Treatment Planning for Challenging Teens with ADD and ADHD
TREAT THE CHILD AND PARENTS AS VALUED PARTNERS. Several nationally recognized children's mental health consultants and staff at the Center for Mental Health Services (formerly part of NIMH) embrace the child and parents as valued, equal partners in the treatment process. The child and parents are actively involved in treatment planning and decision making. Treatment is not something that is done to the family but rather a process they help guide. Their feedback on numerous topics including effectiveness of medication and intervention strategies is invaluable. Most parents are capable of helping orchestrate their child's treatment. They often know their child best and have a long-term commitment plus tenacity that professionals can seldom match. As my colleague Beth Dague wisely observed, "Professionals come and go, parents stay."
DEVELOP AN INDIVIDUALIZED TREATMENT PLAN. A comprehensive treatment plan covering all important aspects of a teenager's life is more effective than a plan that addresses only one or two elements such as medication and counseling. In addition, finding creative solutions to coping with problem behaviors is critical. Information in Table 4-1 from Teenagers with ADD and ADHD may help parents visualize the important concepts of individualized treatment. Specific actions steps are identified in each of four categories:
1) effective medical treatment,
2) ADHD training for both parents and child (support and interventions for the whole family),
3) succeeding at school (provide accommodations), and
4) achieving successes in a variety of community activities.
WORK FROM A "WELLNESS" PERSPECTIVE. Believing in a "wellness model" and building on the strengths of the family is critically important. This is in contrast to an "illness model," which focuses only on identifying problems, diagnosing an "illness," and placing blame on the teenager and parents. To help build on strengths, Dr. Sydney Zentall suggests that we reframe our perceptions of attention deficits in a positive light. For example, she explains that bossiness may also be viewed as "leadership". Strong willed and stubborn may be perceived as "tenacious" and argumentative as "persuasive". Local parent groups such as CHADD, ADDA-SR, are LDA are excellent resources for helping parents find professionals who utilize a wellness approach in treating ADD and ADHD.
TREAT COEXISTING PROBLEMS. ADD and ADHD rarely occur alone. In a recent study by NIMH, researchers found that two thirds of all children with ADHD have a least one other coexisting condition! Several major problems may coexist with an attention deficit and must be treated for the best outcome. According to Dr. Mel Levine, treating ADD or ADHD in isolation is like using a band-aid to treat the problem. The most common coexisting problems are Oppositional Defiant Disorder - 59% (ODD) or Conduct Disorder - 24-42% (CD); anxiety or depression - 28%; and learning disabilities 25-50%+. ODD, CD, anxiety, or depression may respond well to treatment with medication.
1) Learn communication skills that defuse anger and reduce oppositional behavior rather than inadvertently escalate problems. Keep hostile interactions to a minimum. (See Teaching Teens - Summaries 64, 65, 66, and 67 for more info.)
2) Utilize effective parenting techniques such as giving choices and using depersonalization will also help reduce oppositional behavior. (See Teenagers with ADD and ADHD - Chapters 8-9.)
3) To address academic problems, identify specific learning problems and make accommodations in the classroom. For example allow use of a calculator for a student who is unable to memorize or cannot rapidly recall math facts. Request untimed tests or an untimed SAT for a student who has slow cognitive processing speed. (See Teaching Teens - Summaries 12-25.)
4) Sleep disturbances cause problems for half these children. They have trouble falling asleep and waking up, plus may not be getting restful sleep. Sleep problems may be managed through setting up a bedtime routine, exercise, or sometimes taking medication. (See Teenagers with ADD and ADHD - Chapter 9.)
MAXIMIZE MEDICATION EFFECTIVENESS. Medication is often the cornerstone of the treatment program. However, the first medication dosage prescribed may not meet the teenager's needs. For optimal results, "trial-and-error" fine-tuning is often the name of the game for determining the proper medication and dose for each teenager. In their book, Driven To Distraction, Dr. Edward Hallowell and Dr. John Ratey suggest that families not come to the conclusion too quickly that "medication isn't working." In more complex cases, it may take a few weeks to find the best medication or dosing schedule, since each teenager responds differently to medication. If one stimulant medication is not effective, the doctor may consider prescribing a different stimulant medication. Dr. Tom Brown has found that people with ADD inattentive respond well to a combination of a stimulant and antidepressant. Remember also that some problem behaviors such as forgetfulness, disorganization, slow cognitive processing speed, or poor time management may not improve significantly even with medication. You may find Dr. Tim Wilens' popular book, Straight Talk about Psychiatric Medications for Kids, to be an excellent resource for your family.
