Diagnosing AD/HD

Early diagnosis, appropriate treatment , education & understanding: critical factors in determining the future success of individuals with attention deficit/hyperactivity disorder (ADD or ADHD).

Diagnosing Attention Deficit/Hyperactivity Disorder

Attention Deficit/Hyperactivity Disorder (abbreviated as ADD in this report) is an invisible disability. It is a neurobiological disorder that affects behavior, self-control, motivation, motor activity, impulsivity, emotions, ability to direct and sustain attention, availability for learning and the way information is processed by the brain.

At least 5-7% of children have ADD, and as many as 50% of the estimated 3.5 million American children thought to have this disorder are never diagnosed. Current research shows that it affects 3 boys for every girl. Approximately 75% of these children continue to experience problems into adulthood, primarily in organization, self-management, social interactions and impulsivity. ADD is the most prevalent hereditary disorder (30-50% of children with ADD have a relative with the problem).

People are born with ADD, although it may not become a problem until the child’s environment becomes more demanding. This usually happens in 1st or 2nd grade, when students have to sit still for longer periods of time, focus for extended periods on required tasks, follow multiple rules and more complicated directions. Some children who are able to compensate during the early grades may not experience problems until demands increase during the middle or upper grades (coordinating different teachers and moves to different classrooms), in college (less parental and teacher supervision) or the workplace.

There are no definitive psychological, laboratory or blood tests for this disorder. The diagnosis is a clinical one, made by carefully examining the “evidence” — a combination of medical and psychological tests, appropriate personal interviews, patient and family history, etc. The knowledge, experience and skill of the person or persons doing the evaluation is critical. Since all of the symptoms of ADD can be seen in “normal” children at different times, diagnosis requires that a number of symptomatic behaviors be chronic (long-term), pervasive (present through most of the day, although not necessarily all of the time, and in different environments, such as home and school) and of sufficient intensity as to negatively impact on the child’s life and activities. There are three primary subtypes of Attention Deficit/Hyperactivity Disorder: Primarily Inattentive, Primarily Hyperactive/Impulsive, or Combination Type. A child does not have to be hyperactive to have ADD, although hyperactivity may be present but not perceived, as in compulsive hair-twirling, talking, doodling, etc.

The Diagnostic Process

Evaluations can be done by an individual or a team, which may include: Child Psychiatrist, Neuropsychologist, Child Psychologist, Developmental Pediatrician, Pediatric Neurologist, Psychiatric Social Worker, Educational Evaluator, Specialists in Speech & Language, Auditory Processing, Occupational Therapy, and others.

Testing should occur in both the school environment and the doctor’s office. A diagnosis of ADD requires a comprehensive, multifaceted assessment, which should include: a Detailed Individual & Family History, Parent, Child & Teacher Interviews, Physical Exam with Appropriate Lab Tests, Neurological Screening, Parent & Teacher Rating Scales, Self Rating Scales, and, depending upon the child’s age, Classroom Observation, Educational Evaluation, Psychological Testing and Behavioral Evaluation

Some of the more common diagnostic/evaluation tests include:

• Ability – Stanford Binet, Wisconsin Card Sort, WISC-R (Wechsler Intelligence Scale for Children/Revised)
• Achievement – WRAT (Wide Range Achievement Test), Woodcock/Johnson
• Attention – Conners Rating Scale, Porteus Maze, BADDS (Brown Attention Deficit Disorder Scale) and computerized neuropsychological continuous performance tests (TOVA, Gordon Diagnostic System) that measure ability to pay attention, tune out distractions and control impulses
• Impulsivity – Kagan’s matching familiar figure test, paired associated learning, choice reaction time tasks
• Behavior – Conners, Yale Child Checklist, Child Behavior Check List

Comorbid (Coexiting) Conditions

Individuals with ADD often have other problems that co-exist with the ADD. Sometimes the ADD is the underlying reason for other problems, such as drug or alcohol abuse – treat the ADD and reduce the incidence or intensity of the related problem. In some cases the co-existing condition needs to be treated before the ADD; as in the case of high anxiety. Few individuals have ADD without any comorbid conditions:

