ADHD or just being an active kid?

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Dear Melissa,

My daughter’s kindergarten teacher is concerned that she has ADHD. How do I know if she has ADHD or not? If she does have ADHD, what are the best treatment options?

I frequently get this question from parents. The Centers for Disease Control and Prevention calculated that 11% of children in the U.S. had an ADHD diagnosis in 2011. That was up from 7.8% in 2003. Among all children in the U.S., 6.1% were taking an ADHD medication in 2011, such as Adderall and Ritalin, up from 4.8% in 2007. With rates this high, ADHD is a challenge that many families and every classroom teacher will have to face.

What is ADHD?
Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common childhood brain disorders and can continue through adolescence and into adulthood. Kids with ADHD struggle with focus and attention, have difficulty controlling behavior, and exhibit hyperactivity. Attention Deficit Disorder (ADD) is similar to ADHD in terms of deficits in focus and attention, but hyperactivity is not a problem.

ADHD or not?
Many young children have difficulty attending to classroom instruction. But does that mean they have ADHD? Certainly not! According to Dr. George Depaul, a psychology specialist in the field of ADHD research, upwards of 40% of elementary students are reported by their teachers to be easily distracted or lacking in focus (Metcalf, 2012). Considering the rise of academic demands in younger grades, combined with the decline in recess and other extracurricular time, no wonder there are problems! Other explanations for inattentiveness could be classroom chaos, boredom, a family crisis at home, or anxiety and depression problems. By working with your child's pediatrician, psychiatrist and/or psychologist, hopefully the right diagnosis (or non-diagnosis) is reached.

How is ADHD diagnosed?
If your child's teacher raises a concern or you suspect ADHD, a good first step is to talk to your child’s pediatrician. Some pediatricians perform ADHD assessments themselves. However, many will refer the family to a mental health specialist (such as a psychiatrist or psychologist) with a specialty in childhood mental health disorders such as ADHD. The pediatrician and mental health professional will also rule out other possible causes for the inattentive behaviors such as deficits in vision or hearing, seizures, insomnia, anxiety, Autism, depression, and learning disabilities.

Generally, the processes of diagnosis for ADHD include interviews with the parents and the child, as well as various standardized tests and questionnaires. In order to qualify for a diagnosis for ADHD, symptoms need to occur in more than one setting (such as both home and school), and they should also demonstrate a negative impact on an individual’s daily life.

What are Treatment Options?
There are MANY treatments for ADHD available. Stay tuned...I will discuss treatment options on my next post. 

Has your child been diagnosed with ADHD? How did you discover your child's diagnosis?
Please share! share@childrenstherapyteam.com

Resources:

What is ADHD, National Institutes of Health
ADHD or Not? Why a Diagnosis Matters, Web MD, Eric Metcalf (2012)

ADHD, Center for Disease Control & Prevention

ADHD: Clinical Practice Guideline for theDiagnosis, Evaluation, and Treatment of Attention-Deficit/ HyperactivityDisorder in Children and Adolescents, American Academy of Pediatrics, Pediatrics Volume 128, Number 5 (November 2011)

Diagnosing ADHD in Children: Guidelines & Information for Parents, American Academy of Pediatrics, (updated January 2015) 
ADHD, Stimulant Treatment, and Growth: A Longitudinal Study, E. Hardstand, Weaver, Katusic, Colligan, Kumar, Chan, Voigt, Barbaresi, American Academy of Pediatrics, Pediatrics, Volume 134, (October 2014) 
Stimulant Treatment of ADHD and Cigarette Smoking: A Meta-Analysis, E. Schoenfelder, Faraone, Kollins, American Academy of Pediatrics, Pediatrics Volume 133, Number 6 (June, 2014)

ADHD Resource Center, American Academy of Child & Adolescent Psychiatry (updated October, 2014)

"because I said so!"

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Dear Melissa,

When adults tell children to follow directions, “because I said so!” that should be enough of an explanation for any child.

