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DEFICIT DISORDER AND THEIR PARENTS

Scholarly Progect for tt1e Degree 0f M S N
° - MICHIGAN STATE UNIVERSITY
DONNAG STRAWSER
: ' ' I999

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A TEACI-HNG TOOL
FOR ADOLESCENTS WITH ATTENTION DEFICIT DISORDER

AND THEIR PARENTS

by

Donna G. Strawser

A Scholarly Project
Submitted to
Michigan State University
In partial fitlfillment of the requirements
for the degree of

MASTER OF SCIENCE

College of Nursing
1999

Chairperson: Mary Jo Amdt

Addolescents with ADD i

ABSTRACT

Attention Deficit Disorder with or without hyperactivity is a common childhood condition,
affecting 3-5% of children in the United States. It was formerly assumed to be outgrown in
adolescence, but it is now known that 50-70% of the children with the condition are still affected
into adolescence and adulthood. Adolescence is a critical time of growth and development.
Untreated Attention Deficit Disorder causes severe problems for adolescents and can result in
diminished self esteen, decreased learning, and increased risk of substance abuse and conduct
disorder.

Parents of adolescents already face a challenging time. Ifthe child also has symptoms of
Attention Deficit Disorder, the family may present to the Advanced Practice Nurse in primary
care as a family under severe stress. Recognition of this condition in adolescents, knowledge of
the treatment options, and a plan for the most effective sharing of knowledge and options with the
adolescent and parents can be a valuable tool for the APN in primary care. This project created a
modular teaching tool for the practioner to use with families in exploring treatment options. The
teaching tool is written in a style tailored to the special learning needs of adolescents with ADD.
It includes content on three main types of interventions used to treat adolescents with ADD:
pharmacologic therapy, behavioral modification, and classroom adjustments. King’s General
Systems Theory and Theory of Goal Attainment was used to facilitate understanding of how this
condition affects the way the adolescent interacts with his/her environment. The APN can use the
teaching tool to help the family explore the means to achieve the goals that are mutually agreed

upon.

Adolescentsiwith ADD
TABLE OF CONTENTS
Contents ................................................. ii
Introduction .............................................. 1
Background and Significance ................................ 2
Purpose .................................................. 4
Conceptual Definitions ....................................... 5
Review of Literature ........................................ 6
Etiology ............................................ 6
Diagnosis .......................................... 7
Pharmacological Management ............................ 9
Behavioral Therapy .................................. 13
Environmental Support ............................... 15
Psychosocial/Developmental Issues ...................... 17
Limitations of Literature .................................... 18
Conceptual Model ........................................ 19
The Role of the Advanced Practice Nurse in Primary Care ......... . 24
Table l ................................................. 28
Figure l ................................................ 29
Figure 2 ................................................ 30
References .............................................. 31
Using the Teaching Tool .................................... 37

The Teaching Tool ......................................... 40

ii

Adolescents with ADD 1

INTRODUCTION

Attention Deficit Hyperactivity Disorder (ADI-ID) has been called “the Disorder of the
90's” (Buncher, 1996). Key characteristics of this disorder are impairments in attention,
regulation of activity, and impulse control. A second term, Attention Deficit Disorder without
hyperactivity (ADD) has also been accepted as a diagnosis by the Diagnostic and Statistical
Manual of Mental Disorders, 4th Edition. The two terms are often used together, and while they
are not interchangeable, most references to ADD/ADHD refer to characteristics that both
diagnoses have in common.

There is considerable controversy about the frequency of the diagnosis and the use of
medications, especially stimulants, to treat school age children. There is a wealth of professional
and lay material available to read on all aspects and all viewpoints of this controversial disorder.
Many parents, educators, and health care workers believe the diagnosis is overused as a
convenient way to label children with behavior problems. They do not believe medication is
appropriate for this type of condition, but think the child’s behavior should be controlled by
discipline or behavior modification. The use of stimulant (amphetamine type) drugs to treat
school age children is abhorrent to many in the “just say no to drugs” era. Some conditions with
symptoms similar to ADD/ADHD are more common in lower socioeconomic groups (lead
poisoning, fetal alcohol syndrome, for example) so advocates for poor children want to make sure
that giving disadvantaged children Ritalin does not take the place of solving underlying problems
(Buncher, 1996).