• 20-35% of children with ADD also have specific learning disabilities (20-25% of children with LD have ADD)
• 30% have some type of language (speech or auditory processing) impairment
• 35% have oppositional defiant disorder (ODD)
• 30-50% of these children wind up with a conduct disorder (CD)
• 25% have an anxiety disorder
• 25%-50% can be categorized with depression
• 20% have a social disability (problems in interpersonal functioning)

The Differential Diagnosis

A good evaluation determines if a child has ADD, if there are other problems causing ADD-like symptoms, or if the child has both ADD and other medical, neurological or environmentally-caused problems.

It may look like ADD but that doesn’t mean much. Sometimes a child who appears to have ADD, particularly when young, is just immature, or at the low end of normal development. (Using common clinical questionnaires, 1st grade teachers could rate as many as 50% of the boys in their class as having ADD.) That’s why a comprehensive diagnosis is necessary. Many students who are very active, disruptive in class or have problems completing assignments do NOT have ADD. However, if it is ADD, the younger a child begins treatment, the more effective it is. Hyperactivity can be caused by a particularly stressful situation. When the situation changes, or the child learns to deal with the stress, the hyperactivity usually stops. This is not the case in hyperactivity as a symptom of ADD. Sometimes another problem is the underlying reason for ADD-like symptoms, such as inattentiveness and distractibility being caused by dyslexia.

A differential diagnosis will separate ADD from its look-alikes. ADD is often undiagnosed, sometimes incorrectly diagnosed and frequently misdiagnosed. It is crucial that any evaluator be very familiar with both ADD and its possible look-alikes. Although diagnostic criteria for ADD exists, children are all different. While a diagnosis is helpful in defining the problems and as a basis for treatment, it is not infallible nor definitive. Even when a person is determined to have ADD, it can be mild, moderate or severe. How much the person is affected by his or her ADD will also depend on variables such as environment, stress, intelligence and other disabilities that may also be present.

Other conditions that may cause ADD-like symptoms must be ruled out in favor of the ADD-diagnosis. However, they may co-exist along with the ADD (co-morbidity). These include:

SLD (Specific Learning Disorders Childhood)	Substance abuse (drug or alcohol)
Depression or Mood Disorder	Hyperthyroidism
Anxiety	Poor nutrition
PDD (Pervasive Developmental Disorder)	Lack of sufficient sleep
Asperger’s High Functioning Autism	Impaired hearing, auditory or visual deficit
Tourette Syndrome	Boredom due to lack of challenge
Seizures	Toxicity (lead, mercury, fetal drugs, etc.)
Bi-Polar Disorder (Manic-Depressive)	Immaturity or slow development
SED (Serious Emotional Disturbance)	Age-appropriate overactivity
ODD  (Oppositional Defiant Disorder)	Inadequate parenting
CD (Conduct Disorder)	Major change in family (new sibling, death of parent, relocation)
Physical or sexual abuse

Criteria for Diagnosing Attention-Deficit/Hyperactivity Disorder

The most current assessment guidelines for ADD are published by the American Psychiatric Association in its Diagnostic and Statistical Manual for Mental Disorders IV (DSM4). The pages which follow list many of the characteristics — both negative and positive — that can be found in individuals with Attention Deficit/Hyperactivity Disorder, including some that are not specified but are commonly found:

The characteristics (symptoms or traits) of add can be separated into four primary areas:

Activity/Energy Level – Attention/Distractibility – Impulsivity – Emotional

Some character traits/deficits are more prevalent in children who are Primarily Hyperactive/Impulsive; others are more prevalent in children classified as Primarily Inattentive. Not all behaviors are shown by each individual. It is not unusual for a child, adolescent or adult with ADD to have problems related to each category, e.g.: difficulty with self-regulation, aggression, and conduct, poor academic performance and relationships, social skills deficits, emotional immaturity and instability, mood swings, difficulty with motivation, organization and time management, completion, losing things, etc. Behaviors also overlap categories (a quick temper is both emotional and impulsive). Deficits, or problems, can also be strengths; depending upon situation, attitude and application. Each section details both weaknesses and strengths.

