Vicki Panaccione, Ph.D, has extensive experience in working with children diagnosed with ADHD(Attention Deficit Hyperactivity Disorder). Dr. Vicki, as she is affectionately known, has kindly agreed to share some of her expertise with our readers.
Can you give us a little background regarding your experience and qualifications for working with children with ADHD?
I am Vicki Panaccione, Ph.D., aka "Dr. Vicki or "The Parenting Professor." I have devoted my 25 year career as a child psychologist working exclusively with children and families. In that span of time, I would estimate that I have worked with over 100 children diagnosed with ADHD.
My mission is to help and support parents raise happy, successful kids…and enjoy the ride. To this end, I have founded the Better Parenting Institute, serving as a resource for good parents who want to do it better… Because the better you do, the better they become.
Have you ever been interviewed or published in any major publications?
I am very proud to say that I have! I have been interviewed and/or quoted in major national and international publications including: The New York Times, Parents Magazine, Parenting Magazine, Reader's Digest, First for Women Magazine, Family Circle Magazine, Star Magazine, TV stations: Fox, NBC, ABC and CBS.com, Newsday.com, Forbes.com, Good Housekeeping.com, WebMD, LoveToKnow Teens, iParenting.com and affiliates sites, MTV/Nickelodeon's parentsconnect.com and the International Herald Tribune. I have even been invited to appear on the Dr. Phil Show!
I am the developer of the Parenting Enrichment Series (PES), identifying the seven essential aspects of effective parenting, and the author of 101 Parenting Tips Series and Discovering Your Child, a guide for parents to help their children find their path and follow their dreams. I write CaringConnections, a weekly on-line newsletter, and monthly parenting columns for various periodicals and Web sites.
What is ADHD?
ADHD is a neurologically-based condition, resulting from a weakness in self-regulation. It is a nervous-system based difficulty, created by a deficit in certain chemicals in the brain called neurotransmitters. These chemicals help transmit messages within the brain. Studies have suggested that these chemicals (dopamine, serotonin, and norepinephrine) are in short supply or not doing their job well. As a result, the child has a weak regulatory system, or what I call a weak governor. This weakness in self-regulation actually causes a child to pay attention TOO MUCH! They are actually hyper-aware rather than unaware. Every stimulus is of equal importance; the child is weak in the ability to screen out distractions. So, s/he ends up paying too much attention to everything at once. The child is constantly being flooded by stimuli and attending to too many things. As a result, he ends up paying attention poorly to any one thing; hence he outwardly looks as though he isn't paying attention.
An example of this is a boy I sat with at a luncheon, who asked me if I heard the music. (There was no music playing.) When I commented that I didn't hear anything, he told me to listen: he was hearing the music of the silverware scraping the plates, the knives and forks coming together and the subsequent rhythm of 150 people eating! Now: If you are that hyper-attentive, can you imagine sitting there trying to have a conversation and staying focused on one specific topic?
What are the symptoms of ADHD?
ADHD symptoms are categorized in three basic areas:
- Hyperactivity: These kids are described as, 'Bouncing off the walls,' 'always on the go,' 'restless,' and 'can't sit still.' They leave their seat inappropriately, walk around the room at inappropriate times, move constantly (tapping, humming, leg-swinging, fidgeting, squirming, etc.) and disturb other children.
- Inattention/distractibility: Children who are 'inattentive and distractible' actually attend to everything, and therefore appear to be attending to nothing! These are the kiddos who 'don't pay attention,' are easily distracted and off-task, forget things learned, have difficulty following instructions, fail to finish work, daydream and stare off into space.
- Impulsivity/Over-reactivity: Impulsive kids are frequently mislabeled as defiant, disrespectful or oppositional. These are the kids who can't control their impulses. They act without thinking. They don't stop to think of the consequences of their actions; if a thought comes into their mind… they do it. They can be reckless daredevils. And they can be the kids who two minutes ago got in trouble for something, and here they are doing it again. They have difficulty waiting their turn, will interrupt or intrude upon others and blurt out answers without raising their hands.
