They need reminders. They need previews. They need repetition. They need direction. They need limits. They need structure.
7. Post rules. Have them written down and in full view. The children will be reassured by knowing what is expected of them.
8. Repeat directions. Write down directions. Speak directions. Repeat directions. People with ADD need to hear things more than once.
9. Make frequent eye contact. You can “bring back” an ADD child with eye contact. Do it often. A glance can retrieve a child from a daydream or give permission to ask a question or just give silent reassurance.
10. Seat the ADD child near your desk or wherever you are most of the time. This helps stave off the drifting away that so bedevils these children.
11. Set limits, boundaries. This is containing and soothing, not punitive. Do it consistently, predictably, promptly, and plainly. Don’t get into complicated, lawyerlike discussions of fairness. These long discussions are just a diversion. Take charge.
12. Have as predictable a schedule as possible. Post it on the blackboard or the child’s desk. Refer to it often. If you are going to vary it, as most interesting teachers do, give lots of warning and preparation. Transitions and unannounced changes are very difficult for these children. They become discombobulated by them. Take special care to prepare for transitions well in advance. Announce what is going to happen, then give repeat reminders as the time approaches.
13. Try to help the children make their own schedules for after school in an effort to avoid one of the hallmarks of ADD: procrastination.
14. Eliminate, or reduce the frequency of, timed tests. There is no great educational value to timed tests, and they definitely do not allow many children with ADD to show what they know.
15. Allow for escape-valve outlets such as leaving class for a moment. If this can be built into the rules of the classroom, it will allow the child to leave the room rather than “lose it,” and in so doing begin to learn important tools of self-observation and self-modulation.
16. Go for quality rather than quantity of homework. Children with ADD often need a reduced load. As long as they are learning the concepts, they should be allowed this. They will put in the same amount of study time, just not get buried under more than they can handle.
17. Monitor progress often. Children with ADD benefit greatly from frequent feedback. It helps keep them on track, lets them know what is expected of them and if they are meeting their goals, and can be very encouraging.
18. Break down large tasks into small tasks. This is one of the most crucial of all teaching techniques for children with ADD. Large tasks quickly overwhelm the child, and he recoils with an emotional “I’ll-never-be-able-to-do-that” kind of response. By breaking down the task into manageable parts, each component looking small enough to be doable, the child can sidestep the emotion of being overwhelmed. In general, these kids can do a lot more than they think they can. By breaking tasks down, the teacher can let the child prove this to himself or herself. With small children this can be extremely helpful in avoiding tantrums born of anticipatory frustration. And with older children it can help them avoid the defeatist attitude that so often gets in their way.
19. Let yourself be playful, have fun, be unconventional, be flamboyant. People with ADD love play. They respond to it with enthusiasm. It helps focus attention—the kids’ attention and yours as well. So much of their “treatment” involves boring stuff like structure, schedules, lists, and rules, you will want to show them that those things do not have to go hand in hand with being a boring person, a boring teacher, or running a boring classroom. Every once in a while, if you can let yourself be a little bit silly, that will help a lot.
20. Still again, watch out for overstimulation. Like a pot on the fire, ADD can boil over. You need to be able to reduce the heat in a hurry.
21. Seek out and underscore success as much as possible. These kids live with so much failure, they need all the positive handling they can get. This point cannot be overemphasized: these children need and benefit from praise. They love encouragement. They drink it up and grow from it. And without it they shrink and wither. Often the most devastating aspect of ADD is not the ADD itself, but the secondary damage done to self-esteem. So water these children well with encouragement and praise.
22. Memory is often a problem with these kids. Teach them little tricks like mnemonics, flash cards, etc. They often have problems with what Dr. Mel Levine, a developmental pediatrician and one of the great figures in the field of learning problems, calls “active working memory,” the space available on your mind’s table, so to speak. Any little tricks you can devise—cues, rhymes, codes, and the like—can help a great deal to enhance memory.
23. Use outlines. Teach outlining. Teach underlining. These techniques do not come easily to children with ADD, but once they learn them, the techniques can help a great deal in that they structure and shape what is being learned as it is being learned. This helps give the child a sense of mastery during the learning process, when he or she needs it most, rather than the dim sense of futility that is so often the defining emotion of these kids’ learning process.
24. Announce what you are going to say before you say it. Say it. Then say what you have said. Since many ADD children learn better visually than by voice, if you can write what you’re going to say as well as say it, that can be most helpful. This kind of structuring glues the ideas in place.
25. Simplify instructions. Simplify choices. Simplify scheduling. The simpler the verbiage the more likely it will be comprehended. And use colorful language. Like color-coding, colorful language keeps attention.
26. Use feedback that helps the child become self-observant. Children with ADD tend to be poor self-observers. They often have no idea how they come across or how they have been behaving. Try to give them this information in a constructive way. Ask questions like, “Do you know what you just did?” or “How do you think you might have said that differently?” or “Why do you think that other girl looked sad when you said what you said?” Ask questions that promote self-observation.
