We have all had one of these experiences at one time or another. Perhaps it was at the grocery store, watching frustrated parents call their children's names repeatedly and implore them to "put that down." Maybe it was a situation at school with a child who could not seem to sit still and was always in motion. Maybe we noticed a child who appears always to be daydreaming in class-the student who will not focus on an activity long enough to finish it. Possibly the child is bored with a task, seemingly as soon as it has begun, and wants to move on to something else. We all puzzle over these challenging behaviors.
Attention Deficit Hyperactivity Disorder (ADHD) has many faces and remains one of the most talked-about and controversial subjects in education. Hanging in the balance of heated debates over medication, diagnostic methods, and treatment options are children, adolescents, and adults who must manage the condition and lead productive lives on a daily basis.
What is ADHD?
Definition
Core Categories
Comorbidity
Social Impact
Prevalence
Attention Deficit Hyperactivity Disorder (ADHD) is a neurological condition that involves problems with inattention and hyperactivity-impulsivity that are developmentally inconsistent with the age of the child. We are now learning that ADHD is not a disorder of attention, as had long been assumed. Rather, it is a function of developmental failure in the brain circuitry that monitors inhibition and self-control. This loss of self-regulation impairs other important brain functions crucial for maintaining attention, including the ability to defer immediate rewards for later gain (Barkley, 1998a). Behavior of children with ADHD can also include excessive motor activity. The high energy level and subsequent behavior are often misperceived as purposeful noncompliance when, in fact, they may be a manifestation of the disorder and require specific interventions. Children with ADHD exhibit a range of symptoms and levels of severity. In addition, many children with ADHD often are of at least average intelligence and have a range of personality characteristics and individual strengths.
Children with ADHD typically exhibit behavior that is classified into two main categories: poor sustained attention and hyperactivity-impulsiveness. As a result, three subtypes of the disorder have been proposed by the American Psychiatric Association in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV): predominantly inattentive, predominantly hyperactive-impulsive, and combined types (Barkley, 1997). A child expressing hyperactivity commonly will appear fidgety, have difficulty staying seated or playing quietly, and act as if driven by a motor. Children displaying impulsivity often have difficulty participating in tasks that require taking turns. Other common behaviors may include blurting out answers to questions instead of waiting to be called and flitting from one task to another without finishing. The inattention component of ADHD affects the educational experience of these children because ADHD causes them to have difficulty in attending to detail in directions, sustaining attention for the duration of the task, and misplacing needed items. These children often fail to give close attention to details, make careless mistakes, and avoid or dislike tasks requiring sustained mental effort.
Although these behaviors are not in themselves a learning disability, almost one-third of all children with ADHD have learning disabilities (National Institute of Mental Health [NIMH], 1999). Children with ADHD may also experience difficulty in reading, math, and written communication (Anderson, Williams, McGee, & Silva, 1987; Cantwell & Baker, 1991; Dykman, Akerman, & Raney, 1994; Zentall, 1993). Furthermore, ADHD commonly occurs with other conditions. Current literature indicates that approximately 40-60 percent of children with ADHD have at least one coexisting disability (Barkley, 1990a; Jensen, Hinshaw, Kraemer, et al., 2001; Jensen, Martin, & Cantwell, 1997). Although any disability can coexist with ADHD, certain disabilities seem to be more common than others. These include disruptive behavior disorders, mood disorders, anxiety disorders, tics and Tourette's Syndrome, and learning disabilities (Jensen, et al., 2001). In addition, ADHD affects children differently at different ages. In some cases, children initially identified as having hyperactive-impulsive subtype are subsequently identified as having the combined subtype as their attention problems surface.
These characteristics affect not only the academic lives of students with ADHD, they may affect their social lives as well. Children with ADHD of the predominantly hyperactive-impulsive type may show aggressive behaviors, while children of the predominantly inattentive type may be more withdrawn. Also, because they are less disruptive than children with ADHD who are hyperactive or impulsive, many children who have the inattentive type of ADHD go unrecognized and unassisted. Both types of children with ADHD may be less cooperative with others and less willing to wait their turn or play by the rules (NIMH, 1999; Swanson, 1992; Waslick & Greenhill, 1997). Their inability to control their own behavior may lead to social isolation. Consequently, the children's self-esteem may suffer (Barkley, 1990a).
In the United States, an estimated 1.46 to 2.46 million children (3 percent to 5 percent of the student population) have ADHD (American Psychiatric Association, 1994; Anderson, et al., 1987; Bird, et al., 1988; Esser, Schmidt, & Woemer, 1990; Pastor & Reuben, 2002; Pelham, Gnagy, Greenslade, & Milich, 1992; Shaffer, et al., 1996; Wolraich, Hannah, Pinock, Baumgaertel, & Brown, 1996). Boys are four to nine times more likely to be diagnosed, and the disorder is found in all cultures, although prevalence figures differ (Ross & Ross, 1982).
Adapted from U.S. Department of Education, Office of Special Education and Rehabilitative Services, Office of Special Education Programs, Identifying and Treating Attention Deficit Hyperactivity Disorder: A Resource for School and Home, Washington, D.C., 2008.
Page last modified or reviewed by athealth on January 28, 2014
In Part 2 of Motivating Underachievers, James explains what you can do to get your child on track before school starts - and how you can motivate them to do their school work during the year.
For a teen-ager, there are many ways to say "screw you" to your parents. And for underachieving kids, being motivated to do nothing is one of those ways. I believe that when kids are so-called lazy, that's really an attitudinal issue about "Why bother, my life's not going to get any better anyway." And when kids develop that kind of attitude, many times there's a lot of stuff going on in their lives which overwhelms them. Resisting their parents' expectations is one way that they can feel like they're in control. For these children and teens, the path to power becomes a game of withholding and resisting, and they often sink under the waves at school. The sad part is that this game only works until they're young adults - and then no one else will be willing to play it with them.
What to Say to Kids Who Had a Bad Year Last Year
For the kids who had a hard time in school the previous year, parents should be talking to them about what they learned from that hard time. After all, we're supposed to learn from difficulty. While this talk should ideally happen at the end of the school year, you can still have this conversation now. (Be prepared for the fact that kids will often deny that it was that bad a year - that's why it's good to have the conversation while the year is still fresh in their mind, in the spring.)
Before school starts and when things are going well, sit down with your child, and say, "Look, there's something that I think would be helpful to talk about. What did you learn from what you went through last year? I'm not criticizing, but what did you learn?" And then the follow up question should be, "And what will you do differently this year?" Not what they'll say differently. "What will you do differently to stay on top of your grades," or "What will you do differently to get along better with your classmates or with the teachers? Let's pick one thing you can do right now from day one that will help you move in that direction."
When kids stumble and fall, I think our goal is to always ask what they're going to do differently and what they've learned. When my son would fail a test, I would say, "What did you learn from this? And what are you going to do differently?" These questions talk about the future and get the child to think about what they will do to change the outcome. I looked at it this way: the test was over, and he failed it. That was the natural consequence. I didn't need to make speeches at him or blame him, because that's not an effective way to get change. I was interested in what he was going to do so he would pass the next test.
The whole coaching and teaching role is about, "What did you learn from this, what are you going to do differently, how can I help you with those skills?" Sometimes what your child is going to do differently is do his homework at the kitchen table so somebody is there to make sure that he does it. Sometimes it's going to be studying with a friend. But you always want concrete answers to what your child's going to do differently, whenever they have a hard time and whenever they slip up.
If they don't come through with any ideas or say, "I don't know," you should make some suggestions and have them pick one. Certainly, you can try to reason with them. But there's nothing wrong with saying, "I want to see your homework every day till you pass the next test." Or "I want your door open when you do the homework until you pass the next test." It's OK to lay that down on them so that the accountability becomes more personal. But first, you give them a chance. That way, the next time you have this talk with them, your child will know what's going on. He'll have the script, he'll know what he's supposed to say and do.
6 Things You Can Do to Get Your Kids back on Track before School Starts:
1. Start Waking up Early: A week before school starts, have all your kids use their alarms and wake up at the time they'll be getting up during the school year. They should wash their face, brush their teeth and come out and have breakfast. Afterward, they can go back to sleep, start their day - whatever they normally do. What you want to get them used to is doing their hygiene at a certain time, getting dressed at a certain time and showing up in the kitchen in time to make your school bus or their ride.
2. Start Having an Hour of Quiet Time at Night: Have quiet time at night if you don't already have it. This will become part of their homework time. But for now, let them read a book, comics, or magazines. What they do in quiet time is not as important as the fact that there's no electronics - including cell phones and texting - during this time.
3. Stop Allowing Your Teen to Go out at Night During the Week: For older kids, about a week before school, they should not be able to go out at night. They have to get back into their school schedule, which means saying, "No going out to socialize after dinner, you have to stay home." So your child will get used to being home at night. Over the summer, teen-agers tend to get more and more freedom. That's just a natural process, especially if they're older teens. What you want to do is get them to gravitate toward the home, which is one of the centers of their educational life. You go to school from home; you go to sports activities from home; you do your homework at home. In the summer, "outside the home" becomes the focus. Whether it's day camp or camping out with your friends by the lake for four days, the focus is outside of the home. This is good, but now kids need to be brought back in.
Don't be surprised if your child or teen resists this. Let's face it, it's hard to get back on track. Picture yourself coming back from vacation, and think of how hard it can be to get back in the groove at work. You will probably hear your child make excuses like, "It's not school yet, I'm still on vacation." That may be true, but I think you want to say to them very clearly, "You need to get back on track. And once you do these things, if you stay home after dinner, you can do what you want except for that hour of quiet time. And after you get up in the morning, you can do what you want after we meet in the kitchen. You can have breakfast, go back to bed, go hang with your friends."
Remember, Rehearsal and Repetition prepare children for their responsibilities. Intellectualizing doesn't work. Preaching doesn't work. Philosophizing doesn't work. What works is the concrete tasks of rehearsal and repetition. That's true for all kids - and even more so for teenagers.
4. Keep Track of Your Child's Assignments: Have your child's teacher email you his homework assignments or have him carry an assignment book back and forth, so that there's communication between you and the school. You should know exactly what your child has to do that night. And then you should set up some kind of reward system when he does it.
5. Consider Rewarding Your Child for Good Grades: If my son got all A's and B's, he was rewarded with some cash. If he didn't, he didn't get punished; he just didn't get the money. We didn't threaten him or anything; it was just a standing thing in our home. When my son didn't do well on the test, I asked him, "So what are you going to do differently next time?" That's what you have to do with underachievers. "What'd you learn from this?" They might say, "I don't know, I didn't learn anything." And then you can say, "Well, I'd like you to learn that maybe you should've studied more. Or maybe you should've studied with a friend." In fact, sometimes studying with another child helps your child get motivated. Nothing motivates kids like studying with other kids - nothing. In my opinion, well-managed study groups are very helpful.
6. Have Your Child Earn the Right to Study on His Own: You can also motivate your child to succeed by having them earn rights around the house. "When you get all B's and above, you can go to your room and do your homework. But as long as you have C's and B's, you will not study in your room. More than one C and you're down here." It's completely dealt with that way. So in order to function more independently, your child has to achieve. He just doesn't get to go to his room and do his homework by himself - he has to be near a parent at all times.