Children who are over-reactive have two switches: off and high. They lack middle ground; the have difficulty modulating their feelings. So, they are either happy or enraged. They aren't miffed, ticked-off, annoyed, upset, angry, etc… they are furious! Their weak regulatory system creates problems in self-control (be it behavior or emotions).
A child can have symptoms in one or all of the categories, and still be diagnosed with ADHD. For diagnostic purposes, ADHD is subdivided re: with or without hyperactivity. An extremely hyperactive child may be easily diagnosed ADHD. However, the sweet, quiet little girl who sits at her desk and silently daydreams can be harder to identify as an ADHD child.
What causes a child to have ADHD?
We don't know. However, there are some strong correlations between the following:
- Statistics range from 30-50 % genetics. There is a strong biochemical predisposition within families. When I do a family history, there is more often than not a close relative (mom or dad frequently report, "I was just like that at school," etc.) with the same symptoms whether formally diagnosed or not.
- Birth trauma or prenatal conditions such as infections, drug/alcohol use, poor nutrition.
- Head injury
- Iron deficiency/lead poisoning.
There is NO scientific evidence to suggest that sugar, diet or allergies cause ADHD. Neither do environmental conditions (i.e.-chaotic home life, poor supervision, etc.) nor school demands. ADHD is not mental retardation or suggestive of limited intelligence. In fact, there are many gifted children diagnosed with ADHD who also may have learning disabilities! These various issues can impact behavior, and may exacerbate symptoms; but there is no scientific proof to suggest that they cause ADHD.
How early can ADHD be diagnosed?
I have diagnosed children as young as 18 mos. to 2 years of age. These are extreme cases. These are the children who are so hyperactive and wound up that their behavior creates serious safety concerns. These are the kids who are constantly running out into the street, climbing the furniture and jumping from heights, grabbing for hot things, etc.
Generally, the symptoms become more problematic when kids enter school because the demands on their behavior to sit still, pay attention, wait their turn, etc.-all requiring self-control-make their difficulties more apparent. However, ADHD is not a school-based problem; kids don't have ADHD just during the school day. It's a biochemical condition, 24/7.
How is ADHD diagnosed?
It is a huge mistake to make a snap diagnosis!
Usually, in order to rule in a diagnosis of ADHD, it is very important to rule-out other conditions! ADHD-type symptoms can be seen for a variety of reasons: depression, anxiety, learning disabilities, trauma, molestation, change, abuse, psychosocial problems, stressors (i.e. divorce, job changes, moves, births/deaths,) low IQ, medical conditions (such as thyroid problems, high lead levels, etc.,) hearing/vision problems, epilepsy, sleep disorders or poor sleep habits, oppositionality, poor parent management/discipline.
I have seen many, many children misdiagnosed as ADHD who had hearing problems, learning problems or experienced trauma. So, it is very, very important not to simply allow your child to be diagnosed based on behavioral observations, or a simple behavior rating scale. There tends to be way too much reliance and degree of significance given to a simple behavior rating scale, such as a Conner's.
I have seen many school systems have a teacher fill out a behavior-rating scale, find the hyperactivity and/or inattention indices to be significantly high, and tell parents that their child has ADHD, and they need to take her to a doctor and get medication. I have done at least 20 teacher in-services on this topic. Not only does this border on practicing medicine without a license, but their interpretation is frequently inaccurate. What the rating scales can show is that there are behaviors being displayed that are of concern and above the normal range for a child of this age (based on normative scoring.) The behavior rating scale can be a useful diagnostic tool--a tool to be used along with other measures to insure accurate diagnosis.
The only times I have diagnosed ADHD without much exploration, is when the diagnosis was extremely clear. There was a totally consistent history, with parents basically reporting that their child was hyperactive in utero, came into the world with his engine cranked, and behavioral observations from parents, teachers (in the form of verbal reports and/or behavior rating scales) and my own observations are all consistent with diagnosed hyperactivity.
