It's no leap of brilliance to state that kids require consistent limit setting. And yet, we all struggle in different ways as to how to go about implementing it. Our kids resist, often quite resourcefully. We want them to be happy, and we want to be happy ourselves, so we relent, perhaps because just at that moment we're too tired and rundown to rally. Maybe sometimes our neighbors set different standards and we worry they'll judge us, or that our kids will.
Further confusing the picture, some books and websites advocate for fewer limits. They encourage us to anticipate each need of our kids ahead of time, or to treat a two year old how we would another adult. Not only does this burn out parents, it flies in the face of what we know about cognitive development.
We absolutely want to minimize our children's distress and maximize their well-being, treating them with loving-kindness and respect. The overriding goal is a warm and supportive environment that balances clear rules with openness to discussion as children get older. Yet the bottom line is that kids require clear limits to grow, to develop resilience and frustration tolerance, to understand that boundaries are a part of life, and to learn how to interact with the world. From our position as well-meaning adults with the benefit of some life experience, we must strive to keep track of what's best for our children over the long haul.
Limits are a large part of why kids need parents. If children knew how to behave in public, eat a balanced diet, pick clothes that make sense for the weather, treat their friends well, manage their time, handle responsibilities, and make healthy lifestyle choices from the start, we could get them an apartment when they go to kindergarten and leave them to it.
In reality our kids rely on us to help mediate between them and the world, to protect and teach them as they grow. During this phase in life we do everything we can to care for them, knowing that whenever they leave our home, life will present challenges. In anticipating those times our role is to cultivate skills that help in managing the ups and downs of life with autonomy such as emotional resilience, cognitive flexibility and patience.
We know from decades of research that experience shapes brain development. Parenting techniques, lifestyles, and preschool programs that emphasize core social-emotional skills increase the likelihood children thrive both socially and academically. Moving down this path to greater independence depends on our ability to teach boundaries now and to allow kids to encounter, and manage, occasional frustration along the way. Common-sense, old-fashioned parenting sayings - life isn't always fair, you can't have one just because your friend Joseph has one - may appear to be going out of vogue but are often what science suggests children need to thrive.
Would we deprive a child who stepped on a nail a required tetanus shot because they are screaming a blue streak? Of course not. A short-run battle, but long-term prevention. Reality is, children can get incredibly upset over almost anything. And one common flash point is when they encounter a limit: It's bedtime now. You can go out to play when your homework is done. You can't push your sister, go take a time out. These standards sometimes lead to an upset child or a tantrum, yet that reaction does not mean our choice was not healthy or valuable, or that we've let our child down.
It also doesn't suggest we are being 'mean' to our kids. They may feel, and they won't hesitate to let us know, we are 'depriving' them of the newest video game or funkiest shoes and wrecking their lives. It's not fair that the kid next door has a later bedtime. Still, the most skillful option we have is maintaining our open-minded objectivity, taking stock of the situation, making a choice, and then standing by our judgment of what is appropriate. We're rarely doing a child a favor by overindulging them or failing to guide their behavior.
Clear limit setting is therefore inherent to mindful parenting, paying full attention to our family with compassion for everyone. When we truly pay attention to our children - recognizing their temperament and abilities, knowing their likes and dislikes, and responding to their development through the years - we discover an evolving necessity for rules and guidance. At two years, at ten and into their teens the details will change, yet consistently upheld limits remain one of the most essential, loving parenting skills kids require from us.
So what gets in the way of our limit setting? Our own exhaustion, for one. Parents who immerse themselves in rearing children without any acknowledgement of their own needs are at risk for burn out - which often leads to inconsistently managed limits, and potentially a general state of over-indulgence. Yes, you can have the whole box of cookies for all I care as long as you let me finish this phone call and go play.
An important aspect of setting limits for kids is therefore understanding our own. Good parenting recognizes the necessity for time to take care of ourselves. Setting aside a few minutes a day to meditate or hang out with a friend or schedule a date night with our spouse can go a long way towards establishing consistency with our kids. It can be the refresher you need to hold your ground in the face of resistance.
Children are more likely to grow to be settled, happy adults if they develop 'secure attachment' to others. From a psychological perspective, attachment refers to a strong, unwavering emotional bond between a caretaker and a child; it should not imply a child who never experiences frustration or disappointment. Secure attachment does not demand that every momentary desire be met and every problem solved for a child by an adult. Unconditional love, confidence your parents care for you and will protect you, is in no way antithetical to setting limits. Limit setting teaches self-regulation and builds resilience; secure attachment alone isn't enough.
Maintaining clear rules and guidelines also does not mean becoming rigidly strict or draconian. Guide behavior through reward and praise whenever possible. Have fun, make jokes. Offer reasonable options - you can do your homework now or in half an hour (but not at ten o'clock tonight). Pay attention to your choices, and stick to only as many limits as required. Recognize your role in the equation, and remember to take care of yourself. And then, remaining open to discussion and flexible about change when appropriate, establish clear boundaries you adhere to the remainder of the time. This is mindful, caring parenting.
Up Next: Part Two: Exploring Your Own Limit (setting): Mindfully Balancing Attachment and Limits At Home
The statement "he's fifteen and should take responsibility for his school work" doesn't always hold water. It doesn't have anything to do with "should." Either he can or he can't keep track of it. You can "should" him and yourself and his school all you want, but the only real solution creates an appropriate support system in the short term, and teaches required skills over time.
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James is a fourteen year old who looks like any other kid his age, slouched in his chair and mumbling one word answers to questions about his life. The only difference is James has ADHD. Despite all the help he is getting from his teachers and elsewhere, James continues to do poorly in school. His parents aren't happy with his performance, and he doesn't appear to care about academics at all.