Attentional Problems In Children With ADD:

• Difficulty with selective attention and filtering out unwanted or unnecessary stimuli
• Problems occur when sustained attention is required for a task that is lengthy, repetitive, dull and boring
• Easily distracted by the environment – focus shifts to noise, movement, conversations
• Forgetful, often misplaces or loses things
• Problem beginning tasks, particularly those of low interest or high difficulty (low arousal)
• Delays unpleasant tasks (procrastination due to lack of internal motivation)
• Highly distractible when a task is boring, not challenging or overly demanding
• Poor concentration; difficulty staying on-task or sustaining interest in an activity
• Often fails to complete tasks and chores
• Problems with organization and prioritization
• Strives for perfection, without considering if the project is worthwhile or worth the effort
• Hyperfocuses on subjects of interest, e.g., playing Nintendo
• Difficulty with transitions
• Weak or non-existent sense of time when immersed in a project
• Requires (and often demands) a lot of attention and supervision
• Problem determining what is critical or relevant to the current task
• Appears not to listen or hear what was said
• Fails to follow directions or instructions (not due to oppositional behavior)
• Thoughts jump from concept to concept (non-linear thinking)
• Frequently daydreams; appears lost in thought
• Seemingly unconnected or irrelevant comments (a “space cadet”)
• Hyper-sensitive to stimuli (“The Princess and the Pea”)
• Overreacts to or blocks out sensory input
• Excellent experiential or emotional memory but poor short-term or task-oriented memory
• Often an underachiever

Benefits of  “Free-Association” Attention & Distractibility:

• Aware of many things others miss
• Delights in small things
• Heightened perception of environment
• Curious
• Able to hyperfocus on a task
• Creative and intuitive – Sees situations from a novel perspective
• Capable of original thinking
• Excellent problem-solving ability, when directed
• Able to explore and develop new concepts and different ways of doing things
• Rapid grasp of concepts, awareness of patterns and divergent thinking
• Often excels in areas of interest
• Variety of interests and abilities
• Interesting companion
• Good sense of humor

Hyperactivity – Problems With Inappropriate Motor Control:

• Always moving; appears driven… with the gas pedal stuck
• Excessive talkativeness
• Acts out (class clown)
• Noisy Fidgets, squirms and doodles
• Frequently twirls hair, bites cuticles, taps feet, shakes legs, bounces and shifts when seated
• Difficult to remain seated or wait Uncomfortably intense Bothers classmates
• Younger children have more gross motor overactivity: running, climbing, constant movement
• Can be lethargic (particularly non-hyperactive)
• Can become exhausted from effort of trying to concentrate and control actions
• Sleep problems: falling asleep and or awakening
• Action oriented, not reflective

Benefits Of The High-Energy Personality:

• A go-getter
• Able to juggle multiple projects
• Not bogged down by details
• Willing to take on new challenges and try new things
• Open to experiences
• Gregarious
• Functions well in high-stimulation atmosphere (emergency room, stock trading floor, fire fighting, teaching, etc.)

Difficulties Related To Poor Impulse Control:

• Blurts out answers without waiting for question to be completed
• Talks out of turn, interrupts teachers, parents and peers
• Makes comments that are inappropriate or poorly timed
• Acts without thinking then feels sorry can’t seem to “put on the brakes,” even if about to crash
• Fails to recognize limits – gets carried away emotionally, socially, with an idea
• Gets caught up in a behavior and can’t stop it (obsessive)
• Overreacts to real or perceived slights
• Low frustration tolerance
• Angers easily; has a “short fuse” – May yell, throw things, hit, etc.
• Quickly abandons difficult or boring tasks
• Low threshold for boring or routine tasks; continually searches for stimulation
• Sped-up sense of time in boring or anticipatory situation (minutes take forever)
• Impatient; difficulty waiting or taking turns; wants immediate gratification
• Incomplete or incorrect interpretation of instructions
• Messy and careless work
• Often loses or misplaces things
• Inquisitively destructive: takes things apart to see how they work
• Shifts from one uncompleted task to another; from project to project
• Initial interest in many things but poor follow-through
• Disruptive (verbally and behaviorally, especially boys)
• Intrudes into other children’s games and personal space
• Does things that are dangerous without thinking about the consequences
• Wanders off alone (younger child) Requires frequent monitoring

