Understanding and Supporting Children and Teens with ADHD

Editor’s Note: This text is a transcript of the course Understanding and Supporting Children and Teens with ADHD, presented by Heather Schmitt, PhD, LP.

Learning Outcomes

After this course, participants will be able to:

• Define ADHD, including common symptoms and features
• Describe brain-based developmental differences between children with ADHD and their neurotypical peers
• •dentify strengths and support areas in children and teens with ADHD
• Describe practical, evidence-based strategies that promote self-regulation and executive functioning skills

Introduction

Regarding the limitations and risks of this topic, I'll be talking about this from a neurodevelopmental perspective. Although it's based on the latest science and research, other approaches to treatment or perspectives can enhance progress or understanding that aren't incorporated in this specific course. Also, this course, as titled, will focus on child and teen populations. I will not be addressing young adults or adulthood.  Additionally, my training and expertise as a licensed psychologist have been developed in the context of clinical settings and a background in school psychology.  I'm not a certified neuropsychologist. I don't conduct hospital-based work.  Lastly, this course will not be a deep dive into the topic; rather, it is intended to provide a nice breadth of knowledge.

Abbreviations

Some abbreviations that will be used throughout the course are listed below.

• ADHD: Attention-deficit/hyperactivity disorder
• ADHD-I: ADHD, predominately inattentive presentation
• ADHD-HI: ADHD, predominately hyperactive-impulsive presentation
• ADHD-C: ADHD, combined presentation
• EF: Executive functioning

ADHD Defined

I want to define ADHD and provide some background information from a diagnostic standpoint so that you have an accurate understanding of what it is.  Under the umbrella of ADHD, there are different ADHD presentations.  In other words, diagnostic labels are used to describe ADHD, and they are based on two different types of clusters of symptoms.  There is the inattentive cluster (ADHD-PI) which was previously known as ADD, there is the hyperactive-impulsive cluster of symptoms (ADHD-PHI), and there is the combination of both (ADHD-C).

Previously and pretty extensively, these were called types of ADHD. Very recently, there's been a change to that wording to call them presentations. The change was made to emphasize that at different times an individual with ADHD may have more or less of one of those dimensions present. It's not a distinct or separate type of ADHD. 

ADHD-PI

The first presentation is the primarily inattentive type. This tends to be the child or teenager that might be described as a daydreamer or a "scatterbrained" individual. They have a lot of difficulties maintaining attention and listening, following through with different instructions and tasks, and keeping tasks and physical materials organized. They are easily distracted by things going on around them.  They might be forgetful and lose or misplace items. They have difficulty with attention to detail, and these children might avoid or dislike tasks that require sustained mental effort, which tends to be a lot of academic-focused work.

The highest rate of inattentive presentation is among adolescents. That means that of all of the individuals preschool through adolescents diagnosed with ADHD, the highest rate is among adolescents. Think of it as the expectations of younger children versus those of older children as they mature. It kind of matches development. Difficulties with these skills will be noticed more in adolescents, and these types of skills can become even more critical to success and independence.

ADHD-HI

The next presentation is the hyperactive impulsive predominant presentation. This is the child who is often "driven by a motor." They might be fidgety or restless, have difficulty staying in their seat, or prefer to stand up to do things. They might run or climb around excessively. They have difficulty doing things quietly, even if it's playing by themselves or speaking when it's a quiet environment. The child may talk excessively and may impulsively blurt things out rather than waiting to share what they have to say. They interrupt others and have difficulty waiting their turn.

For this presentation, the highest rate is among the preschool population. As children age towards school age and adolescence, that percentage is lower. You'll see why when I talk more about brain development. 

ADHD-C

Third is ADHD-C, which is the combined presentation. With all the symptoms mentioned above, these children show a fair number of both of those clusters of symptoms. The highest rate of ADHD-C tends to be among school-aged children. Developmentally, it makes sense that difficulties with those skills become more apparent versus observing a preschooler or an adolescent who might have ADHD.

According to the DSM-V, there are other factors to consider for a child to be diagnosed with ADHD. First, it has to emerge in childhood and be inconsistent with what we would expect for their age in terms of their ability to sit still, pay attention, remember things, etc.  Typically we expect to see this earlier in childhood; at least has to be by age 12.

Also, the number of symptoms that must be present differs by age. Up to age 16, six of the previously mentioned symptoms must be present to meet the criteria for that presentation. If they're 17 years old or older, then five of those symptoms must be present. Think of each of those presentation clusters as a group of symptoms. If a child has six or more symptoms in the hyperactive-impulsive cluster, then they meet the criteria.  Do they have six or more inattentive symptoms? Then they meet the criteria for ADHD-PI. If it's both, then they would be combined.