Short of that, my diagnosis is based on at least:
- An in-depth psycho-social history-the child doesn't live in a vacuum
- Behavioral observations (my own and others)
- Behavioral rating scales
- Developmental/medical history
- Physical exam conducted by the pediatrician-including vision and hearing screening, blood tests if seem warranted and sleep patterns/habits; many children have sleep disorders that create symptoms looking like ADD.
When there is still a question of WHY the behaviors are being exhibited, then psychological/psychoeducational assessment is indicated. The specific test instruments are determined based on the questions raised and what I want to rule out. So assessment (I don't used the word, 'tests' with kids because that implies the possibility of failure, and causes many to become anxious. I usually say we have a bunch of work to do to see what they are good at and what they are not so good at, in order to help them have the best year in school possible.)
Assessment might include:
- Processing/perceptual measures
- Emotional (Projective and subjective instruments)
Are there other conditions that occur with ADHD?
Yes; there are frequently what's called co-morbid conditions; other diagnostic conditions/symptoms. So, in making diagnosis, I want to rule things in/out; and oftentimes they are both! They are not mutually exclusive. They include:
- LD (specific learning disabilities) (About 20% of ADHD kids)
- Tic disorder
- Visual-motor/written expression problems
- Coordination problems (i.e.-clumsy)
- Oppositional/defiant behaviors
- Mood disorders (such as: anxiety, depression, bipolar, OCD)
Additionally, with ADHD, secondary characteristics (resulting from the primary diagnosis/diagnoses) frequently occur:
- Poor self esteem; feelings of inferiority
- Lack of self-confidence/sense of competence
- Poor peer relations
- Secondary depression
- Performance anxiety
- Behavior problems (due to frustration)
- Somatic complaints (headaches, stomachaches, etc.)
- Sleep disturbance
- Poor coping skills
This can be a vicious cycle: Poorly controlled behavior leading to frequent criticism and underachievement, leading to lowered self-confidence and anger directed at self/others… back to more disruptive behaviors. And if you give a mouse a cookie….
Should medicine always be prescribed for ADHD?
If you truly understand that this is a biochemical conditions, why would one not want to balance out their child's chemicals? Why would a parent want their child to struggle and suffer when the problem is neurologically-based and not within his total control?
So, the answer is---In my experience with 100's of kids, the most effective way I have seen to treat a child who is truly and accurately diagnosed ADHD, is to balance his chemicals. Since I am not a medical doctor, I cannot say that a child needs medicine. What I can recommend, however, is that a child be seen by a physician with expertise in ADHD and be evaluated for medication based on my clinical findings. Parents don't want their kids on medicine. I don't either. However, if their child was insulin-dependent diabetic, they would give them insulin. If their child needed glasses, no one is going to argue that they hate to see their child have to wear glasses, or that correcting their child's vision 60% of full correction is good enough.
Yet, that's what many do with ADHD medications. Either they hate to given them medicine, or they refuse a recommendation to increase the dose because the philosophy is to limit the amount of medication the child takes; so, 60% improvement is good enough.
Another HUGE problem is parents' giving children the medication only during the school week, not on the weekends/holidays/summer. This is a tremendous disservice to the child. It's like the child who needs glasses, but is only allowed to wear them during the school week. Then, on the weekend/holidays, he is not provided his glasses, yet expected to see well and actually gets in trouble if he doesn't. Again, medication is prescribed to give the body what it needs to alleviate a chemical imbalance. It is not fair to the child to withhold something his body requires to function adequately!
And the other misconception is the idea that the goal is to get their kids off medication. That's like saying that they want their child to 'outgrow' the need for glasses, or that they will encourage their child to see well enough on his own, so one day he won't have to wear glasses anymore!
Sometimes, balancing out the chemicals is really all a child needs. But that's infrequent. Usually, there are secondary characteristics to address, as well as parenting issues, possibly academic issues, etc. Treatment generally involves a combination of:
Generally, stimulant medication works the best; many think it is paradoxical to give a hyperactive child uppers. However, stimulant medication stimulates the governor. It supplements the deficiency. This results in improving the child's ability to regulate himself. Important: The medicine gives a child the ability to better manage himself. But a child still is the one to make use of his greater ability, or not. So, I tell children that the medicine did not make his butt stay in the chair, read the story or wait his turn on the playground. The child did that. The medicine only gave him greater ability to be able to and choose to do so. In this way, the child is empowered, while deflecting the tendency to give all the credit to the medication.