Natural Consequences: Let me be clear: failure is a part of life. By the time kids hit their teenage years, they're sick of failure. But failure is just one of the things that they encounter all along the way, from the time they're two years old to when they're 17. Believe me, kids know when they've failed, they understand what that means. I personally believe that you have to let your child experience natural consequences. This means you should let them fail that year in school or let them fail that subject. If that still doesn't motivate them or if it adds to their lack of motivation, that's when you have to seek professional help.
Why are Smart or "Gifted" Kids Sometimes Underachievers?
Gifted is a funny word. People throw it around a lot these days, and parents cling to it because they crave it. But gifted is as gifted does. In other words, gifts are not gifts until you use them to accomplish something. There may be wonderful gifted painters in the world, but we see DaVinci's work. There may be wonderful, gifted actors, but we see DeNiro's body of work. We see people who have used their gifts and worked hard to create something. Maybe DaVinci and DeNiro were gifted, but they also worked their butts off to produce their accomplishments.
If they told me that my son was gifted, that would not be good news for me unless he was performing. If your child is doing well and they actually tell you he's gifted, great. But if he's not performing and they tell you he's gifted, they're telling you that something's wrong. What they're telling you is, "He understands what's going on and he's making the non-constructive choice not to do it." And that's not good news. Also, I would caution parents not to get confused by words like gifted and smart; that's how you're being misdirected. I think that when the school says your child is gifted, sometimes what they're saying is, "We don't want to take any responsibility. He's smart enough to do this himself."
I believe that while sometimes we're too stingy with praise, we're sometimes too quick to give it. Sometimes we're too quick to say "That's a great job" instead of saying, "I see you're trying harder. That's cool." We're too quick to label a child gifted without giving him the right kind of help. I recommend not to give kids things as if they're completely accomplished in life. Always talk about their progress.
When you're working with teenagers who are underachievers, it's hard to sit down and have these conversations sometimes. Believe me, I know it is hard work to talk with teenagers. But you have to do things that are hard if you're a parent; there are no shortcuts. We need to be coaches, teachers and limit setters for our children if we want them to succeed in life. Coaching your child to do better is one of the key ways to become a more effective parent. Always remember, the goal is not to become a good parent - and it's not even to avoid being a bad parent. Rather, the goal is to become a more effective parent. That's not ever an easy task, but the goal is extremely worthwhile.
Motivating Underachievers II: Get Your Unmotivated Child on Track before School Starts reprinted with permission from Empowering Parents. For more information, visit www.EmpoweringParents.com
Author: James Lehman, a behavioral therapist and the creator of The Total Transformation Program for parents, worked with troubled teens and children for three decades. James holds a Masters Degree in Social Work from Boston University.
Are you facing the new school year with dread because you have an unmotivated or underachieving teen or pre-teen? Is your child's answer to everything, "I don't care" or "It doesn't matter?" In Part 1 of this two-part series, James Lehman, MSW explains why your child does have motivation - and how you can coach them to better behavior.
The first thing to understand about teens and pre-teens who seem to have no motivation is this simple truth: It's impossible to have no motivation. Everybody is motivated - it just depends on what they're motivated to do. I think it's helpful to see that rather than being unmotivated, these kids are actually motivated to not perform and to resist their parents. In other words, they're motivated to do nothing.
Parents often think that if they can find a new way to encourage their child, he or she will magically start achieving more. I don't think it's like that at all. In fact, I think the problem is that these kids are motivated to resist, withdraw and under-perform. In effect, instead of acting out, they're acting in.
Think of lack of motivation as an action problem - and the action is to resist. These kids are making excuses; they're pushing their parents away. At school, they're motivated to resist studying and homework. They're also motivated to resist their teachers. Look at it this way: these kids are motivated to say "I don't care," either with their words or with their actions. They're saying those words; they're telling you what they're doing - they're not caring.
How Can Parents Motivate Their Teen or Pre-teen?
Once you realize that your adolescent is motivated to do nothing, it will become obvious to you right away that he actually puts a lot of energy into doing that "nothing." He puts a lot of energy into resisting you, to withdrawing from you, to making complaints. When you talk to an adolescent who's an underachiever, what you hear are a lot of errors in thinking. "I can't; it's too hard; it doesn't matter; I don't care." In fact, "I don't care" is their magic wand and their shield - it takes off pressure and makes them feel in control all at the same time. The words "I don't care" empower them. When they start feeling anxious about their place in life, it soothes them to say it doesn't matter; they use it like a soporific or a drug. "I don't care" also helps them deal with their anxiety. Fear of failure? "I don't care." It's hard to do? "I don't care." It dismisses everything.
Frankly, you can't make your child care. Let's be honest, the old saying, "You can bring a horse to water, but you can't make him drink" is true. But understand that while we can't make our kids drink, we can certainly try to make them thirsty.
9 Ways to Get through to Your Underachieving Child or Teen
1. Look at What Your Child Likes: Look for things that can be used as rewards for your child. Make a point of observing what your child likes and enjoys now. And don't take his word for it; he'll tell you he doesn't care about anything; that "nothing matters." But look at his actions - if he watches a lot of TV, plays on the computer, if he likes video games or texting, you know what he likes. Ask yourself: does he like going to the movies? Does he like going fishing? Does he like taking walks? Take an inventory of the things he enjoys and write it all down on a piece of paper. (While I usually recommend that parents sit down with their kids and draw up this list together, in the case of kids who tend to withhold, I don't think it's a good idea. Don't ask a child who uses passive aggressive behavior; because he won't tell you - remember, withholding is his way of maintaining control.) Later, you can use these things as incentives.
2. Take the Goodies out of His Room: I think underachieving kids should not have a lot of goodies in their rooms. Look at it this way: their room is just a place for them to withdraw. If you have a child who holes up in his bedroom, the computer should be in the living area - and if he's going to use it, he should be out there with other people. He also shouldn't have a TV or video games in his room, and if he's not performing, don't let him have his cell phone, either.
I also want to be clear and state that it's important to realize that there's a difference between being motivated to do nothing and being completely withdrawn. A child who won't attend to his work or do his chores is different from someone who's depressed. If your child won't come out of his room, doesn't seem to care no matter what you take away, and is often isolated and withdrawn, you have to take that seriously and seek professional help.
3. Make Sure Everything is Earned Each Day: I think that you have to hold unmotivated kids accountable. Make sure everything is earned. Life for these guys should be one day at a time. They should have to earn video games every day. And how do they earn them? By doing their homework and chores. They earn their cell phone today and then start over tomorrow. Let me be clear: for these kids, Mom should hold the phone.
4. Have Conversations about What Your Child Wants: When times are good, I think you should talk to your child about what he would like to have some day. Try to sneak in different ideas to get your child to think about how he will achieve what he wants in life. Sit down with your child and say "So what kind of car would you like to have? Do you like Jeeps?" Try to get him to talk about what he'd like. Because later on you can say, "Look, I care about you and I want you to get that Jeep - and you're not going to get it by not doing your homework."
As a parent, I'd be talking this way to your child from pre-adolescence. You can say things like, "Just think, some day you're going to have your own place. What kind of place would you like?" That's the type of thing you use to motivate adolescents because that's what is real to them: they want to get an apartment, they want to have a girlfriend or boyfriend, they want to get a car. So have conversations about what it takes to attain those things. And don't forget, it's a mistake to give your teen or pre-teen lectures when you want them to do something - instead, make them see that completing their responsibilities is in their best interests, because it leads to the life they'd like to have in the future.
5. Don't Shout, Argue, Beg or Plead: Personally, I think if you're shouting, you're just showing your frustration - and letting your child know that he's in control. Here's the truth: when people start shouting, it means they've run out of solutions. With kids who are underperforming, I think you have to be very cool. Arguing, pleading, and trying to get your teen to talk about how they feel is not very effective when they're using withholding as a relationship strategy.
In my opinion, you can try almost anything within reason for five minutes. So you can negotiate, you can reason, you can ask your child about their feelings. It's fine to say, "Is something wrong?" Just be aware that a chronic withholder will be motivated not to answer you.
6. "It Matters to Me." I think parents have to be very clear and tell their children that what they do matters to them. Personalize it by saying, "It matters to me. I care about you. I want you to do well. I can't make you do it and I won't force you. But it matters to me and I love you."
By the way, when I tell parents to personalize it by saying "It matters to me," that doesn't mean you should take it personally. Taking something personally means believing that your child's inappropriate behavior is directed at you. It's not - in reality, it's their overall strategy to deal with the stresses of life. The concept of "It Matters to Me" helps because relationships can be motivating, but your child is his own person. It's no reflection on you if he doesn't want to perform. You just have to set up the scenario and enhance the probability that he's going to do what he needs to do. But don't take it personally, as if somehow you have to make him do it. The truth is, you can't.
7. Stop Doing Your Child's Tasks for Him: "Learned helplessness" is when people learn that if they don't do something, someone will step in and do it for them - and it's a very destructive pattern. When kids and teens use this shortcut, they don't learn independence. In fact, in families where this occurs, many times you'll find that the kids weren't allowed to be independent very much. Perhaps they had to do things a certain way and all the choices were made for them. Eventually, they gave up; they surrendered.
Regardless of why your child might have an attitude of learned helplessness, as a parent, it's important to stop doing things that he needs to do for himself. Don't do his homework - let him do it. You can be available for help if necessary, but don't take on his tasks. I believe one of the most important things an adolescent has to learn is independence, and if you take on his responsibilities, you're robbing him of this chance to develop.
8. Learn How to Be a Coach: Let's face it: it's often sports coaches who get the most out of our kids. It's their job to help kids want to improve their skills. So the coach learns a little bit about each of his players. A good coach is not constantly saying, "You're great, you're the best, you're a superstar!" Rather, they always keep their athletes looking forward by complimenting them on the specifics of their progress: "Nice layup, Josh. You positioned your hands better that time. Keep it up." I think parents need to learn more about the Coaching parenting style. Always keep your child looking forward. Comment on his or her progress instead of telling them how great they are when they haven't put forth much of an effort. Kids see through flattery and false praise just like adults do - and it usually backfires.
9. Set Deadlines and Use Structure: Tell your child clearly when to do chores and schoolwork - and when you want them done by. I think it's important to schedule these kids, to give them structure. "Do your chores from 3 p.m. to 4 p.m., and then you'll have free time until dinner. And during free time, you can do whatever you want to do." There are other ways to motivate your child by saying, "If you can accomplish this in X amount of time, we'll go to your cousin's house on Saturday" or "I'll take you to the boat show this weekend." Remember, not everything that your child likes to do costs money, so add those activities into the equation.
I think it's important for parents to realize that being an underachiever gives your child a sense of control and power, because then he doesn't have to worry about the anxiety of failure or meeting challenging responsibilities. He doesn't have to compete with other kids. He doesn't have to deal with people's expectations. In fact, a large part of underachieving has to do with managing other people's expectations. That's because once you start to achieve, people expect more of you. Kids feel this quite powerfully and they don't have much defense against it. So you'll often see that when people start expecting more of these kids, they fall apart.
