Social Skills | Dr. Robin Tucker Lapidus, LLC

ADHD, as stated in my last post, is one of the most common chronic health conditions for children. Those with this condition have difficulty regulating their behaviors, attention, and/or impulsivity. ADHD presents itself in school, home, and the community and can present challenges in each environment.

ASSESSMENT

A comprehensive assessment involving multiple methods conducted by multiple professionals within different settings is important for arriving at a diagnosis of this disorder. Too often the diagnosis of ADHD is made too quickly or by observation alone. The assessment should consist of communication with the child’s medical professional, and other sources, including a psychologist, educational personnel, and family. A direct assessment of the child is also recommended. The assessment should address the age of onset of the symptoms, the degree that it impairs the child, and any other features.

How do we obtain information from different sources? First, I believe a good history is essential, one involving the child’s health, family background, and when the child’s developmental milestones were reached. A thorough history is also ascertained from information provided by school records, the child’s physician, and family members, as well as any others who might be familiar with the child.

Secondly, a physical evaluation is essential (and oftentimes, a neurological evaluation is also indicated) to rule out other causes of the disorder.

Next, information obtained from family should address different settings and include ADHD parent and child rating scales or checklists, including the assessment of inattention, hyperactivity, and impulsivity. The family assessment should also include structured and unstructured interviews.

School/classroom assessments are teacher-reported and can provide information including teacher rating scales and checklists of inattention, hyperactivity, and impulsivity, teacher narratives and reports, schoolwork, grades, and work samples, as well as specific data regarding the child’s behaviors in the classroom.

Finally, an assessment of coexisting conditions should take place that rule in or out other disorders that may include depression, learning disabilities, and anxiety, to name a few.

TREATMENT

There is no cure for ADHD at this time, but many treatments exist which are effective in the management of the disorder. When speaking of any treatment, most important is the education of the family and school staff about the nature of the disorder and its management for children. But among all of the treatments available, which ones are most effective?

The treatment that results in the greatest degree of improvement in the symptoms of ADHD is stimulant and nonstimulant medications. Before medications are considered, though, academic and behavioral interventions and accommodations should be implemented for a reasonable time. Sometimes these interventions are effective alone. According to the American Academy of Pediatrics (AAP), 80 percent of the children who use stimulant medications, either alone or with behavior therapy, show increased focus and decreased impulsivity. The most common stimulant medication, Ritalin, has been used for over 40 years in children and has shown to be safe. Strattera is a nonstimulant medication that is frequently used with children, as well. Antidepressants seem to be less effective, but are often used with those who have coexisting symptoms of mood disorders. Some children may need a combination of medications depending on if they have other disorders along with their ADHD. There are side effects to these medications and they should be discussed with the physician who is in charge of prescribing them.

The decision to use medications can be a difficult one for parents, and rightly so! If you do decide to try medication for your child’s ADHD, there must be close monitoring and frequent reassessment to decide if the treatment is working. Each decision about whether to try or not try medication should be based on what is best for the child as an individual. There is a great deal of information available on the pros and cons of starting your child on ADHD medications.

Psychological treatments, such as behavior modification in school, social skills training, and parent training in child behavior management techniques have shown to have short- term effects. Some studies suggest that once treatments end, so do the gains obtained (as with medication treatment, as well). Therefore, ADHD should be seen as a chronic condition that requires ongoing treatment for good, long-term management of the symptoms. Counseling can help parents and children understand the disorder, improve social skills, assist with behavioral interventions, and help those who are having difficulty coping.

Some children with ADHD may be eligible for special education services in the public schools under the Individual with Disabilities in Education Act – IDEA- and/or Section 504 of the Rehabilitation Act of 1973. To qualify for these services, the symptoms of the ADHD must be interfering with the child’s ability to learn in school. Thus, the comprehensive evaluation is important to ascertain whether the school services are warranted.

In summary, the treatment of ADHD requires a comprehensive behavioral, psychological, educational, and sometimes medical evaluation, along with the education of family members as to what this disorder is and the methods proven to assist with its management. Once the ADHD condition is managed, those with this disorder can usually lead adjusted and productive lives.

Please feel free to comment about this topic. I welcome your feedback!

Last week’s post focused on an introduction to the use of time-out. I emphasized the fact that your child must have the skill set to meet adult expectations before you consider using time-out. I also discussed defining appropriate behaviors for time-out, assigning time out areas (location) at home and at school, and preparing for the use of time-out at home. This week I will focus on the actual steps of implementing an effective time-out procedure.

When you are ready to implement a time-out, your child should be told quickly what behavior earned the time-out and what behaviors are required to end the time-out. Remember these important points: it is recommended that you NOT engage your child in a long dissertation about his/her behavior, and there should be NO negotiating, begging, or arguing, as that will only reinforce the inappropriate behaviors.

After you’ve identified the behavior and calmly stated why he/she is going to time-out, remove your child to your specific time-out area for brief and pre-determined periods of time. A time-out should last no longer than 1 to 2 minutes for each year of the child’s age. For example, an 8-year-old will be in time-out for 8 minutes, a 2-year-old, 2 minutes, etc. A child in time-out should be supervised for the entire period, with attention focused away from the child. Do not converse, engage, or play with your child.

When time-out is over, I like to use an audible signal to indicate that the child may come out of time-out. A kitchen timer, oven timer, microwave timer, or audible wristwatch may be used to signal that time-out has ended. In this way, the child learns to NOT leave time out until he hears the signal. (On many occasions, it will remind the adult, as well!).

The child may come out of time-out ONLY if their behavior is appropriate, i.e. sitting quietly for the final 30 seconds to 1 minute of the time-out. If you release your child from time-out during a tantrum, while screaming, or being disruptive, your child learns to express these behaviors to end the time-out. If your child refuses to leave time-out, ignore him/her. Do not engage in arguments at this time as it can lead to noncompliance with the time-out process.

When your child leaves time-out, he/she must complete the task or request that occurred just prior to the targeted behaviors. Allowing a child to use time-out to avoid a task or situation is counterproductive. For example, your 10-year-old spilled a glass of juice on the floor, resulting in a tantrum and refusal to clean the spill upon your request. After the 10 minutes in time-out, he/she will be required to clean up the spillage – not you.

When time-out occurs in a school situation, it should be shared with all staff involved with the child. How long the time-out lasted, the child’s behavior while in time-out and the behavior directly preceding or leading to the time-out should be documented and posted in entry/exit of the time-out location for other staff members.

Written documentation can reveal important data about your child and his/her behavior and the effectiveness of the time-out. It is imperative if your child is in time-out in school that proper documentation is recorded for every occurrence. However, I personally do not believe that documentation at home is as important as at school UNLESS your child’s behavior has become so problematic that documenting it would help other caregivers. In all situations, if the behaviors do not decrease after two weeks, then reevaluate the procedure, with one important exception—If the behaviors are dangerous, it is recommended that you not wait two weeks before seeking the help of a professional.

Of course, time-out does have limitations to consider. When in time-out, the child is removed from positive learning and/or social situations. For children with limited social skills, this is particularly concerning. Some children LIKE being alone and time-out is too reinforcing for them. Time-out can also be reinforcing to adults as it removes the difficult child, which can entice the adult to use time-out too frequently, for longer periods of time than recommended, or for other than targeted behaviors. That is why keeping a written log and reviewing it daily or weekly can be so important. If the log indicates that the procedure is not working, then the program may be tweaked to make it more effective.

Time-out is a very effective procedure for behavior change if used properly, with good planning, documentation, and review. I would love to hear your experiences with time-out with your children or students. Please leave me a reply with your comments, suggestions, or possible future topics.