Benefits Of An Open, Independent & Impulsive Personality:

• Willing to take chances
• Accepts new challenges
• Entrepreneurial character
• More interested in the broad picture than the details
• Doesn’t get dissuaded easily; persists at tasks of interest after others give up
• Dynamic personality
• Spontaneous and enthusiastic
• Curious; wants to know “why” and “why not”
• Able to push through obstacles and objections to accomplish goal
• Lives in the moment so can be 100% “there,” rather than bogged down by the past or worried about the future

Emotional Difficulties Seen In Children With ADD:

• Low self-esteem Lack of trust
• Persistent, low-level worry
• Quick and frequent mood shifts (emotionally labile)
• Moods escalate rapidly
• Very sensitive to criticism
• Prone to angry outbursts (blow up under stress due to emotional “flooding”)
• Easily depressed (when emotions “implode”)
• Argumentative; quick to disagree and even fight
• Difficulty with authority figures
• Easily frustrated and overwhelmed
• Very reactive – quick to respond with anger or despair
• Enjoyable behavior easily becomes irritatingly intense
• Rigid – inflexible, self-righteous and frequently didactic
• Very controlling (partially a reaction to feeling out of control emotionally and vulnerable)
• Sets standards that are unrealistically high
• Seeks perfection in areas of interest (may refuse to do something if can’t do it perfectly)
• May withdraw when stressed; can be apathetic
• Lacks many social skills and awareness of how others are affected by their actions
• Self-esteem at risk due to repeated criticisms and failures
• Quick to blame others for problems
• Feels different than peers, may feel isolated
• Often a “loner” though can be very entertaining company
• Irresponsible and immature
• Self-conscious
• Confused

Emotional Strengths Found In Children With ADD:

• Multidimensional personality
• Very perceptive and intuitive
• Innovative
• Self-reliant
• Can be exceptionally compassionate, empathetic and sensitive to others
• Demands high performance from self and others
• Quick to praise
• Highly affectionate
• Loyal and driven when committed to an idea, project or person
• Often a strong personality; can be an excellent leader

Treatment

There is no cure for ADD – with appropriate treatment the child learns to compensate for problems and maximize his or her strengths.

Treatment Requires a Team Approach:

• The Child Parents/Guardians Caregivers & Other Family Members
• Teachers & In-School Special Service Providers
• Tutors, Speech & Language Specialist, Occupational Therapist, Etc.
• Physician/Pediatrician Psychiatrist/Psychologist

Multimodal Treatment is Critical, and Usually Includes:

Medication, when required, Family involvement Psychological/behavioral intervention Academic/educational intervention It’s also important to include: Regular exercise Proper nutrition (especially in the morning) Training in & practice of stress reduction & relaxation techniques Education – the more you know, the more you can achieve.

The professionals you select to treat ADD must be exceptionally knowledgeable about it:

There are still child psychiatrists who insist a non-hyperactive child can’t have ADD. (The situation is much worse for adults who go for evaluations.) There are still psychologists who dismiss the idea that ADD is a problem for an individual who has done well in school or been successful in business.

There are many physicians, including psychiatrists, pediatricians and neurologists, who are not very familiar with the various medication alternatives for treating ADD, or who prescribe dosage “by the (often out of date) book,” or who fail to properly titrate for maximum efficacy.

There is still a lack of understanding that ADD affects all aspects of a person’s life, and that taking medication should not be limited to school hours.

You are your child’s advocate (and your own!). If you don’t see the results you want within a reasonable period of time, or if you have doubts about a treatment provider – GET A SECOND OPINION!