For me, it's not about who's to blame; it's about who's going to take responsibility. A kid who's an underachiever is motivated to do less - or to do nothing - because it gives him a sense of power and it gets him out of the stress of having to meet responsibilities. Your job as a parent is to help him by coaching him to meet those responsibilities in spite of his anxiety, fear or apathy.
In Part II of our series on Underachievers, James will talk specifically about ways you can motivate your child in school. Stay tuned to learn how you can get your underachieving child on track for the school year - no matter what his or her issue is.
Motivating Underachievers Part I: When Your Child Says "I Don't Care" reprinted with permission from Empowering Parents. For more information, visit www.EmpoweringParents.com
Author: James Lehman, behavioral therapist and the creator of The Total Transformation Program for parents, worked with troubled teens and children for three decades. James holds a Masters Degree in Social Work from Boston University.
For the parents of a child with ADHD, everyday tasks turn into battles-from getting the child out the door in the morning to getting him to bed at night. My son was diagnosed with ADHD at age 6, so I remember what it was like to have a daily tug of war with an attention disordered child all too well. Parents look for help everywhere. They may read one book after another and hear a parade of behavioral experts speak who give them parenting tips that don't seem to work. The more books they read and experts they seek out, the worse their child's behavior seems to get.
In my practice and in my work with my own son, I discovered a number of techniques and strategies that can help parents improve the behavior of a child with ADHD.
ADHD Secret #1: Parenting Techniques Must Be Adapted to Kids with ADHD
What works for adolescents with ADHD may not work for a seven-year-old with this diagnosis. Likewise, if a behavior modification technique works for 95% of children, that doesn't mean it will be effective for the 5% of kids with ADHD.
The time out is a classic example of a behavior modification tool that is often misused with children who have ADHD. Timeouts are often recommended to help children with ADHD learn to control impulsive behavior such as talking back, hitting or hyperactivity. However, standard application of this popular intervention may not work in the presence of ADHD.
Parents are usually told to apply 1 minute of timeout for each year of age, thus 6 minutes for a six year old. For a child this young with ADHD, this may be too much time. Psychologists suggest applying the 30% rule to kids with ADHD and learning disabilities, which means that social-emotional development for these kids may be 30% less than their peers. Thus, a 6 year old should be considered to react more like a 4 year old. Therefore, 4 minutes would be more appropriate.
ADHD Secret #2: Use Reward, not Punishment
One of the most important things to realize about children with ADHD is that they respond much better to reward than to punishment. So here's how to adapt the time out to a child with this diagnosis so that the tool is more effective. If your 6 year old won't sit quietly in timeout, tell him the timeout is 8 minutes (double the time based on the 30% Rule). But he can reduce it to 4 minutes by sitting quietly. Then watch how hard he tries to earn the "reward." By moving away from punishment and giving the child a reward, albeit a simple one, you are speaking the language that an ADHD child understands.
Helpful tip: Don't nag! Help your child to correct errors and mistakes by showing or demonstrating what he should do rather than focusing on what he did wrong.
ADHD Secret #3: Leverage the Child's Desire for Positive Attention
Children with ADHD usually crave positive attention while being more likely to have a severe over-reaction to negative attention or punishment. Using what is called "selective attention" can be very helpful in increasing appropriate behavior while decreasing inappropriate behavior. Begin to pay attention to appropriate behavior through praise while ignoring inappropriate behavior. For example, your child is wiggling around and making silly noises while you are helping him with homework. Ignore the behavior and say, "Let's see how fast we can get this work done." When he settles down you can say, "Wow!, you are really working hard and look, we're almost done now." This may be difficult at first because it's usually the opposite of how parents tend to respond to behavior. It's our instinct to jump on irritating behaviors and try to correct them, simply to make them go away. But without knowing it, we are rewarding the inappropriate behavior because, with these children, any kind of attention is better than no attention at all. Even worse, when we ignore appropriate behavior, we don't reinforce it. So the child with ADHD doesn't learn that appropriate behavior often leads to positive attention. When you use selective attention, rewarded behavior will increase while ignored behavior will decrease. It's a parental 180-degree turnaround that can work wonders with a young child who has attention and hyperactivity problems.
Helpful Tip: Inappropriate or irritating behavior should be ignored 100% of the time while appropriate behavior should be praised 70% to 80% of the time at first, and then to less than half the time as things improve. The goal is for the child to gradually be able to control their behavior on their own.
ADHD Secret #4: Teamwork Works with ADHD
You + Your Child = The Team
Most programs for kids with ADHD focus on training parents, which is very important, but these programs do not speak directly to the child. Instead, I recommend that parents and kids work together as a team. For instance, in the Total Focus Program, the parents and the child are shown ways of working together on relaxation exercises that improve concentration and reduce frustration. The exercises are fun, and a chart is kept to track progress. They end up having a good time, improving their relationship and learning new skills together.
Many of the programs for kids that are on the market focus on improving only one skill. But they offer no magic cure. In my practice, I've had success using a broad spectrum of approaches (cognitive rehabilitation, behavior modification and relaxation therapy) that are integrated together with a newfound "I Can" attitude to produce results that lead to major improvements in behavior and learning achievement. When I work with kids and parents, I teach problem solving skills and social skills to improve motivation and self-esteem. By doing this, the child learns to put in the work to achieve the major skills he needs to master: improved attention, concentration, and functions including memory and self-control. As a result, the whole family benefits.
ADHD Secret #5: Young Children with ADHD Respond Well to Touch
Most kids with ADHD need lots of physical contact. Love them by touching them, hugging them, tickling them, wrestling with them.
ADHD Secret #6: Focus on the Child's Strengths Daily - and more than you would with a child who does not have ADHD
Look for and encourage their strengths, interests, and abilities. Help them to use these as compensations for any limitations or disabilities. Reward your child with praise, good words, smiles, and a pat on the back as often as you can.
ADHD Secret #7: Practice Motor Skill Improvement to Reduce Frustration
Make a game of practicing motor activities that will stimulate them in their development. For example, skipping to music, playing catch or tossing a bean bag at a stack of blocks improves coordination and the ability to follow directions without frustration, giving the child more self-confidence as well.
ADHD Secret #8: Consistency Pays
Being consistent is good advice for any parent. For parents of young children with ADHD, it is vitally important. Exhausted parents crave a "quick fix" to impulsive, unmanageable behavior. So they tend not to stay with one strategy long enough to see it work. When you use the techniques suggested here, remember that consistency is important to achieving success with a young, attention disordered child.
ADHD is a "brain difference." You child's brain works differently than 95% of his peers. So "one size fits all" parenting techniques won't necessarily fit your child. Your parenting strategies may need to be administered in smaller doses with more emphasis on rewards and on your child's strengths. I teach parents how to understand the unique traits and behaviors of their child and how to adapt "tried and true" approaches so they will work for their child. I also help parents to develop a positive approach that helps them to be able to develop patience and insight that will result in happier days for parent and child.
ADHD and Young Children: Unlocking the Secrets to Good reprinted with permission from Empowering Parents.
Author: Dr Robert Myers is a child psychologist with over 25 years of experience working with children and adolescents with Attention Deficit Hyperactivity Disorder and learning disabilities and is the creator of the Total Focus Program www.trytotalfocus.com. Dr Myers is Associate Clinical Professor of Psychiatry and Human Behavior at UC Irvine School of Medicine. "Dr Bob" has provided practical information for parents as a radio talk show host. Dr. Myers earned his PhD from the University of Southern California.
Page last modified or reviewed on January 27, 2014
If you're the parent of a young child who acts out at school, you've probably asked yourself, "If my child is out of control now, how will I be able to deal with him when he's ten - or a teenager?" Once a toddler or kindergartner becomes known as a child who "plays too rough" or "always has to have his way," parents often find that invitations to playdates and birthday parties begin to dry up. Instead of hoping your child will be well-liked at school, you might be saying to yourself, "If only Ben could find just one friend to play with - and maintain that friendship for longer than a day!"
Let me start by saying that many of the difficult behaviors your young child displays - including pushing, hitting, and refusing to share and take turns - are perfectly normal for their developmental level. While you still need to address those issues, I think it's helpful to understand that they are very common amongst young kids - and you are certainly not alone in what you are dealing with. I personally believe that one of the keys to helping your young child improve their behavior at school lies in having them work on this same behavior at home. The good news is that as a parent, you are in the best position to coach, teach and hold them accountable for their behavior.
In my experience, of all the issues parents have concerns about when it comes to young kids at school, these three tend to be the most common - and the ones parents worry about most:
My Child is Overly Aggressive
Nobody wants their child to hit, yell, or play too roughly with others, but it's important to realize that this is typical in young children - in part because most toddlers and kindergartners still lack adequate verbal skills to deal with their emotions. For a young child, reasoning through a situation when they are upset can be very challenging, if not altogether impossible. And for many kids, hitting, pushing and yelling are the best problem solving skills they have at their fingertips. This is not to say you should excuse aggressive behavior, or that you can't coach your child to behave appropriately on their own eventually. While it's important to recognize that what your child is doing is normal, you also need to use rules and consequences to clearly teach them how to stop behaving too aggressively.
What Parents Can Do:
It's up to you to let your child know that their actions will no longer be tolerated. When things are calm, get down on their level, look them in the eye and say, "Hitting, biting, kicking and pushing are wrong and they hurt people." Be sure to tell them what their consequence will be: "If I see you hurting anyone, or if the teacher tells me you hit someone again at pre-school today, your consequence will be no television when you get home." Keep the consequences short term and give them to your child as soon as possible after they have behaved inappropriately. Try to have your child spend time with someone close to his age. Watch them closely so that you can see when your child is starting to become upset and coach him in that moment to use his words. Consequences alone will not change his behavior--but using consequences to require your child to practice the skills he needs to develop will change behaviors.
I also believe it's important to coach your little one to find his voice instead of lashing out at others. Keep in mind that this will require practice and lots of repetition. You can start by teaching your toddler, pre-schooler or kindergartner a saying to use at school or home when they are angry and frustrated. In place of pushing, for example, tell your child to say something like, "I don't like that!" or "I'm not going to play with you if you take my toys!" Another good thing to do is show your child how to walk away when he is angry or upset. Be sure to role play this with him, and switch roles so he can see how each side might react.
I also recommend that parents work with their child's teachers as much as possible: let them know you are doing your best to curb aggressive behavior at home. Oftentimes, the teacher will have helpful suggestions for you to try, as well. The important thing is that you get on the same page and try to work together with the school as much as possible.
My Child Won't Share or Take Turns
Ahhh, sharing. This is one of the toughest things you'll deal with when it comes to young kids, both at home and at school. It's important for you to remember that your child is at a developmental level that makes sharing extremely difficult. Since sharing with others and taking turns is not a behavior that comes naturally to young children, it's your job to teach your kids why it is so important. After all, learning how to share is central to a child's ability to make and keep friends. Keep in mind that you can't force your kids to share any more than you can force them to eat their broccoli - but through practice, they can learn to do it.
