Continuing Medical Education

Daily life with a child or teen who has ADHD demands a tremendous amount of energy and planning from their parents.¹ Children with ADHD generally engage their parents the moment they wake up. This means that parents desperately need not only your expertise in choosing the right treatment and dosage but especially your informed advice.

All the infosheets cited in this article are linked to a specific pictogram (see the Toolbox). They were developed by the Clinique Focus team and are available online in the Tips section at www.liniquefocus.com and www.ttentiondeficit-info.com. You can use them in your clinical practice. You can also refer parents to them so that they develop the automatic reflex of visiting these sites to find tools that can help their child or teen with ADHD. The Tips section will be continually updated and enhanced as new clinical practices and findings on ADHD emerge. Readers of the online version of Le Médecin du Québec can access the info­sheets mentioned in this article by clicking on the different icons in the Toolbox section.

As you may have seen in other articles, some disorders sometimes co-occur with ADHD. It is vital to know about them because they complicate the clinical presentation, reduce the effectiveness and impact of parents’ interventions, and negatively affect their relationship with their child, while increasing their stress.² Oppositional fefiant disorder (ODD) (Toolbox Icon 1) not only commonly co-occurs with ADHD but is also sometimes mistaken for it.³

Parents who have to all too often intervene with their child with ADHD may even end up believing that it is normal for their child to be argumentative or to refuse to listen to them. Psycho education is key in this case. It can help parents not only understand what ADHD is but also recognize it and differentiate it from potentially co-occurring disorders, such as ODD. Parents also need tools to be able to effectively intervene with their child who has both ADHD and ODD (Toolbox Icon 2). That is why it is important for physicians to keep in mind the list of concomitant conditions, especially oppositional defiant disorder, during their assessment to determine if the child or teen has ADHD. Apart from parents’ exhaustion tied to the demands of caring for their child, their relationship with their child is often tense and contentious. These parents need effective strategies to help their child with ADHD.

The next section proposes practical, easy-to-use tips that you can share with these parents.

What Do You Suggest, Doc?

Previous articles have mentioned the high risk of ADHD being transmitted from one generation to the next (see the articles “ADHD: Truths and Misconceptions” and “In-Office Assessment of ADHD: Step-by-Step Approach”). The parents who come to consult you are therefore highly likely to have ADHD themselves, whether or not they have been diagnosed. They may have a hard time paying attention to the information that you are trying to give them. It may also be difficult for them to retain the information, organize it and apply the strategies proposed. They often need coaching and assistance to encourage them to keep applying the good habits they have newly acquired.

Some of the tips (Toolbox Icon 3) are essential for attracting the attention of children with ADHD (see Info Box). Setting routines is a crucial way to help them. Routines provide children with structure and help them get organized.⁴ Routines for children with ADHD are like daytime planners for adults. To be fully effective, routines must be posted on a wall and visible both to the child and to the parents. Besides making tasks easier to see, this method also helps them learn the routines and increase their self-sufficiency. Different routines can be developed (e.g., morning, after-school, homework, bedtime).

The morning routine (Toolbox Icon 4) may concern wake-up time and activities such as getting washed and dressed, taking care of teeth and hair, tidying up the bedroom, taking a medication at a set time, eating breakfast, and managing free time. Leaving for school (Table 1) (Toolbox Icon 5) should be a separate routine posted in the front hallway. This poster should contain the pictograms showing the things that the child should gather together to be able to leave home in an organized way, reducing the risks of conflicts. The behaviours expected of the child during the trip to school must be formulated in clear, positive statements (e.g., You attach your seatbelt. You keep calm in the car). These must of course be repeated in a calm voice each morning. Parents must act as role models that the children can rely on to develop self-talk, which can help them better manage their emotions (Toolbox Icon 6).

School is a large part of the lives of children and teens with ADHD. School staff also need practical tips to guide students along the path through the school system. Two infosheets (Toolbox Icon 7A and Icon 7B) are designed as tools for school staff. Parents can give them to their child’s teacher, given that the family-school partnership is key to children’s academic success.⁵

After-school time is without question a critical time of day because children may be more tired and agitated and may have difficulty attending to tasks. It is important to plan this time well (Toolbox Icon 8). After-school time can be made easier with a visual aid in the front hall reminding children to put away their coats, shoes, lunchboxes and schoolbags.

Homework time (Toolbox Icon 9) can severely try parents’ patience and skills because both children and parents are tired at the end of the day. Good planning is important at this time so that children with ADHD can continue to muster their attention skills. Fitting in a transitional down time, taking into account the arrival time, snack time and dinnertime, is a virtual balancing act. Ideally, homework should always be scheduled at the same time, just before or just after dinner. A visual aid makes all of this easier for parents and children.

Mealtimes are often ripe for the outburst of conflicts and all sorts of incidents (e.g., spilling milk, slouching at the table, interrupting conversations). Life rules are therefore a must. These must be few in number (no more than three) and must be formulated in clear and positive terms (Toolbox Icon 10). Parents must first decide on them and then present them to the family so that everyone agrees to follow them. These rules are relatively universal: politeness, respect and honesty (Table 2). There is no need to link these rules to the loss of privileges because they simply involve asking children to say please and thank you, to excuse themselves after doing something impolite, to tell the truth and to admit to their mistakes. With oppositional children, daily rules can be linked to warnings and the loss of certain privileges (Toolbox Icon 11). A specific number of warnings (like three strikes in baseball) (Toolbox Icon 12) are necessary, and each daily rule disobeyed must be associated in advance with the loss of a privilege. Doing so can help parents avoid giving unreasonable consequences, being inconsistent, feeling guilty and lacking consistency in managing the loss of privileges.