The DSM-V also has a specifier for the amount of impairment or how severe those symptoms are. A child may present with symptoms in two clusters, but it may minimally impact them at home and school. An ADHD-Combined presentation might also be mild. But if a child presents with eight inattentive symptoms and, two of them are hyperactive-impulsive, but there is considerable impairment across all settings (social, academic, home, extracurricular), then that child would be diagnosed with ADHD, primarily inattentive, and specified as severe.

The ADHD Brain

Next, I want to describe the ADHD brain. This is important for understanding what ADHD looks like and why.

Genetic Factors

ADHD is highly hereditary. Genes are the biggest contributor to ADHD. It's truly one of the most genetically-influenced disorders. It exceeds anxiety, depression, and many other disorders that we know are heritable. It is rivaled, maybe, by bipolar disorder and autism, which are also fairly similar in hereditariness.

We know about genetic factors because of different family studies. For example, research has shown that there is an elevated risk of ADHD among biological relatives of children that have been diagnosed. Depending on the study, 10-35% of biological relatives are at risk of having ADHD when a child does. If a parent has ADHD, there's a risk of up to 57% of children presenting with it. All of that speaks to the high hereditary factor.  We also know through adoption studies that there is no increased risk of ADHD. This further supports the role of genetics and biology. When discussing genetics, we typically don't attribute ADHD to chromosomal abnormalities, differences, or extra chromosomes. For example, we don't see Fragile X or Down's syndrome as causing ADHD. However, children with those rare genetic abnormalities may be at increased risk for developing ADHD or presenting with those symptoms.

Neurological Factors

Many neurological factors related to ADHD can be tied to brain structures and how they function. MRI studies and other brain imaging have shown differences in the volume or the size of select brain regions and reduced blood flow to these particular regions. There is typically a  significantly smaller right frontal region of the frontal lobe, which is kind of the "boss" of the brain.

Areas like the basal ganglia, corpus callosum, and anterior cingulate cortex are impacted regarding executive functioning skills as well as other higher-order skills that I will discuss shortly. Basically, structure and functional differences emerge when an individual has ADHD.

We also know there are many neural networks. One network seems to relate to hyperactive symptoms or motor systems in the brain being highly active. Another network underlies more of the attentional symptoms related to planning-related executive functioning skills. A third network mediates or impacts impulse control, and a fourth neural network explains self-regulation difficulties which is a type of gateway to the emotional brain or when the limbic system gets highly activated. All of these networks are known to influence the presentation of ADHD symptoms.

The last neurological factor related to ADHD is neurotransmitter deficiencies. This hasn't been as established as the other factors, but there is clearly a role for dopamine and norepinephrine levels. We know this because individuals with ADHD often respond positively to stimulant medications that address neurotransmitters distributed in the brain's neural networks described above.

Environmental Factors

Several environmental factors can cause ADHD. This does not include psychosocial factors like teaching or child-rearing approaches. There is no current credible evidence that ADHD exists purely because of social factors. With environmental factors, I'm referring to how things in the environment might interact with the genetic factors that a child is predisposed to. Those types of factors, particularly environmental biological factors, can impact the development of ADHD.  For example, exposure to toxins (e.g., smoking, alcohol) during pregnancy and fetal brain development has shown some relation to ADHD causality. Also, low birth weight, any associated minor brain hemorrhaging, and environmental toxins, such as postnatal lead exposure in the first two to three years of life, can cause ADHD.

Role of Medication

Lastly is the role of medication. There's a growing amount of research suggesting that treating ADHD with medication may actually result in more normalized brain development. Basically, there is a neuroprotective effect, meaning comparative medications are never used if there's an effective dosage of a stimulant used to increase brain activity in underactive neural networks. We see continued increases in the functioning of those brain regions with that medication use. So, functioning can be closer to typical as those medications are used.

Brain Development: ADHD versus Neurotypical

An important way to think about and understand the neurodevelopmental basis of ADHD is by comparing brain development between individuals with ADHD and their neurotypical peers. An imaging study by Shaw and colleagues (2007) compared how the brain matures in ADHD versus neurotypical peers. Maturation in these studies is defined as the cerebral cortex thickening. When the outer layer of the brain, that neural tissue (i.e. gray matter), is at its peak thickness, that is considered maturation. Once the brain reaches that point, it starts thinning, which is that "pruning stage" you may have heard of in brain development. The purpose of that pruning stage is to make the brain more efficient post-puberty during the teenage years. So scientists want to know when does the brain reaches maturation, meaning it's heading into that pruning stage and becoming more efficient. When scientists looked closely at the ADHD brain compared to normal development, they found that the ADHD brain follows the same pattern of maturation, but the rate is quite delayed in children with ADHD.