The above statement actually comes from a discussion I had with a local child psychologist several months ago. If I thought saying, "because I said so!" provided children with opportunities to develop thoughtful self-discipline, then I would be all for it. However, it is difficult to make that argument. I strongly feel that every direction I give to a child is a little, two second teachable moment. It is my hope that if I provide enough of these tiny teachable moments, then I have given the child the tools he needs to make the best choices he can throughout his life. 




My trial and error approach 

I have gathered these ideas from lots of books and blogs then taken a trial and error approach over 7 years of being a mama and over a decade of being a pediatric occupational therapist. As a disclaimer, this blog is largely my opinion. This is simply me sharing my personal style of behavior modification and preferences in dealing with challenging behaviors. 


Teaching children...not programming robots

We want our children to learn how to make good choices rather than blindly following directions. If we don’t teach a child the reasoning behind our directions, then how will they know how to make good choices when we are not there? 




My formula for giving directions

Give a 5-7 word command followed by a 5-7 word explanation to describe the “cause and effect” nature of the situation. That’s it. My directions are not up for debate. Who has time for that? If the child starts to argue, I just repeat my directions.




Examples of cause and effect directions and natural consequences 

Direction: "Wash your hands. I don't want you to get sick."

If a child refuses to wash his hands, then I won’t let him touch any of the fun equipment in the clinic to keep him/others safe from germs.




Direction: "Hold my hand in the parking lot, so you don’t get squished by a car."

What if the child refuses to hold my hand in the parking lot? Then I will help him “practice” by pacing back in forth in the parking lot, holding my hand. My #1 job in life is to keep children safe.  

Direction: "Wear your coat. You will feel cold outside without one." 

No coat? Then no playing outside. We can sit at the table and work inside, because again, it is my #1 job to keep kids safe. 

Keep it simple

Children can’t process a 5 minute discussion over every command. Their language skills are simply not that advanced. After the first few words, your voice simply turns into “wah wah wah” like the teacher in the Peanuts cartoons.  




Give "the look"  

What about the child that keeps asking why?  Well, you have given your direction. You have already answered “why”.  This is when I throw in "the look” and simply say, “I have given you my explanation." 

Choices

Eons ago one our own TEAM OT's, Cara Duran, and I were roommates during OT school. It is from her that I picked up a phrase that I use daily: “Life’s all about choices.” Sometimes we have two good choices like cake or ice cream. Sometimes we have two bad choices like tooth pain or a root canal. By teaching children about causes and effects, we empower them to make good choices even when confronted with challenging options. 




I love, love, LOVE having fun and playing with kiddos and I hope they think of me as fun adult who loves them to pieces. However, it is not my job to be their best friend. It is my job to teach them how to make good choices. I will not always be there to look over their shoulder and prompt them. At some point, I need to be able to trust them to make their own choices.

Your thoughts? Please share!

share@childrenstherapyteam.com

Resources:

20 Things You Should Never Say To Your Child, Carla Field, WYFF News (2014)

The Explosive Child, Ross Greene (2014)

25 Ways to talk so children will listen, William Sears, www.askdrsears.com (2013)

Picky Eaters

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Dear Melissa,

My goal for the new year was to get my 4 year old to try new foods, but it isn't working!  It seems as if every meal time has turned into a battle for control and I think I am losing! Any ideas?

That sounds really frustrating! The good news is there are many, many tricks to help create more success at meal times. However, let me start by sharing my three basic tenets when dealing with children. As soon as you learn to let these go, the easier your life will be.  

1. You can’t make them eat.
2. You can’t make them sleep.
3. You can’t make them potty. 

Given these tenets, a parent may think there is no hope. However, by finding ways to decrease battles for control, parents can have success tackling these traditionally challenging arenas of parenting. With the parents I work with I often share "The 5 Rules" to help decrease tension and battles over control at meal times. These rules create a black and white “contract” between you and your child. There is no room for negotiation. Both parties know exactly what to expect, are allowed to make their own choices, and have an element of control.* 

*Note: Talk to your physician and therapist before proceeding if your child is significantly underweight or has severe sensory aversions toward food. Severe sensory aversion is defined as having less than 20 “preferred foods” or having eliminated entire food groups.