What Parents Can Do:
Bear in mind that there are some things your child will not want to (and shouldn't have to) share: A special treat given to them by their Grandma; a new toy from their birthday party; their favorite stuffed animal or security blanket. It's okay to say, "I know that's special to you and you don't want to share it." And after all, you probably wouldn't want to "share" the ring your parents gave you when you graduated from high school, or that brand new pair of dress shoes you just bought.
Of course, there are times when your child needs to share: if they're hoarding a package of crayons while their best friend is sitting empty-handed, for example, it's time to intervene. Teach a little empathy by saying, "Jamie, how would you feel if Sarah had all the crayons and wouldn't give you any? Can you think of how to share your crayons?" Some kids may realize this seems selfish, while others may hold on to those crayons all the more tightly! Feel free to give your child a choice here: "Jamie, you can give Sarah five crayons." If your child refuses to let go of the crayons, tell her that you will give her ten seconds to release the crayons or you will put her in time-out. The same thinking applies when it's time to take turns. "Jamie, it's Sarah's turn to pick a video next. You chose last time." If a tantrum ensues, your child should face a consequence such as a time-out - or you can leave the play date altogether.
If you hear that your child is having a tough time sharing or taking turns at school, again, let your child's teacher know that you are working on this specific issue at home, and ask for advice. By the way, I would not give your child a consequence for this when they come home - let the teacher handle it in the classroom. What I would suggest is that you talk to your child in a calm moment about sharing and taking turns. You can say something like, "You know, part of being a good friend is learning how to share. Sometimes it's a hard thing to do, but taking turns is a big part of playing with someone else and making new friends." You might also tell them about a time when you had a difficult time taking turns as a child, and how you learned to deal with it. Kids love to hear stories about their parents when they were kids; I've found that telling them about your experiences can be very effective in helping them understand the situation and improve their behavior.
I also cannot stress this enough: when you see your child sharing or taking turns nicely, be sure to compliment them and reinforce why it's important: "I noticed how nicely you were sharing with Connor the other day. It shows that you're really trying hard to be a good friend. I'm really proud of you." That positive reinforcement makes all the difference in the world - especially with young kids.
My Child has a Hard Time Making - and Keeping - Friends
Many parents tell me that their kids have difficulties making and keeping friends. Sadly, a child who is demanding or argumentative with other kids often finds himself feeling isolated as a result. And that's really the natural consequence for this type of behavior - soon, other children just won't want to play with him anymore.
Kids are aggressive or bossy for many reasons: some get anxious when in groups, while others have not learned proper boundaries or social skills at home. In either case, it's a good idea to step in and help your child change their behavior as soon as possible.
What Parents Can Do:
Start by being honest about what social skills your child lacks, and then make a commitment to help them work through those issues. Many parents tell me that their child observes few boundaries with other kids at school: their child will jump into the middle of games and try to take over, knock down the other students' Lego buildings, or grab toys from classmates. While again, this type of behavior is normal for this age group, it's not something you want to go unchecked.
I believe this problem can be resolved in large part by creating better boundaries at home. What that means is, try not to give in if your child whines or pleads, and set firm rules for them. When your child takes over a family dinner conversation or their sibling's game, remind them that someone else was talking, or that now it's their brother's turn to do the puzzle. And follow through on the consequences you have laid out for them. You can say, "You know the consequence for ruining your sister's game when she has a friend over. You need to go to your room for a time-out and stay there for five minutes."
I know that parents can become exhausted when dealing with young kids who act out; let's face it, it's hard work! But I want to be clear here: it may seem like a small thing in the moment when you fail to be consistent, but consider this: each time you give in when your child acts out, you are setting the stage for future acting out throughout their development. And when you don't expect them to behave properly within their own relationships at home, the truth is that you are also hindering their ability to act appropriately with their friends at school.
Coaching Your Young Child toward Better Behavior
If you have a young child who acts out at school, realize that he may need some extra coaching as he tries to change his behavior. I recommend that you start by explaining to him what type of behavior you expect him to have. In a calm moment, you can say, "I expect that when you are here at home or with friends at school you will practice sharing, you will not hit, and you will not be bossy." Rewarding your child for good behavior is also key. I always suggest that parents use a chart at home when they are trying to help improve their child's behavior, because it is an excellent motivator. The chart might have sections at the top that say, "Plays Nicely with Little Sister"; "Shares and Takes Turns" or "Uses an Inside Voice." Sit down with your child and show the chart to him - you can even create it together. Be sure to tell him, "If you can do these things, you will get a sticker for your chart each day. When you reach 10 stickers, you'll get a special surprise." When your child is able to accomplish these goals, make sure you tell him what a great job he did. Point out specifics like, "I really liked watching you and Gracie take turns with the paints. It seems like you are working hard!" Kids love it when you are aware that they are attempting to change their behavior, and they will try all the harder if they know you're watching.
If your young child continues to act out with kids at school, let him experience the consequences the teacher doles out, but continue to coach him at home in ways to be less aggressive or bossy. You can also ask his teacher to maintain a "good school behavior chart" -you can even give your child extra points on his chart at home for good behavior there.
Finally, many parents tell me that they often feel their child has been labeled "difficult" by the school which can make the whole family feel like outcasts. If this is your experience, know that it's never too late to try to improve the situation. Call a meeting with your child's teacher and state what you are doing for him at home. Let the school know about any outside help your child may be receiving, such as counseling or tutoring. While you can't control what a teacher thinks of your child, you can at least feel good knowing you are doing everything in your power to help the situation; in my experience that makes all the difference. As a parent, it's not always easy to help our young children change their behavior, but I believe it's one of the most important and worthwhile things we will ever do.
When Challenging Behavior Becomes a Problem: Some Guidelines on When to Seek Help
While it is normal for aggressive behavior, bossiness, or refusing to share or take turns to creep into your young child's life at some point, it is also important to know when to seek outside help. The main criteria for contacting your pediatrician or child mental health expert are:
When your child's behavior chronically interferes with the order of the classroom or family to the point of daily disruptions. Is your child's teacher continually calling you to talk about behavior issues, or asking you to come to school and talk? This would include serious infractions at school, such as punching, kicking, or pushing other kids repeatedly and destroying school property. If the teacher is unable to do his or her job because they are dealing with your child's behavior issues, it is time to seek outside help.
When the behavior interferes with your child's ability to maintain friends. I am not suggesting an inability to be popular or have loads of buddies, but rather, when your child is actively disliked by their peer group or has no connections with other children to the point of isolation. This is a cause for concern which you need to address immediately.
When the behavior interferes with your child's ability to understand or grasp schoolwork. Again, I'm not suggesting that struggling with learning to read or being bored with a project in kindergarten means there's a problem. If, however, your child finds it so hard to concentrate that he or she can't understand the basic concepts appropriate for their developmental level, talk to his or her pediatrician.
If you feel you have set all the appropriate limits on your child and they still do not respond. When you set limits, use consequences, coach and teach your child on how to behave and nothing seems to be working, it's time to seek outside help.
Sometimes anxiety, learning disabilities or other issues are the reason that your child has trouble with other kids at school. While it's true that children with those issues might lack appropriate boundaries, in my opinion that's all the more reason for you to work on this with them. It's vital that they learn to develop these skills, or make no mistake, they will grow up without really understanding how to interact socially. If your child has been diagnosed with a disorder such ADHD or ODD, for example, use it as an incentive for you as a parent to work harder at helping them develop proper boundaries.
Young Kids Acting Out in School: The Top 3 Issues Parents Worry about Most reprinted with permission from Empowering Parents. For more information, visit the Empowering Parents website.
Author: Joan Simeo Munson has a PhD in Counseling Psychology and is the co-author of the forthcoming 50 Plus One Great Life Lessons to Teach Your Children. Over the years, Dr. Munson has worked with incarcerated individuals, families, adolescents, and college students in a variety of settings, including county and city jails, community mental health centers, university counseling centers, and hospitals. She also has a background in individual, group, and couples counseling. Dr. Munson received her PhD from The University of Denver, her Master of Arts degree in Community Counseling from George Washington University, and her Bachelor of Arts degree in Sociology from the University of Illinois. Dr. Munson lives in the Boulder area with her husband and three children.
Page last modified or reviewed on January 24, 2014
What is an adjustment disorder and how does it occur?
There are six major adjustment disorders:
Adjustment disorder with depressed mood;
Adjustment disorder with anxiety;
Adjustment disorder with mixed anxiety and depressed mood;
Adjustment disorder with disturbance of conduct;
Adjustment disorder with mixed disturbance of emotions and conduct;
Adjustment disorder unspecified.
What are the characteristics associated with an adjustment disorder?
A person with adjustment disorder often experiences feelings of depression or anxiety or combined depression and anxiety. As a result, that person may act out behaviorally against the "rules and regulations" of family, work, or society. In some people, an adjustment disorder may manifest itself in such behaviors as skipping school, unexpected fighting, recklessness, or legal problems. Other people, however, instead of acting out, may tend to withdraw socially and isolate themselves during their adjustment problems. Still others may not experience behavioral disturbances, but will begin to suffer from physical illness. If someone is already suffering from a medical illness, that condition may worsen during the time of the adjustment disorder. People in the midst of adjustment disorders often do poorly in school or at work. Very commonly they begin to have more difficulty in their close, personal relationships.
Listed below are some of the characteristics associated with adjustment disorders:
A person with an adjustment disorder with depressed mood may have mostly a depressed mood, hopeless feelings, and crying spells.
A person with an adjustment disorder with anxiety would experience anxious feelings, nervousness, and worry.
Someone with an adjustment disorder with mixed anxiety and depressed mood would, obviously, have a mixture of anxious and depressed feelings.
An individual with an adjustment disorder with disturbance of conduct may act out inappropriately. This person may act out against society, skip school, or begin to have trouble with the police.
A person with an adjustment disorder with mixed disturbance of emotions and conduct would have a mixture of emotional and conduct problems. Do adjustment disorders affect males, females, or both?
In the United States the same number of males and females experience the various adjustment disorders.
At what age can an adjustment disorder appear?
Adjustment disorders can occur at any age. People are particularly vulnerable during normal transitional periods such as adolescence, mid-life, and late life.
How often does adjustment disorder appear in the community?
Adjustment disorder is very common in the United States. More than five percent (5%) of all persons seen in clinical, outpatient mental health settings have some type of adjustment disorder.
How is an adjustment disorder diagnosed?
A mental health professional makes a diagnosis of an adjustment disorder by taking a careful personal history from the client/patient. It is important to the therapist to learn the details that surround the stressful event or events in that person's life. No laboratory tests are required to make a diagnosis of adjustment disorder nor are there any physical conditions that must be met. However, it is very important for the therapist not to overlook a physical illness that might mimic or contribute to a psychological disorder. If there is any question whether the individual might have a physical problem, the mental health professional should recommend a complete physical examination by a medical doctor. Laboratory tests might be necessary as a part of the physical workup.
What happens to a person with an adjustment disorder?
