Caring for Inattention, Restlessness, and Impulsive Behavior

“Our third-grader’s teacher has been hinting that he might be ‘hyperactive.’ She says it’s hard for him to sit still, he talks a lot without raising his hand, and he’s distracted by any little thing. At home, I have to constantly remind him to do things; he says he just forgets. He can play Nintendo for hours, but if he is supposed to write something for school, it seems like it is torture for him to sit in the chair.”

In last month’s column, we described “attention deficit/hyperactivity disorder” (ADHD), which may possibly apply in the case of this third-grader. In this column we will discuss things that parents and teachers can do to help children who are inattentive, restless, and impulsive.

Assessment

All children are distractible, fidgety, and act without thinking some of the time. ADHD refers to a cluster of related symptoms that are biologically based in the constitution of the child. The key diagnostic questions are degree of severity and consistency of symptoms across settings and times.

Other biological conditions, or purely psychological factors, may present a picture of behavior similar to ADHD. And ADHD may coexist with other biological conditions (such as sensori-motor delays) or psychological factors (such as anxiety due to family discord). Every parent knows that children are complicated!

People who discount the reality of ADHD because they believe children are over-medicated (occasionally true) or parents are too preoccupied or busy with other matters (sometimes true) are taking an overly simplified stance that misses an important constitutional factor that disrupts the lives of many children, families, and classrooms.

As discussed in the previous column, your first step is a thorough assessment by a psychotherapist or physician. The suggestions below will also be helpful for many children, especially those who are spirited but do not have ADHD.

Summary of Care for ADHD

In sum, we recommend four key elements in the care of ADHD

• Education and understanding
• Community and support
• Sensible physiological interventions
• Psychological interventions both “inside” the child and “outside” at home and school environments

Generally do these four elements first. If those do not produce a sufficient result after at least several months of real effort, consult a child psychiatrist or pediatrician for possible medication (e.g., Ritalin). On the other hand, if you just know that the “full-court press” approach of the four bullets above is not going to happen, or a child’s behavior has gotten rather serious and needs rapid improvement, you may want to consider medication early on.

Understanding and Education

Sometimes when we look into dense forest, we suddenly put together a pattern of “brown here, long line there” and see . . . a deer.

Identifying ADHD is like seeing the deer. What had been seemingly unrelated details come together into a coherent whole. Once we see the whole “deer,” the unifying and underlying pattern of ADHD, we can also track it as it moves through different environments such as classrooms, birthday parties, going to bed, or forgetting chores.

Through understanding, we can be more compassionate with our child, knowing that he or she is does not deliberately “doing it to us.” We can help our child with “deerness” in various settings, and not get distracted by the details of different situations. And as we said in our last column, we regard ADHD as a normal variation on human temperament that has persisted during millions of years of human evolution because it was useful in the hunter-gatherer groups that everyone lived in until agriculture began to spread 10,000 years ago. The problem is not with hyperactivity, impulsivity, and distractibility per se, but with the fit between those characteristics and the tightly scheduled, controlled, sit-down-for-six-hours-a-day environments in which most children spend their days.

Study ADHD. Since there is a genetic basis for ADHD, you may find aspects of yourself, your spouse, or your relatives in the pages of the books recommended in “Resources” below.

With young children, avoid labels; talk about aspects of ADHD in everyday language such as “focusing,” “jumping around,” “daydreaming,” “organization,” etc. Depending on the age of the child, the severity of the condition, and the conspicuousness of classroom interventions, more explicit descriptions may be called for.

Be positive and hopeful. Focus on pieces of behavior and not the whole person. You are addressing small aspects of an overall wonderful child.

Community and Support

Connecting with other parents with children who have ADHD can be extremely helpful. The main support association for ADHD is CHADD (Children and Adults with Attention Deficit Disorder).

Caregivers need care too, especially when dealing with a child who may sometimes be exasperating and stressful. ADHD is a long-term project, so parents need to think about the ongoing support for themselves that will enable them to sustain their efforts for many years.

Sensible Physiological Interventions

Always assess a child for physical conditions (such as allergies or chronic low-grade infections) which may be exacerbating ADHD. Sensori-motor delays often accompany ADHD and should be cared for in their own right, often through a program of exercises conducted by a sensori-motor specialist; schools or therapists can offer referrals.

