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.
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
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, w 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
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
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
Be positive and hopeful. Focus on pieces of behavior and not the
whole person. You are addressing small aspects of an overall
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). In Marin,
CHADD can be reached through Matrix at 499-3877.
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
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
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.
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
• 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,
• 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.
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
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
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).
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.