One of the major problems with medication is that teenagers with attention deficits have difficulty remembering to take it!! As one psychiatrist humorously observed, if a teenager can remember to take his medicine consistently, he probably doesn't have an attention deficit. "Medication refusal", which sometimes occurs during adolescence, may actually be "medication forgetfulness". Teenagers may need help devising a system to remember to take their medicine. For example, parents may place meds in a weekly container and put them by his breakfast plate or bathroom sink. Or if parents are away from home, they can beep him as a reminder. He may also set an alarm on his watch, ask to be prompted by teachers, or simply take a sustained-release medication.
It is important to avoid conflicts over medication. If parents mistakenly assume the worst, that the teenager is refusing the medication rather than just forgetting it, taking medication may unnecessarily become the focal point of a major power struggle. Teenagers tire of constant questioning about medication. When a teenager misbehaves or is forgetful, the temptation is so great for adults to immediately ask, "Did you take your medicine?" If medicine is placed in a see-through weekly container, parents can tell at a glance, without asking, whether or not he remembered to take it. In reality, many teenagers don't mind taking their medication because they can tell the difference in their ability to concentrate. It feels good to succeed in school.
If he is refusing to take his medication, ask why he has reservations. Listen and respect his input. Make changes to accommodate his concerns. Sometimes teenagers are embarrassed to take medication at school since they may not want other students to know they are on medication. Taking a long-acting form of stimulant medication such as Adderall, Concerta, or Strattera, will eliminate this problem. If the family can't resolve problems regarding medication, a treatment professional may be helpful. Occasionally, not taking medicine may pose a safety risk. In these instances, parents might say, "When you drive the car, you must take medication."
ENSURE SUCCESS AT SCHOOL. Succeeding at school is critical for teenagers with attention deficits. Learning problems are extremely common and must be identified and accommodations made in the classroom to ensure academic success!! If a teenager has untreated learning problems, a vicious cycle of school failure, conflicts with adults, and lower self-esteem may occur. Parents must be educated about provisions of key federal laws (IDEA and Section 504). Teach parents to write an IEP and negotiate for classroom accommodations. Teaching Teens with ADD, ADHD, and Executive Function Deficits provides extensive suggestions for ensuring academic success.
Examples of common learning problems and classroom accommodations include: If a teenager with short, working or long-term memory problems cannot memorize multiplication tables or quickly recall basic math facts, allow him to use a calculator. Giving tips for memorizing information may also be helpful. (See Teaching Teens - Summary 25 for memory tips.)
A student who has slow cognitive processing (slow reading or writing) may be given shortened homework assignments or extended time for tests. Students who are extremely forgetful and disorganized may be given assignments in writing. Accommodations might also include making changes to the school environment. For instance, it might help to switch to a classroom teacher who is more understanding of students with attention deficits or to schedule difficult academic classes earlier in the day.
KEEP A DISABILITY PERSPECTIVE. Dr. Russell Barkley reminds us to keep a "disability perspective." ADHD is a disability for some teenagers! Parents and professionals should examine their attitudes about attention deficits. If we think the teenager is maliciously misbehaving and intentionally failing to do school work, then a logical response is to believe that he will get better only if we force him to do things or punish him. On the other hand if we believe that he wants to do well but is struggling to cope with a disability--an attention deficit disorder, then we will convey a different attitude. We will be positive, provide support and guidance, teach new skills, consider medication, and when needed, implement consequences for misbehavior.
Teach the teenager to cope with his disability and solve his own problems. "I believe you are doing your best but your attention deficits is making school difficult for you. I am convinced you want to comply with rules and do well academically. What do you think needs to do done to solve_____? How can I help you?" If he has no suggestions, then suggest something like, "Completing your homework is essential for passing your classes. Let's develop a plan for making certain your homework is done every night."
UTILIZE A COACH. Dr. Hallowell and Dr. Ratey suggest enlisting the help of a "coach" for keeping up with the details of everyday living and school work. Often parents must serve as the coach. It is important for professionals to give them permission to be involved. Sometimes parents are put on "guilt trips" for providing essential developmentally appropriate support and supervision for their teenager, after all their teenager lags behind his peers 4 to 6 years in some skills. Parents often hear, "He is old enough to accept responsibility for getting his school work done." or "He must be held accountable for his actions." Of course, there are elements of truth in these statements but we must remember also, he is developmentally behind his peers four to six years plus inattentive, emotional, and forgetful by nature. He may not be able to take full responsibility for his homework assignments, books, or chores until a later time when he is more mature. Break each skill into smaller steps, start at his present level of performance, and teach the next step! By "shaping" his behavior and teaching him needed skills, eventually, he will learn to compensate or do these tasks even though it may be at a later age.
TEACH PARENTING SKILLS. A dozen parenting "pearls of wisdom" may be helpful:
1) Use positive parenting techniques more often than negative ones.