Since you know Nathan’s family well, along with the father’s impulsivity and the mother’s tendency to buy peace, you take the opportunity to provide some psychoeducational information, which highlights the importance of helping Nathan better manage his behaviour by gaining greater control over his emotions through self-talk, or mental instructions to keep calm or to calm down.

Bedtime is often challenging (Toolbox Icon 13). A routine is useful because children can visually follow the different steps leading to bedtime (Table 3). Difficulty falling asleep is also one of parents’ regular complaints and concerns regarding their child with ADHD. Limiting video games in the evening reduces the over-excitement that is so commonly seen. To help children get to sleep, parents should dim light sources, including all screens (computer, television, tablet). The light emitted by these devices resembles daylight and naturally triggers the secretion of melatonin, which delays sleep onset.⁶ Conversely, exposing children to daylight in the morning (opening up the curtains, turning on the lights) helps them wake up and start the day off right (see the article “Pills and ADHD: Why, For Whom and How?”).

How to Help Children/Teens Better Cope with Their ADHD

Since the relationship between parents and children with ADHD can unfortunately be tense and fragile,⁷ it is important to recognize the child’s qualities and to value the quality time spent with them. Interventions must be guided by the importance of restoring and strengthening the attachment bond. It is important to praise the child’s successes because they are unfortunately often overshadowed by the many difficulties they experience on a daily basis.

Since these children have difficulty applying effective concentration techniques, parents can give them examples and propose exercises to improve their attention (Toolbox Icon 14). Pictograms are also very useful. A picture of eyeglasses illustrates the importance of looking people in the eye. An “ear” indicates the need to listen. A “stop sign” means “think before you act.” A “parrot” reminds them to repeat instructions in their heads. A “camera” encourages them to make a mental image that will help them better retain information. These pictograms can be posted in strategic areas (e.g., kitchen, bedroom, school desk).

Who Can Help?

Nathan is being oppositional toward his parents. He is argumentative, tries to negotiate everything and has temper tantrums when he does not get what he wants. His parents have applied your practical tips and strategies for managing oppositional defiant disorder. However, at times they still feel helpless in dealing with their son’s opposition. Referring Nathan to a psychologist will better equip them to help their son cope with his ADHD.

Parent coaching is aimed at developing greater awareness and recognition of the different conditions co-occurring with ADHD. It also promotes parental empowerment and consistency. It restores parents’ feeling of self-efficacy and enhances their skills.⁸ Apart from oppositional defiant disorder, psychologists are consulted for other reasons, such as anxiety, emotional management, social skills, parent-child relationships, and school performance. Multidisciplinary work is a must in treating ADHD. Referring parents to a psychologist, a special educator, an occupational therapist or a support group (see the supplement on page xx for the definition of these terms) is a key reflex action. Whether through parent coaching or psychotherapy, psychologists help parents, children and adolescents cope with ADHD.

Like other children, Nathan is getting older and becoming more mature. He is learning to function better with his ADHD. He will need to keep using the strategies that work for him and his family. Nathan will also need to develop n ew strategies to deal with the challenges awaiting him. But what does the future hold for him?⁹ //

French Version: Received: January 27, 2013 Accepted: March 21, 2013
Translated in English: September, 2014

Dr. Johanne Perreault and Dr. Katia Sirois have no conflicts of interest to declare. Dr. Michel Sirois was a speaker for Janssen Pharmaceuticals in 2012–2013 and an advisory committee member for Shire and Janssen Pharmaceuticals in 2012.

references

• 1. Tamm L, Holden GW, Nakonezny PA et al. Metaparenting: associations with parenting stress, child-rearing practices, and retention in parents of children at risk for ADHD. Atten Defic Hyperact Disord 2012; 4(1): 1-10.
• 2. Hinojosa MS, Hinojosa R, Fernandez-Baca D et al. Parental strain, parental health, and community characteristics among children with attention deficit-hyperactivity disorder. Acad Pediatr 2012; 12(6): 502–8.
• 3. Biederman J, Faraone SV, Milberger S et al. Is childhood oppositional defiant disorder a precursor to adolescent conduct disorder? Findings from a four-year follow-up study of children with ADHD. J Am Acad Child Adolesc Psychiatry 1996; 35(9): 1193-204.
• 4. Forgeot B. Intérêt de la remédiation cognitive dans la prise en charge du trouble de déficit de l’attention. Université Paris 8 – DESS psychologie clinique; 2004.
• 5. Letarte MJ, Nadeau MF, Lessard J et al. Le rôle de la collaboration famille-école dans la réussite scolaire d’enfants ayant un trouble de déficit de l’attention/hyperactivité. Service social 2011; 57(2): 20-36.
• 6. Chellappa SL, Steiner R, Blattner P et al. Non-Visual Effects of Light on Melatonin, Alertness and Cognitive Performance: Can Blue-Enriched Light Keep Us Alert? PLoS One 2011; 6(1): e16429.
• 7. Chronis AM, Chacko A, Fabiano GA et al. Enhancements to the standard behavioural parent training paradigm for families of children with ADHD: review and future directions. Clin Child Fam Psychol Rev 2004; 7(1): 1-27.
• 8. Hauth-Charlier S, Clément C. Programmes de formation aux habiletés parentales pour les parents d’enfants avec un TDA/H : considérations pratiques et implications cliniques. Pratiques psychologiques 2009; doi: 10.1016/j.prps.2009.01.001.