The conditions associated with adjustment disorder develop within three months of the beginning of the stressful problem. An adjustment disorder usually lasts no longer than three to six months. The condition may persist, however, if an individual is suffering from chronic stress such as that caused by an illness, a difficult relationship, or worsening financial problems.
How is an adjustment disorder treated?
Therapy can be very helpful to lessen or alleviate ongoing symptoms of adjustment disorder before they become disabling.
Group therapy can be useful to individuals who are enduring similar stress.
In some situations the use of prescription medications can be very useful to ease the depression or the anxiety associated with adjustment disorder.
What can people do if they need help?
If you, a friend, or a family member would like more information and you have a therapist or a physician, please discuss your concerns with that person.
Page last modified or reviewed by athealth on January 28, 2014
Athealth.com:Welcome Dr. Liddle. I would like to start by inviting you to talk about the most important recent developments in the area of adolescent substance abuse research and treatment.
Dr. Liddle: This is a very important question with historical and contemporary overtones; there are several key issues to consider here.
First and foremost, adolescent substance abuse has become a bona fide clinical specialty in its own right, with its own theory, basic and applied research, practice guidelines, and policy studies. Clinical work in the field is grounded in the knowledge of adolescent development. Today's "state of the art" treatments are not step-down adult treatments applied to teens. Rather, they are tailored to the particulars, complexities, and multiple systems that make up the teen's ecology. Additionally, there are many opportunities for research of all kinds through federal funding agencies, foundations, and state and local agencies. The existence of research centers is a testimony to the specialty's evolution. Professional and scientific organizations and many scientific publications focus on the problems, needs, and policies pertaining to adolescence. I believe we are witnessing the beginning of a renaissance period in the history of the adolescent treatment specialty.
Second, the multidisciplinary nature of the specialty should be considered a major development, as well as a rich asset. Today adolescent substance abuse is addressed by a number of people who play vital roles in the lives of adolescents: teachers, school counselors, juvenile justice representatives, primary care doctors, psychotherapists, social workers, parents, and family members. Different professional specialties have come together to make theory based, practice and research contributions to the specialty. In treatment, the new models advocate a broadly coordinated response to the needs of the patient. This response is based on a systemic and ecological conceptualization. And, the systems approach more accurately reflects the real life of the adolescent, since they're involved in multiple social ecologies--each of which makes a unique as well as a shared contribution to the developmental outcomes of each teen. In treatment, therapists have to engage the adolescent in a productive manner; that really means understanding the subtleties and complexities of the teen's world. A "distant" stance does not facilitate the change process. There has to be a level of involvement in the life of the adolescent that demonstrates respect, interest, and caring, certainly, but also knowledge about his or her world-the world that teens live in today, not the world that teens inhabited years ago. Concurrent work with the parent is fundamental to success as well.
Third, there is an integrative spirit about combining these multiple perspectives. We now have a much broader range of understanding about adolescent substance abuse that encourages the inclusion of the unique perspectives of medicine, developmental and clinical psychology, addictions studies, social work, and other disciplines. Our job as researchers and professionals in practice is to capitalize on this synergy of information in our treatment approaches.
Additionally, we have at our disposal a wealth of information on the basic scientific aspects of drug abuse such as how these problems come about, the efficacy of treatments, and so forth. Today more than ever before treatments are predicated on accurate, scientifically based knowledge about how problems develop (for instance, what the key risk factors are for substance abuse in early adolescence) and credible evidence about the kinds of characteristics and malleable environmental circumstances, such as family life, that protect kids against drug problems. This probably accounts for the increase in effectiveness of some of today's treatments. They are based on scientifically established knowledge about kids and their circumstances, not myths or assumptions that may or may not be accurate.
This brings me to my final point. The diverse nature of the studies being done has resulted in an explosion of information in the field. Data is available on many fronts and the challenge is to organize and apply the knowledge in a way that has a direct bearing on outcomes.
This is where the Internet can be helpful, namely, in packaging and delivering the information. Clinical journals advance research, theory, and practice, but they don't always answer the questions that practitioners have on a daily basis. The goal of using these advances in knowledge to influence everyday clinical practice in the variety of clinical settings is a major theme in the field now. Some of the most important challenges are how to take research-based, effective therapies and adapt them for use in regular treatment settings.
Athealth.com:Do you see any positive trends in the area of treatment outcomes, prevention, and intervention, specifically in terms of evidence-based practice guidelines?
Dr. Liddle: Evidence-based practice guidelines and treatment manuals are now available. The American Academy of Child and Adolescent Psychiatry has practice guidelines available for a variety of adolescent disorders, including ADHD, conduct disorder, and substance abuse. While these documents are not "how-to" treatment prescriptions, they are helpful because they sketch the psychological, behavioral, and environmental terrain of a clinical problem.
The execution of clinical interventions, as always, rests with the clinician; here we are dependent on her or his level of clinical competence.
The Center for Substance Abuse Treatment has revised TIPS volumes (Treatment Improvement Protocol Series) on "adolescent treatment" and "adolescent substance abuse assessment." Additionally, there is a forthcoming TIP from CSAT on family treatment of adolescent substance abuse.
On the "how-to" front, there is progress as well. In the Project MATCH tradition, CSAT is publishing several adolescent treatment manuals from brief interventions that were tested in the very successful Cannabis Youth Treatment (CYT) Multi-site Study. The preliminary findings from this study are available at online at Chestnut Health Systems.
Within the next couple of years, CSAT will also publish more adolescent substance abuse treatment manuals as part of their exemplary treatment model initiative. This new wave of treatment manuals will demonstrate that this specialty has come of age. These are well articulated, clinically feasible, and, in many cases, effective treatments that providers and systems of care (state mental health and substance abuse systems) need to know about.
The training that needs to occur in order to follow up on the advances brought by these manuals is another matter. Will the state systems support the kind of training that is needed to bring these effective treatments and interventions to counselors working hard in the clinical trenches? I sure hope so. If they can make that kind of commitment of resources and funds-well, that would be a breakthrough in the field itself.
Athealth.com:Could you elaborate on the outcome trends?
Dr. Liddle: The outcome trends are significant:
Large numbers of adolescents and their families can be engaged in these new "state of the science" therapies;
Adolescents can change drug taking habits as a result of these therapies;
Adolescent involvement with legal and juvenile justice systems can be decreased dramatically;
Pro-social aspects of the teen's life can be facilitated--parents and families can change, kids can stop affiliating with deviant peers, and adolescent school attendance and performance can increase significantly (See reviews by Weinberg, et al, 2000; Ozechowski & Liddle, 2000).
Family-based treatments are the most effective according to some reviews (Stanton & Shadish, 1997; Williams & Change, 2000). According to these experts, one of the "state of the science" family therapies is the treatment of choice for adolescent drug problems.
Evidence Based Practice Guidelines
As far as evidence-based practice guidelines are concerned, developments here are fairly recent and the by-product not only of increasing research and attention over the past decade, but also of the problems and complexities associated with treating adolescent substance abuse. Some examples of evidence-based practice guidelines are:
Practice Parameters for the Assessment and Treatment of Children and Adolescents with Substance Use Disorders
Screening and Assessing Adolescents for Substance Use Disorders
Treatment of Adolescents with Substance Use Disorders
Athealth.com: What are your thoughts about the pharmacological treatment of substance abuse in adolescents?
Dr. Liddle: This is one of the most important areas and topics in our specialty but has received little research so far. Most researchers developing psychosocial interventions for drug using teens now accept that just as they must craft combination therapies in the behavioral realm, they need to devise combination therapies of behavioral and psychopharmacological interventions in the treatment of substance abuse as well.
In two of our current clinical trials, for instance, clinical teams of substance abuse counselors and psychologist supervisors work with contextually oriented child psychiatrists to determine appropriate, concurrent psychotropic medications for the kids in the treatment protocols. The child psychiatrist, of course, is fully in charge of the diagnosis and determination of the medication to be used, and she closely monitors medication compliance, reaction, and efficacy.
At the same time, the clinicians are in close contact with the child psychiatrist while they conduct the multiple systems oriented therapy-family work, school intervention, vocational planning, tutoring, other case management, and naturally, individual work with the adolescent.
These different interventions, including the use of medications for the teen or the parent, are coordinated. Interventions occur in the different realms simultaneously. The collaboration between the clinicians and the child psychiatrist is fruitful; it replicates in this clinical setting what happens in regular clinical practice. It also seems to address the practical, clinical needs of the case quite well. The medications for the teen typically target symptoms such as depression and anxiety, and they can facilitate the adolescent's or parent's participation in the individual, family, or group behaviorally-oriented treatments.
Athealth.com: What are your thoughts on inpatient treatment?
Dr. Liddle: When we consider any treatment plan or intervention it is important to bear in mind that there is, or at least there should be, a spectrum of care available (both in terms of intensity and level of restrictiveness). Residential treatment falls on the end of the spectrum. It is an intensive intervention and represents a restrictive kind of care. A stay at a residential care facility can interrupt the cycle of drug taking and the deepening of a drug using lifestyle.
Residential treatment needs to be understood as part of a continuum of services that teens and families require. Studies indicate that the quality of the post-treatment environment--particularly relationships with family and non-drug using friends and involvement in school and pro-social activities--are critical predictors of recovery. In other words, without a change in the teen's post-residential care environment, residential treatment alone is unlikely to be effective.
This is where aftercare or outpatient services enter the picture. And again, the nature and quality of these services is critically important. These services can now be based on available scientific evidence-evidence on which a transportable and clinically practical treatment model can be based.
Folks looking for residential or outpatient services need to inquire about the scientific evidence that has influenced that particular program. If the program providers are skittish about discussing this with a parent, teen, or other referral source, there may be cause for concern. Today, given the stage of development of this specialty and the spirit of accountability in all care systems, every treatment program should be based on the available clinical research evidence about how kids recover from drug problems.
Athealth.com: What do you consider the "most dangerous" drug(s) available to adolescents today?
Dr. Liddle: This is a tricky question since the response has to correspond to how we understand adolescent drug use today. That is, if we understand adolescent drug use contextually and multi-dimensionally, then the answer must not only be in terms of this or that particular drug but also include the significant psychosocial and current environmental factors that contribute to the teen's drug use or abuse.
At a basic level, the classic answer is that either heroin or cocaine is a "more dangerous" drug than alcohol or marijuana. However, if the teen is binging heavily on alcohol (going to parties, driving while intoxicated, engaging in high risk sexual behavior or alcohol-related violent acts) he or she is engaging in day to day behavior that is extremely dangerous and surely life threatening.
Additionally, as our knowledge about drugs increases, the answer to this question might change. Consider the case of marijuana, the most frequently used illegal drug in the United States. The drug's active ingredient, THC, affects nerve cells in the part of the brain where memories are formed. We have good evidence that short-term memory is severely affected by marijuana and that smoking marijuana causes some changes in the brain that are similar to those caused by cocaine, heroin, and alcohol.