27. Make expectations explicit.
28. A point system is a possibility as part of behavioral modification or a reward system for younger children. Children with ADD respond well to rewards and incentives. Many are little entrepreneurs.
29. If the child has trouble reading social cues—body language, tone of voice, timing, and the like—try discreetly to offer specific and explicit advice as a sort of social coaching. For example, say, “Before you tell your story, ask to hear the other person’s first,” or, “Look at the other person when he’s talking.” Many children with ADD are viewed as indifferent or selfish, when in fact they just haven’t learned how to interact. This skill does not come naturally to all children, but it can be taught or coached.
30. Teach test-taking skills.
31. Make a game out of things. Motivation improves ADD.
32. Separate pairs and trios, whole clusters even, that don’t do well together. You might have to try many arrangements.
33. Pay attention to connectedness. These kids need to feel engaged, connected. As long as they are engaged, they will feel motivated and be less likely to tune out.
34. Give responsibility back to the child when possible. Let him devise his own method for remembering what to put into his bookbag, or let him ask you for help rather than your telling him he needs it.
35. Try a home-to-school-to-home notebook. This can really help with the day-to-day parent-teacher communication and avoid the crisis meetings. It also helps with the frequent feedback these kids need.
36. Try to use daily progress reports. These may be given to the child to hand on to his parents, or if the child is older, read directly to the child. These are not intended as disciplinary, but rather as informative, and encouraging.
37. Physical devices such as timers and buzzers can help with self-monitoring. For example, if a child cannot remember when to take his or h
er medication, a wrist alarm can help, rather than transferring responsibility to the teacher. Or during study time, a timer placed on his desk can help the child know exactly where the time is going.
38. Prepare for unstructured time. These kids need to know in advance what is going to happen so they can prepare for it internally. If they suddenly are given unstructured time, it can be overstimulating.
39. Praise, stroke, approve, encourage, nourish.
40. With older children, suggest that they write little notes to themselves to remind them of their questions about what is being taught. In essence, they can take notes not only on what is being said to them, but what they are thinking as well. This will help them listen more effectively.
41. Handwriting is difficult for many of these children. Consider developing alternatives. Suggest learning how to type. Consider giving some tests orally.
42. Be like the conductor of a symphony. Get the orchestra’s attention before beginning. (You may use silence, or the tapping of your baton, to do this.) Keep the class “in time,” pointing to different parts of the room as you need their help.
43. When possible, arrange for students to have a “study buddy” in each subject, with phone number (adapted from Gary Smith, who has written an excellent series of suggestions on classroom management).
44. To avoid stigma, explain to the rest of the class and normalize the treatment the child receives.
45. Meet with parents often. Avoid the pattern of meeting only when there are problems or crises.
46. Encourage reading aloud at home. Read aloud in class as much as possible. Use storytelling. Help the child build the skill of staying on one topic.
47. Repeat, repeat, repeat.
48. Encourage physical exercise. One of the best treatments for ADD, in both children and adults, is exercise, preferably vigorous exercise. Exercise helps work off excess energy, it helps focus attention, and it stimulates certain hormones and neurochemicals that are beneficial, and it is fun. Make sure the exercise is fun, so the child will continue to do it for the rest of his or her life. John wrote a best-selling book called Spark: The Revolutionary New Science of Exercise and the Brain in 2008, and has devoted a whole chapter in this book to talking about the benefits of exercise and how it acts very similarly to our stimulant medication.
49. With older children, stress preparation prior to coming into class. The better idea the child has of what will be discussed on any given day, the more likely the material will be mastered in class.
50. Always be on the lookout for sparkling moments. These kids are far more talented and gifted than they often seem. They are full of creativity, play, spontaneity, and good cheer. They tend to be resilient, always bouncing back. They tend to be generous of spirit, and glad to help out. They usually have a “special something” that enhances whatever setting they’re in. Remember, there is a melody inside that cacophony, a symphony yet to be written.
Common Problems in the Treatment of ADD
The treatment of ADD varies considerably from person to person. Depending on the severity and complexity of the situation, the treatment may last from a few sessions to several years. Sometimes the treatment consists just in making the diagnosis and providing some education. Sometimes the treatment becomes very involved, requiring years of individual and family therapy, various medications, and much persistence and patience. Sometimes there is spectacular improvement; sometimes the change is so slow that it is difficult to recognize. There is no one recipe for the treatment of ADD. Each case presents its own problems and requires its own solutions. But there are general principles one can follow, and they have been outlined in this chapter.
In addition, there are particular obstacles one encounters frequently in the treatment of ADD. What follows is an analysis of ten of the most common.
1. Certain key individuals in the person’s life—teacher, parent, spouse, employer, friend—do not accept the diagnosis of ADD.