James takes medication daily and everyone agrees he now has little difficulty focusing. He's stopped talking out of turn and his grades have improved, but not enough. His test scores are all over the place, from 55 to 95 and then back down to 75, reflecting what he actually knows only inconsistently. He rarely gets his homework in on time, if at all. All his teachers have offered to stay after school to help him keep up, but he just leaves at the end of the day. There are complaints that he seems unmotivated, disengaged, or lazy. What's gone wrong?
High schools approach academic support for children differently than primary and middle schools do at lower grade levels. Kids, both with and without ADHD, are expected to take responsibility for their education. They are supposed to manage their schedules on their own, handle intense homework loads (and hand everything in on time), and coordinate time around all their after-school activities. The pressure can be intense, but most kids without ADHD sort it out, make a plan, and thrive.
Yet even without ADHD, teens don't have the brain of an adult. The average teen is still developing their executive function abilities - the mental capacity to regulate emotions and behaviors, organize, plan, manage time, and a host of other related tasks. A burst of neurological growth starts in adolescence and progresses through the mid to late twenties. In one way, adolescence is about surviving impulsive decisions and scattered thinking and then to become an older, wiser grown up - as reflected by these changes within the brain.
As parents we allow teens to grow and become individuals, hand them responsibilities and let them fail at times, but we also must keep an eye on the bigger picture. Executive function relates to concepts such as 'wisdom' and 'maturity,' and does not plateau in its development until near age thirty. This cognitive progression leads to a decrease in risky behaviors and a better ability to monitor our behavior and to plan for the future. Any individual may have more or fewer of these skills, but from a neurological perspective the expectation that most teens will make rational, long-sighted choices does not make sense. (It's one reason to insist kids wait until they are older to consider something like a tattoo.)
While most teens struggle with executive function, those with ADHD fall even further behind. Their capacity to organize and plan lags by several years. Because of their neurology they struggle with staying on task, transitioning from activities, keeping track of lists, handing things in, and managing their time. The ability to connect immediate behaviors (I don't feel like going for extra help today) to future consequences may not exist yet.
This attribution to 'effort' or 'motivation' is the fundamental flaw undermining many academic plans for teens with ADHD. These issues have little, if anything, to do with motivation. Even with lots of effort if a teen does not possess age-appropriate executive functioning the essentials for school success are not going to be found without the involvement of responsible, caring adults.
Visiting a teacher for after-school support requires the ability to remember the possibility exists, to keep track of time, to put aside the current activity, and to maintain attention from point A to point B. It requires recognizing a need for help, making a plan, and then sticking with the plan over the long haul. As teens fall further behind the stress increases and at the same time more and more school work accumulates, further taxing their limited executive function skills. For someone with ADHD, it may be too much to ask.
Someone who looks and acts like a teen-ager may have the executive function and self-monitoring skills of a child years younger. A fifteen year old with frontal lobes going on ten has the capacity of a ten year old to manage his workload and responsibilities. Establishing a school plan for a ninth grader with ADHD is a set up for failure when relying entirely on that teenager for planning and communication. Superficially, it might not seem to make any sense that high school teachers must communicate with parents about school work, but for certain students that intervention is a vital part of short-term planning. Parents stay in the loop, aware within days if work falls behind.
The statement "he's fifteen and should take responsibility for his school work" doesn't always hold water. It doesn't have anything to do with "should." Either he can or he can't keep track of it. You can "should" him and yourself and his school all you want, but the only real solution creates an appropriate support system in the short term, and teaches required skills over time.
Teens require an opportunity to collaborate, to feel like they are individuals and are being heard, and they may rebel when too much is dictated about their lives. If a particular teen can handle their schoolwork, you can run with it, let him take responsibility and prosper. If he can't stay on top of things because of ADHD and executive function, then he can't.
What helped James get back on track? Offering controlled options, such as posing the question, "Which teacher would you like to work with?" instead of "Would you like to work with a teacher?" Moving some organizational help outside of regular school hours, with a tutor, because he didn't want to feel different during the school day. Making an end-of-day resource room part of his schedule, instead of voluntary. Giving direct instruction in organizational skills, instead of an open-ended study hall. His parents and teachers established a safety net that kept James on target, with a goal of handing him back responsibilities at a rate he could manage on his own.
Some children do lose motivation because they have been struggling for so many years. However, as motivation typically builds from success and a sense of mastery, the initial step to improved motivation is putting the right plan in place. The long term goal of independence doesn't change, but without the support network kids become overwhelmed.
As always, the bottom line is a compassionate and objective view of someone's real skills. We must seek a clear understanding of our teens' capacity to manage their lives, instead of leaving them to flail when they fall behind. We may have an entirely different picture of what a teenager 'should' or 'shouldn't' be doing in life, but reality may be different. Just because a student has entered high school doesn't mean they are ready to thrive on their own.
In the 1950s smoking was everywhere.There was a cultural assumption that it was cool to smoke and everyone had the right. People smoked sitting next to you on planes or restaurants, and in the office. Advertisements were plastered on billboards around the world, and actors smoked throughout both television shows and movies. Even doctors touted their favorite cigarette brand in magazines. And then, slowly, we realized that smoking has significant health risks. It became a well-defined public health concern and steps were taken to protect our children from the hazards of cigarettes and second-hand smoke.
Today our society seems more attuned to potential risks in our environment. A few years ago, preliminary evidence uncovered a possible danger from a certain plastic found in bottles. Parents leapt into action and because of that pressure companies stopped using it. Studies about potential risks of pesticides and food dyes make headlines for weeks and weeks after their release.
Imagine what would happen if a substance in our water supply was linked to obesity, poor academic performance, aggressive behavior, and early sexuality in teens. It sounds horrifying, impossible we would expose our children to such risk. There would be a public outcry. Yet in reality, that 'substance' already exists. Unregulated media time for children and teens has been linked to all these problems and more. A generation from now, what are we going to think about the excesses we are now allowing?