On the other side of the controversy, there are many psychologists, educators and parents

who are crusading to get children (and adults) with this disorder appropriate assessment,

Adolescents with ADD 2

diagnosis and treatment, and to remove the stigma attached to the diagnosis. Psychological
research supports that telling a person with a disability to “just control yourself and work harder”
and implying the diagnosis is not real is destructive to the self image of those with the disability.
Advocates of this viewpoint are very eloquent about the effects of this attitude on the child’s
ability to learn and succeed in school (Barkley, 1990; Hallowell, 1992).
BACKGROUND AND SIGNIFICANCE

According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition
(DSM IV), the prevalence of ADI-ID in school age children is estimated between 3% and 5%, or
more than 2 million children nationwide. At one time this was assumed to be a childhood
disorder, but it has been established that 50-75% of these children continue to have symptoms
through adolescence and adulthood (Buncher, 1996; Heiligenstein & Keeling, 1995; Calandra, i
1998; Lambert, Hartsough, Sassone, & Sandoval, 1987). Since treatment for ADD and ADI-ID is
commonly initiated by a pediatrician or child psychologist, those diagnosed as children may not
receive continued treatment through adolescence. Teachers, parents, and some health care
providers ofien have the expectation that the child will “outgrow” the disorder by their teen
years. Adolescents themselves who have accepted and even welcomed treatment as children often
rebel against the need to take medication or accept school and environmental support because it
makes them feel “different” fiom their peers. The motor over activity associated with ADHD
commonly diminishes during adolescence, leading to an assumption by providers, parents, and
teachers that treatment is no longer needed. The inattention and irnpulsivity that are still
significantly more pronounced than in typical adolescents (where some irnpulsivity and inattention

is expected) have a serious impact on school and social performance. These teenagers are often

Adolescents with ADD 3

labeled as academic underachievers and often have poor relationships with peers and families
(Amen, 1997). Research has indicated that adolescents with ADD/ADHD are at greater risk for
delinquent behavior and substance abuse than their peers without ADD (Phillips & Sofer, 1996;
Lambert et a1, 1987; Homer & Schreibe, 1997).

ADD/ADHD is independent of IQ; thus, these teenagers range through average to even
over average intelligence (Barkley, 1990). However, studies have documented that they show
deficits in adaptive skills such as cormnunication, socialization, and daily organizational skills
(Stein, Simkiowski, Blondis & Rotzen, 1995; Phillips & Sofer, 1996). Adolescents with a history
of ADHD had lower self esteem and worse social adjustment than their peers without ADHD
(Siomkowski, Klein & Mannuzza, 1995; Phillips & Sofer, 1996). Disruptive disorders are
prominent, with 60% of ADHD children also receiving a diagnosis of conduct disorder or
oppositional defiant disorder in adolescence (Phillips & Sofer, 1996).

Advanced Practice Nurses in primary care need to identify these adolescents through a
thorough history, recognize the potential for their special needs as adolescents with ADD, and
communicate effectively with the adolescent and parents about the options for meeting the needs
of support for self esteem, improving relationships, and succeeding in school. Safety is a major
need for these adolescents since some studies have indicated they have up to four times as many
automobile accidents as teens without ADD/ADHD (Amen, 1997), increased injuries on bicycles
and skateboards (Buncher, 1996), as well as the increased risk of substance abuse. Identifying
these potential problems can assist the APN in completing focused assessments and developing
preventive interventions. Adolescents with ADD/ADHD have special learning needs. Presenting

information in a short, simple format with written reinforcement is helpfirl (Amen, 1997).

Adolescents with ADD 4

The volume of literature available and the divergence of opinions about diagnosis and
treatment make it very difficult for parents of a child with ADD/ADHD to make informed
decisions about treatment and to follow through on those decisions (Amen, 1997). As popular
literature continues to feature the ADD/ADHD spectrum fiom childhood through adulthood,
more parents and teenagers will be seeking treatment in primary care (Craig, 1996).

Gaining knowledge about the differing viewpoints will assist the APN to help the
adolescent and parents to gain an understanding of the condition and how it afi‘ects the way the
child interacts with society, and to formulate their own paradigm from which to make rational
decisions. Whatever decision the family group makes will undoubtedly need defending from
differing opinions in the community, the school and/or the health care system. Choosing to use
stimulant medications or choosing to avoid them and focus only on behavioral modifications will
arouse opposition from someone involved who has strong opinions on the other side of the
controversy. Providing the family with some anticipatory guidance in thinking through their
decisions and dealing with others who may have negative feelings about these decisions can assist
the family in following through on the treatment plan that is agreed upon.

