Tuesday, April 21, 2015

Six Steps to Managing ADHD Overload

guest blog by Mark Bertin, MD

When the logistical details of life and school accumulate, they become overwhelming for students with ADHD. If they have weak executive function skills, they will require ongoing support from an adult.

What steps can you take to help children and teens with ADHD learn to manage the academic demands that increase as they grow older? And if your child falls behind and must somehow weather an academic storm, what strategies can change the situation and teach him or her to better manage ADHD challenges?

1. Clear the decks. When needed, hit the reset button. Forge a one-time amnesty, forgive the backlog, and begin from scratch. If someone is not yet able to do what is being asked every day, there is not much chance they are going to keep up plus catch up. If amnesty is not entirely possible, at minimum we distribute the backlog over time so that the total work required every day is sustainable. The goal is maintaining a reasonable amount of work each day, within what is possible for any individual.

Kids should not expect this type of amnesty to be constantly available. However, “responsibility” and “motivation” only follow from success, and success stems from asking kids to work within their actual ability level. Homework isn’t meant to bring to mind Sisyphus pushing his boulder up the hill, never to quite reach the top before it rolls down again. If a child can get five things done each day and we keep asking for six, eventually the child will fall behind.

2. Establish a daily plan. Create a detailed and easy-to-follow daily checklist. Setting and sustaining a plan to manage homework is not intuitive to most children with ADHD. Knowing when to get started, predicting time, keeping track of books and assignments, and many related skills are all related to executive functions. Parents should set a homework time and create a distraction-free place to get things done. If the after-school schedule varies, instead of a specific time the rule might be “work starts fifteen minutes after getting home.”

Most students benefit from a step-by-step, written checklist for how to complete work appropriately. To make certain things get back to school, include a clear ending such as “put your homework away in your homework folder.” While working, children also often find it easier to focus with scheduled stretches on task interspersed with timed breaks (such as twenty minutes on, five minutes off). In-school supports involve breaking down assignments into daily parts, checking out with a teacher at the end of the day, reminders to hand in work to the teacher, and countless other possibilities (see the CHADD Educator Manual for more).

Monitor the child's development. A ten year old might have the skills of a six year old when it comes to organization. Unfortunately, there is no one perfect measure of executive function in real life, so observe, make informed choices, and readjust based on how a child progresses.

Maybe the child is not ready to manage his or her own to-do list at school. Maybe he cannot yet see how to break a longer project into its component parts. Maybe initiating her work after school is hard, or prioritizing time, or estimating how long various assignments will take each night. All these difficulties require direct support and instruction. By sustaining a daily routine over months or years of school, it becomes a habit all the way through adulthood.

3. Externalize the system. Maintain adult support and involvement. Getting off task from a long-term plan is a routine part of ADHD, and does not typically stem from poor effort or laziness. Identify a parent, teacher, therapist, ADHD coach, or anyone else who can make sure the details are being followed. While written checklists and physical alarms also can act as external reminders, children need someone supervising with higher-level organizational skills.

A solid solution often involves parents and teachers almost taking over organization in the short run. Temporary relief from responsibilities allows more energy for learning and keeping up with the more methodical plan you’ve created. A long-term plan hands back responsibility at whatever pace a student proves capable.

4. Consider modified homework. Avoid the counterproductive punishment of adding more to an already daunting load. In Understand Your Brain, Get More Done: The ADHD Executive Function Workbook (Specialty Press, 2012), psychologist Ari Tuckman writes, “It is vital to keep up with work as it comes—because it becomes impossible to do it all at the end. Homework can sometimes be (or feel like) a losing battle where it is impossible to keep up at all. At those times it may be helpful to speak about homework reductions, especially when a student is spending a lot of time but not getting enough done.”

ADHD isn't an excuse for slacking off. Children with ADHD should show good effort and do what is needed to learn. But they also should not spend their whole lives treading water, up to their necks in schoolwork. The goal is to find a groove where a child works hard but does not get consumed. Homework is meant to augment classroom academics. While the research is vague, the recommendation is around ten minutes per grade.

5. Offer stress management tools. A first step to managing stress may simply be managing ADHD itself. ADHD compounds stress by making it hard to get anything done all day long. With ADHD, every detail may be taking ten times the effort with five times the uncertainty. Assertive management supports long-term success by balancing behavioral, educational, medical, and even complementary options when appropriate.

Stress itself makes managing ADHD difficult. Under stress, most of us fall back on old habits, become more reactive, and lose our resilience. For an individual or family living with ADHD, these patterns make it harder to keep up with any plan. Working with a behavioral therapist or ADHD coach may help both in addressing executive function deficits and in developing stress management tools. The practice of mindfulness is also an evidence-backed, accessible way to manage stress.

6. Create an early warning system. Schools should contact families as soon as assignments are missed. Finding out about seven missed homework assignments over two months is hard to address, but finding out about two over a week is manageable. Don’t allow the back-up to happen in the first place.

If work starts accumulating, step back and look at the bigger picture: Can the child do the work asked of him? Has he had an appropriate educational evaluation? At least half of children with ADHD also have a learning disability and others have language delays. Assigned homework should consider present academic abilities and avoid material above a student’s ability level.

When the student continues to miss assignments, consider whether he or she is able to handle the workload right now. Does the child need more directed organizational supports? Modifications that cut back on the amount required each night? Does medication need adjusting? Is homework even being done during the window of time medication covers?

THROUGH THE COMBINATION of an external system, adult monitoring, and modification of work, school and homework should become more manageable. As the system become more ingrained, most students with ADHD can handle a workload similar to that of their peers.

A slow drip of missed details can affect anything your child must keep up with in life, but the same technique applies. Emails pile up; the solution balances getting the in-box back to zero and creating a plan to keep up every day. If the child has an astoundingly messy room, start with a one-time effort to put everything in place while in tandem establishing a new system of some kind — maybe ten minutes of cleaning before bedtime. Balancing short-term exertion with a realistic and empathetic long-term plan creates an entirely new way of living with ADHD.

A longer version of this post appeared in the June 2013 issue of Attention magazine. Join CHADD and receive every issue!
Join conversations about parenting kids with ADHD on Attention connection, your social network for all things ADHD!

Mark Bertin, MD, is a pioneering developmental pediatrician in private practice in Pleasantville, New York, and assistant professor of pediatrics at New York Medical College. He trains physicians, teachers, and psychologists in ADHD care and leads stress-reduction classes for parents. From 2003 to 2010, he was director of developmental pediatrics at the Westchester Institute for Human Development. He is the author of The Family ADHD Solution (Macmillan, 2011).

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