THE 5 RULES 

1) Parents Choose "WHEN"
Parents decide when meals and snacks are scheduled. Ideally, a child will have 3 meals and 1-3 snacks depending on age, with snack frequency decreasing as a child ages. This allows 4-6 opportunities for good nutrition per day. However, “grazing” is NOT allowed.

2) Parents Choose "WHERE"
Parents decide where the child/family will eat. At the dinner table, in the car on the way to/from school, etc. However, taking a bite or 2 and walking away from the dinner table, coming back, walking away, coming back, is NOT allowed.

3) Parents Choose "WHAT"
Parents decide what will be placed on the plate, or what snack/meal will be packed. (Kids are required to allow the food to at least exist on the plate, even if they literally don’t even touch it).

4) Kids Choose "WHETHER"
Kids choose whether or not they will eat a certain food. It is OK if they only eat one type of food at a particular offering. You can offer a preferred food from a different food group at the next food offering. The key is to get a bit of variety of the course of day/week, not necessarily at a particular meal.

5) Kids Choose "HOW MUCH"
Kids choose how much of a particular food they will eat. Kids have the choice to eat more than one serving of a particular food without touching the other food(s). However, you do have the right to limit the number of servings at some point so as to not give 10 servings of bananas, because of course, that would cause a tummy ache.

GUIDANCE FOR PARENTS

Stick to your guns.

A child should not be allowed to throw a tantrum or whine in order to pick out whatever he wants from the pantry. Yes, this should be obvious, but this rule is routinely broken. Stick to your guns! You are the parent, you can do this!

Offer choices...but don't be a short order cook.

1) Meals should have 3 different items offered.

2) Snacks should have 1-2 different items offered.

3) Offer at least 1 preferred food and 1 non-preferred food per meal (unless you get to the point where your child eats so well that there is no need to offer non-preferred foods!).  

4) Do not cook spaghetti for the family and chicken nuggets for the “picky eater”. If the family wants spaghetti, the entire family gets spaghetti. You can modify it by not adding sauce for example, but everyone gets spaghetti. Just make sure that there is at least 1 preferred item on the “picky eater’s” plate, such as a banana, roll, etc... 

Plants are a must (french fries don't count...sorry!).

1) Every meal and most snacks should contain a plant. I always tell my children “pick a plant” and then give them 2-3 fruit/veggie items to choose from. Numerous studies have shown if you simply give children a choice of “plants” then they will be much more likely to actually eat them. This has created some weird combos in my house (Taco Bell with steamed broccoli, anyone?), but it has created an expectation that ALL meals contain real plants (french fries don’t count, sorry!). 

2) Do not worry so much about a child eating vegetables, as long as he is getting a wide variety of fruit. Keep offering the veggies as non-preferred foods and keep putting a bite or two of veggies on the plate. 

Don't worry...

1) If it feels like your child has “skipped” a meal, don't worry. In reality, he probably had a few bites of food and a cup of milk. That is a meal for a young child! 

2) It is OK for a child to choose to pass on a meal/snack. Again, as long as your child’s doctor is not concerned that your child is extremely under weight. Your child will likely make up for the missed calories at the next meal, or even the next day. 

Begin a food adventure

If your child does decide to eat a small portion of a new food, you can add additional incentives such as sticker charts or nickels to work toward rewards. You can also create a “food adventure guide” to help a child record his new food discoveries. 

Seek out extra help if... 

If you have tried the above techniques without success, you may need a more tailored approach to your child’s food aversions. Talk to your child's pediatrician and/or therapist if your child exhibits any of the following behaviors/symptoms: 
a) routinely skips several meals in a row,
b) appears to have severely controlling behaviors surrounding food,
c) expresses significant anxiety with new foods,
d) is losing weight,
e) routinely gags when trying new foods.