Psychological/Behavioral Interventions:

• Therapy for the child – individual counseling to improve self-esteem, and learn ways to deal with frustration and to better control impulses and anger
• Directed cognitive behavioral training – changing how a person thinks and functions; “reframing” perceptions
• Coaching – to learn compensatory strategies for overcoming challenges (organization, time management, productivity, etc.) Similar to cognitive behavioral training.
• School or group counseling for socialization-related issues
• Study Skills (organizational thinking) training
• Communication and social skills training
• Relaxation/stress reduction training
• Family counseling to provide education about ADD, reunite dysfunctional families and to examine coping skills and built-up feelings
• Couples counseling (by someone who really understands and has experience with ADD)
• Parenting skills training in behavior management techniques

NOTE: Traditional psychotherapy has not been effective in treating the ADD

Academic/Educational Interventions

Classroom interventions – modification of classroom environmental and teaching strategies Appropriate modifications/accommodations in testing, homework & classwork, including the use of assistive devices such as computers, teacher/student headsets, calculators, etc. Remedial assistance for academic skills, speech and language, fine motor coordination, etc. Skills training in organizational, time management and study skills

NOTE: You are your child’s advocate — find out what your child needs to succeed in school and work to get it (See sections on School Advocacy & Legal Issues). Don’t assume the school will automatically provide appropriate services and modifications.

Medication:

Medication enables the child to better attend, utilize more self control & show more self-directed behavior. “It’s like there’s someone tapping me on the shoulder to remind me what I should do, …but it’s still my choice – I don’t have to listen.” Medication is extremely effective in most cases: 75 to 80 percent of children with ADD respond favorably to psychostimulant medication, and to the newer non-stimulant medications. Only 5-8% of children with ADD fail to respond to either stimulants or antidepressants.

Medication helps the child’s self control and focus, so he or she will concentrate better on specific tasks and be more likely to think before acting.

Titration: Establishing the correct dosage and timing for taking medication is critical. Too often medication is prescribed, but not properly monitored and adjusted. This should be done under a doctor’s care, carefully monitoring different levels of medication for efficacy, until the most appropriate dosage is established.. A medication may appear ineffective when the dose is too low. A child may appear “drugged” if the dose is too high. Optimal dosage for attentional efficacy may be different than optimal dosage for control of hyperactive behavior. The amount of time medication “works” varies from person to person. Know how long it takes for your child’s meds to start working and how long the beneficial effects last. Then establish dosing schedules that overlap slightly (the next dose begins to “kick in” as the prior dose stops working, which prevents highs and lows or “rebound”). If needed, medication should be given to assist the child with homework and social activities, not just school. Medication should be continued during the summer if it helps the child’s self-esteem by improving peer interaction, emotional stability or the ability to focus and enjoy sports and leisure activities. The speed of onset and the efficacy of a dose may be affected by certain foods, drinks or other medication (including over-the-counter meds, supplements, etc.). Talk to your doctor.

Possible Side Effects

Although most of the medications commonly prescribed to treat ADD in children have been extensively tested and found safe, your child may still experience side effects. Some of these may be temporary and soon disappear; others are more serious. Always tell your doctor!

Possible side effects include:

• Appetite reduction, resulting in weight loss or failure to gain (usually temporary). Good nutrition is always important.
• Difficulty falling asleep Headaches or stomachaches
• Dry mouth
• Increased irritability as the medication wears off (known as the “rebound” affect)
• Temporary sadness Height suppression, once thought a problem if children took methylphenidate, is no longer considered a concern.
• Tics (involuntary movements or repetitive sounds) may develop, in fewer than  XX % of children taking stimulants. Tics may be indicative of Tourette’s Syndrome, which usually manifests later than ADD (65% of individuals with Tourette’s also have ADD). Some medications require periodic monitoring of blood, heart or liver. Check with your doctor.