It's the Message and the Messenger
In the same way as smoking once was, video screens today are inescapable. Televisions and computers sit throughout the house, in living rooms and kitchens and bedrooms - even in those of young children. They are in our cars, and media is accessible on our laptops and phones. We encounter more screens at the gas pump, barber, in airports, doctor waiting rooms, in line at the supermarket, and everywhere we turn. They continue to multiply, seemingly exponentially, without any real attention paid to possible implications. We are living on autopilot, individually and as a society, allowing it to happen to us instead of giving fair consideration to what is beneficial, what is harmful, and what could be simply inappropriate for many younger viewers.
Children don't fully understand the difference between reality and the pretend situations they see on TV and the computer screen. Younger children don't see the difference at all. Older children may be able to label something 'pretend' and still not fully grasp the subtle (and not so subtle) implications of anything from a violent police show or video game to reality television in general. Many teens lack the judgment to separate fact from fiction, recklessly mimicking inappropriate behaviors they watch on screen without recognizing the potential implications in their own, very real, lives.
This inability to understand media fully has always been true for kids, but the medium has changed immensely. The level and type of violence seen in cartoons and shows, the sexual content, and the direct sales pitches aimed at kids are nothing like a generation ago. The images are far more graphic and realistic, the marketing more targeted and inappropriate.
Studies have shown that as media hours increase, so does the risk of everything noted above - from obesity to sexuality and experimentation with alcohol to behavioral issues. They have shown that exposure to violence and aggression numbs children to them. They have suggested that increased media hours may even correlate with academic and attention problems.
Who do you want to sway your child's choices, your family and friends or a corporation? Marketing influences behavior or it wouldn't exist, and billions of dollars are spent on it. Children are particularly susceptible to media influences and companies take advantage. Advertisers have known for years a basic fact - seeing a product promoted multiple times makes it more likely a child will prefer it to another (perhaps healthier) option. Businesses today have become as skilled at defining what motivates young children as child psychologists, if not more so. (We may be starting to catch up - just this week regulations on marketing to kids were recommended by the government.)
I don't mean to say that we should get rid of our televisions, smart phones, or computers. Technology is part of the fabric of society and provides many benefits and plenty of healthy entertainment. But for some parents, there seems to be an assumption that media trends are either untamable or completely benign. Instead of waiting a generation to regret the effects of unfiltered media, we can start by making long-sighted, rational choices that fit our individual families' needs.
Smoking and media is not a perfect analogy. Smoking is absolutely bad for anyone in any quantity and media is not. Media is entertaining and at times informative, and helps us organize and find information. So perhaps it would be more precise to say this: Media is to healthy child development what dessert is to healthy eating.
We don't expect children to regulate their own dessert intake. Most kids, if allowed to make their own choices, would elect to eat more junk food than is best for their health. Instead of letting that happen, we guide them and set boundaries that over time teach self-care. Some children need more supervision, some children need less - but all of them need guidance. In the same way, it is imperative that instead of letting anything just happen to us, parents make intentional choices about the role of media in our lives.
Action Steps for Media Control
Here are some starting points for any parent to consider.
• Decide how much media time makes sense for your household. Choose an amount, set a timer if needed, and establish clear limits. Consider scheduling weekly media-free days for everyone in your family. Establish healthy family habits early by keeping the television off during meals, and turning it off when no one is directly watching. The American Academy of Pediatrics recommends no more than one to two hours of screen time a day total; younger kids need far less. Other healthy alternatives, especially as homework loads increase, are to allow none at all during the week or none until homework is completed.
• Set clear limits about how much time is appropriate each day, or each week. Few kids are going to be strong arbiters about what content makes sense, or when to stop. Children's brains are not wired to self-monitor; that skill doesn't fully develop until they are in their 20s. Some children prove themselves more capable of self-regulation around media than others, but letting children find their own way is rarely the best answer.
• Know what is appropriate and what is not. Confirm that media content is appropriate for your child. The ratings systems are industry created, so check with a neutral source like Common Sense Media (n.b. I am on the editorial board for this organization). Watch a few minutes of the games your kids are playing and the shows they are watching. You may be shocked at how graphic they have become. Choose the shows your children will watch, never letting them channel surf. Many Internet service providers, computer companies, and cable companies offer software that filter media based on parental choices; install it early.
• Limit exposure to commercials and advertising. While marketing is now woven into plot lines and harder to skip, to minimize advertising influence emphasize DVDs and use digital recording to skip commercials.
• Tell your kids what you're doing and why. Since we can't avoid all marketing, take the time to discuss its influence with children while it is happening. Make a game of it, if you like. Make sure they understand at an early age that advertising aims to change how we think and behave.
• Keep screen time to the public parts of the house. Don't place computers or TVs in your kids' bedrooms. For portable media like laptops and phones, move it downstairs at bedtime.
• Monitor what media has been replacing in your child's life. We know of distinct benefits for cognitive development found through free play, sharing family meals and unstructured social time with adults and with peers. There is a large difference between 'active' entertainment, which involves creativity, imagination, and socializing, versus 'passive' entertainment, which (even when it is exciting) involves a computer leading and offering options. Educational software may prove to have benefits one day, but we are only in the beginning stages of figuring out what works and what doesn't for computer-based education.
• Observe your family lifestyle. Are your children learning about unstructured, creative play? Are they discovering ways to entertain themselves, and to honor down time? Do they have the ability to maintain linear thoughts, dig deeper into activities, and problem-solve rather than skim along the surface? However entrenched or inevitable some habits may seem, other choices are always possible. At any point in time, you have the ability to pause, reassess, and take a step onto a new path.
Media Time and ADHD
When children have behavioral or developmental issues in particular, media time often allows adults to get things done. But while all children are susceptible to marketing tactics and influenced by inappropriate content, those with conditions like attention deficit/hyperactivity disorder (ADHD) are particularly vulnerable. The list of child development concerns related to media exposure roughly parallels the risks of having ADHD; both media and ADHD increase the risk of obesity, aggression, academic problems, early smoking, and early sexuality. The combination may increase the likelihood of issues developing down the road.
