Behavioral Management of Children with ADD

Dr. Schofield started by saying there'd been "an explosion in research" within the last 4 to 5 years for ADD although much has not yet filtered down. The work is and will appear in journals and then find its way into daily practice. One such major advance is in the area of ADD without hyperactivity. This area was virtually ignored until relatively recently. The same can be said for adult ADD.

He recognized ADD was present both with and without hyperactivity and that there were subtypes of each. Behavioral characteristics included learning disabilities, mood management, and auditory processing difficulties. "There is no one-size-fits-all" prescription or approach to ADD", he said.

Non-hyperactive ADD can look like hyperactivity although it is usually situational. Dr. Schofield spoke of the terms pervasive vs. non-pervasive as the older terms which were used. He noted that about one half of the hyperactive element diminishes in adults. Adults also have more of a choice of evading or changing their activities to minimize the effects of hyperactivity.

Medications and/or behavior modifications usually form the basis for management strategies. Many children don't like behavior modifications which can make this difficult. Some do very well while there can be real difficulties if behavioral strategies result in destructive action by the children.

He then went on to talk about auditory processing difficulties telling us to be careful that we not confuse this with hearing loss as that's something else entirely. Auditory processing difficulties should be considered after normal hearing has been confirmed. He also noted that standard hearing tests do not reveal processing difficulties. With auditory processing problems, people do hear what's said, they just don't act on it properly. Not all audiologists buy into the audio processing concept. Leon noted that in most of Europe, the term ADD isn't used although a certain percentage of their population "fits" the definition of ADD.

Auditory processing difficulties involve confusion within the central nervous system, not the peripheral hearing system. People with this can do very well with visual stimuli although auditory processing difficulties are more easily distorted without the visual component.

Further, many with auditory processing deficiencies (APD) have excellent response to memory tests. Their performance, however, can be situational. Another aspect of APD is that even heavy doses of medication don't help these kids. It is of paramount importance to split APD from ADD during the diagnosis. Again, more reason to look at each individual case.

Thyroid, hypoglycemia, etc. need medical checkups to isolate.

Language disorders can also be frequently confused with ADD i.e. articulation, vocabulary, debating skills and the like. If one is frustrated by "trying to find the right words" or stringing thoughts together, these may be indications of the presence of ADD. Language skills involve sequencing, reading, and writing. A good "silent reader" is using their brain a lot. Like APD, language disorders do not respond to medication.

"We will likely see that APD and Language Disorders can be self-correcting in time which is another indication they can be separated from ADD".

Some aspects of ADD "spill out into the social skills environment" he said.

Traditional parental strategies i.e. punishment aren't particularly beneficial. A system of rewards is known to work much better. ADD children can also "push back" and/or have an oppositional response. Dr. Schofield wanted us to know that he was NOT advocating no punishment, just that we have to realize the limitations of this strategy and understand they are not as effective with children with ADD than with others. Punishment, he stated, was more for the "convenience" of the parent, not the child.

He joked about life not being like those on TV and said ADD kids can be quickly and readily agitated. Many kids with ADD have a tough time with tactile areas i.e. hugging and touching.

Traditionally the parent "gets in their face". The child sees this as a threat and this is like waving a red flag at them sometimes. The same is true of the traditional "hard ball" approach in school of having a child report to the assistant principal!

Why don't these things work for those with ADD? Their brains are "wired differently". ADD kids can "fly off the handle" with situations considered insignificant to people without ADD. Sometimes you can hear a child say things like, "He looked at me funny and I didn't like it!?"

Depression is at a high rate with ADD adults. "50% of anxiety complexes i.e. obsessive compulsive disorder, panic and general anxiety are comorbid with learning disabilities" he said.

There are also affective (emotional management) issues. Those with ADD can be very aggressive, have tantrums, stress from anger and Oppositional Defiant Disorders. Affect management is very difficult and Dr. Schofield felt we'd be missing the boat if we address only the anger elements. We need to understand why the individual reacts this way, not just label it he said.

Other examples of poor affect management, particularly in social skills, include rough and tumble play, misinterpreting body language and the lack of the ability to be "warm and fuzzy".

With all of this, Dr. Schofield told us it was necessary to understand the fix the problems, not "wander around them".

Leon had a handout from an earlier workshop he was using for this presentation, but there wasn't sufficient time to review the entire sheet during this time. The following is a listing of the handout items:

Parent Affect: Denial, loss cycle; Contributions of extended family and others; Insecurity and fear of the future; Diminishing resources; Parental style differences and conflicts.

Parent Affect Management: Validation; Knowledge; Support; Respite; Safety

Child Affect: Fatigue; Intense affect; Limited language mediation; Limited social scripts; Shame and embarrassment; Poor self image, automatic responding.

Child Affect Management: Pause, time out; Physical activity; Mental activity; Lower stimulation; Writing, drawing, rehearsal; Family government, the "town meeting".

Social Skills Building: Disarming the "I don't know/I don't care" response; Paradoxical techniques i.e. reframing, symptom prescription, restraining, relapse prediction; Priming the pump and avoiding the passivity trap; A word on "Internal vs. External locus of control"; Selecting behavioral targets i.e. nonverbal issues, body language, polite discourse, affect reducing strategies, internal speech, limit and boundary setting, the art of compromise, "win-win".

Role Change - the art of shock, surprise and fun: Postpone a fight; Alter roles; Family "upward bound" adventures; The role of helping, volunteering.

Changing the Environment: What are the child's limitations?'What about the needs of a parent and siblings? What about quiet areas? What about clutter? Noise?

Specific, typical ADD Problems: Sibling rivalry; Homework.

In response to a question asking for more definition of rough and tumble play, Dr. Schofield noted the standards have to be situational. As an example, he felt rough and tumble play with another child in the waiting room where one child did not know the other was an indication of inappropriate behavior. The aggressor, in that example, was not in a position to know if the rough play would be welcomed by the other.

Another question involved a parent not being able to tell what her child was thinking, feeling, etc. Frequently she got no response. Dr. Schofield said this was an area we needed more research on. He also asked us to remember that medications do nothing to develop social skills. We, as parents, have the responsibility to help our kids "grow their options" and get out of their limited social scope or comfort zone.

Ed Note: Dr. Leon Schofield is a licensed clinical psychologist and a NYS credentialed alcohol counselor in private practice. He has hospital privileges at Strong , F.F.Thompson, and Clifton Springs Hospital and Clinic and is an assistant professor at the University of Rochester Medical School.