For youth with ADHD, the researchers found, on average, a three-year delay in different brain regions compared to their age-matched peers. Specifically, they found a delay in the maturation of the prefrontal cortex, which is largely responsible for executive functioning skills and often affected by individuals with ADHD. 

Interestingly, the motor cortex matured faster in the youth with ADHD. Researchers speculate that this mismatch might account for some of the restlessness and fidgety symptoms that are common in children with ADHD. The thought is that the brain is maturing at a different rate, and there is a big gap in the difference at that maturation stage, a three-year difference when a child has ADHD versus a child who doesn't have ADHD.

Common Myths

It is important to understand common myths of ADHD so that we can debunk them when they come up in different situations. 

Myth 1: ADHD doesn't exist

The first myth is that ADHD doesn't exist. The child's just lazy, and they're unmotivated. I hear or see these labels a lot. At the same time, some youth who struggle with ADHD have passions and strengths outside of the classroom. I always encourage families and other professionals to reframe this idea of a child being unmotivated. It is more likely that they have a skill deficit. It's not that they won't do a certain task as a matter of principle or because they're lazy, it's because they can't do it.  In terms of ADHD not existing, plenty of research validates that ADHD is a neurological lifelong disorder.

Myth 2: Someone with ADHD cannot pay attention and/or sit still

The idea that someone with ADHD cannot pay attention or sit still is false. There are times when they can sit still and/or pay attention.  ADHD affects people in non-preferred, difficult tasks or demanding environments. For example, attentional difficulties occur when the child's expected to sit for a long period of time and there are a lot of demands on their attention, versus sitting still while passively watching a movie about a topic they're very interested in. This can be really frustrating about ADHD and how it presents for certain people. It's consistently inconsistent sometimes. A child might be able to do something in one situation or in one setting, but they struggle the next time. 

Myth 3: Someone with ADHD cannot complete their work, get good grades/test scores

ADHD is not related to intelligence or IQ. I'm sure you've also seen this often: "When a child with ADHD can pay attention, they're quite smart." It's not about being unintelligent. There are many gifted individuals who also have ADHD.

Myth 4: ADHD can be caused by the environment - like parenting approaches or TV/video games

As I said before, no credible evidence indicates that social environment alone can lead to a child developing ADHD. We know because of the sibling and twin studies I referenced earlier. After accounting for those genetic factors, there's little variation that can be explained by other things. Social factors like parenting approaches or video game use certainly impact functioning and possibly outcomes for a child, but they do not alone single-handedly create ADHD.

Myth 5: Medication can cure ADHD or become addictive

Another myth is that medication can cure ADHD or, problematically, ADHD meds become addictive. First, there are no medications that cure ADHD. The medications are used to effectively treat the symptoms and address the brain-based differences so the person can manage tasks temporarily.

Regarding addiction, there is no credible evidence that using stimulant medications to treat ADHD in childhood leads to an addictive disorder in adolescents or adulthood. That said, are there individuals who misuse stimulant medications? Of course. But when those medications are used as prescribed, in a therapeutic dose, there's no evidence of addiction. In fact, there's evidence of quite the opposite. With appropriate use, medications can be a protective factor.  In other words, it decreases the likelihood that someone will misuse substances to self-medicate or unhealthily cope with difficulties that arise.

Myth 6: Children eventually outgrow ADHD

The last myth is that children eventually outgrow ADHD. Although there are many ADHD symptoms that improve over time, most adults diagnosed with ADHD at a young age have some difficulties that persist. Remember, since the normal pattern of maturation is simply delayed, that can explain why many youth with ADHD are first described as immature. Their brain development is likely similar to a child that is younger at that point in time. But as the child ages, that maturation starts to catch up to their peers a bit. It may seem like they outgrew it, but what is really happening is that gap or difference in maturation and brain development starts to close as they age.  By age 15 or 20, those functioning differences or discrepancies become less noticeable or milder in presentation than their peers.  But they aren't actually outgrowing it 100%.

Identifying Strengths and Support Areas

It's important to identify strengths and support areas for any child, particularly the child with ADHD because it's highly likely that he or she has received much negative feedback about their areas of difficulty. Think about some behaviors that can be disruptive or challenging, particularly for hyperactive impulsive children. Researchers have found that children with ADHD are exposed to much more criticism and correction than their neurotypical peers. They're often viewed and described as not living up to their potential. They are labeled the class clown, disruptive, the troublemaker, and lazy.  In fact, this is so significant that experts in ADHD have estimated that by age 12, children with ADHD have received 20,000 more negative messages from their parents, teachers, or their peers than children without ADHD. That is a significant number.