Excessive, unregulated media time is even more risky for kids with ADHD than the rest of thepopulation, and they will need even more parental guidance. ADHD is a delay in social judgment and self-regulation, and children with ADHD are therefore less able than others to govern their own choices around media. Some psychologists believe people with ADHD are at risk for an actual "internet addiction". That doesn't mean you should never use the television or computer to distract your kids while you make dinner or pay bills. It does mean staying aware and monitoring both the amount of time and content of media along the way.
Research Highlights
In the United States, children average between three and six hours a day of television and computer time. Research shows that increased television hours correlate with many adverse behaviors in children:
• Children who watch more television are more likely to be obese. Television may replace healthier activities, and encourages the consumption of advertised foods and drinks.
• Children may learn to act aggressively through television viewing. They may become desensitized to the reality of violence, and may model situations where violence solves problems.
• Teens (and preteens) who watch more television are more likely to be sexually active early. Even in shows geared to 2-11 year olds, in a recent study 29% of conversation was shown to involve sex and dating.
• A 2008 study linked the risk of teen pregnancy with sexual content within shows they watched.
• Attitudes about drinking are learned from television. Children report wanting to be happy and have fun like people shown in ads related to alcohol.
• Studies have also shown a correlation between having short attention span and increased television viewing when young.
A 2011 study from the journal Pediatrics found that near 60 percent of children with ADHD have an associated writing disability. Beyond the effects of distractibility, rushing through assignments, impulsivity and all the rest of ADHD, these children have a neurologically-based deficit around writing. The ability to effectively gather their thoughts, organize them and get them onto the page is impaired directly, not only by their ADHD. Often overlooked and under-diagnosed, a writing disability impacts not only the specific tasks of producing coherent sentences, paragraphs and essays but also testing and note-taking. Without intervention the added time and stress around writing-related tasks affects overall school performance.
One of the most basic principles in supporting a child with ADHD is looking for other conditions that often tag along with it. These are termed "co-morbid conditions," and common ones include developmental delays (fine motor, language, etc.), various learning disabilities and specific mental health conditions such as anxiety. Nearly two-thirds of people with ADHD have at least one of these, and that statistic doesn't even count the far-reaching effects of executive function deficits inherent to daily living with ADHD.
School planning sometimes overlooks these possibilities, many of which are of particular importance in the classroom. Academic motivation depends on a sense of mastery and success and rarely develops when children feel at a loss or lack the tools they require to thrive. For students to enjoy and take ownership of their own academic career, underlying issues affecting school must be addressed first.
Here are suggestions (in fewer than three hundred words) to avoid common pitfalls while planning for the upcoming year:
- Make sure evaluations have looked for specific learning disabilities, especially when children with ADHD have persistent academic problems.
- Address difficulties with executive functioning at home and school. Children with ADHD require more structure and adult support to manage their work, and more direct instruction in organizational skills than peers. Because of their ADHD, they benefit from a scheduled routine instead of open-ended supports that say things like, "You can visit Ms. Jones if you feel you are falling behind." Their capacity to identify a problem ("I need help"), create a plan to address it and then stick to it over time is directly impaired by ADHD. Instead of open-ended solutions, schedule supports into their day: "Right after fourth period, you have a study session. Would you prefer to meet with Ms. Jones or Mr. Frank?" Similarly, most benefit from a consistent homework plan established at the start of the school year, before their workload increases.
- Implement a structured, reward-based behavioral plan proactively. Don't wait for classroom tension to start before focusing on behavioral change.
- Ask for placement with structured teachers who run classrooms that permit fewer distractions in the environment. Classroom set up (e.g., desks facing the teacher when she's teaching and not peers) and management (e.g., clear and consistent rules) matter greatly when children have ADHD.
- Encourage schools to use evidence-based instructional methods for children with ADHD. Today, the most commonly used curricula rely on learning through exposure to academics without an emphasis on direct teaching of skills. Children with ADHD are less likely than peers to thrive without an emphasis on core skills, repetition and rote instruction.
Educational planning of this kind is one of the three foundations of ADHD care. Integrated with appropriate behavioral supports and judicious use of ADHD medications, children with ADHD can thrive at home and school through the upcoming year and beyond.
On your mark, get set, go. Off they race, the children of America, into our collective future. The end point of this particular race is a healthy, happy and productive adulthood. So here's the question: Are the odds equal that anyone who puts in the effort will reach that finish line?
Basic Training Starts Here
The premise of a certain 2012 presidential platform (you decide which one) appears to be this: Life is an even playing field. As long as we try hard enough we all equally thrive. It's as if the secret to success is effort alone, and if you're not successful you're just not trying hard enough.
Research in child development contradicts this idea entirely. By the age of five, environmental experiences often handicap a child throughout a lifetime. Does effort matter? Absolutely, but countless factors affect the cognitive and emotional development of young children long before they make their own active choices about how to live.
The United States will never be the 'land of opportunity' for everyone without addressing this reality. Thankfully, many of these hurdles can be eliminated through interventions both compassionate and cost effective. To tackle these inequalities, some basic necessities of early childhood include:
A safe and stable home environment
The concept of 'toxic stress' may seem vague, but from a medical point of view excess stress has a significant impact on development. As outlined in a 2012 American Academy of Pediatrics statement, prolonged, excessive stress stacks the odds against children. Early adversity affects the entire body, from the brain through the immune system and even influences which of our genes express themselves. Too much stress can cause lifelong impairments in both physical and mental health and, as the authors state, "many adult diseases are, in fact, developmental disorders that begin early in life."