A balanced, healthy diet with low sugar or junk food, and frequent small meals, can reduce ADHD symptoms. Physical exercise can be calming. Homeopathy can also provide a beneficial effect. Biofeedback may sometimes be helpful.

Watch out for dogmatism and quackery in the biological treatment of ADHD. Sound research has not discovered any magic bullets. What usually works is the accumulation of moderate benefits (through many treatment modalities) that together amount to a large change.

Psychological Interventions

At school and home, psychological interventions include:

• modifications in the environment (e.g., removing distractions, placing a child with quieter classmates, or a bulletin board with reminders in a child’s bedroom)
• teaching self-awareness (e.g., noticing the feeling of one’s mind wandering)
• creating ways a child can self-calm (through time-outs or special places he or she can go to settle down and re-group)
• rewarding positive behaviors and the absence of negative behaviors (e.g.,”smiling faces,” extra privileges, or other small rewards for completing an assignment in a reasonable period of time, catching oneself before grabbing a classmate’s pencil)
• penalizing problematic behaviors or the absence of appropriate behaviors (through withdrawing privileges, charging a child a nickel, requiring a child to make amends, etc.)
• developing social, physical, emotional, and cognitive skills (such as social skills groups, practice in guided relaxation, using words and not hands, making plans, applying “the brakes,” etc.);
• parental guidance
• counseling to help develop skills and to deal with the psychological effects on the child of having ADHD

The books below will give you many, many detailed suggestions about how to implement the interventions noted above. But as broad, general principles:

• The key elements in all these interventions are structure and coaching.
• Support self-esteem, the most common casualty of ADHD.
• Have clear expectations.
• Communicate expectations clearly. Emphasize brief and visual or kinesthetic communications. Show, don’t say. Keep instructions simple, broken into many steps.
• Teach self-monitoring: Help children become aware themselves of what they are feeling, thinking, and doing.
• Emphasize self-awareness, cognitive skills, and rewards over penalizing negative behaviors. Caregivers can get locked into attacking problematic behaviors.
• In general, the more potent the rewards and the penalties, the more quickly you will see change.
• Keep information flowing between school and home. Work as a team with teachers.

Medication

ADHD does not equate to medication! Parents may be illogically unwilling to contemplate ADHD in their child’s case because they don’t want their child on drugs.

Medication is typically a stimulant (such as Ritalin or Benzedrine) which paradoxically slows a person down; antidepressants have also been used to good effect in some cases. Fears about medication leading to drug abuse, growth suppression, or low self-confidence have generally not been supported by research. Medication works for roughly two-thirds of those treated. There can be side effects which should be monitored. The response to medication is often very individualized so that one must try two or more medicines before finding the one that works best.

Done properly by an child psychiatrist or pediatrician, with sensitive and sensible communication with the child, medication can transform a child’s experience and performance at home and school. Done casually, or without the other four categories of care discussed above, medication can make a child feel drugged and like “damaged goods.” Without other interventions (see the four categories of care above), when medication is stopped children usually revert to previous (problematic) academic and social behavior.

Resources

Based on the Americans with Disabilities Act of 1990, ADHD is considered a disability that is protected under law. School districts are obligated to provide resources in order not to discriminate against children with ADD.

CHADD can direct interested parents to the many legal, medical, academic, and psychological resources available to help with ADHD.

Good books: Driven to Distraction (Hallowell), How to Reach and Teach ADD/ADHD Children (Rief), Keeping a Head in School(Levine), Your Hyperactive Child (Ingersoll), ADD: A Different Perception (Hartmann).

Perspectives

Unlike a degenerative condition such as multiple sclerosis, ADHD usually gets better over time. Nature is on your side!

Also, what really matters is the whole child. It can be easy to get “ADHD-fixated and lose sight of the being who is experiencing – and sometimes suffering – ADHD. At the end of the day, or at the end of childhood, what will matter most is a child who feels well-loved, respected, and confident.

This is an article adapted from the book Mother Nurture (2002) by Rick Hanson, Ph.D., Jan Hanson, M.S. and Ricki Pollycove, M.D.