Think about the classroom.  It's probably realistic to guess that a child with ADHD might get a negative correction or a comment from a teacher every 20 minutes or three times an hour, "Sit down in your seat." "Go back and focus on your work." "Stop talking to your friend." "Get started." A student is in class for six hours a day, 180 days a year.  That's more than 3,200 corrections or criticism statements that are directed at that child. They're not ill-intended, but that's a lot of negative feedback. That's not including parent comments, coach comments, corrections, or comments from their peers. The point is that these youth are at risk of developing a damaged view of themselves and a negative view of school. So, it becomes very important to incorporate strengths into a child's everyday life. 

Find out what the child is passionate about and good at.  It is important to actively embrace their strengths and what they care about outside of school. Incorporate those things, and give them attention and value. I can't emphasize this to parents enough. Children with ADHD are just as smart as other children. They're often creative, outgoing, intuitive, artistic, and artistic. They have the ability to become wildly successful adults. Let's ensure we're doing justice to those attributes.

Another important aspect when working with a child with ADHD is to recognize that they work harder than most of their peers because the world is not built for their brain. A child with ADHD tends to struggle a lot in that traditional academic setting where you sit still, you listen, you pay attention, you do worksheets, et cetera.

They spend so much time, about six hours a day, doing tasks or activities that can be excruciatingly difficult and not super-rewarding for them.  It's actually a strength that they are managing to get through the academic world. A good analogy is it's like being on an NBA team, but you're the shortest guy. You made it to the NBA, and you're obviously a skilled basketball player, but you probably had to work a lot harder than someone who was tall. You might have to compensate and come up with skills like a fancy hook shot or a drop back three in order to play at the level of your taller teammates.

Another way to support those with ADHD is to meet them where they are. We should not be making expectations based on what a same-aged peer can do or what a neurotypical sibling did at that age.  Often, ADHD challenges aren't about a knowledge deficit; rather, the child just can't perform. So think about how can we get this child one step closer to performing while meeting them where they are.

We also want to regularly recognize growth, especially when they receive criticism and corrections. Find ways to give positive feedback and praise even those small steps towards success. Encourage teachers, parents, coaches, et cetera to be extra mindful and do it in a systematic way. For every one criticism or correction you're giving (it's okay to do that), be sure to give them at least three to five positive reinforcement comments. Provide some praise that's deserved for how hard they're working.  This might require looking outside the school arena. Balance that need of, "We're going to focus on you getting your homework done and succeeding academically," with what the do outside of the school. Where can we give them their praise?

Another aspect related to embracing strengths and understanding is psychoeducation. Often, the child misunderstands what ADHD is, and there can be a lot of stigmas.  For example, I recently started meeting with a middle schooler who had previously been in therapy to target difficulties with organization and impulsiveness. He's taking medication but didn't understand why he was taking it.  He also didn't know he had ADHD. So I spent some time explaining what ADHD is and isn't so that he could better understand his brain and why certain things are hard. As we discussed that, he explained that students at his school use ADHD to mean stupid or dumb. So, it was basically a derogatory statement.   And he honestly believed that's what it meant. When he learned he had ADHD, he thought that meant he was stupid or dumb. So that education piece is so important.

Lastly, we must practice flexibility and creativity.  Think about those passions and strengths the child has and how you can change what you are doing or how you can structure tasks to help the student succeed.  For example, I frequently give breaks for focus time and work time and therapy. Instead of doing a fun activity at the end of the session, I do 15 minutes of focus and work and then take a short break to do a fun or physical activity. I am also more intentional with incorporating movement around the room.  I'm finding ways to embrace that child's activeness and incorporate it as a strength in the work that they need to do in therapy. 

Some additional examples of strengths are: 

• Can do many things at once
• Ambitious
• Have many different ideas
• Can tell when others are hurting
• Strong emotions
• Determined, won’t easily give up
• Social
• Passionate about things interested in
• Love telling others their opinion
• High energy
• Love to move around
• Adventurous
• Kind to people
• Imaginative, creative
• Great with animals
• Good at knowing history
• Play video games well
• Amazing builder
• Very artistic

The idea is to reframe our thinking.  It might be easy to say the child is too distracted. However, we could say the child can do many things at once. Rather than saying a child is overly sensitive, maybe we say they can really tell when others are hurting. Rather than saying a child is too talkative, we can say that they love telling other people about their opinion, which is a strength. 