Many researchers believe that these changes place a person at greater risk of becoming addicted to other drugs such as heroin or cocaine. On the basis of this new scientific information, we ought to be much more worried about drugs such as marijuana-a drug that many parents of today's teens tried or used. Consequently, these adults may make sharp distinctions between the danger of drugs such as alcohol and marijuana versus that of cocaine or heroin. These distinctions may not hold up so well when we take a contextual approach-an approach that asks about the level and nature of the multiple impairments that accompany a teen's substance use or abuse.
Drug abuse derails the developmental trajectory of a teen. Longitudinal studies about the consequences of drug abuse paint a very unsettling picture:
Serious mental health and relationship instability
Marital and job dissatisfaction and failure
Criminal justice involvement and legal problems
Alcohol and drug addiction
These are some of the negative, long-term outcomes for kids who begin using early, progress to drug abuse in the teen years, get involved in the juvenile justice system, perform poorly in school, get thrown out of school and their home, and affiliate with drug using peers.
It is a process that further solidifies a drug using lifestyle that treatment must replace.
Athealth.com: Are there simple assessment tools for substance abuse you would recommend for use by therapists who are not chemical dependency specialists?
Dr. Liddle: Yes, there are many assessment and screening instruments: The Problem Oriented Screening Instrument for Teens, the GAIN, the Personal Experience Inventory, and the Teen Services Review.
Athealth.com: Establishing a therapeutic alliance with an adolescent sounds fairly intimidating to most professionals. Do you have any special tips to offer?
Dr. Liddle: I like the fact that you chose the word intimidating. There really is a lot of truth to that for therapists. Let's talk about your vignette first, and then I will say a few words about intimidation and therapists.
A 15-year-old girl is brought in for her first visit by her mother. The mother reports that the client has been using alcohol since age 11, marijuana since age 14, and the mother suspects that the daughter is also using ecstasy with her 23-year-old boyfriend. The mother is hysterical and is threatening to kick her daughter out of the home. The client has had several issues with school (one suspension, missing school, etc.) and has recently been arrested for possession.
Dr. Liddle: Clinically, there are numerous questions to be explored. A major challenge is to come up with a case conceptualization that leads to comprehensive, well-coordinated therapeutic action. A treatment program using today's best therapies addresses multiple aspects of a teenager's life simultaneously.
Let's take a look at the risk factors that are presented:
Here is a young girl who is already advancing along the continuum of drug abuse by engaging in increasingly dangerous drug abuse. Early use (age 11 clearly qualifies as early initiation) is a strong predictor of the development of an abuse diagnosis as well as a host of other poor developmental outcomes. Alcohol experimentation and use at age 11 would make a therapist think that there must be alcohol available in the girl's house and that the parent or guardian is drinking and/or laissez faire about the girl's risky behavior./li>
She is at risk for being put out of her home.
The relationship with her mother is quite strained. Parent-teen relationship factors are among the strongest predictors of use and, on the other side of the coin, they are among the strongest protective, or risk buffering factors, against drug use and deviance in general. Even after problem behaviors, including drug use, have begun, parenting skills and the family environment matter. In the context of certain forms of treatment, family relationships can be a very strong antidote to deviance and the slide toward serious problems.
She is involved in a suspect and advanced relationship with an adult. This circumstance, in combination with her drug use, is very deleterious. The girl's development is both immature and accelerated. Circumstances such as these accelerate or catapult development into areas that the teen may be emotionally, psychologically, and developmentally unprepared to meet, especially in terms of appreciating the risks and consequences of behavior.
Her school problems show a lack of connection and represent missed opportunities for her to develop needed competencies. Lack of education opens the door to an escalation of life problems. Expulsion from regular school, the slide toward alternative schools, and then no school at all-these are dangerous and also predictive of a tough road ahead.
Legal problems requiring a response from the juvenile justice system can represent the straw that breaks the camel's back. Juvenile justice systems (drug court models, collaboration with juvenile court judges) are not necessarily sympathetic to therapeutic jurisprudence philosophy (preferring to build more prisons to warehouse younger and younger offenders). Depending on the jurisdiction, the level of coordination between juvenile court, the treatment provider, and the skill that the treatment provider possesses in coordinating a treatment program that fits, hand in glove, with the sanctions that are imposed by the juvenile court, this girl's involvement in the juvenile justice system could be like that of so many other kids: filled with punishment and devoid of any opportunity to participate in scientifically proven treatments.
A clinician here would be worried not only about this list of clear and present dangers, but also about the interaction, current trajectory, and pace of acceleration of this girl's problems. Teen problems, drugs, behavior problems, risky sexual practices, and driving while intoxicated--these all correlate with becoming disconnected from social institutions that are important to development (i.e. schools, religious or faith based institutions, pro-social peers groups, and families).
In a situation of this sort, double, triple, or quadruple trouble can occur. When so much risk is present, the odds turn more and more against you, and something is bound to give. One problem leads to and compounds the next: school expulsion creates tension at home; legal and juvenile justice problems create less opportunity for attention to the underlying causes of problem behaviors, and so forth.
As a teen is dislocated from developmentally important, indeed vital, social institutions, he/she is further disconnected from mainstream life. In these situations the teen has fewer opportunities to develop needed competencies and more opportunities for affiliation with deviant peers. An insidious pessimism can overtake teens as well as parents. Failure in a treatment program (and the treatment program's failure to help them), failure in school, and failure in and by families creates a powerful spiral of pain, pessimism, and doom.
It is this progression that we seek to decelerate and eventually reroute. To that end, therapists are taught not only about the risk and protective factors (how to block or facilitate them) but also what we could call the "physics" of a situation-the relationship between cascading problems and terrible life outcomes. This "interaction effect," the negative synergy that can exist between problem areas, can saturate the lives of those who enter treatment.
Much of the initial work involves addressing the teen's or family's emotional reactions to the circumstances. Our treatments are very practical and focus on family management strategies including monitoring and building skills for developing new kinds of family relationships. The initial work often involves a frank appraisal and airing of the despondency, pain, frustration, anger, embarrassment, and despair that is present.
Parallel Dynamics
Of the many parallel dynamics that a therapist is trying to manage, I would like to stress three that I feel are deserving of primary attention. These are important because therapists who are unaccustomed to working with adolescents may not be sure where to start and may experience the turmoil associated with adolescent life and development as a therapeutic obstacle rather than as a therapeutic window of opportunity.
The Quality of the Therapeutic Alliance In establishing a therapeutic alliance, it is critical to find a stance that is neither too authoritarian (like a police officer or probation officer), nor too "pal-sy" (as in, "treat me like your friend", or, "I belong to your world").Instead, the therapist must negotiate a middle ground that will allow for appropriate advocacy. It is important to be a visible and practical advocate in the teen's life; by that I mean:
Working with juvenile justice, going to court with the adolescent, standing in front of the judge and talking about how the treatment is progressing;
Working directly with the school district to find the most appropriate setting;
Sitting down with the parent(s) and the adolescent to begin to engender therapeutic dialogue;
Visiting the teen in his/her environment. Understanding something about where this young person hangs out, where he/she lives, and the people with whom he/she associates. Or, helping the teen comply with his/her urinalysis regimen.
The trust and reliability that is established through this type of advocacy--this type of "being there" for and with the adolescent--is one that will not prove to be as transient or capricious as that of the "friend" or as problematic and contentious as that of the "probation officer."
Establishing the therapeutic alliance sets the stage to engage the adolescent in a way that will be more conducive to exploring change and changing.
Windows on the Life of the AdolescentA key to effective therapy is to know which windows are open. In the above case study there are many open windows, or active issues that need attention. Some of these windows open to the outside world of the adolescent (i.e., her academic problems, her legal involvement, and her peer group).Other windows open into the inside world of the adolescent. For example, one might consider her relationship with her mother or boyfriend. However, the core issue here is her self-identity--who she is, what she wants, who she wants to be. Obviously, the existential distinction between inside and outside is blurred. Nevertheless, it is important that the therapist see the windows already open as well as those the teen opens as she moves through therapeutic change and not force windows open at inopportune moments because it is a therapist's prerogative or agenda.
Engage the Adolescent - Find creative ways to meaningfully engage the adolescent. This means going where they go and understanding what makes sense to them.Another way of looking at this is the advent of play therapy for younger children. Play therapy was developed in an effort to engage children meaningfully in therapy. By the same token--and because we know that working with adolescents is not the same as working with adults--we must find ways to engage the adolescent in the therapeutic process. This is critical because of the adolescent's extrusion from supportive relationships and environments and entry into precarious relationships and dangerous settings.Although this can be a challenge for therapists, it remains a critical ingredient to the therapeutic alliance.So, in our case above: What are her interests? Where does she hang out? What healthy activities does she enjoy? At the same time, use the windows that are available to allow the therapeutic alliance to take on depth and breadth in concert with the complexity of the adolescent's life.Now, this brings us back to the issue of the therapist who feels "intimidated" by the prospect of treating adolescent substance abuse. Even in the case noted above, knowing where to start can be intimidating.Looking at a straight line, I can determine where it begins and ends. However, if I am looking at a circle, it is difficult to say for certain where it begins and where it ends. In the latter case, the therapist must look for, and start with, the windows that present themselves as opportunities to engage the adolescent in a meaningful way.Another issue to consider is the countertransference that therapists encounter when working with adolescents. The volatility of adolescent development complicated by substance abuse, social extrusion, disenfranchisement, and other problems can be quite challenging for any therapist. These issues can challenge the therapist's sense of competence. In order to manage this dynamic, therapists are called to a higher level of self-awareness and self-monitoring.
Athealth.com: How do you encourage therapists to work with parents, families, and/or guardians?
Dr. Liddle: There is no inoculation against adolescent drug use, but we now know a great deal about what puts a teenager at risk for developing drug problems and what kinds of things that can protect a teen from antisocial activities such as alcohol and drug use.
Relationships are critical in combating teenage drug use. The slogan of one of the more effective, science-based campaigns is Parents - The Anti-Drug. It captures an important message-the power of parents to influence the development of their kids throughout the teenage years. Drug use is not thought of as a moral failing but as a health, lifestyle, or mental health issue. Parents need to adopt a developmental perspective when trying to make sense of their teen's drug use.
Adolescence itself brings a new and dramatic stage of family life. Parents and teens are required to make changes in own lives and their relationships with each other. It is best if parents are proactive about the developmental challenges of this stage--particularly those that pertain to the possible use of alcohol and drugs. Parents should not be afraid to talk directly to their kids about drug use, even if the parents have had problems with drugs or alcohol themselves. The following are strategies that help parents prevent or address teen drug use:
Families matter. Realize that the parent-adolescent relationship is a critical ingredient in preventing and addressing teen drug use (even after drug use has begun).
Adopt a developmental perspective about drug use. Think about why kids do what they do. Teens say they use drugs for different reasons: relieve boredom, feel good, forget troubles, relax, take risks, ease pain, feel grown-up, demonstrate independence, belong to a particular group, look hip, etc.
Give clear no-use messages about smoking, drugs, and alcohol. Communicate your family values about this in direct and indirect ways.
Express love and concern as the basis of your expectations about no-use.
Help your teen address and deal with peer influence and pressure to use substances.