Examples of Alternative Treatments and Additional Interventioins

Exercise

The effects of exercise on the brain are often similar to those of medication. Physical exercise or activity is an important component of an overall treatment plan. Also, children “forced” to sit for long periods in school do better when they have short “movement breaks.” Changes in diet to accommodate food allergies (such as the Finegold Diet) – have a beneficial affect on fewer than 1% of children diagnosed with ADD, in double-blind research studies Food and vitamin supplements – have not been proven effective when studied in independent, controlled scientific testing, although there are anecdotal stories attesting to efficacy.

Keep in mind that “natural” does not mean safe.

Also, the required dosage of prescribed medication may change with the addition of certain supplements. Biofeedback – being researched by the NIMH; it has some positive affects on some children, but long-term benefit is questionable. Even the advocates of biofeedback usually recommend that it be used as an adjunct to conventional treatment (particularly medication) L-Tyrosine – an amino acid (protein) that helps the body produce norephinephrine. Now undergoing testing. Chiropractic adjustments – still no scientific basis for the claim to cure, or even help, ADD. May be helpful for relieving tension and stress.

Even Without Treatment

Many children who are not treated for their ADD grow up to be productive adults (although many report they have difficulty in achieving goals and holding relationships). The ability to compensate is linked to both IQ and social environment. Fortunately, many ADD youngsters are very bright (and charming), and so manage to “get by.” However, these are the kids teachers criticize as “not trying to reach their potential” or as being “underachievers.”

Strong family support and consistent structure at home helps. Unfortunately, children with ADD often gravitate towards peers exhibiting “fringe” or “antisocial” behavior, feeling more comfortable with children who are different, enjoying the stimulation of “risky” behaviors and feeling less pressure to achieve academically. The more prevalent the opportunities for engaging in fringe behaviors, the more likely the untreated child with ADD will do so. This translates into a generally less successful prognosis for children from poor environments. In a study of prison population, almost 80% of the inmates were found to have undiagnosed Attention Deficit Disorders and/or Dyslexia and other learning disabilities.

Early intervention and appropriate, multimodal treatment can change the patterns of alienation and frustration, turning potential “failures” into achievers.

Behavioral Interventions For Parents

• Provide Structure & Consistency Enforce daily routines, including time to awaken, do homework & go to sleep
• Post schedules
• Keep Things Calm & Healthy
• Speak clearly, quietly and calmly
• Avoid arguments and power struggles through the use of management techniques
• Maintain order in the house and child’s room
• Leave extra time so there’s no need to rush
• Avoid crowds and hectic environments
• Blocked in quiet time Limit playdates and the number of playmates (one is usually best)
• Make sure the child has enough sleep (fatigue creates problems)
• Monitor food intake and quality – it’s okay to say no to junk food
• Promote regular exercise (independent sports are usually best, such as swimming, running, bicycling, karate, fencing, horseback riding, etc.)
• Have A Positive Attitude
• Emphasize the child’s strengths
• Reinforce your unconditional love; you may dislike the behavior, but not the child
• Try to look at things from your child’s perspective
• Think before you speak and re-language your comment if necessary (see section that follows) Keep your expectations realistic
• Maintain A Close Watch Don’t assume that something will (or won’t) be done just because your child knows what she should (or shouldn’t) do. Check on activities, schoolwork, etc. Don’t assume that if something is working, it will continue to work.
• Monitor the situation and be prepared to make changes. Allow autonomy, but on your terms.
• An Elastic Contract gives the child more independence, but requires the child to show more responsibility. You agree to stop monitoring homework so closely, but only if your child gets it done, on time and correctly. If he doesn’t keep up his end of the Contract, you go back to closer supervision. As his work improves, you back away.
• Work For Success.  Limit tasks and activities to one at a time, to finish & put away before beginning the next
• Strive for improvement, not perfection. Reward effort, not just achievement
• Keep social activities short; end a playdate while both children are still enjoying each other
• Problem-solve with your child’s input. Have his agreement on an appropriate course of action. When a person “buys into” a plan, it’s more likely to be successful. Your child has a vested interest in making it work, since he agreed (or even suggested) the plan.
• When appropriate, offer your child choices, but limit them to two and make sure that both are acceptable to you. “Do you want to put the dishes in the dishwasher or fold the laundry?” “Would you like to prepare the salad or set the table?” “Do you want to do the math homework now or after you’ve practiced your piano lesson?”
• Be A Detective. Know your child – track what works, and what doesn’t; anticipate reactions and behaviors
• Experiment with different intervention techniques
• Help your child discover things that really interest them, skills and abilities
• Rules – Consequence – Rewards. Both verbal and written expectations
• Clearly posted charts listing Individual Responsibilities and House Rules
• Pre-determined consequences and immediate application of those consequences
• Rewards that are immediate and attainable (Star Charts, Coin Banks, TV-Time, etc.)

