ADD/ADHD and Effective Parenting

A talk given for Parents by Dr. Sam Goldstein at the European Conference on ADHD - Oxford - 8th April 1997.

Dr. Goldstein is a psychologist working in the Neurology, Learning & Behaviour Centre in Salt Lake City, Utah.

Some key points from that talk follows:

  • We as parents should be asking, what do we want for our children?
  • Why do we want it?
  • What price for success?
  • We need to focus on competence/assets (not on dead men's behaviour)
  • As parents our job is to a case manager. We have to become an expert.
  • We need to be proud patent, persistent and be there for our kids.
  • We need to focus on resilience, finding protective factors, islands of self-esteem, replenishment for the journey.
  • We define children's behaviour by its impact onus.

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Children's behaviour divides broadly into two types:

Annoying--------------Worrisome
Disruptive--------------Non-disruptive
Externalising--------------Internalising

These types range in degree:

  • On the disruptive side ADHD on its own, is at the mild end of the spectrum, and conduct disorder is at the really unsettling end.

    On the non-disruptive side emotional distress may be fairly mild, but can range to include serious depression and anxiety. Developmental impairments often play a role.

    ADHD has a catalytic quality. If you mix it up with bad stuff, you are more likely to have bad endings.

    Of the children who come to clinics, only about 15% have ADHD alone - most have other things as well.

    The core problem of ADHD is impulsively - OTM. OTM = ON THE MIND, OUT THE MOUTH.

ADHD is a disorder of faulty inhibition (not attention). To be successful on our world, you have to learn to inhibit impulses and use language.

Inattention and distractibility are not a problem, if kids are interested and invested in a task.

ADHD kids have the most difficulty when tasks are:

  • Repetitive
  • Uninteresting
  • Effortful
  • Unchosen

As these things become less, the ADHD kid will have fewer problems.

ADD without hyperactivity is a whole separate problem - a disorder of vigilance.

  • ADD kids get in trouble for showing emotions. They are on an emotional rollercoaster, have problems with intimacy, inability to modulate (faulty inhibitions), too much emotion too quickly.
  • ADD kids have difficulty with rewards.
  • They cannot delay.
  • Long term rewards are not effective.
  • They experience frequent negative reinforcement.
  • 80% of the time ADHD kids are working to avoid aversive consequences. We are cursing these kids to "help them". What can we do about this ? (It is better to learn to get half the work done with some sense of independence.)

What these kids need are more frequent re-enforcers:

  • Immediate
  • Frequent
  • Predictable
  • Salient

Contingency based rewards (controlled by the environment) VS rules governed rewards (coming from inside). Contingency-based rewards become rule governed of after a time. It takes ADHD kids lots longer to develop cues/internalise. They don't catch the cues in the same way as non-ADHD kids. If you can be patient, you can get ADHD kids to move mountains, to learn to self-regulate and self-monitor. Incompetence is not non-compliance.

ADHD is a disorder of inconsistency. It reflects exaggeration (either too much or not enough). It is not a time limited disorder. It is not determined by a single gene, but part of a very complicated system where protective genes may play a part. Biology is not necessarily destiny.

Effects on parents of having an ADHD child may include:

  • Increased stress
  • Greater psychopathology (e.g.: more depression among mothers)
  • Greater marital discord
  • Child exerts great control

Overview of the elements of treatment

  1. Appropriate assessment (essential)
  2. Knowledge of the disorder (essential)
  3. Medication
  4. Behaviour management
  5. Educational interventions
  6. Focus on resilience
  7. Building islands of competence

A model of parenting an ADHD child will include these elements:

  1. Education
  2. Incompetence vs. non compliance
  3. Positive directions
  4. Rewards
  5. Timing (keep track of what you do & when you do it.)
  6. Response costs
  7. Planning
  8. Take care of yourself
  9. Take care of your child

Response costs - The ratio of reward to penalty for an ADHD child is about 8:1. The child needs to get 8 rewards to feel they are succeeding for every 1 taken away is to fall. The best strategy is to use a full plate of rewards and encourage them to keep it full, rather then starting from 0. A possible strategy would be to give the full allowance and take away say 5ps for any of 5 rules broken. (You can build up rules over time.) In the end, the relationship you have with your kid is the best predictor.

For good outcomes, the most powerful resilient factors include:

  • An easy temperament
  • Consistent family relationships
  • Competent care-givers
  • Development of self-esteem
  • Emotional security

HOPE, ENCOURAGEMENT AND SUPPORT ARE MORE IMPORTANT THAN RITALIN.