Making sure children are well fed and have health care is a start. Being undernourished or chronically ill affects an adult's capacities in daily life profoundly, children even more so. Additionally, programs that educate at-risk parents about supporting their children's development are impactful. Down the road, people who have received appropriate services while young are more likely to be reasonably settled when they have children -- and then their kids are better off. Adults who grew up in stable environments are more likely to be doing well in general, and less likely to require ongoing medical attention, mental health care or financial support from the government.
Education
The average low-income child has heard thirty million fewer words than peers by the age of three years, and this pre-school vocabulary score predicts language ability at age nine. Falling behind in these skills puts youth at high risk for school failure. School failure itself places children further in jeopardy of unemployment, underemployment, poor health choices and other difficulties.
Further compounding their disadvantage, these children exhibit a 'knowledge deficit,' which stems from decreased exposure to general information about the world. Limited content knowledge affects reading comprehension and related abilities, as understanding text relies on the reader's own background knowledge. One study showed poor readers who were baseball fans tested better for comprehension on a baseball passage than more skilled readers with little interest in the topic. While the more advanced readers could read the words, they didn't have the context to sort out jargon like 'a 6-4-3 double play.' Reading comprehension correlates with academic achievement, and also success after schooling ends; home and school based programs can help address the gap.
The types of schools we create matter greatly as well. A strong education starts with reasonably sized classrooms run by well-trained teachers. Children with mental health concerns, ADHD, autism or learning disabilities typically need services to keep up academically; these interventions are often unavailable or underfunded in low-income neighborhoods. Quality schools, developmental services, and mental health care head off long-term problems for not only individuals, but for the community as well. Without intervention, these same children are less likely to become healthy and independent adults.
The opportunity to learn through play
Free play is a foundation for later cognitive, communication and social skills. It also encourages emotional resilience and creativity. While you might think all children get an equal chance to play, many don't. Poverty interferes with play at home, at school and after school. Educating parents about the importance of free play and creating both community and school-based environments that facilitate it promote long-term development.
Team in Training
Failing to emphasize these early childhood services fails society as a whole. It perpetuates problems such as early school dropout, teen pregnancy, substance abuse and many other issues exacerbated by unstable childhoods. Investing in children at an early age even saves money over the years; without early intervention, we pay almost exponentially when adults struggle later. A RAND study, for example, suggested a minimum near two-to-one return for every dollar spent on early childhood services, and potentially as high as seventeen-to-one.
Eliminating early childhood programs turns a blind eye to the stark reality that life is not, in fact, a level playing field. Children need healthy nutrition and health care to grow. They need to be raised in nurturing, mentally engaging environments that encourage activities like imaginative play and reading. They require appropriate schools and stimulating after school experiences. Without intervention, these same kids often end up having children similarly at risk and the cycle continues.
When society abandons children before age five, we leave them adrift for a lifetime. Only through a concrete and prolonged investment in early childhood do we truly create an opportunity for all individuals to thrive. As the American Academy of Pediatrics states, "a vital and productive society with a prosperous and sustainable future is built on a foundation of healthy child development." Any plan that cuts or eliminates early childhood services fails not only our children but also our communal desire for a successful and stable society.
The complex educational reality for students with ADHD.
When a child has a language delay, people tend to accept this fact at face value: Joseph is 6 but speaks like a 3-year-old. While understandably upsetting to many parents, no one expects Joseph to speak differently before he is able. There's a scramble to start services, and a patient approach while allowing language to develop.
The same attitude does not hold for attention deficit/hyperactivity disorder (ADHD). ADHD is a developmental delay in a broad skill set called executive function. A huge body of research defines it as a medical disorder; neither parents nor children benefit when people suggest otherwise.
Executive function represents our capacity to self-regulate, encompassing everything from focus and impulse control to long term planning, prioritizing, organizing our lives, and emotional control. It is required for social interactions and classroom learning. Imaging studies confirm that children with ADHD experience immature brain development, showing again that it's neither a child's fault, nor a parent's, nor society's.
A child with ADHD may be 6 years old but going on three when it comes to self-regulation. Often parents hear, or even feel themselves: He's just lazy. He needs to get his act together. He knows better. Yet inconsistency is inherently part of ADHD, with moments of clarity balanced by a perplexing inability to hold it together over an entire day. So he probably does know better, but without typical executive function, he lacks the skills of other children his age to follow up.
Classroom Performance and Executive Function
To address ADHD only as a disorder of attention or hyperactivity also underestimates its impact on education. Impairments in executive function directly affect how children learn. In addition, up to two-thirds of children with ADHD have a separate learning disability; according to Dr. William Barbaresi of Harvard, studies suggest that nearly 40 percent have specific deficits in reading, math and writing. For children to maintain motivation and succeed, individualized planning must take a multi-faceted view of ADHD.
While a common starting point, even the best neuropsychological or educational battery of tests does not fully capture real life. Executive function defines how we live, moment to moment, and is not consistently reflected by testing. Children with average abilities on scores like 'working memory' (the ability to hold onto and manipulate information real time) may still have difficulty in the real world. Testing suggests average skills, and yet they cannot keep track of a list of instructions in their head, or assemble an intelligible essay. More than test scores, an individual's real life experience matters most.
A useful activity for understanding ADHD can be brainstorming all the steps of executive function underlying even a basic task. What does it take to write down daily homework assignments? It requires a strategy for action (having a day planner, for example), paying attention when the assignment is put on the board and prioritizing the act of writing down your notes over any other activity at that moment. And even if you have a day planner, you have to remember where it is and find it in time to use it, and track down a pencil as well.
The stress continues, as you must hold the information in mind long enough to get it on paper, while avoiding procrastination or assuming it can be written down later (both prioritizing and holding thoughts in mind rely on executive function). Then you must get the planner back in the correct place in what is probably a chaotic mess in your backpack. And that's only an abbreviated list.
