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.
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.
New ADHD guidelines encourage improved preschool diagnosis and intervention
The American Academy of Pediatrics just released updated guidelines for the evaluation and treatment of ADHD. Although specialists have been identifying ADHD in preschool children before now, the guidelines expand the 'official' age range for diagnosis down to age four. They still encourage behavioral interventions before medication in preschool children. Early identification often allows families to address issues before they escalate, and helps keep children on track in their development.
Among several other recommendations, the guidelines also emphasize looking for conditions that co-occur with ADHD, a vital aspect of care. Most children with ADHD have something else going on with it, ranging from a learning disability to oppositional behavior to any number of concerns. For families using medication, the importance of 'titration' is reaffirmed, as best results frequently require trying more than one medication and various doses before choosing what fits for any individual child. While there is little emphasis in the paper on the role of executive function, the guidelines should improve care and clarify evaluation and treatment of childhood ADHD.
The holiday season can be a time of great, uncomplicated joy -- honestly it can. It doesn’t have to be an intense, draining, consumer-driven mess. We cram into four weeks a stew of stress-raising ingredients for our families, letting it simmer until New Year’s Day. But with a little mindfulness and mental effort, we can keep ourselves grounded and together and help our families find a sense of peace in the midst of it all.
We can start by taking an honest look at what we’re doing to ourselves these next few weeks. Forewarned is forearmed. A short list of what the season serves us: Too little sleep, too much food, too little sunlight, too much alcohol, strained budgets, challenging gift purchases, hours of schmoozing with people we see once a year at the same party but never in between, too little exercise, too much travel, extreme weather, and various family crises. And our kids live through the season on sugar and poor sleep and lack of exercise, and probably have become certain that the only path to true happiness is to have the hottest new ... whatever fits their vision of nirvana.
It’s stressful even writing about it. The holiday season, meant to bring us all together in happiness, consistently accomplishes exactly the opposite for so many people. So what’s the point? What can we do instead?
There is another option. Instead of letting it all just happen, we can remind ourselves what matters most -- and what we’d like our kids to learn. Emphasize, for our own sanity and for that of our children, the simpler side of the holidays. Find time for fun activities outdoors or in the city or wherever else, without settling for the lowest common holiday denominator of overspending and overscheduling.
In spite of the external pressures, we can value taking care of ourselves. Too little sleep amplifies stress; exercise reduces it. Also helpful is eating healthily, not necessarily at the parties themselves but perhaps the rest of the month. Schedule quiet time alone or with someone who calms you or makes you laugh. Find the humor in the midst of the seasonal insanity. Whatever works for you the rest of the year, instead of letting it slide for a month, protect it, a holiday gift for yourself.
Avoid perfectionism. We sometimes amplify the emotional impact of buying gifts or hosting parties by unconsciously holding them to impossible standards, fitting them to the storybook pictures we’ve created in our minds. Not only do we invite all our family and friends but we expect angelic behavior from our kids, or stay up late meticulously centering the candy noses on cookie reindeer, or maybe actually expect our parents not to bicker this year, although they have fought fairly consistently over the last few decades. “No bloodshed and a few good laughs” may be more than enough for any given event.
Let yourself mentally quiet down at times throughout the day. Left unattended, one stressful thought leads to another, and the cycle ramps up all day long. Eventually, life feels like a crisis even on a relatively ordinary December day. Without disrupting your schedule, without adding another “thing to do,” take fifteen slow breaths as needed, focusing as best you can only on the physical sensations related to breathing.
Instead of letting your thoughts escalate, let your mind settle. Spend a moment not doing or planning anything. Don’t expect a holiday miracle; your mind will remain busy much of the time. We can’t completely stop ourselves from thinking, and there’s no need to try. But on the train, in the aisle of the toy store, trying to get the children to the dinner table, or whenever you feel yourself ratcheting up, give yourself a break for a few moments.
As suggested in a recent New York Times article, one other trick to lowering stress is to make a practice of gratitude. In spite of the millions spent in seasonal marketing to convince us our long-term well-being depends entirely on a massive TV set or a diamond necklace, we know better. Instead of buying into the hype, express appreciation at the end of every day for several things that went well. On an off day maybe simply relish the opportunity to put it behind you and go to sleep. Whatever you discover, small or large, write it down or spend a few moments mentally giving thanks.