Mass

The objective of this project was to review a cross section of the literature about
ADD/ADHD in adolescents, and to develop a teaching tool which considers the learning style of
the adolescent with ADD. The Advanced Practice Nurse may use the tool with parents and the
adolescent with ADD/ADHD in discussing medication options, behavioral interventions and
environmental strategies designed to improve success in school, social and home environments.

The most useful teaching tool for use with these adolescents will consider their learning style and

Adolescents with ADD 5

be presented in an attractive modular format with information given in short simple steps
(Hallowell, 1995; Amen, 1997).
Assumptions

1. People have the right and ability to make choices about their health care.

2. The adolescent has the right and ability to participate in decisions about health care.

3. Adolescents desire and value self care responsibility.

4. People are better able to make decisions consistent with their values and beliefs if

they are informed and educated about their condition and treatment options.
5. Teaching tools and instruction tailored to the individual’s needs and developmental
stage are more efl‘ective than generalized information.

Conceptual Definitions

Definitions of Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder are
well documented in literature and include the diagnostic criteria indicated in Table 1 (page 25).
. The essential feature of ADHD is the persistent pattern of inattention and/or
hyperactivity/unpulsivity that is more fi'equent and severe than that typically observed in persons
at a comparable stage of development. DSM-IV diagnostic criteria state that symptoms must
include (1) at least 6 of 8 indicators of inattention, (2) at least 6 of 9 indicators of
impulsivity/hyperactivity, (3) onset of some criteria before age seven, (4) some impairment in two
or more settings, (5) significant clinical impairment in social or occupational functioning, and (6)
symptoms that are not better accounted for by another medical disorder (American Psychiatric
Association, DSM-IV, 1994). For this project, ADHD will be defined as meeting all of the above

criteria. ADD will be defined as meeting all of the above criteria except that indicators of

Adolescents with ADD 6

hyperactivity/rmpulsivity will not have been present in the previous six months. This type of ADD
is coded in DSM—IV as Attention Deficit/Hyperactivity Disorder, Predominantly Inattentive Type
(APA, DSM-IV, 1994).

A definition of adolescence from Tabers is the period of time from the onset of puberty to
maturity . Studies of adolescents in relation to ADHD/ADD have specified age ranges of 11-19,
12-19, or 14-19 (Foley, Carlton & Howell, 1996; Homer & Scheibe, 1987; Phillips & Sofi‘er,
1996). For purposes of this project, the commonly accepted ages of 12 through 19 will be used
as the defining age range for adolescence. The target population for the teaching tool presented
in this project is adolescents entering high school, commonly 13 through 15 years of age.

Parents when used in this discussion will indicate the biological mother and father, step
parents who live in the home, or any adult who fills the role of custodial, responsible person for an
adolescent with ADD/ADHD

REVIEW OF LITERATURE

Writings about attention deficit/hyperactivity disorder can be found in pediatric literature
since the 1900s. The recent popularity of the subject in lay literature may have helped spark the
increased volume of medical literature. One review of medical reports found 163 published
reports in 1995, 90 of which were data-based studies (Phillips & Sofer, 1996). Further data are
becoming available each year, and the focus of the literature is moving fiom pediatric concerns
with ADD/ADHD to adult and adolescent experiences. The condition is now recognized as
affecting individuals throughout the life span. Much of the available literature can be categorized

as describing the etiology of the condition, describing diagnostic parameters, or focusing on

Adolescents with ADD 7

medication and/or behavioral treatment. A cross-section of the recent literature is reviewed in
this project, focusing on the reports that are most applicable to the adolescent population.
Max

One of the first medical descriptions of children exhibiting inattentiveness, hyperactivity
and irnpulsivity was published in 1902 by George Frederick Sill, MD. He postulated a
biologically-based etiology for the excessive behavior. In succeeding years environmental causes
have been advanced, such as birth trauma, lead poisoning, poor parenting, and dietary
idiosyncrasies. These factors are now considered to be potential exacerbating factors but not the
underlying cause of ADD/ADHD (Buncher, 1996).

