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August 2011 Archives

A study out this month in the journal Pediatrics found that near sixty 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 underdiagnosed, 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 'comorbid 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 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?'
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 curriculums 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.
Published on August 30, 2011 by Mark Bertin, M.D. in The Family ADHD Solution
More Than a Full Plate
One common, under-addressed symptom of attention deficit-hyperactivity disorder (ADHD) is its impact on eating.  A new study in the Western Journal of Nursing Research suggests the possibility of screening anyone with a chronic weight issue for ADHD since one in five adults who were obese turned out to have multiple symptoms of it, compared with around one in thirty in the general adult population. Previous studies have also found that children and adults with ADHD are significantly more likely to be overweight. With so many millions of people affected by ADHD, any risk of increased obesity influences the health of huge numbers of people. Is the connection with ADHD affecting you or someone you care about?
The link between ADHD and poor eating habits isn't surprising when you consider that it is a disorder of executive function, a set of cognitive skills which act as our brain manager. Executive function impacts almost every aspect of living, encompassing our ability to self-regulate, organize, plan, prioritize, and anticipate the future. Eating is only one of many facets of ordinary life influenced by ADHD, yet typically flies under the radar.
 The Makings of Self-Control
Executive function deficits get in the way of everything from noticing when we are full to making healthy food choices in the midst of a stressful day. For kids and adults, impulsivity leads well-intentioned diets out the window in a moment, making it that much harder to walk past a MacDonald's or avoid the pile of donuts left by the coffee machine. Executive function affects the ability to judge time, perhaps to see that today's 'exception' is part of a larger pattern. It's not a rare splurge, it's the same as four times this week already for ourselves or for our children.
Studies looking at eating habits in general, not specific to ADHD, have shown that distracted eating - eating while watching television, playing games, or simply daydreaming - increases calorie intake. Stress and anxiety, especially when amplified by ADHD, can push anybody of any age to reach for food. And then when a new diet or lifestyle is needed for a teen or young adult, executive function skills are required to develop and stick with the plan.
Guiding children with ADHD becomes even more important than it does for other kids, from behavioral patterns around food to the choices and the brands they encounter at home, and learn to prefer. ADHD causes some children, unless taught otherwise, to unknowingly overeat at every sitting or always grab an extra cookie from the pile. They may be less tolerant of hunger, quicker to raid the cabinet, melt down near the cash register candy, or experience any of a host of related moments that add up to a longer-term problem. Recognizing all the myriad ways executive function influences eating allows for a deeper perspective and suggests new possibilities for change.
A Hidden Ingredient
As a starting point, we must look for and identify the influence of ADHD in the first place. When children with ADHD overeat or begin to gain weight, we can dig deeper into their ADHD, looking for ways to manage it better. If an undiagnosed child struggles chronically around food, we should consider the possibility of ADHD, looking for symptoms in other areas of life. Other studies of obese adults have showed more than in four to be affected, and the rate in children could prove even higher as more kids have ADHD than grown-ups.
Many parents of children with ADHD have symptoms of the diagnosis as well. With adult ADHD it becomes that much harder to maintain long-term plans and healthier lifestyles, so the whole family may need outside support. Often these parents battle their own difficulties with self-regulation around nutrition, from how they manage the family pantry to their own eating style. Unaddressed, parental issues increase the risk that their kids will struggle with the same.
Parents are concerned about weight loss as a side effect to ADHD medication and rightfully so, although in practice most kids do fine. In fact, medical treatment of ADHD can lead to healthier eating habits through a decrease in impulsivity and distractibility and all the rest. Kids who start out overweight sometimes seem to lose weight only until reaching a more appropriate one for their height, and then resume typical growth. In some situations improved eating habits, not the potential medication side effect of appetite suppression, may explain their initial weight loss.
Recipe for Success
It's not only about what we serve or when we serve it, it's about the example we set. We can choose to model only eating when eating, instead of staying half-engaged in other activities, such as reading the newspaper, watching television, working, or daydreaming. When at the dinner table we can leave our food alone while in conversation, pausing instead of mechanically lifting our fork again and again. We can practice putting our utensils on the plate between bites, serving ourselves on smaller plates, or never eating directly from the bag. Our children watch, and learn.