We depend on executive function for activities as simple as getting out the door on time for the bus to complex activities such as planning a long-term project. A high-school student of 15 with the executive function skills of a 10-year-old needs to be supported like a much younger student in order to succeed - it is not a matter of effort alone. We can teach children what they need to know only if we see their struggles as they actually are, a frustrating and demanding developmental delay.
Executive function and educational policy
Many educational choices today put children with ADHD at a further disadvantage. From classroom design to curriculum, schools place huge demands on executive function. These skewed expectations often start in kindergarten, with academic tasks assigned far beyond the development level of an average 5-year-old. Fourth grade classrooms frequently require what used to be a sixth grade level of self-regulation and planning. For a child with ADHD, already years behind peers in this area of development, the gap grows between what is expected and their actual skills.
Children with ADHD benefit from smaller, well-structured classrooms. Classes over the last generation have grown larger, with twenty-five or more students and one adult. Layout is often in desk clusters, with children sitting in a circle. And yet, it is intuitive that it is easier to attend when directly facing the teacher, without your best friend at your elbow and another across the way. Desk clusters lead to distractibility and off task behaviors. Smaller classrooms that minimize distraction go a long way to helping children with ADHD, as well as all students.
ADHD related deficits directly impair learning, separate from classroom focus or misbehavior. Children fall behind in reading as it requires attention to details, working memory to keep track of information, efficient processing of information, and countless other aspects of executive function. One study suggested half of kids with ADHD have writing disabilities; the capacity to organize information and get it onto the page relies heavily on executive functioning. Math is the same, with careless mistakes rampant and multiple executive-function driven steps inherent to solving any problem.
Traditional curricula rely on sustained instruction regarding the basic building blocks for any subject. These techniques are presently out of fashion in mainstream settings. However, if you ask experts in almost any field they will tell you that we require automaticity of the basics before acquiring advanced skills. You can't play a Mozart sonata without first learning to play the scales fluently.
Many popular programs used in schools today rely on 'experiential learning,' playing down the crucial need for a solid academic base built through routine and memorization. And yet, as recently stated in the journal, American Educator, "while experts often thrive without much guidance, nearly everyone else thrives when provided with full, explicit instructional guidance (and should not be asked to discover any essential content or skills). ... Decades of research clearly demonstrate that for novices (comprising virtually all students), direct, explicit instruction is more effective and more efficient than partial guidance."
Delays in executive function skills in ADHD, meanwhile, often make assimilation of new information particularly difficult. To develop expertise in any area of academics, even more than other students children with ADHD need repetition, routine and a solid foundation of academic facts. Without it, the academic gap grows.
What do these modern curricula look like? Silent reading time is emphasized. For someone with ADHD who is distractible, impulsive, and behind in reading skills, there is an unrealistic expectation they will attend, behave, and basically teach themselves during this unstructured instructional time. In writing, children who struggle to organize their thoughts are asked over and over again to create coherent essays without a linear outline. In math, children still counting on their fingers are pushed to not only solve higher-level problems but to show their work, an activity which relies again on their ability to organize and get their ideas on paper.
A vicious cycle potentially develops. Until facts become hard-wired children with ADHD struggle even more than peers. Demands on executive function go up whenever facing something unfamiliar, but without an emphasis on teaching basic facts nearly everything remains unfamiliar on some level. Already maxed out in their ability to assimilate new information, the curriculum moves forward before they are ready.
Lastly, as discussed earlier, many children with ADHD also have a learning disability. If every child with asthma had a 66 percent chance of having kidney disease too, would we screen them for kidney disease? Probably so. Yet, once ADHD is identified further educational testing sometimes gets put to the side with an assumption ADHD explains all. For children with ADHD, full educational testing is required if any academic concern seems particularly severe or if issues persist once ADHD is addressed.
Righting the educational ship
One of the best metaphors for ADHD is that of an iceberg. The tip signifies the best known symptoms, ranging from hyperactivity and impulsiveness to distractibility and poor focus. The rest of it, often hidden but resoundingly impairing, is the near countless facets of executive function. Disruptive behavior and trouble completing work tend to dominate the discussion when in fact most children with ADHD require far more emphasis on addressing the less obvious parts of the iceberg. Without appropriate intervention the impact on child development and education is profound, including self-esteem, motivation and a host of less quantifiable measures of well-being.
How can we best help students with ADHD succeed? A compassionate approach to parenting or teaching fully accepts a child as they are, expecting them to behave appropriately and work hard, but only within reasonable parameters. We aim to assess short-term requirements accurately while building skills for the future. Right now, today, any individual with ADHD may not have capacity to manage homework, focus, control their impulses or any of a host of other abilities that impact their lives. We best support children with ADHD by not expecting skills they simply lack to develop out of thin air, but rather by proactively creating a comprehensive educational plan.
Children with ADHD typically require an intensive short-term safety net that more or less takes over executive function. Then, at whatever rate individual skills develop, we hand responsibilities back. Books including Executive Function in the Classroom and The CHADD Educator's Manual describe the academic impact of ADHD along with recommendations for intervention too detailed to list here. But the first step to meeting a child with ADHD exactly where they are in their development is acknowledging the full impact of this complex medical condition.
Originally published in Child Development Central on May 16, 2012.
Adult ADHD affects near five percent of the population, although the actual diagnosis rate is far lower. Many adults live unaware of what sits behind their chronic struggles with attention, time management, emotional self-regulation, and a host of related abilities that impact family, work, and well-being. And those already diagnosed often have a hard time finding providers familiar with adult ADHD management.
Dr. Lidia Zylowska is one adult provider aiming to make a difference. A friend and colleague of mine, Dr. Zylowska achieved some notice several years ago when she published a pilot study adapting for ADHD the acclaimed mindfulness based stress reduction program. While some were skeptical that adults and adolescents with ADHD could sit and practice mindfulness, almost everyone entering the program completed it - even with a meditation component built around attention training. Participants reported lower stress and an increased sense of well-being. Specific measures of attention and executive function improved.