The disorder has in the past been called brain-injured child syndrome or minimal brain
disorder. Sugar and red dyes are part of folklore etiology and some parents still modify diets of
their children trying unsuccessfirlly to control behavior (Barkley, 1990). Heredity through
polygenic transmission is a currently favored explanation for the distribution of ADD/ADHD
(Leung, Robison & Fagin,l994). When a child is diagnosed with ADHD, there is a 35% chance
that another sibling will have it, a 40% chance that one parent has ADD, and a 95% chance that
an identical twin will have it (Barkley, 1990; Buncher, 1996; Hallowell & Ratey, 1995)

Current research supports a neurobiological etiology (Hallowell & Ratey, 1995; Buncher,
1996). National Institute of Health research has indicated an imbalance between
neurotransmitters such as dopamine in the brains of patients with ADHD (NIMH, 1997). ADHD
patients’ brain cells were found to be 8% less active than non-ADHD patients’ brain cells in

certain areas of the brain and to have a reduced glucose metabolism (Buncher, 1996).

Adolescents with ADD 8
Diaggosis

Use of the DSM-IV criteria is most common in making the diagnosis of ADD/ADHD. A
comprehensive and detailed history is essential to obtain the appropriate information for
diagnosis. It is critical to compare attention span and impulsive behavior with behavior that is
appropriate for the age and stage of development. There is no specific test or clear cut symptom
that is definitive for ADHD. One DSM-IV criteria is that the symptoms cannot be better
explained by another disorder such as situational adjustment disorder, dissociative disorder or
anxiety disorder.

Some other conditions may produce some similar behaviors and should be eliminated
before the diagnosis of ADD/ADHD is made. Genetic abnormalities such as Tourette’s
syndrome, sickle cell anemia, or Tumer’s syndrome and medical disorders such as
hyperthyroidism, head trauma, lead poisoning, fetal alcohol or cocaine exposure must be ruled out
as causes of hyperactive, inattentive behavior (Buncher, 1996). Hearing or cognitive impairments
and psychological disorders such as depression should also be eliminated. Environmental factors
such as abusive or dysfirnctional family life should also be considered before attributing symptoms
to ADD/ADHD.

The comprehensive history includes interviewing the adolescent and parents and also
obtaining teacher observations related to behavior in school. DSM-IV criteria are clear that
dysfunctional behavior exists in school, at home, and in relationships. Inattention and
hyperactivity/impulsivity in only one setting indicates environmental factors that should be

pursued rather than ADD/ADHD. Screening tools such as the Conners Teacher Rating Scales

Adolescents with ADD 9

and ADD Evaluation Scale may be helpful in gathering part of the information needed (Adesman,
1991; Amen, 1997).

Assessment of the adolescent should include language and motor firnction, social skills and
his/her perception of school performance. Language skills can be a key indicator: a rapid,
“machine-gun” style of expression is a common finding among ADHD adolescents (F aigel, 1995).
Physical assessment is generally normal, although evidence of frequent accidental injuries may be
observed. A thorough neurological exam should be done including gross and fine motor
coordination, cranial nerve fimction, motor reflexes and sensory function. Although the neuro
exam may be normal, some minor neurological signs are not uncommon in ADD/ADHD children.
For example, eye signs may include unilateral winking deficits and nystagrnus or strabismus.
Motor abnormalities may include tremors, awkwardness, and asymmetrical reflexes (Buncher,
1996). Children with ADD/ADHD are more likely to have left-right confirsion and clumsiness
(Leung, et al., 1994).

Arriving at a diagnosis of ADD/ADHD may actually be a relief to the parent and child.
Guilt feelings related to parenting skills and lack of success in school may be eased as the parent
and child learn more about the condition. Teaching, resource identification and planning for
management choices all have a role in reestablishing hope for the firture once the diagnosis is
made.

Pharmamlogical Mmgement

The Advanced Practice Nurse in primary care may become involved in the management of

the adolescent with ADD years after the initial diagnosis is made. Therapies that were effective

in managing the child with ADD/ADHD often are no longer effective in adolescents.

Adolescents with ADD 10

Pharmacological treatment has received overwhelming attention in the popular literature. Options
for drug treatment must be considered as part of the plan, but a balanced treatment plan includes
behavioral therapy and environmental intervention. Adolescents participating in treatment
decisions may opt for reserving medication as a second step after trying some behavioral and
environmental modifications. A contract with written goals for academic and social performance
can be signed by provider, parent and child so that expectations fiom each party are clear and next
steps to try in the treatment program are laid out (Buncher, 1996).

