Multi-Modal Treatment of ADHD: What Every Parent Needs To Know

A talk by Roger Yeager, PhD, M. Ellen Gellerstedt, MD, and Dan DeMarle, M.S.

Dr. Yeager was up to bat first, and he noted that our audience was made up of people who have been dealing with the subject of ADHD for a long, long . . . long time, while others were quite new. He gave a brief introduction to the topic so we were all starting on the same foundation for the presentation. He explained that the term ADD was and would be used although the technically correct term is now ADHD. The speakers were going to use these terms interchangeably tonight.

ADD is a biologically based difference in how some areas of the brain function. That means a couple of things: it is not caused by bad parenting, and it's not just a willful child and, believe it or not, it isn't caused by sugar. ADD is around for the long haul; it doesn't go away so it is necessary to look at it from that perspective. In addition to the usual list of characteristics, Dr. Yeager noted resilience, imagination, creativity, boundless energy, and risk-taking as examples of the exciting aspects of ADD.

"ADD can be thought of as a skill deficit problem", he noted. It was frequently a question of degree and frequency. Tonight's talk, although directed at parents, would be of value to adults with ADD if they reflected on their younger years.

Every child and family has unique strengths and needs. Parenting challenging kids requires that you become a chef, not just rely on a cookbook recipe. When using a cookbook approach, you have to follow a recipe exactly and if you're missing some of the ingredients, or don't like the results, you're stuck. But if you're a chef, you know how to substitute or what to improvise. You know what's possible and when and how to use the possibilities.

"Tonight, we'll give you some recipes but also show you how to become a chef in the field of behavior." Just as the techniques and strategies must be tailored to the individual situation, often a team of people have to work together to execute the treatment. Prepare a custom developed plan to enhance the strengths of a family and teach skills to compensate for the deficits. Treatment is not a "One size fits all" proposition. There are four areas the team would address tonight.

What is the goal of treatment? To get a good fit of children's skills/deficits and those of the parents. Find a coach, one who will help keep the "big picture" in mind, and monitor progress over time.

Educate yourself, your family and others about ADD as a skill deficit and how it manifests itself in your situation i.e. know that a lack of organization in a child is a skill deficit, not stupidity. Parenting difficulty is a lack of special skills, not incompetence. Part of the education process is to learn what does and what doesn't work.

Mental Health Interventions include behavior management. There are caveats to this which include: positive reward systems help; use consequences rather than reasoning; don't yell or hit; expect performance; don't blame, don't shame or humiliate; avoid inconsistency; affirmations are important; and avoid the "how comes".

Individual Therapy - Why is it needed? Where is it not needed?

Family Therapy - Remember that ADD may exist in only one member of a family, but it affects the whole family.

Social Skills Training is also an important area to be aware of.

Dr. Yeager then turned the microphone over to Dan DeMarle who addressed educational interventions.

Dan noted that an analogy would be helpful for his portion of the talk. Imagine yourself as a terrible gymnast, which isn't too much of a stretch for some of us?! Although strong in other areas, you just hate gymnastics. But you know that for the next 12 years, you'll be judged on your gymnastic ability. Either you'll pass or fail. Then you're told that the way you perform may well affect your future children's quality of life. This is very much the way children feel as they're going through school.

ADD kids are at risk for difficulty in school. "Children with ADD are fragile learners, power learners, active learners and at risk for problems with self-esteem. ADD kids need to be involved, both mentally and physically, in what they're being taught. For children with ADD, we must learn that if it's important, make it novel. If you can't make it novel, make it active", Dan said. Using the right instructional techniques for these children enables the child to turn their natural activity level from a negative into a positive.

In school there are strategies for both environmental modifications and interventions to change behavior. There are ways we can teach children to do better on homework. Don't become the "homework monster", though, when there's trouble in this area. More important than turning a particular assignment in the next morning is that the child needs to know you are a loving, caring parent they can turn to when they need you the next time. One solution may be to split up the homework between parents. Another way may be to involve a tutor.

Schools can and should be an invaluable asset to you as a parent working with your child. Unfortunately, in many cases the parent and school can be at opposite ends of a tug of war with the children caught in the middle! What we want to happen is to have parents and school staffs working together for the benefit of the child's future! The two most important aspects of the parent/teacher relationship are effective communication, and having a joint understanding of the child's strengths and needs both at school and at home. Again, a coach (particularly at school) can be an invaluable asset.

As parents, it is important to be "informed consumers" so we can help the schools make appropriate decisions about education. It's important to find the treatment tools that work and that we find new ones when the old ones don't work as well, and help the schools do the same.

As a closing thought, recall the analogy of gymnastics. As a society, we make children go to school. Yet as members of our society, if we make these fragile learners go to school every day, then we as parents and child advocates must help to insure that going to school is a useful and productive activity for these fragile children.

Ellen Gellerstedt then addressed us.

Let's put some things in perspective i.e. get the big picture. We may have all these thoughts and this information flying around in our heads, but it is important to realize every child, every parent, and every family is unique. You don't need 100 strategies or interventions in action at once. We have to know that what the child needs in 1st grade may have nothing to do with their needs in the 5th grade. You don't have to know it all. There's a lot of expertise in our community - - Use them!

A physician can do a number of things: diagnosis, medication, help monitor progress over time, monitor what's going on with new treatments. "All that's hyper is NOT hyperactivity." Some causes of symptoms similar to those of ADD include Anxiety, Depression, Learning Disabilities, Obsessive Compulsive Disorder, Tourette's Syndrome, Oppositional and Defiant Behavior, Thyroid Condition, Manic-Depressive Illness, Lead Poisoning, Processing Problems, Seizures, Family Disruptions and a Chaotic Environment.

When should we think about medication? Medication doesn't cure ADD but it can, temporarily, alleviate some of the symptoms that are causing children so much trouble.

The long term goals of ALL treatments are: Confidence, Self Awareness, and Independence. We need to have them learn the skills they need so they can make their mark in the world.

Learn and understand what medication can do as well as what it cannot do. Medications used for ADD CAN'T cure ADD, CAN'T motivate someone, CAN'T give them skills, CAN'T make them either smarter or dumber, and CAN'T eliminate oppositional or defiant behavior. Medication CAN be extremely important, but it can't be the only treatment. Dosage and schedule must be individualized. Talk to your doctor often. Physicians can also help with networking or getting a team to work together.

In summary, there is no generic ADD. The hallmark of Multi-Modal Intervention is to enhance the strengths and teach the skills that are deficient. ADD is a biologic entity; the characteristics of it may be life-long. Many of the traits are blessings while some are true disabilities. The needs for the child and family change over time, and members of the team may change over time. The goals of treatment are to maximize the development of the child's cognitive, social and academic abilities and to maximize the growth of the family and the unit. There are no magic cures, but the situation is far from hopeless.

Roger Yeager, PhD - Psychologist, M. Ellen Gellerstedt, MD - Pediatrician, and Dan DeMarle, MS - Educator are with the Behavior Pediatrics Program at the Rochester General Hospital.

This article appeared in the Winter '94 GRADDA Newsletter. The Greater Rochester Attention Deficit Disorder Association. PO Box 23565, Rochester, New York 14692-3565. e-mail us at gradda@net2.netacc.net

Thanks to Dick Smith of GRADDA and the authors for permission to reproduce this article.

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