They do not “believe in” ADD, and they do not want to talk about it. It almost seems to go against their religion or core ethics. They make the person with ADD feel like a fraud or a faker. Such a disbelieving response can undermine both the hope that begins with the diagnosis and the treatment. One often hears variations on the theme of “There’s no such thing as ADD. It’s just an excuse for being lazy. Put your energy into buckling down and working harder instead of pursuing bogus diagnoses.”
Dealing with this response can be tricky. It is best that the individual with ADD not take the chief responsibility for handling it, because that usually leads to a struggle. It is wiser for the professional making the diagnosis to address whatever skepticism or disbelief may arise among those involved with his patient—be they extended family, spouse, teacher, employer, or friend.
The name of the game is education. Give the people the facts. Stay with the facts, confronting superstition, rumor, hearsay, prejudice, and misinformation with fact. Try to avoid inflammatory debate. Often those objecting to the diagnosis will be using their objections to conceal an emotional agenda. They may be angry with the person being diagnosed. They may resent him for all his past sins, and they don’t want to see him get off with just a diagnosis. They want punishment. So they will grow angry at the notion of ADD, and try to discredit it. At these moments it is best to stay with the science, to stay with the facts we have about ADD. At some point one may need to address the angry feelings for what they are: angry feelings. They usually derive from past annoying behavior on the part of the person with ADD. These angry feelings are totally understandable and valid; however, they should not be used to invalidate a correct diagnosis of ADD.
2. After an initial burst of improvement, progress slows.
Often when the diagnosis of ADD is made—particularly in adults—there is an initial period of euphoria: at last there’s a name for all the suffering the person has endured through the years. And usually there is an initial spurt of emotional growth as the treatment begins. However, after some months, the growth curve begins to level off, and the individual may become despondent. This is normal and understandable. The beginning of treatment is exciting, and it is disappointing to confront the fact that the treatment does not make all of life’s problems go away. It is at this point of dismay that support is crucial—from a therapist, from a support group, from friends, from family, from books. The individual needs help to stay on course and not revert to old habits of negative thinking and self-sabotage.
3. The person with newly diagnosed ADD does not want to try medication.
His reasons are not quite clear, but he has a strong, negative reaction to the idea of medication. This is very common, both in adults, children, and parents of children. Understandably, no one wants to take medication unless it is necessary. Any medication, but particularly medication that affects the brain, deserves special care. No one should take medication against their wishes (unless they are mentally incompetent), and no one should be bullied into taking medication.
If the individual strongly objects to taking medication, he should not take it. However, before making this decision, it is best to get all the facts and make a scientific, rather than a superstitious, decision. Sometimes it takes months or even years before a person decides to try medication. Everyone has their own timetable. But the medication stands a much better chance of working if it is taken with a full understanding of its measured benefits and risks.
4. No medication seems to work.
The key here is to keep trying. Since the field of treatment for ADD, particularly in adults, is young, and since new medications are being developed all the time, and old medications are being tried in new ways, we are still operating largely on a trial-and-error basis. There is as yet no way to predict with certainty who will respond to what medication for the treatment of ADD. If one medication does not work, another one may. If the second does not work, a third may yet. And changes in dose and timing of dose can also make a big difference. It can take many months to fi
nd just the right medication, dosage, and dosing schedule.
Some people are exquisitely sensitive to medication. This is not a problem as long as it is recognized. Some people cannot tolerate anything but the tiniest dose of any medication. When they get a headache, they take a quarter of an aspirin. Just a sip of coffee keeps them up all night. So it can be with the medications used for ADD. Ten milligrams of Norpramin, a very small dose, may be too much and may make some people feel too activated. They may need to take 10 mg every other day, or, as one of my patients does, cut the pill in quarters and take 2.5 mg a day. It is important to keep this dosing sensitivity in mind, because some who could benefit from microdoses of medication give up too soon, thinking they cannot tolerate the medication at all.
It can be very frustrating for the patient—and the doctor—as they try to find just the right medication, or combination of medications, and the right dosage, but it is important to keep trying.
5. In filling some prescriptions, some pharmacists, in their attempt to comply with federal drug regulations, make consumers feel as though they are obtaining illicit drugs.
Looking up from behind the counter, the pharmacist’s eyes seem to say, “You want Ritalin? What are you, some kind of drug dealer?” This is because of the association between Ritalin and “speed” in some people’s minds. Until it is widely known that Ritalin is a safe, effective, and non-habit-forming treatment for ADD in adults, this unfortunate situation will probably continue to exist.
6. You can’t find other people who understand what it feels like to have ADD.
One of the hardest parts about having ADD can be the feeling of being alone, of being “different,” of feeling misunderstood. An excellent way to deal with this problem is to join a support group. These groups bring people together, supply information, build confidence and camaraderie, and over time reduce one’s sense of loneliness or isolation. Most parts of the country now have active ADD groups. You can consult your local pediatrician, psychiatrist, neurologist, or hospital to locate these groups, or you can call the organizations listed above or at the end of this book.
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