Pharmacological therapy has a dual purpose: to reduce ADD/ADHD symptoms and to
help the adolescent focus more attentively so that behavioral therapy can be more successfirl
(Hallowell, 1995; Vinson, 1994). Medications should always be initiated on a trial basis with
specific goals and evaluation steps built into the plan. The effect of stimulants such as
methylphenidate (Ritalin) on ADD/ADHD children is to stimulate the under active parts of the
brain that regulate attention span and impulsivity (Ernst, Zametig & Matochek, 1994). Thus, for
these individuals, the stimulant has a calming and focusing effect. If the adolescent’s inattention
and impulsive behavior have an etiology other than ADD/ADHD, the stimulants will worsen the
condition. Close follow up during the initial trial period is essential.

Stimulants such as methylphenidate (Ritalin), dextroarnphetamine (Dexedrine), and
pemoline (Cylert) are the cornerstone of ADD/ADHD treatment (Craig, 1996; Taylor, 1987).
They work by increasing the concentration of neurotransmitters (norepinephrine and dopamine) at
the synapse, resulting in stimulation of the reticular activating system, limbic system and other
parts of the brain that control attention, arousal and the inhibitory process (Leung et a1, 1994).

These stimulants produce a good response in 70% - 80% of children with ADD/ADHD. The

Adolescents with ADD 1]

most common side effects are decreased appetite and insomnia (Barkley, 1991; Leung et al,
1994). Less common side effects are abdominal pain, headache, dizziness, drowsiness, dry
mouth, constipation, irritability, nightmares, and hypertension. Grth suppression has been a
concern. Studies indicate grth suppression may occur at methylphenidate doses greater than 1
mg/kg/day and at dextroamphetamine doses greater than 0.05mg/kg/day. Ultimate height of the
child does not appear to be affected (Leung, et al, 1994.; Richters, Arnold & Jensen, 1995).
Adderal is a mixture of dextroamphetamine salts, and for some children has a smoother onset and
longer duration of action (up to 6 hours) than other stimulants. Pemoline (Cylert) may be usefirl
in children who do not respond to methylphenidate or dextroamphetamine, but it can cause
hepatotoxicity. Liver enzymes should be measured every 3 months in children taking pemoline
(Richters, et al., 1995).

There are many studies supporting the efficacy and safety of stimulant therapy in children
with ADD/ADHD. Recent studies continue to document the positive effects of methylphenidate
(Ritalin) on school performance and learning (Schachar, Tannock, Cunningham & Corkum, 1997;
O’Toole, Abrarnowitz, Morris & Dulcan, 1997; Swanson, Wgall, Greenhill & Browne, 1998).
One study of 23 children indicated that higher range doses of methylphenidate (0.8mg/kg)
improved retention and recall of complex nonverbal information over lower doses (0.3mg/kg)
(O’Toole, et al., 1997). A study by Rapport and Denney (1997) attempted to evaluate the
practice of dosing by body mass. This study of 76 children failed to support the practice of
increasing the stimulant dosage per body weight (Rapport & Denney, 1997). The results may
have been skewed by the fact that non responders (up to 25% of children and up to 40% of

adolescents) were not excluded fi'om the study. A recent study of long term stimulant treatment

Adolescents with ADD 12

revealed continued benefits and few side effects in 62 children treated for 15 months (Gillberg,
Melander, & Von Knorring, 1997). More long term studies are needed, since the length of
therapy is being extended through adolescence and adulthood.

Additional studies have focused on the concern about grth deficits in children on long
term treatment for ADD/ADHD. The growth slowing effect of stimulant treatment has been
shown repeatedly to be temporary (Spencer Biederrnan & Harding, 1996; Rao, Julius, Breen &
Blethen, 1998; Leung, et al., 1994). This growth delay appears to normalize by adolescence, and
in one study the growth delay appeared to be related to the ADD/ADHD itself rather than to the
treatment (Spencer, et al.,l998). More studies describing the long term effects of the condition
on adolescents and the effectiveness of therapies in adolescents are needed.

Stimulants are still the preferred drug as children reach adolescence, but 30% - 40% of
older children and adults may lose their response to stimulants and respond better to second line
medications (Craig, 1996). Some clinicians believe tricyclic antidepressants are more helpfirl in
many children after puberty. Tricyclics work by increasing the available dopamine and
norepinephrine at the synapse, but they have severe side effects such as drowsiness, hypertension,
dry mouth, and constipation (Scahill & French, 1996). Toxicity from tricyclic overdose can be
fatal due to cardiac arrhythmia and conduction defects. These drugs should not be prescribed for
adolescents who are a suicide risk.