Dr. Zylowska's new book The Mindfulness Prescription for Adult ADHD offers mindfulness through a practical, eight-step program. It includes accessible discussions of how ADHD related executive function deficits affect people day-to-day. It even integrates advice for how to maintain these practices consistently in the midst of a busy life. The Mindfulness Prescription for Adult ADHD is a unique resource for adults with ADHD, particularly those looking to explore the practice of mindfulness or to build on an already existing one.
If you are a harried parent, an adult with ADHD, or (as is common) both a harried parent and an adult with ADHD, mindfulness is meant for you. Through mindfulness we build an ability to attend more fully to our experience as it happens, wrestling less with a sense that things aren't as they 'should' be. Whatever our natural tendencies, we increase an ability to focus our attention where we want while also cultivating compassion for ourselves and others. While a practice of meditation is often suggested, it is a style in which we never aim to eliminate thought, only to sit more comfortably with a busy mind.
ADHD also has a profound effect on relationships. Both a child's and a parents' symptoms affect the whole family, and parents of children with ADHD have a significantly increased risk of having this highly heritable condition themselves. And then adult ADHD makes it harder to stick to recommended parenting strategies which generally depend on consistent routines and limit setting, escalating a tough dynamic.
The executive function deficits inherent to ADHD don't affect only attention and impulse control, they interfere with a host of self-regulatory skills that can affect almost any aspect of daily living. Difficulty with executive function may be the most prominent feature for adults with ADHD, who commonly lack the 'hyperactivity' component (as is also true for anyone with ADHD-inattentive type, or 'ADD'). While much can be done to diffuse the situation, to address the potential impact of ADHD on a household we first need to know it's there. So, to identify the often hidden influences of ADHD, parents may first need to look at the possibility that they have it too.
If you're curious about yourself, a free adult ADHD screener is available through the World Health Organization. Information about adult ADHD and listings of resources are available through the ADDA. And many good books have been published about the effects of ADHD on families and relationships, offering tips for minimizing its effects on you and your loved ones. Finding the time to take care of yourself as a parent with ADHD is an often vital part of caring for your children... which may include proactively addressing the impact of your own ADHD.
Originally Published on March 30, 2012 by Mark Bertin, M.D. in Child Development Central
The fact that some individuals harbor unfounded doubts about ADHD isn't surprising to see in print once again. The fact that a reputable newspaper like the NY Times would publish an individual's opinion stated as fact, without regard to basic science, was more troublesome. If believed, last Sunday's op-ed about ADHD, "Ritalin Gone Wrong," would undermine the lives of countless children and families struggling with the condition.
ADHD is a proven medical disorder. Dozens if not hundreds of studies show that unaddressed ADHD (ADD is not unique from ADHD, it is considered a subtype) greatly increases the risk of everything from school failure and car accidents to obesity. These risks make sense when ADHD is understood as a condition that affects an individual's capacity to manage their lives, moment-to-moment, throughout the day.
To truly and compassionately support a child or adult with ADHD, we need to recognize its underlying - and proven - medical cause. An underactive part of the brain impairs an individual's ability to focus, organize, prioritize, and a host of other related life skills. The reason to seek diagnosis is not to decide about medication; it is to help understand an individual. Dr. Russell Barkley has said ADHD is not a disorder of not knowing what to do, but of not doing what you know. There is a huge difference between a child misbehaving because they have poor impulse control or are overly forgetful, and making the false leap that he doesn't care or is being intentionally 'bad' in some way.
Dr. Sroufe's perspective absolutely slams parents. ADHD causes intense stress because of all the difficulties it leads to in life, and parents of children with ADHD report higher levels of anxiety, depression and divorce. Simply getting out the door in the morning becomes a daily crisis. And this happens regardless of how a child was raised: ADHD is not a parent's fault. ADHD symptoms are influenced by environment and parenting style, and we should continue to explore how we can best manage it, but no reputable study has ever suggested that ADHD is caused by environment alone.
Lastly, regarding medication. No respectable practitioner wants to use medication unnecessarily. Yet there actually are clear, research based guidelines demonstrating concrete benefits to ADHD medications that the NY Times op-ed dismisses. We certainly need to explore behavioral and educational interventions that could help any individual, and I often suggest them first. When trying ADHD medications, these non-medical approaches are still needed; even when well utilized and well tolerated, medication alone can't solve everything. Parents and clinicians alike must consider a wide range of possiblities to fully address this complex condition.
At the same time we should aim to help parents find some objectivity in decision making, to step away from the bombast and propaganda inflamed by essays like "Ritalin Gone Wrong." Regardless of what any individual family chooses, they should at least know that the research says non-medical interventions rarely improve ADHD symptoms nearly as much as medication. Decisions should be made as much as possible by seeking facts, not stoking fear.
In regards to the claims made in the op-ed: Multiple studies do show long-term benefits of ADHD medications, with improvements in academics and many other aspects of life. As examples, Dr. Robyn Powers in a 2008 Journal of Child and Adolescent Psychopharmacology report showed that adolescents, off medication by then, were doing better academically if they took medications when younger than others students with ADHD who never did; one from the Journal of American Psychiatry by Dr. Tomohiro Nikao in 2011 documents a trend towards normalization of brain functioning in those who took medications as children. And the Times article fails to mention that recent, larger studies of ADHD medication do not suggest any persistent growth changes. Meanwhile, while any medication has potential side effects, simply allowing a child to regulate their own behavior well enough to succeed in school, socially, and to have an easier relationship with their family even for a few years has a profound impact on their long term well-being.
It is sad to see these ADHD myths perpetuated. We need to reach out to families that are dealing with it by acknowledging their struggles. A child with ADHD has a developmental delay in their capacity to manage life - and an ADHD diagnosis helps us define the supports they need at home and school to thrive, separate from decisions about medication. Medication itself has been shown, to the best of anyone's knowledge to date, to be at minimum a useful option that does not have long term side effects. Suggesting otherwise lets down children and parents alike.