- Parental resistance to use of medication
- Giving up too quickly if the first medication and/or dosage is not effective or has side effects
- Resisting a higher dose because, "It's good enough"
- Not giving it on weekends/holidays/summers
- Setting a goal to get the child off medicine
- Unrealistic expectations
- Thinking the medication is the magic bullet with no need to consider other interventions, or take any responsibility for the interventions, as well
- Accommodating a different eating schedule
- Primary care physician vs. pediatrician vs. pediatric neurologist
- Dealing with MD when parent questions the choice of meds, side effects, or schedule (i.e.: If MD wants the kids off in the summer, and parents disagree)
- Non-medical specialists (such as myself) trying to educate the physician and parents without stepping on toes!
- Helping parents understand ADHD, deal with their ensuing guilt, fears and feelings of inadequacy and the need to reframe their observations
- Therapy to undo the damage done from years of failure, ridicule and never measuring up, addressing the secondary problems, reduce negative behaviors, decrease impulsivity, increase attention span, frustration tolerance and coping skills
- Empowerment: Helping child understand that the meds help balance their chemicals, but he is the one choosing to make good use of the increase in abilities
- Effective parenting
- Social skills training
- Good sleep rituals and schedule
- Good dietary habits, particularly in light of medication side effects
- Family involvement to balance the needs of one with the needs of many
- Organizational and time management skills
- Study skills
- Learning compensatory strategies
- Behavioral management: effective parenting and environmental structuring (rules, routines, etc.)
Educational Intervention: Academics
- Advocating for an IEP or 504 when indicated
- Helping parents understand their rights for academic accommodations
- Helping the teacher understand the child's needs, and probably the need to reframe his/her perception and interpretations of past behaviors
- Providing structure, possibly modifying the workload or providing interventional strategies
How can parents help a child handle ADHD?
Actually, these recommendations are great for all kids. However, parents of an ADHD child need to understand why he exhibits the behaviors he does, so they can put the behaviors in context and respond accordingly. It's about providing external structure, while helping him learn to develop his own internal mechanism for responsibility and organization.
- Love unconditionally.
- Be consistent. Make sure that your child knows what to expect.
- Develop routines. Provide predictable, consistent routines and rituals.
- Be firm; set limits and boundaries and stick to them.
- Have clear, definable and realistic expectations.
- Develop an effective behavior-management system with clearly defined goals and meaningful rewards and consequences.
- Teach compensatory strategies.
- Be a great role model. Set good examples for dealing with frustration, anger, etc.
- Provide outlets for channeling negative effect.
- Seek help and support, if needed (i.e. CHADD-parent support group)
- Help your child develop his OWN strategies-what works for him. (Make charts, lists, sticky notes, etc. to help him follow-through.)
- Teach your child to self-evaluate. "What's wrong with this picture?" Or, "Did you check your list?" Don't point out the mistakes/problems/omissions---help him find them himself. (This goes for school work---but also cleaning his room, doing his chores, etc.)
- Give chores/responsibilities and hold your child accountable. Help him internalize responsibility. Again, cue reminders rather than tell. "What are you supposed to do after dinner?"
- Restrict behaviors to avoid chaos (i.e.-play with one toy at a time.)
- Give limited choices. Help teach simple decision-making. Don't ask, "What do you want for breakfast?" Instead, give a choice of, "Would you like cereal or waffles?"
- Accept your child' limitations. Play to the strengths and work around weaknesses.
- Help your child learn to organize. Develop a simple system of organization not only for school, but also for toys, clothing, etc.
- Punish behaviors and not the child.
- Catch him being good---everyday!
- Foster positive self-esteem; help him pursue successful avenues.
- Find reasons to be positive; highlight behavioral improvements, and even the attempts at improving. "I really like how you tried to …."