2) Make consequences instructive not just punitive. As my colleague Dixie Jordan explains, "Teach him needed skills rather than just punish him for his lack of skills."
3) Focus on the teenager's strengths--the things he does well--rather than his deficits. Don't dwell on the negative aspects of his behavior.
4) Help these teenagers find some joy in life each day.
5) Maintain a sense of humor. Hopefully parents can laugh after a crisis has passed. Somehow the stories of their ADD/ADHD misadventures, such as driving the car into a tree at age two, seems more humorous with the passage of time.
6) Pick and chose your battles. School failure or speeding tickets are usually a higher priority for intervention than a dirty room.
7) Ignore less serious things. If parents correct or punish a child with an attention deficit for everything he does wrong, everyone in the family will be hostile and exhausted. "Don't sweat the small stuff". Penny Dieckman, a very wise CHADD colleague and parent once said, "I used to sweat the small stuff until I figured out what the big stuff was."
8) Give limited choices. When choices are given, teenagers are more compliant, less hostile, and more productive.
9) Use depersonalization rather than placing blame. For example, you might say, "Some teenagers with attention deficits have trouble remembering their homework assignments. How can we work together to solve this problem?", rather than "You never do your homework". Don't forget that one of the diagnostic criteria for ADHD is forgetfulness--for many teens, it is part of their disability.
10) If you can't change the ADD/ADHD behavior, change the environment. Put the list of chores in writing or beep him when it is time to come home.
11) Anticipate that crises may occur on a regular basis. Teach the family coping skills, give them tips on preventing crises, and have confidence that they will weather each crisis as it arises.
12) Keep ADD/ADHD in perspective. Success in school is not the only measure of a child's worth! A teenager's life includes much more than just twelve years in school.
Although behavior management is one of the best strategies parents can use, even it has some limitations.
- First, behavior management techniques that were effective during childhood do not work as well with teenagers. Many teenagers have been on behavioral programs since they were children and are sick of "charts and stars." As teenagers, they may rebel against what they perceive as being constantly manipulated.
- Second, since teenagers with attention deficits don't learn from rewards and punishment as easily as other children, these techniques are slightly less effective. Although negative interventions such as punishment or withholding rewards or privileges can be used to change a child's behavior, Dr. Barkley is quick to point out, however, that punishment alone is usually ineffective! Using logical consequences instead of arbitrary punishment will sometimes minimize a teenager's hostility toward parents.
PROVIDE SUPPORT, TRAINING, AND COUNSELING. Since traditional approaches to discipline don't seem to make lasting changes in the behavior of youngsters with attention deficits, learning new parenting skills to channel the teenager's energy and cope with misbehavior can be a lifesaver. It is also unrealistic to assume that an outside treatment professional will be able to solve all the teenager's problems for the family.
1) Parent training classes and parent support groups may be especially helpful in introducing parents to behavior management and other effective parenting techniques. Parents often find it reassuring to learn that so many other parents of children with ADD or ADHD have experienced similar problems.
2) Sometimes parents attend counseling alone to learn new skills to cope with problem issues.
3) Later, educational classes or counseling may be offered to the teenager. It is critical to teach teens about their attention deficit so that they understand themselves better, understand why they do the things they do, learn coping strategies, and learn to take charge of their own lives and this challenging condition! Even if problems are mild, someone--parents, the physician, teacher or counselor--needs to educate the teenager about ADD/ADHD. In one or two sessions, the teenager should be able to grasp the basics of the attention deficit disorder and how it affects his behavior, to reframe the positive elements of his condition, to understand that he can cope with and compensate for ADD/ADHD, and to be assured that a lot of successful people also have it. Medication is not a miracle cure. He should know both its benefits and limitations. He needs to understand that he must make a conscious effort to improve his organizational skills and school work. He must learn to compensate for having an attention deficit.
My son Alex and I wrote A Bird's-Eye View of Life with ADD and ADHD, expressly for the purpose of educating teens, preteens, and young adults about their ADD or ADHD in an entertaining yet scientifically accurate way.
4) A training session or video tape featuring teenagers talking about the medication they take, how it makes them feel, and how they remember to take it, is a very powerful way to educate children. (See our new DVD, Real Life ADHD, for great information from 30 teens and a physician who have ADHD.)
Hopefully, as children with attention deficits reach adolescence and abstract thinking improves, their ability to learn from skills training classes may carry over into real-life situations. Skills sometimes addressed by schools, mental health, or counselors include: communication, organization, getting along with peers, anger control, study habits, time management, and test taking.
In summary, develop an individualized treatment plan through a partnership between the family and treatment professional.
Be tenacious! Don't give up! Believe in your teenager and your family!
Do whatever it takes to help the teenager succeed!!