Get involved-become familiar with your teen's friends and their parents.
Talk to other parents, particularly parents of the teen's friends.
Supervise teen activities.
Encourage healthy activities. Help teens find alternatives to just hanging out. After school activities and sports protect against drug experimentation.
Increase awareness of and monitor the teen's whereabouts.
Take every opportunity to build relationships with the teen. Small talk isn't really small; it can sustain critical connections with a teenager.
Spend time with the teen. Family activities and dinners together are important.
Set a good example. Be honest about your own experiences with drugs and alcohol, but be firm in your insistence that no drug or alcohol use is allowed.
Notice the way you talk to your teen. Make your comments appropriate to the teenager's age. Resist the urge to threaten or badger. Above all, elicit and listen to what the teen has to say throughout the day and whenever you are in contact.
Seek resources and information from friends, school, church, social groups, or professionals.
Remember that even after drug use has begun, parents and families can still affect their teen's behavior and persuade them to stop using drugs.
Also remember that there are new treatments for adolescent drug problems that have been shown to be effective.
Athealth.com: Do you frequently encounter adolescents with co-occurring disorders? If so, what are the primary disorders that you see in conjunction with adolescent substance abuse?
Dr. Liddle: In fact, we do. Some studies demonstrate that up to 80% of adolescent substance abusers present with conduct disorders; over 30% present with anxiety disorders and ADHD; over 30% present with depression; and again, over 30% present with PTSD.
The main message for clinicians is that treatment of adolescent substance abuse disorders is complex. These rates of co-morbidity require that a therapist be knowledgeable about many things-drugs, depression, anxiety, trauma, family conflict, learning problems, developmental delays, and dysfunction of all sorts.
It also illustrates how difficult it is to disentangle and make sense of the clinical presentation of most teen substance abusers.
The third implication is in the area of clinical training. Many of us in the field are deeply concerned that clinicians are not being properly trained to treat adolescent substance abuse.
Athealth.com:Tell us a little about your work at the University of Miami.
Dr. Liddle: We develop and test therapies for adolescent substance abuse. Our research has determined that a comprehensive, theory-based, family-oriented treatment can be devised, manualized, and taught to clinicians.
In this sense, therapists can be equipped with progressive treatment alternatives that demonstrate efficacy in treating serious adolescent drug abuse and mental health problems. Our studies show that the effects of this treatment, called multidimensional family therapy, are durable. We have followed kids and their families for one year after treatment ends, and results show that positive changes, including decreased drug use, an increase in school grades and involvement, and changes in the family's functioning, persist a year after treatment. Obviously, longer-term follow-ups are needed. Other kinds of services may be needed to maintain these changes, but we are very encouraged by the longitudinal results of these studies.
As these treatments have become refined and their scientific basis has increased, we have moved toward testing and transporting these therapies into non-research, clinical settings. Here, we address how to apply research-based treatments in regular clinical settings--as well as how to deal with the system and provider level challenges that arise in the adoption of manualized, evidence-based therapies.
One of our more exciting ventures is my work with the states of Connecticut and Vermont to bring family-based treatment into their substance abuse delivery systems. These locales are very committed to importing evidence-based treatment that will transform the practice delivery system.
Athealth.com: From your perspective as an expert in the field of adolescent substance abuse, what are the most important recommendations you would convey to a clinician who encounters an adolescent with substance abuse issues in their practice?
Dr. Liddle: First, there is the question of whether the therapist has been prepared to work with cases of this kind. Has the therapist been trained in adolescent development and dysfunction specifics? Has the therapist been trained in family therapy? Does the therapist know how to work with multiple systems of influence, such as schools and juvenile justice systems? And fundamentally, has the therapist been trained in adolescent drug abuse treatment?
Knowing about a teen's mental health problems or knowing how to do family therapy does not say anything about a therapist's capacity to treat adolescent drug problems.
Knowing how to take a comprehensive drug history, understanding how to do integrative therapy that addresses mental health and drug abuse, learning how to work with multiple systems and forces that need to be addressed and directly targeted in the treatment of adolescent drug use--this is a tall order for most therapists. Not insurmountable, but surely a tall order.
This is where training comes in. The field has to pay more attention to, and provide practitioners with, more opportunities for ongoing, in-depth training in these research-proven therapies. In addition, there are many good clinical articles and treatment manuals for working with teens with drug and behavior problems. There are also practice guidelines, Internet sites, and, of course, research studies that tell practitioners which therapies have the best evidence of efficacy.
Second, we need to acknowledge that the foundation of treatment is the therapeutic alliance with the teen and the parent. Our studies show that a therapist can do things to facilitate or make worse a working alliance with the teen or parent. It is important that the therapist know how to convince teens and parents of the basic proposition that there can be something in the therapy for the teen, individually, and for the parent as well.
Third, a multisystemic assessment is fundamental to drug abuse treatment with adolescents. Key questions include:
What is happening in the family?
Is the parent using drugs?
What is the family environment on a daily basis?
What is the emotional temperature in the house on a day-to-day basis?
Is the teen in school and how is she or he doing there?
Does the parent have any contact with the school?
Are there learning or behavior problems at school?
What developmental competencies does the teen have and which ones are absent?
What about his or her peer relationships?
How connected is he or she to a deviant peer culture or to antisocial ideals?
Athealth.com:What do you most enjoy about your work with teens?
Dr. Liddle: I enjoy the challenge of conducting progressive, meaningful research and advancing the clinical work being done to improve outcomes for adolescents through our clinical ideas, our treatment manuals, and our data.
It really is a challenge. The stakes are high for these kids. They generally have had problems for some time, and when we pick them up, they have moved pretty far along the trajectory of life problems. Their families are fed up, the social institutions have excluded or want to punish them, and only the deviant peer underworld wants them.
Our work, strange as it may sound, has an existential level. There are "meaning of life" dimensions to our therapy-we are engaging the kid and his or her family in a quest to determine what kind of life they want, what kind of future they want to have. Will his or her future be one that is filled with heartache brought on by addiction, job failure, relationship and psychological distress or one with a job that pays a decent wage, a family life that is supportive and nurturing, and personal relationships that can be fulfilling without drug use?
That's the real fun-when it all comes together. We formulate these theories, package them in interventions, and test them using good scientific methods. Then, we take great joy in watching some of the kids and their families not only change their drug use and abuse but also their lives at the most basic levels. I feel so fortunate to be able to do this kind of work.
Athealth.com: Thank you on behalf of our community of mental health practitioners. It has been a pleasure to speak with you today.
Attention deficit hyperactivity disorder (ADHD) is a common childhood neuropsychiatric disorder affecting 3-10% of children that often remains unrecognized or "hidden" in adulthood. Although ADHD was once thought to disappear as children grew up, data suggest that one to two thirds of children with ADHD continue to have significant symptoms throughout life (Wender, Wasserstein, & Wolf, 2001). Adult prevalence estimates vary widely. Conservatively, 1-6% of adults are believed to meet formal diagnostic criteria.
The core symptoms of ADHD - hyperactivity, inattention, and impulsivity - change as the child grows older. Research suggests that hyperactivity declines with age, attentional problems remain fairly constant, and executive function problems increase in adulthood. Coexisting psychiatric conditions, learning disabilities, and social difficulties are common. The persistence of ADHD into adulthood first became apparent in the 1970's, but is only recently becoming more generally known in the adult mental health field (Wender, Wolf, and Wasserstein, 2001).
Minimal Brain Dysfunction, Hyperactivity, ADD, ADHD, and Learning Disorder: How Do They Relate?
While there is agreement that ADHD occurs in adults, the terminology and our understanding of its underlying pathology are still emerging. The names and criteria for this syndrome have changed frequently over time, reflecting shifts in prevailing thinking about key symptoms or underlying mechanisms (see Wender et al., 2001, for review). Originally designated as "minimal brain dysfunction" (MBD), the terms "hyperactivity" and/or "hyperkinesis" were used in the 1960's, "attention deficit disorder (or ADD), with or without hyperactivity" in the 1980's, and finally "attention deficit hyperactivity disorder" (or ADHD) currently. These changes in terms reflect changes in thinking away from a focus on structural brain damage (e.g., MBD) toward a focus on symptoms or behavior, such as excessive activity and inattention. The terminology is likely to continue to change as we further develop our understanding of what we have come to call "ADHD."
The shift away from the original MBD label also signaled an emerging recognition of the difference between disorders of behavior (i.e., in activity level or attention) and specific disorders of learning (i.e., learning disabilities such as dyslexia, dyscalculia or dysgraphia). These cognitive and behavioral problems often coexist, but are now believed to be based on different genetic clusters and mechanisms (Farone et al., 1993).
Symptoms of ADHD
The American Psychiatric Association (1994) recognizes three types of ADHD:
ADHD Predominantly Hyperactive Impulsive Type, characterized by motor and impulse control problems;
ADHD Predominantly Inattentive Type, problems in attention or arousal; and
ADHD Combined Type, significant problems in both areas.It is still unclear whether these subtypes reflect a common neuropathology or whether they represent distinct disorders (Faraone, Biederman & Friedman, 2000). It has also been argued that these categories, which were created primarily for children, may not apply equally for adults (Wolf & Wasserstein, 2001).Children with ADHD are often overactive, impulsive, and inattentive. In order to be diagnosed in adulthood, it is essential that some level of these core symptoms were present during childhood. Over activity generally decreases by adolescence and is often replaced by fidgetiness and/or cognitive restlessness. More recently, researchers are focusing on self-regulation (i.e., problems with executive functions), rather than attention or activity level as the main deficit in ADHD (e.g., Barkley, 1997). Associated features in both children and adults may include moodiness, poor social relationships with peers, and a variety of different learning problems. Other psychiatric conditions are often also present, clouding the picture (e.g., see Marks, Newcorn & Halpern, 2001 for review).
What are the Pertinent Adult Problems?
Substance abuse, antisocial behavior, and even criminality are among the better-known problems of some adults with ADHD (Hechtman, Weiss, & Perlman, 1984). However, these issues are hardly universal, and may be more likely in some groups of patients. Poor social skills or deficits in self-awareness are also frequent.
When unrecognized, and therefore untreated, ADHD occurs along with other psychiatric conditions, it can contribute to the failure of medication and psychotherapy. This is because the "comorbid," or coexisting, conditions are then the only focus of treatment (Ratey, Greenberg, Bemporad, & Lindem, 1992).
Problems with independent adaptive functioning are among the most common complaints of adults who have ADHD and seek therapy (Silver, 2000). For example, they may have difficulty finding and keeping jobs, trouble maintaining routine and organization, and problems with self-discipline. In contrast, behavior control issues are the more usual complaints in children with ADHD. The difference between children and adults may reflect the fact that parents, teachers, and society can provide external forms of regulation for children, but cannot fulfill that role for adults. Additionally, the tasks of adulthood generally require more self-regulation, thereby making deficits in this area more apparent.
Problems with social skills and adaptive functions can be very stressful to relationships. Adults with ADHD may thus have a greater likelihood of family violence, divorce, and multiple marriages.