- Recognize his feelings-even when they are in the form of behavioral acting-out, oppositional behavior, and bad attitude. These behaviors can all be a result of frustration, negative self-esteem, etc.
- Have different expectations for behavior when medication is in his system vs. when it wears off.
- And, again, most importantly... love unconditionally and make certain he knows it!
What are some simple steps teachers can take when dealing with ADHD in children?
Intervention isn't necessarily viewed as 'simple,' because it takes work, energy, focus and time. However, many of the interventions are simple, in that they are basic, effective strategies used to manage children's behavior---only you may need to multiply the investment of time, energy and effort by 10! 100?
- Create a partnership with parents to manage behavior. A behavioral plan can be developed that determines evening rewards/consequences based on teacher feedback. If you know that the child can earn a particular reward based on his behavior, then you can cue him during the day: "Keep up the good work so you can…when you get home."
- Create an on-going dialogue with parents. Keep lines of communication open.
- Provide structure and effective behavioral strategies in the classroom.
- If the child has an Individual Educational Plan (IEP)-follow it! This is a legal document; you are required to provide the interventional strategies included in the document.
- Catch him being good.
- Help social relations by pairing him with a study-buddy or group.
- Use many of the behavioral strategies listed above.
- Help screen out distractions: Use study carrels, provide a quiet corner, turn his desk to the wall. These kinds of strategies need to be used NOT as punishments, but as compensatory strategies that the child can use, if needed. (So, if he finds himself getting distracted, for instance, he has permission to turn his desk around, go to the quiet corner, etc.)
- Help child become less overwhelmed. Give one assignment at a time; have him turn in that worksheet and then get the next.
How can parents advocate for their children at school?
- Be the squeaky wheel. Don't be afraid to speak up and stand up for your child. Be an advocate for your child.
- Be informed/educated. Know what your child's rights are regarding 504 plans and IEP's for provision of interventional services at school.
- If attending an IEP meeting, school conference, etc., be prepared and don't allow yourself to be intimidated. You really have the authority to make decisions.
- Keep lines of communication open and be in frequent touch with your child's teacher, if necessary.
- Partner with the teacher to develop a behavioral management system that can carry over between school and home. (See above teacher recommendations)
- Remember that you are on the same side. If you feel that you and the school personnel have adversarial roles, ask yourself 'why,' and take a look at how to remedy that. Ultimately, you and the teacher/school want your child to be successful, even if you have different opinions/strategies for how to get there.
- Take responsibility for what you can do at home. The school needs to be held accountable for helping your child; and so do you.
- Show appreciation to the teacher for his/her efforts and willingness to work with you.
- Volunteer in the classroom, if your time permits. Being in the actually school setting can give you a great deal of insight into how your child behaves, the demands/flow of the classroom, other children's behavior/responses compared to your own and the teacher's style/personality and demeanor.
Is there any way to prevent a child from experiencing this behavior disorder?
None. You can't prevent a child from needing glasses, and you can't prevent a child from experiencing ADHD. It's a neurological condition…chemical wiring. And please note: There is no 'cure' for ADHD. And children don't "outgrow it."; it's a life-long condition. However, symptoms can improve with medication, compensatory strategies and maturity. Symptoms can change over the years; the governor will continue to mature, as does all children's. However, it won't catch up! As kids go out into the world, they will gravitate toward certain jobs that will better accommodate their style…or not. Many adults ignore their ADHD, and struggle with meeting deadlines, etc. Others have many projects going at once, and never seem to finish anything before they begin another. These are frequent laments from employers, spouses and friends.
What other information would you like to share with our readers?
If you have any concerns that your child may have ADHD, or has been diagnosed and the interventions are not proving effective, please find a child psychologist to do a thorough evaluation.
Do you have any Web sites that our readers can visit?
If you would like more information, please feel free to go to Ask Dr. Vicki and submit a question through my Web site. Reference this Web site. Questions that come to us as a result of this article will be given priority status.
- Better Parenting Institute-Because the better you do, the better they become!
- ADDitude Magazine
- Parents Connect
Enjoy the Ride!