD and, if applicable learning disabilities. For the adolescent, knowledge and acceptance of his strengths and weaknesses can help him make good choices. Denial of one’s difficulties is common at this age.
Ultimately the most important thing is to instill in your child a positive self-esteem and an attitude of responsibility and mastery. The child should be encouraged to learn all he can about ADHD. At the same time, the child should take responsibility for his actions.