Originally Published in Child Development Central on February 8, 2012.
Compassionate ADHD care starts with fully understanding executive function.
For each area of executive functioning in your child, there is a reality: Does my child have these executive function skills, or don't they? Be curious; look for patterns. As best you can, look objectively at your child's abilities in comparison to their peers. Attributing ADHD traits to willfulness or assuming they will simply be outgrown increases your own stress, strains relationships, and may frustrate your child. It also doesn't usefully address the underlying problem.
Children with ADHD are as bewildered as the adults in their lives as to why things that are so easy for other kids come so hard to them. Like everyone else in the world they would like to be happy, at ease, and successful. They may begin to wonder, what's wrong with me?
They often need an intense short-term safety net, a realignment of demands and commitments balanced with lots of structure to make sure they learn and keep up at home and at school. And then they benefit from a coherent, long-term plan to develop their abilities and coping strategies.
Understanding a child with ADHD, and optimally supporting and helping her, means understanding how executive functions relate to ADHD. In order to offer compassionate support, build confidence, and create a plan for the future, the first step for parents is to sort out the reality of underlying issues present in ADHD, including all the varied implications of executive function. By holding onto these basic facts, you can appropriately challenge your children to grow while building for long term success.
Excerpted from "The Family ADHD Solution" by Mark Bertin M.D. Copyright © 2011 by the author and reprinted by permission of Palgrave Macmillan, a division of Macmillan Publishers Ltd.
One of today's standards of American education is the concept of 'heterogeneous grouping' within 'mainstream' classrooms: Children of every skill level remain together in every subject. This may be a pushback against a time when grouping children according to their abilities lead to a sense of isolation, with kids seeming to languish on the special education track. Yet to meet any long-term goal of integrating children with their peers, the short-term concern should be addressing immediate educational needs--a goal not always accomplished in the mainstream.
Individualized planning requires an objective exploration of strengths and weaknesses. This perspective often reveals a need for smaller, more structured classrooms and more refined placements; for any student who has extensive academic, behavioral or social difficulties, we need to consider all possible options. Yet due to policy trends in education and presumably the pressure of economics, many schools have eliminated these possibilities entirely. Now, left behind is a ubiquitous policy of placing every child in a single setting; a trend that fails many of our children.
All for One ...
School districts today tend to educate everyone lumped together. Instead of modifying content, this style of 'individualized' plan doesn't adjust the basic material--even though a student may not yet have grade-level skills. Children with special needs receive a few minutes of direct attention targeted to their particular abilities during the day, but the vast majority of time is spent trying to keep up with everyone else.
Academic motivation develops best through success and mastery and is undermined when children flounder with work that is over their heads. Steve, a ninth grader in my practice with reading disabilities, is a good illustration of this. He was asked to read Ulysses over the course of several months, in spite of the fact, that he lacked the ability to decode the words and comprehend the story. A teacher's aide outlined and helped him with vocabulary when he felt like asking questions. As that had become habitual, Steve instead checked out on the entire project.
Given a more skillfully chosen book that Steve was capable of reading with minimal support, he might have continued to engage. With remediation to close the gap in his reading skills, which he was no longer receiving, he might have caught up. Even with tutoring he struggled, not only with reading, but motivation in general, overwhelmed by school work far beyond his abilities. Any potential benefits of spending his days with mainstream peers were completely overshadowed by his belief, mostly correct at that point, that he couldn't do the work even when trying his best.
... And One for All
Leaving students together throughout the day also means the curriculum is not tailored for remediation. Academic interventions are typically added by having teachers and therapists visit kids in their classroom, often called 'push-in' services. These in-class networks of therapists and special educators work for some children, but many feel singled out. Living as the only one who doesn't easily 'get it' in a classroom of kids who generally do, leaves many children dwelling on the difference, and feeling like failures. Why am I the only one who has all these extra teachers?
Another push-in approach adds a special education teacher to an otherwise mainstream classroom. This set up (often called an 'inclusion' or 'integrated' setting) helps children whose primary requirement is additional adult attention, such as those with behavioral issues. And having a second adult in the room with a special education background can be beneficial to all, lowering the teacher-student ratio and adding a specialist's expertise. Yet, as a catch-all intervention inclusion does not inherently address the needs of all children with special needs such as those with learning disabilities, ADHD, autism, or any other concern that requires a more targeted curriculum.
There are also logistical issues when adding a special education teacher to a mainstream class. Grouping children for direct instruction by the special educator, while another teacher continues a lesson for the rest of the classroom is often distracting for all the children, and limiting for the special educator. And like other push-in services, children may feel more stigmatized, not less, when pulled aside from peers in the same classroom. Lastly, as in mainstream settings there is frequently a requirement that children tag along with grade-level content and pacing most of the day instead of following their own prescribed curriculum.
A Custom Fit
On a practical level, contained settings address the needs of children in ways often impossible to implement otherwise, and they still do exist in places. There are classrooms and even entire schools geared to evidence-based academic instruction for children with learning disabilities. Some are structured to meet the needs of children with ADHD, allowing these intelligent, typically well-motivated children an opportunity to learn as well as any of their peers. Others are tailored for development of social and communication abilities in children with autistic spectrum disorders.
Every fall, I see children blossom after switching rooms, able to manage their work on their own, and to master it with the same level of help all the children around them receive. In spite of fears to the contrary, children generally feel more at ease when moved to a well-supported setting. Suddenly, they realize that their issues don't define them: Here I am with ten other kids, all of us are smart and all of us can't read well! I'm not different after all! Reduced stress and gains in self-esteem lead not only to academic growth but to social and emotional benefits outside the school setting. While kids should never be 'stuck' on a special-education track, self-contained settings are sometimes their clearest path to social-emotional well-being and academic success.
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