We might even notice how we habitually shop. Maybe decide not to keep challenging foods in the house at all, or only to buy them when consciously deciding it's time for a treat. If a child raids the pantry, constantly debates about having more junk food, or refuses healthy snacks for the chips they know are available ... don't have the overly enticing items on the shelf. We do the shopping, we can choose not to have them around.
The practice of routinely having family dinner has been linked to healthier habits, as well as fostering various emotional and behavioral benefits, but keep in mind that having the television on during dinner reverses much of that. In the midst of a hectic afternoon or butting up against larger behavioral issues elsewhere in life, we may give in to complaining about food, or use food to calm irritated children. Or conversely, we might stick to a different routine: Two cookies after dinner and no junk the rest of the day, dessert only on Saturday, or whatever else best fits our lifestyle. Establishing these healthy habits early often heads off troubles before they start.
The Whole Enchilada
So often, we compartmentalize troubles related to ADHD: My daughter has a hard time focusing and is more reactive than I like, and overeats and misplaces her homework all the time. Maybe you wrestle with a similar set of difficulties as a parent. We often judge our kids or ourselves for being 'bad' or to be failing in some way: How come this looks so easy for all his classmates, and is so hard for my son? We scramble to address ADHD through hodgepodge solutions targeting each bump in the road (or mountain) separately. Yet in reality these all reflect the same condition, the same executive function deficits.
Plenty more may be going on around food for any individual, rarely is it a simple relationship. Beyond the range of struggles typical for many of us, anyone may experience an eating disorder, mental health concern, or a difficult family situation that affects their relationship with food. And this entire article is written from the perspective of a country where famine is rare, where most of us have options; when food is truly scarce, everything must change.
While there may be layers and layers of emotional and behavioral habit contributing, observing eating through the lens of ADHD allows for a deeper exploration, instead of chasing only the end point - eat less and exercise more. That's an answer, but executive function lets it happen. For anyone with ADHD it may seem weight control and five or ten different things are going 'wrong' at once, yet executive function ties them all together. While not a miracle cure, all will be easier managed when we acknowledge this often overlooked element in the recipe of life.
Published on August 1, 2011 by Mark Bertin, M.D. in The Family ADHD Solution
One truth of family life is that it is inherently uncertain. We feel everything is under control one moment and then things suddenly change around us. We make plans that don't work out exactly as we pictured. We imagine our future one way, and then life takes a different path. Sometimes we make assumptions ... and then make more assumptions based on little more than those tenuous beginnings.
As parents we also have countless habits, many of which we are not fully aware. We may make quick decisions and then unthinkingly stick with them - or maybe our habit is that we never stick with anything. We define ourselves or our children in some way ('He never works hard'), and assume that can never change. Day-to-day, both the sense of uncertainty and the influence of our lifelong habits are amplified when we feel overwhelmed or stressed, as frequently is found when living with ADHD.
But as parents, we can change and make living with ADHD far less taxing. People who spent only eight weeks practicing mindfulness reported an icreased sense of well-being and decreased stress, according to a recent Harvard study. This was no surprise, as similar results after mindfulness training have been shown many times. 
This study found something even more extraordinary. The researchers documented measureable growth in the brains of participants, even though they had practiced mindfulness on average only twenty-seven minutes a day during the eight weeks. Areas of the brain involved in emotional self-regulation, memory, and learning actually increased in size. Not only did people feel better, but concrete neurological changes followed. These findings confirm the potentially life-changing benefits of even a short time spent training in mindfulness - something I have witnessed in many parents, with and without children who have ADHD, after completing a six-week class. 
Getting in Touch with Mindfulness 
So what is mindfulness, and how is it achievable? On one level, mindfulness means paying attention and experiencing life as we live it, right now, while maintaining an open and honest perspective about whatever we encounter. With mindfulness, we still have experiences we like and some we dislike, but maybe we don't wrestle quite as much with either. Mindfulness is a way of building cognitive abilities that benefit ourselves and those around us. Through it, we cultivate an ability to manage our lives with a greater sense of balance and less stress. 
Meditation, which is often part of mindfulness training, is like weight lifting. Hit the gym regularly and moving furniture around the house becomes easier. During meditation, we strengthen our ability to notice when we're acting without reflecting a moment before taking action, or doing one thing while distractedly thinking about another. 