Support: Self-Regulation & Executive Functions Skills

Although there's no single agreed-upon definition of what executive functioning (EF) is, many agree that it's often a key deficit area for children with ADHD. All of these different processes are housed in the prefrontal cortex of the brain, where that slower maturation occurs.

These abilities center around the concept of self-regulation. Self-regulation is any action an individual directs at themselves to result in a change in their behavior to achieve a certain outcome or goal in the future. All of these different skills, organizing and starting, staying focused, keeping our attention there, managing distractors, and keeping our emotions in check, are working together to help us toward that goal.  They involve regulating ourselves. Regulating our behavior, regulating our emotions, and regulating our brain or our cognitions.

Here is an example. I have a New Year's resolution to eat healthier snacks with less sugar. I walk into a coffee shop and immediately see this beautiful display of pastries and cookies. The situation might tempt me to buy something that will ruin my resolution. To deal with that, while I'm waiting for my latte, I focus on my phone instead of the cookies. Or maybe I'll walk to the far side of the shop so I don't see them as much. I might even visualize how good I will feel eating something healthier. All of this involves self-regulation.

Many executive functioning skills are at work in this scenario.  I have to be aware that I'm in this dilemma and that I'm having this urge. I have to inhibit that emotional response or thought of, "Oh my gosh, that cookie would go perfectly with my latte, and I want it." I have to redirect my attention away from that display case. I have to look at my phone and manage my attention accordingly. I need to talk to myself and visualize the future and what outcomes might be most helpful. That's a lot of working memory. I am also brainstorming different ways to cope with my urge and thinking of different things I could do. I need to organize myself and problem-solve.  

To identify self-regulation or executive functioning skills systematically, I recommend information-gathering with parents, teachers, and other people who work with the student. There are also some normed questionnaires, such as the BRIEF-2, the CEFI, and the BDEFS-CA, that can give a sense of impairment or show where the biggest challenges are. They all range from age 5-18.

There are also some informal checklists, such as the Executive Skills Self-Assessment (in Hansen, 2013), that targets executive functioning skills in teenagers. It has a nice, brief self-report inventory.  It asks different questions about how true something is for that teenager, then groups those questions into specific skills that may need to be addressed. 

Evidence-Based Strategies

Overview

Regarding ADHD treatment, medication is the primary recommendation for children, which is often not what people want to hear. I'm definitely not a pill-pusher by any means. I'm a psychologist, and I do therapy. But because of those brain-based differences, medication can be such a game-changer in addressing that biological piece. It can be a critical part of treatment, but it's not the end all be all. Research consistently shows medication can provide some benefit.  Behavioral approaches and targeting skills can provide some benefit as well. But if medication is combined with behavior therapy, that is where we see the most benefit for most individuals with ADHD.

When it comes to behavioral supports, there are two categories. One category focuses on the environment, and the other focuses on the individual. Environmental supports are behavioral therapy approaches that typically involve parents or the school. We are structuring the environment so that the child can be successful because of how their brain develops and how it works.

With the individual-focused category, there is evidence for some of those CBT approaches to treat ADHD-related challenges. Again, it's most helpful to think about ADHD difficulties as a performance deficit, not a knowledge or a skill deficit. Often a child with ADHD can understand what they need to do or what something means, but they struggle to perform it. They just can't do it in the moment because their attention is hard to regulate; they're easily distracted and can't inhibit their impulses. This is key for intervening effectively and appropriately and understanding what's difficult, when, and why.

Consider looking at different inconsistencies to determine where there's a skill deficit versus a performance deficit. For example, maybe a child can organize his backpack really well but has a disastrous desk. Is it because he doesn't know what being organized looks like or what it means? Probably not. He can probably describe a clean desk as having pens in a pouch and papers stacked up neatly. The student has the knowledge but can't put it into action. Maybe the classroom only does desk cleanings once a month, so he's left to his own devices to implement strategies. At the end of the day, he can't perform it even though he understands it. But he can keep his backpack organized. Why is that? It might be because the child's parent works with him daily and reminds him where things belong. They've color-coded and labeled everything and put a system in place to help him keep up with it. So, the environment becomes key to providing social supports where those problems exist.

Strategy 1: Instruction/Task Delivery

The first environmental strategy is how you present instructions or tasks to the child. There are hallmark symptoms of difficulty paying attention to details and keeping attention. Our instructions need to be simple and to the point. The fewer words, the better.  If it's too lengthy or wordy, we will lose the child's attention. 