Who can help?
A certified Speech and/or Occupational Therapist with additional specialized training should be able to help. Many of Children's Therapy TEAM's therapists have had extensive training in helping families overcome food defensiveness. Many of our therapists have received Food Chaining Certification, considered a gold standard training in broadening a child's picky palate. 

Is your child a picky eater?  

What techniques have you used to help your child try new foods?  

email: share@childrenstherapyteam.com

Resources:

Seven New Strategies for Feeding a Picky Eater, Evonne Lack, BabyCenter.com
Food Chaining: The Proven 6-Step Plan to Stop Picky Eating, Solve Feeding Problems, and Expand Your Child's Diet, Cheri Fraker, Mark Fishbein, Sibyl Cox, Larua Walbert (2007)
Busy Moms' Resolutions, Children's Therapy TEAM Blog (2014) 

W Sitting, a cause for concern?

Dear Melissa,

I just started noticing my 18-month-old daughter "W" sitting today. When is there cause for concern?

To address your question I have invited Shannon McIvor (PT, DPT), a member of our fantastic TEAM physical therapy department, to be a guest writer this week. She shared the following response to your question:

Don't worry...

If your daughter occasionally transitions through w-sitting when playing, then don't worry. It is not uncommon for kids to transition through w-sitting to achieve a new position. This posture may sometimes be used for stability and balance while playing. There are many positions of sitting that a child may use throughout the day. In addition to w-sitting, these may include ring sitting, sitting on heels in a low kneel, taylor sitting (criss-cross applesauce), long sitting with legs in front, side sitting, etc. 

It is a concern...

If you notice that w-sitting seems to be your child’s only means of sitting and she has great difficulty with other sitting positions, this should be brought to the attention of your pediatrician. If your child uses w-sitting more frequently than other positions, then she may simply need frequent cuing to change position.

If a child frequently w-sits, then...

She may be predisposed to hip dislocation and knee conditions later in life. Therefore, w-sitting should be discouraged in all children, but especially in children with diagnosed developmental delay, lower extremity orthopedic concerns, changes in muscle tone, or a diagnosed neurological condition.

Be proactive.

The easiest way to prevent this sitting posture, and any long-term problems that it may cause, is to not allow it to become a habit in the first place. This is particularly important when your child is first learning how to sit. Promoting other sitting positions and having your child practice various positions will enhance their trunk control and abdominal strength. 

Provide cues, again, again, and again.
For older children who have already turned to w-sitting as their “go-to” sitting position, persistent verbal cues of “fix your legs” will be a frequent phrase heard in the household, preschool, school, daycare, after-school care, etc. This may mean that the child starts with side-sitting, allowing one leg to still be behind the body, or pulling her legs closer together and turning her feet in to sit on her heels. Eventually she transitions to ring sitting or pretzel sitting (criss-cross applesauce) as a more proper means of floor sitting. Consistency and persistence from family members and caregivers throughout the day will eventually assist children into a sitting position that is better for their knees and hips. 

How a pediatric PT can help.
A pediatric PT can work with families to support the transition to healthier seating postures. They can work with a child directly to strengthen their hips and abdominals. This will assist in obtaining and maintaining other seated positions. PTs can also provide individualized guidance for families given the child's specific needs.

Helpful Resources

Zero to Three Development, National Center for Infants, Toddlers and Families (2014)

Does your child W-Sit?, Donna Greco, Physical Therapy and Rehab (1999)

What's Wrong with "W Sitting" in Children, Jaime Ruffing, Early Intervention Support, www.earlyinterventionsupport.com (2014) 

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Thank you Shannon for guest writing this week! 
Your expertise is greatly appreciated.

Parents: 

Please feel free to share your questions or comments at: share@childrenstherapyteam.com

I love hearing from you!