Meditation is a part of most programs that teach mindfulness, though inherently it is not a spiritual practice. In this type of meditation the task is one of focused attention, nothing more. Our mind wanders, always, over and over again. That's what minds do - they make thoughts. While meditating we try to focus our attention on whatever we choose, such as the sensation of breathing. When it wanders (as it always will), we deliberately bring it back again instead of remaining in rumination, daydreams, or wherever else we've gone. This simple, immensely challenging act can affect how we live moment to moment. As a parent, I've found it a source of strength and perspective, and parents of children with ADHD report the same.
So Many Benefits 
We spend so much of our day-to-day time on 'autopilot.' We find ourselves playing a board game while we're really rehashing the argument we had trying to get ready for school. We're eating dinner as a family, but visualizing unsettling images of our child failing to ever get his act together in school and winding up who knows where. Or, we're consumed by a fear we've mishandled the latest outburst. Meanwhile, without full consciousness, we're reacting to things that are said or done at the table, correcting behaviors, and answering questions. Or maybe snapping in anger, or disappearing into ourselves, withdrawn and defensive.
Without effort, we become lost in fantasy and fears and planning and all sorts of random and not-so-random ideas and emotions. When we practice focusing our attention, in meditation and in our lives, we address this pattern. Right now, I'm going to give full attention to my children and not to planning what I'll say in tomorrow's meeting. While we'll still find ourselves becoming distracted at times, we may recover and return more easily. Children often notice the difference. 
In the midst of a thousand distracting thoughts on a scattered day, focusing our attention back to real life is a radical step. Not every idea or fantasy or plan we encounter in our mind is worth validating with a response. Many of the ideas and sensations and emotions that come and go through the day seem permanent and unchangeable, yet they generally aren't. Fearing something bad will happen doesn't make it true. 
When we pause and pay attention, we find some thoughts are worth our attention and others ... not so much. Thoughts arise and, with a sense of calm and discernment, we enjoy what there is to enjoy and more easily sort out the rest. And, then, since anything we experience repetitively rewires the brain (as shown in the Harvard study), this change in perspective becomes part of our underlying neurology. 
We practice meditation because it influences how we act throughout the rest of the day. We find our mind wandering off over and over again, and then we guide it back without ripping ourselves for having "failed" at what is basically an impossible task. As in life, we cannot always get it right, and we give ourselves the benefit of the doubt for working at it in the first place. By training our ability to be attentive, we also may find ourselves more able to bring our full attention to our families, or reacting less reflexively when life makes us frustrated or angry, or discovering a new solution to an old problem. 
Parenting can be a humbling experience. So much is uncertain and unpredictable. We plan and predict and try to have as much fun as possible with it all, but we cannot control everything. In the face of these facts, we can instead aim to teach children basic life skills, including the capacity to handle life's ups and downs with equanimity and wisdom. But, first, we need to cultivate these traits in ourselves. 
Mindfulness training is a proven way to start. By practicing mindfulness meditation, we permit ourselves a few minutes a day to let our minds quiet. We strengthen our ability to notice when we're distracted and come back to reality. Every time we stop ourselves for a moment and reflect, we have the opportunity to choose where to place our next step. Lost in thought, we miss easier, lighter moments with our kids. Reacting without pause, we fall back on the same old habits, for better or worse. Taking a moment to pause and pay attention, we refocus ourselves on our daily life and on all the moment-to-moment choices we make every day.
Mindfulness: Getting Started 
Here's a simple place to start bringing mindfulness into your life:
Three times a day for several weeks, pause and pay attention. Pick easy times to remember, such as when you are about to leave the house, or when the kids get on the bus, or before each meal. Or, practice taking a brief break when the day starts feeling overwhelming or tense. 
Take a minute to focus on several breaths.  Pay attention to the sensation of breathing, the physical movement of air passing through your nose or mouth, the rising and falling of your chest or belly, or whatever else is most apparent. Notice whatever you think and feel at that moment without, for one minute, doing anything more than observing: I am rushed and my feet hurt. I am quiet and at peace now, but worried about tonight. If you need, you can take care of something when you're done; right now, just give your mind a moment to settle. Count five or ten breaths, if you like. Then, gathering your resources, choose what you will do next.
****Published on March 29, 2011 by Mark Bertin, M.D. in The Family ADHD Solution
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