The visual piece is also key. By having something visual, it takes what would load onto the frontal lobe, or working memory, and puts it in the real world.  

How we present commands is also important to consider.  It can impact how likely the child is to listen and understand. Here are some examples of what NOT to do:

• "Let's" commands  - These are unclear, tell the child that you will help and that the two of you are doing the task together. Instead, make those commands very clear in terms of what's expected, "You need to pick up your plate" or "Please grab that toy." Not, "Let's do it."
• Vague commands - "Stop it." "Be good." That's short and sweet but very unclear for the child. Instead, remove any need to think or pay more attention and say exactly what you want, "Place your hands in your lap" or "Walk slowly with me." Make it specific.
• Chain commands - If you tell a child with ADHD, "All right, go upstairs, take a shower, brush your teeth, grab that laundry and throw it down to me, then put on your pajamas and start to read before bed," they might get as far as the stairs.  These tasks must be broken down into at least one or two steps.
• Buried commands - Again, thinking about their attention, we don't want to bury our instructions.  For example, we don't want to say, "It's going to rain today. The forecast is calling for a lot of storms, so please put on your coat, or you might get wet and track water into the house, and it will be a mess." It's okay to have long conversations or to elaborate, but when giving an instruction or an expectation, get straight to the point. Give one small detail, such as, "Put on your coat; we're leaving."

Also, check for remembering. It can be helpful to have the child repeat the direction back to you so you know they were attending and listening. However, just because they can repeat it back to you doesn't mean they can do it. Be sure to follow some of the other strategies that were discussed previously. 

Another strategy that can help youth with ADHD initiate the next task, shift attention, manage emotions, and be flexible is to give warnings for transitions versus shifting focus abruptly. For example, if we play a card game in a therapy session, instead of suddenly saying,  "Okay, time to stop. We have to get back to practicing our coping skills," I'm going to give a reminder at the start of the session, "Remember we have a short break, and then we get back to work." As we approach the transition, say, "Remember, three more minutes until 45." The transition may not go perfectly, but it does make it easier for the child the more we can warn about those transitions.

Strategy 2: Externalize Information

I mentioned this earlier, but externalizing information and having many visual cues are great ways for the child to access the steps or the details they need without depending on their working memory. This is great for homework time, routines, different rules or expectations at school, tasks that must be completed, notes with reminders, or anything that involves a certain amount of time.

We can also use a timer as a visual.  ADHD can be thought of as a "nearsightedness" with time or time blindness. It can be thought of as a time disability.  Children with ADHD often don't use that internal clock to manage their behavior and to organize. We want to incorporate learning or experiencing how long tasks take or how much time has passed. When it comes to time and timers, we can practice that with them.  For example, "Let's see how long it takes to walk to the mailbox and back. We'll time it every day and learn how many minutes that takes." Being able to estimate time helps with learning to plan and complete tasks efficiently and effectively.

Visual schedules are also great. It can be very helpful for children with ADHD to have proportional blocks of time. If I'm showing that first, we have school and then we have soccer practice, but we know that school is six hours and soccer practice is one hour, we want to make activities visually proportional to the amount of time spent doing them versus the same size.

Visuals should be appealing.  We may need to revamp them or use new ones more often for children with ADHD than other children.  We want to capture their attention in the moment versus blending in the background. So think about changing photos or letting a child pick a new visual or a new font so that it continues to be exciting and relevant for them.

Strategy 3: Swift, Frequent, & Potent

This next strategy is related to the time disability concept.  We want to decrease the time between when something happens, how we respond to it, and the outcome. We want it to be swift. We want to act quickly and often with children with ADHD. 

Regarding immediacy, we want the correction or praise to be given right after the behavior occurs.  Delays of any kind make it less effective for children with ADHD. This applies to giving rewards or punishment. If the behavior happened 10 minutes ago, it may well have been last year. The connection is not there. 

Frequency is the idea of giving more praise for tasks that seem simple or that children without ADHD can do without much effort.  Also, a child with ADHD will have the urge or impulse to do something else, especially if what's expected is unrewarding or tedious. So think about frequency and give positive feedback throughout a task, not just at the end of it.

Finally, there is potency. I mentioned earlier that we compete with the environment for the child's attention and ability to regulate. Anything that's implemented has to be prominent and stand out. Reinforcers have to be more powerful. The same is true with punishment. We need to think about how we can increase the strength of a reward. We might have to change that formula, especially when considering potency. Children with ADHD habituate much quicker to rewards. Many people will say, "Oh, that's not really working anymore." However, we can keep the system and the rewards but change the potency. Think about changing it and making it more potent or interesting for them. 