The Home/School Connection

Rethinking – Reframing – Re-Languaging

Often, the way we think about something is based on history and habit. the words we use can describe the same thing in either a positive or negative manner. When we choose our words, we also communicate an attitude. The words our children hear help frame their self-image. Unfortunately, words commonly used to describe children with add include: lazy unmotivated irresponsible immature selfish inconsiderate insensitive disappointing careless sloppy inept troublemaker / bad when you use these words, the child hears: “I’m a failure.” “I can’t do anything right.” “I’m stupid.” “I’m not worth loving.” “I do nothing but cause problems.” “I’m no good.” “I’ll never amount to anything – It’s useless to try.” Instead of feeling good about what they can do, the child feels: guilty hopeless ashamed hurt inadequate.

Their self-image becomes distorted (disabilities far outweighing abilities) and their self-esteem is damaged. They become less capable of succeeding than they were initially. A child might cope with his or her negative feelings by: acting out, becoming aggressive, getting into fights, being verbally combative, engaging in reckless and/or antisocial behaviors, etc. internalizing the pain, guilt and shame by withdrawing, becoming depressed, taking on the passivity of a victim mentality, etc. channeling feelings through their bodies, with headaches, stomach or backaches, generalized aches and pains in hands or legs, feeling sick, lethargy, developing food -related disorders, etc. attempting to control their environment, avoiding stressful situations through manipulation. an example is when a child is the class clown. This role provides the child with attention (stimulation), and a way to avoid appearing dumb in class or having to do boring work: say something which will disrupt the lesson, or push the button tht gets you thrown out of class.

We ask our children to try harder, when they are already putting in tremendous effort just to be where they are. We want them to do better, when they haven’t the skills or appropriate motivation. We tell them, you can if you wanted to, when they can’t, at least not without help. They may even want the same things we do, but aren’t able to figure out the how or drum up sufficient internal motivation to just do it.

ADD is Not an Excuse, But It Is An Explanation

What Can You Do Differently?

Rethink How You Interpret A Situation or Comment:

“This homework is sloppily written, misses the point of the assignment, has poor spelling and you haven’t included the date.”
“I think you’re teacher wanted you to write your opinion of the story, rather than a summary of it. Would you like my help to pull this together?”

Praise whatever you honestly can:

“This story you’ve written is absolutely wonderful!”
“I really like the way you described the main character, but I’m confused about the plot… where did the monkey come from and who is Zap?”

Point out something that has improved (reinforce the positive while improving the negative):

“You refuse to put your dirty clothes in the hamper!”
“I appreciate that you’ve taken your dirty clothes out of your room. Could you please start putting them in the hamper instead of on the bathroom floor?”

Criticize the action, NOT the individual:

“You’re inconsiderate.”
“Leaving your bike in front of the entry door was an inconsiderate thing to do. Please don’t leave it there again – it goes in the garage.”

Express things from your perspective; “This is how I feel…”:

“You don’t care about anyone else!”
“I feel you don’t care about my needs when you blast the stereo while I’m trying to work”

Be very specific when you criticize (and when you give directions):

“Your room is a disaster area.” (Think how your child will interpret this sweeping comment that has no attached plan of action for improvement of the item being criticized)
“Your room needs to be cleaned up. There are papers on your bed and racing tracks all over the floor. Please put them away before you go over to Jennie’s house.”

Provided by Shire