Recognizing ADHD in Adults
There are two main groups of adults with ADHD: (1) those who were diagnosed as children and still have symptoms, and (2) those who were never diagnosed. The second group may be more likely to include females. When looking at childhood symptoms, it is important to consider that a highly organized home life can mitigate the expression of ADHD symptoms. Pronounced difficulties may only emerge during higher education, or even later in the work world, when environmental demands become more complex. Often there is also a strong family history of ADHD, learning disabilities, or both.
There is no definitive diagnostic test for ADHD, although standardized ADHD scales are extremely helpful in understanding current (and past) symptoms. Examining for comorbid psychiatric conditions and ruling out alternative psychiatric problems that can resemble ADHD (such as depression or anxiety disorders) is essential. The goal of assessment is to understand the individual's unique pattern of strengths and weaknesses in order to design appropriate interventions (whether medical, psychosocial, or remedial). Fear of stigma, shame, and denial can interfere with seeking help.
Treatment
As is the case for children, the best treatment involves both drug and psychosocial interventions. Among drugs, stimulant medications, such as Ritalin, are usually tried first. Individuals who do not respond to stimulants, or who have comorbid substance abuse problems or depression, may be treated with antidepressants. Generally, medications are better at addressing inattention and hyperactivity than impulsivity. Comorbid illness, if present, affects the choice of drugs.
Psychosocial treatment is also key. These interventions typically involve (1) psychotherapy addressing how the ADHD affects the person's life (relationships and functioning), and (2) education about the disorder. Technologies helpful for ADHD include structured external supports like day planners, computers, and coaching, as well as some specialized forms of cognitive remediation (see Wasserstein, Wolf & Lefever, 2001, Part V; Nadeau, 1997).
ADHD in Adult Education and Employment
Adults with ADHD often face their biggest challenges in higher education and later in the work world. Executive and planning abilities are extremely challenged in the young person with ADHD who is making the transition from the structured environments of high school and home to an unstructured life at college. Similarly, working adults need to create multiple layers of structure at work, and they must manage to integrate work demands with competing personal responsibilities. In other words, adults need to plan and execute their own internal structure, which is especially difficult for those with ADHD. Poor time management, chronic lateness, and difficulties completing paperwork and meeting deadlines are exceedingly common work-related problems of adults with ADHD.
Some students and/or employees with ADHD may be eligible for supports and/or accommodations. Students and employees who are disabled by ADHD may be covered under Section 504 of the Rehabilitation Act and the Americans with Disabilities Act in school and work settings. These laws prohibit discrimination on the basis of disability and guarantee equal access to programs and facilities. All adults with ADHD and clinicians evaluating them should become familiar with these statutes in order to evaluate their need, and eligibility, for services (Wolf, 2001).
References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.) Washington, DC: American Psychiatric Association. Barkley, R.A. (1997). ADHD and the nature of self-control. New York: Guilford.
Faraone, S.V., Biederman, J., & Friedman, D. (2000). Validity of DSM-IV subtypes of attention-deficit/hyperactivity disorder: A family study perspective. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 300-307.
Faraone, S.V., Biederman, J., Lehman, B.K., Keenan, K., Norman, D., Seidman, L.J., Kolodny, R., Kraus, I., Perrin, J., & Chen, W.J. (1993). Evidence for independent familial transmission of attention deficit hyperactivity disorder and learning disabilities: Result from a family genetic study. American Journal of Psychiatry, 150, 891-895.
Hechtman, L, Weiss, G., & Perlman, T. (1984). Hyperactives as young adults: Past and current substance abuse and antisocial behavior. American Journal of Orthopsychiatry, 54, 415-425.
Marks, D.J., Newcorn, J.H., & Halpern, J.M. (2001). Comorbidity in adults with attention deficit/hyperactivity disorder. Annals of the New York Academy of Sciences, 931, 216-238.
Nadeau, K. (1997). Adventures in Fast Forward. New York: Brunner/Mazel.
Ratey, J., Greenberg, S., Bemporad., J.R., & Lindem, K. (1992). Unrecognized attention-deficit hyperactivity disorder in adults presenting for outpatient psychotherapy. Journal of Child and Adolescent Psychopharmacology, 4, 267-275.
Silver, L. (2000). Attention deficit/hyperactivity in adult lives. Child & Adolescent Psychiatric Clinics of North America, 9, 511-523.
Wasserstein, J., Wolf, L.E., & LeFever, F. (Eds.) (2001). Attention deficit disorder: Brain mechanisms and life outcomes. New York: The New York Academy of Sciences.
Wender, P.H., Wolf, L.E., & Wasserstein, J. (2001). Adults with ADHD. An overview. Annals of the New York Academy of Sciences, 931, 1-16.
Wolf, L.E. (2001). College students with ADHD and other hidden disabilities. Annals of the New York Academy of Sciences, 931, 385-395.
Wolf, L.E. & Wasserstein, J. (2001). Adult ADHD: concluding thoughts. Annals of the New York Academy of Sciences, 931, 396-408.
Source: ERIC Digest
ERIC Clearinghouse on Elementary and Early Childhood Education
December 2001
Authors: Jeanette Wasserstein, Adella Wasserstein, Lorraine E. Wolf
Page last modified or reviewed by athealth on January 29, 2014
Anyone at any age can have a drinking problem. Great Uncle George may have always been a heavy drinker - his family may find that as he gets older the problem gets worse. Grandma Betty may have been a teetotaler all her life, just taking a drink "to help her get to sleep" after her husband died--now she needs a couple of drinks to get through the day. These are common stories. Drinking problems in older people are often neglected by families, doctors, and the public.
Physical Effects of Alcohol
Alcohol slows down brain activity. Because alcohol affects alertness, judgment, coordination, and reaction time--drinking increases the risk of falls and accidents. Some research has shown that it takes less alcohol to affect older people than younger ones. Over time, heavy drinking permanently damages the brain and central nervous system, as well as the liver, heart, kidneys, and stomach. Alcohol's effects can make some medical problems hard to diagnose. For example, alcohol causes changes in the heart and blood vessels that can dull pain that might be a warning sign of a heart attack. It also can cause forgetfulness and confusion, which can seem like Alzheimer's disease.
Mixing Drugs
Alcohol, itself a drug, is often harmful if mixed with prescription or over-the-counter medicines. This is a special problem for people over 65, because they are often heavy users of prescription medicines and over-the-counter drugs.
Mixing alcohol with other drugs such as tranquilizers, sleeping pills, pain killers, and antihistamines can be very dangerous, even fatal. For example, aspirin can cause bleeding in the stomach and intestines; when it is combined with alcohol, the risk of bleeding is much higher.
As people age, the body's ability to absorb and dispose of alcohol and other drugs changes. Anyone who drinks should check with a doctor or pharmacist about possible problems with drug and alcohol interactions.
Who Becomes a Problem Drinker?
There are two types of problem drinkers--chronic and situational. Chronic abusers have been heavy drinkers for many years. Although many chronic abusers die by middle age, some live well into old age. Most older problem drinkers are in this group.
Other people may develop a drinking problem late in life, often because of "situational" factors such as retirement, lowered income, failing health, loneliness, or the death of friends or loved ones. At first, having a drink brings relief, but later it can turn into a problem.
How to Recognize a Drinking Problem
Not everyone who drinks regularly has a drinking problem. You might want to get help if you:
Drink to calm your nerves, forget your worries, or reduce depression
Lose interest in food
Gulp your drinks down fast
Lie to try to hide your drinking habits
Drink alone more often
Hurt yourself, or someone else, while drinking
Were drunk more than three or four times last year
Need more alcohol to get "high"
Feel irritable, resentful, or unreasonable when you are not drinking
Have medical, social, or financial problems caused by drinking
Getting Help
Older problem drinkers have a very good chance for recovery because once they decide to seek help, they usually stay with treatment programs. You can begin getting help by calling your family doctor or clergy member.
Your local health department or social services agencies can also help.
Resources
Alcoholics Anonymous (AA) is a voluntary fellowship of alcoholics who help themselves and each other get and stay sober. Check the phone book for a local chapter or write the national office at: 475 Riverside Drive, 11th Floor, New York, NY 10115; or call (212) 870-3400.
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) provides information on alcohol abuse and alcoholism. Contact:
Agoraphobia is the fear of being in a situation where one might experience anxiety or panic and where escape from the situation might be difficult or embarrassing. People with agoraphobia may feel anxious about such things as loss of bladder or bowel control or choking on food in the presence of others. They also might feel anxious about being home alone, leaving home, or being in a crowded place, such as on public transportation or in an elevator, where it might be difficult or embarrassing to find a way out. To avoid the anxiety associated with these situations they refrain from putting themselves into such situations. The severity of agoraphobia is quite variable. Some people with agoraphobia live essentially normal lives as they avoid potentially anxiety-provoking situations. However, in severe cases of agoraphobia, people are homebound. These people work very hard to avoid any and all situations that might cause them to become anxious.
What characteristics are associated with agoraphobia?
Two major characteristics are associated with agoraphobia:
People develop anxiety when thinking about being in a situation out of their comfort zone. They fear feeling trapped in a situation where they judge it would be difficult or embarrassing for them to leave the situation.
People avoid those situations which bring them anxiety or panic. It is the fear of the anxiety that leads to the agoraphobia. Does agoraphobia affect males, females or both?
About twice as many women than men report that they experience agoraphobia. Frequently, people report that the onset of their agoraphobia followed a stressful or traumatic event in their lives.
At what age does agoraphobia begin?
The most common age for agoraphobia to begin is when a person is in his/her mid to late 20's.
How often is agoraphobia seen in our society?
Less than one percent (1%) of the population of the United States is thought to have agoraphobia.
How is agoraphobia diagnosed?
People suffering from agoraphobia sometimes fear that they are "losing" their mind or "going crazy" because of their fears and anxiety. Consequently, they might seek advice from a mental health professional.
Also, it is common for a friend or family member to notice that another person is reluctant to leave home without a companion. For instance, a spouse might notice that his/her mate finds reasons not to leave home. In these cases, the friend or family member often urges the agoraphobic to seek professional help.
A mental health professional arrives at the diagnosis of agoraphobia by taking a careful personal history from the client/patient. There are no laboratory tests required to confirm a diagnosis of agoraphobia nor are there any physical conditions that must be met. However, it is very important for the therapist not to overlook a physical illness that might mimic or contribute to a psychological disorder. If there is any doubt about a medical problem, the mental health professional should refer to a physician who will perform a complete physical examination and request any necessary laboratory tests.
How is agoraphobia treated?
There are three main types of treatment for agoraphobia:
Therapy
Medications
Combination of therapy and medications Behavior and cognitive therapy are the treatments of choice for agoraphobia. If panic accompanies the agoraphobia, people are sometimes referred for a brief course of a prescribed medication, such as an antianxiety medication.
What happens to someone with agoraphobia?
Severe cases of agoraphobia can be very difficult to treat and can last many years.
What can people do if they need help?
If you, a friend, or a family member would like more information and you have a therapist or a physician, please discuss your concerns with that person.
Page last modified or reviewed by athealth on January 29, 2014