Strategy 4: Resource Replenishment

The frontal lobe, which houses executive functioning abilities, requires a lot of mental resources and effort within the brain. It's like water in a reservoir or in a glass. When we're using our executive functioning skills, that resource is exhaustible, there's only so much in the cup, and it's going to drain.  Different tasks are going to drain that cup quicker.  If it's something more difficult, lengthy, or boring, that water will drain faster. For children with ADHD, that cup is much smaller because of their developmental delay, and it often empties quicker.

This is where replenishing is key. We can replenish with routine physical exercise and movement. We don't want schools using recess as a punishment and removing it. That is a refuel time. We can replenish during executive-functioning loaded tasks. When a lot of sustained effort or persistence is required, or something is long, these children need breaks during that task. They can be brief, but they'll need them during and after, with rewards along the way.

Strategy 5: Facilitate “Social Economy”

Another key strategy is what I call "social economy." We want to promote positive social opportunities and successes for these children. They can exhibit poor social behavior or be viewed negatively by peers because of their difficulties. For example, there are studies in which a peer is told, "Oh, this kid has ADHD," when that is not true (the experimenters are just saying that), and they proceed to play and interact with that child differently and more negatively than if the peer was not told the child had ADHD. So, it's important that peers see this child with ADHD in a positive way. 

The way we can do that for them is to plan and structure opportunities for success.  At home, have structured play dates where you're setting limits on activities that they can or can't do. You're making it more formal versus just running around and playing. Maybe you're doing a science experiment or a craft. These children need that one-on-one at first to succeed with a peer, and then you can slowly add more children.

They're probably going to need more adult check-ins or facilitating appropriate behaviors. Social interactions and opportunities might have to be shorter at first. We want to ensure they are going well and smoothly; then, we can increase the length of time or the number of people.

Also, keep in mind what the goal is. Is it simply for them to have a friend over? Then, focus on that and not correct a bunch of other behaviors. Ways this can look at school is giving the child special jobs that their peers see them doing well and getting a lot of positive attention. It can be earning privileges for the class. For example, maybe one of their rewards is the class gets a bonus recess. That can facilitate a positive economy for that student. And remember, it is common for children to misunderstand or misuse the ADHD label. We have to make sure peers are educated on neurodiversity so that there is acceptance and receptiveness to those differences.

Strategy 6: Social Behavior Skill Training

Research suggests that social skill training can be very effective. But a key piece is promoting generalizing. How do we do that? We give direct instruction on a social skill, rehearse it, coach the child directly, and then give feedback. Social skills are like making conversations or sharing how we follow along with rules during a game, or take turns.  Working on that in a session is helpful, but we must focus on generalization. Oftentimes, there is this train-and-hope philosophy of the child learning the correct thing to do, and now they will go do it.  But they can't enact it well because they're not self-monitoring in that moment. They can't regulate their impulses, so they need an adult or a parent to coach them and promote their successful use of it. Plus, those adults are more likely to be in naturally occurring situations. We can do social skills training to generalize by coordinating across settings and with different adults to reinforce the skill.

Here is a sample practice sheet that I might have a child take outside of a session. Maybe we're focusing on back-and-forth conversations, so we practice building a conversation together, like building a tower. So I will have them practice it. I will have them notice situations, and the parents will help them monitor them and become more aware.

Strategy 7: Organizational Skills Training

Difficulty with organizational skills becomes prominent around third grade, and then it persists. Third grade has a curriculum where students are expected to be much more independent. So early intervention, particularly before middle school, becomes key because we know as students advance into middle school, there are many more demands on organizational skills. They have numerous classes or homework and less adult supervision.

Similar to social skills training, there's a lot of direct instruction in organizational skills. You're rehearsing and coaching the child in the moment. Tracking tasks is a good example. How do I record my assignments? How do I manage materials or time? What are some ways to organize my room or my binder? 

We can teach them to track how long tasks take or plan what to do first, second, third.  We can teach them how to break tasks into steps and monitor progress. We are working on these organizational skills in a clear, direct way. There are numerous great curriculums available for organizational skills training.

It will be important to incorporate rewards. Learning organizational skills is hard, so using the system or starting to learn steps will be important when focusing on this with a child with ADHD. And as always, we're scaffolding. So the adults are present and engaged while helping the child build and maintain that system.

A few more examples include a child who is having difficulty turning in their homework. I want to think through all of the steps involved in that and what skills we want the child to develop.  Is it writing it down in their notebook or bringing home the right materials? Another example here is a teenager who is working on organizing their room. We want to think about the steps it takes to clean and organize that space. 