We can’t eliminate all that the season throws our way. We can’t do anything about that or the people around us who may be more wound up than usual. But we can acknowledge the inevitable challenges without getting sucked in. Instead of letting the holiday season run amiss, we can find the opportunity to celebrate and connect with friends and family and create for ourselves and those around us healthier, more relaxing, and restorative times.
Fifty years ago, the first fast food restaurants opened in our country. Since that time there has been a steady increase in obesity. Whenever American fast food is introduced in a new nation, obesity soon follows. Obesity is an epidemic related to the modern proliferation of fast food chains, along with other similar style food products and marketing, yet fast food restaurants are now so ubiquitous it's hard to say how to address the issue on a societal level.
Frighteningly, we're letting the same thing happen to our collective health again. Just as the food industry undermined the dining habits of several generations, we are now allowing the media and entertainment industry to define how we use their own products. Parents, raised immersed in television and computers, often dismiss the problem. The kids are having fun, let them be. It doesn't seem pressing, and there are other things to worry about besides screen time. But without action - not eliminating media, but intervening and learning to handle it better - we're raising an entire generation at risk for ‘fast food brain,' with minds chronically unhealthy and cognitively out of shape.
This month in Pediatrics, a study showed that short-term exposure to a fast-paced cartoon affected mental skills called ‘executive functioning' for the worse. Executive functioning relates to overall well-being, as well as social, academic and work success. It acts as our brain manager, monitoring our behavior and the organization of our thoughts throughout the day.
In the Pediatrics study, executive function was measured after viewing nine minutes of a popular cartoon and after watching a slower-paced program. Children showed measurable decreases in their executive function after viewing the fast-paced cartoon, but not the slower-paced program. In other words, their ability to self-regulate suffered almost instantaneously. In the real world, when I ask families how much media time their children get every day, they often pause and do the math and end up somewhere between one and three hours - far more than nine minutes.
The cartoon used in the study isn't anything particularly violent or obscure. It is a wildly popular, geometrically shaped character who resides on the sea floor - Spongebob. We've all seen him around and have probably watched the show ourselves. And while the study's findings are unique, they support many others that have documented the long-term ill effects of media time, including concerns that too much media correlates with shorter attention spans - one of our most central executive function skills.
To set our children up for success we must encourage the growth of cognitive skills that help manage the ups and downs of life. Unattended media use gets in the way; excess media and inappropriate content for children correlates with everything from obesity to aggressive behaviors. It's easy to shrug it off - it can serve as a useful babysitter and is mindlessly fun - but that doesn't make all of it benign.
Media exposure affects brain development on a foundational level. Another study out this month shows again that television, as opposed to reading, impairs language growth and early literacy skills. With its underlying cognitive and developmental effects, ‘fast food brain' impairs social and academic progress and long-term happiness. Media is nothing more than cotton candy for the mind. A little is fine, but you don't want to overdo it too often.
However you've managed it up to now, the choice is yours as to what comes next. Don't live on autopilot. Don't let the effects of media passively happen to you and yours without making a conscious decision about what is wisest for your household. Kids shouldn't consume media without guidance any more than they should be permitted to eat fast food and candy all day long. Stop, reflect, and think proactively about both the amount and the content of television shows, video games, and movies your children experience and the potential effect on brain development. Will you decide how media is used in your family, or leave the choice to all the marketers aiming for your children?
With fast food we missed our chance to make intelligent plans as a society. Now we are scrambling to undo the damage. This time around we can make individual statements for our families, but also band together as a whole. We have time to refocus our culture on a healthy lifestyle, emphasizing what we know is best for child development, while still allowing for plenty of down time, random fun and for letting kids to be kids. The clock is ticking. The choice is ours to make.
Published on September 22, 2011 by Mark Bertin, M.D. in Child Development Central
I think that parents are responsible to do something about what their kids are up to. Undoubtedly each scenario is different; but the situation can't be ignored....
Dr. Mark Bertin, a board certified developmental behavioral
pediatrician, studied at the UCLA School of Medicine and completed his
training in general pediatrics at Oakland Children’s Hospital in
California. He was first a general ...Read More
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