All of these examples are based on some organizational skill training workbooks or materials that are included in the resources.  

Summary

My goal with this course was to describe what ADHD is, including common symptoms. Explain brain-based differences between children with ADHD and their neurotypical peers, including common myths. Identify strength areas and support areas. And discuss how to implement practical, evidence-based strategies that promote self-regulation by adapting the environment and working with the child directly.

Questions and Answers

Do you think ADHD in adolescence is overdiagnosed?

That's a hard question because I think right now is a time when we're becoming more aware of it. But I will add that often, ADHD can be misidentified. So just because a child is distracted doesn't mean they have ADHD. Many kids with anxiety, for example, are highly distracted. They're thinking about things that could go wrong or trying to monitor themselves, and they're thinking about it and worrying. So we know anxiety can affect executive functioning and attention.  So, I think it can definitely be misdiagnosed if we just assume a child who's inattentive must have ADHD. That's where getting a comprehensive evaluation, a comprehensive neuropsych evaluation or psychoeducational eval is such an important piece before we just jump to conclusions.

Does positive or negative reinforcement work for children with ADHD, or is ADHD something a young child, like a second grader, wouldn't be able to control?

It's a balance. We don't want to expect a behavior that the child cannot, but we do want to promote a behavior for success. So a lot of that brings me back to this expectation I have for this second grader.  Are my expectations based on another second grader who doesn't have ADHD, and I'm setting the bar too high?  If so, that will be impossible for the child with ADHD to reach because of those neurodevelopmental differences. Or am I thinking about something the child needs to do to succeed and steps we can reinforce and promote to make that happen? So, it varies on the individual case, but, often, we need to ensure that our expectations are realistic. We also have to ask if the environment makes it possible. I think that becomes a huge question. I'm expecting this kid to regulate their emotions, but if I have an environment that's overwhelming their executive functioning skills, they won't be able to regulate that emotion.

Do you have recommendations regarding school or homework skills like organizing spaces?

I do. There is an organizational workbook listed in the references. I would highly recommend looking for anything that's described as organizational skills training. That is very evidence-based.  I'm not promoting certain material, but this is a really great curriculum that talks about different trainings and skills and helps to break them down into steps.

How do you teach neurodiversity in the classroom?

There are a lot of great children's books, especially for younger students, that are wonderful at illustrating what strength lies in diversity and what it means, and what it doesn't mean. They are written in a way that's accessible for children too. Often in the classroom, I recommend that teachers include them in their curriculum. Have that be the story time, have that be the topic, without singling out a specific child if the child doesn't want to share that about themselves. These stories are a great way to create an environment of understanding and acceptance. Videos that explain what ADHD is are great resources too.  There's a really good one on YouTube that is cartoon-style, and it's a child explaining to another child that they have ADHD, here's what it is, and here's what it means. 

References

American Psychiatric Association (APA). (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

Barkley, R. A. (2022). Improving clinical diagnosis using the executive functioning—self-regulation theory of ADHD. The ADHD Report, 30(1), 1-9.

Barkley, R. A. (Ed.). (2018). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (Fourth edition). Guilford Publications.

Connaughton, M., Whelan, R., O'Hanlon, E., & McGrath, J. (2022). White matter microstructure in children and adolescents with ADHD. NeuroImage: Clinical, 102957.

Drechsler, R., Brem, S., Brandeis, D., Grünblatt, E., Berger, G., & Walitza, S. (2020). ADHD: Current concepts and treatments in children and adolescents. Neuropediatrics, 51(05), 315-335.

Gallagher, R., Abikoff, H.B., & Spira, E.G. (2014) Organizational skills training for children with ADHD. The Guilford Press.

Hansen, S. (2013). The executive functioning workbook for teens. Instant Help Books.

Miller, K. (2018). Thriving with ADHD: workbook for kids. Althea Press.

Shaw, P., Eckstrand, K., Sharp, W., Blumenthal, J., Lerch, J. P., Greenstein, D. E. E. A., ... & Rapoport, J. L. (2007). Attention-deficit/hyperactivity disorder is characterized by a delay in cortical maturation. Proceedings of the national academy of sciences, 104(49), 19649-19654.

Tourjman, V., Louis-Nascan, G., Ahmed, G., DuBow, A., Côté, H., Daly, N., & Sadek, J. (2022). Psychosocial interventions for attention deficit/hyperactivity disorder: A systematic review and meta-analysis by the CADDRA guidelines work GROUP. Brain sciences, 12(8), 1023.