Clonidine (Catapress) is helpfirl in some older children who are especially aggressive and
impulsive who do not respond to the stimulants (F argason & Ford, 1994). Clonidine is available
in a convenient transderrnal patch. Close follow up of blood pressure as well as ADD/ADHD

symptoms is necessary.

Adolescents with ADD 13

Some adolescents and adults have also responded favorably to serotonin reuptake
inhibitors such as fluoxetine (Prozac) and sertraline (Zoloft). The anti-seizure drug
carbamazepine (Tegretol) has been helpful in some cases of ADHD treatment also (Craig, 1996).

Some medications that have been tried in the treatment of ADD/ADHD and found not
helpful include haloperidol (Haldol), chlorpromazine (Thorazine), benzodiazepenes (Valium,
Xanax), and barbiturates. Levodopa (Sinemet) has also been tried as a treatment for
ADD/ADHD since it works for Parkinson’s disease, another disorder of neurotransmitter
availability, but was not found to be clinically helpfirl (Buncher, 1996).

Studies of adult treatment of ADD/ADHD are becoming more prevalent. A meta analysis
of six clinical trials of pemoline or methylphenidate in 137 adult subjects demonstrated that
50-70% of adults have a good response to stimulant therapy (Wilens & Biederrnan, 1992). A
double blind study of 224 adults treated with stimulants versus placebo produced a robust positive
response in 60% of the patients treated with stimulants (W ender, 1998). Adult response to
stimulants was not as consistent as childhood response, and side effects were more fi'equent in
another study of adults (Ernst, et al., 1994). Some studies which have shown equivocal results
with stimulants in adults did not exclude patients with major depression and borderline personality
disorder, which may have confounded their results (Craig, 1996). Adults who have endured years
of attempting to firnction with untreated ADD/ADHD are more likely to have developed
comorbid psychosocial disorders that are difficult to sort out from their ADD/ADHD symptoms.
Behavioral Therapy

Retraining problem behaviors is an essential part of the treatment for ADHD/ADD. Many

teenagers with this disorder appear to focus their behavior on causing turmoil and strife around

Adolescents with ADD 14

them. The theory has been advanced that conflict and turmoil actually stimulates the under active
areas of their brain, making their misbehavior a form of self medication (Amen, 1997).

Behavior modification techniques can be used to decrease the reward for unwanted
behaviors and to reward desired behaviors. An example of a clear plan for parents to use includes
the following steps:

1. Discuss the desired and undesired behaviors.

2. Establish a baseline period of one month where the desired and undesired

behaviors are logged. This will allow for comparison to see if interventions
are effective.

3. Clearly communicate the rules and expectations. Written rules are more

effective and can be referred back to frequently.

4. Reward the desired behavior. Praise, privileges, even monetary rewards are

efl‘ective with teenagers. Building up points toward a desired purchase or event
can be very effective. Consistency is important and there should be no extending
“credit” on these rewards. Rewards are much more effective than punishments.
The key to shaping behavior is noticing the positive behavior and rewarding
it while diminishing the attention to the negative behavior. Consequences to
negative behavior must occur (loss of privileges, etc.) but the parent should
avoid arguing or negotiating over these consequences and simply refer back to
the rules. (Amen, 1997).
Teaching simple deep breathing relaxation techniques to parents can be effective in helping

to break patterns of yelling, belittling and nagging. These latter responses to adolescent disruptive

Adolescents with ADD 15

behavior can actually be reinforcing to the undesired behavior. Parental understanding of this,
ability to pause and de-escalate and to communicate consequences in a soft firm voice can be
much more effective. Positive reinforcement is more effective than punishment since difficulty
modifying behaviors based on previous experience is a particular problem for children with
ADD/ADHD (Leung, et al.,l994).

Interventions for social skill development are also important in treating ADD/ADHD.
Using behavior modification techniques to decrease aggressive behavior is important since
aggression is a strong predictor of peer rejection (Horton & Scheibe, 1997). The APN can
encourage parents to have discussions about appropriate social behavior and then provide
controlled settings for the adolescent to practice skills with peers.
Environmental Suppprt

It is helpful for the parent of an adolescent with ADD/ADHD to form relationships with
school administrators and teachers. Educators who are willing to learn about ADD/ADHD and
make adaptations in class techniques can make the difference in helping adolescents with
ADD/ADHD improve in school performance (Amen, 1997). For some teenagers with
ADD/ADHD decreasing the amount of assignments (completing every other problem) or allowing
additional time is very helpful. Oral testing, willingness to repeat directions and supply positive
reinforcement are helpfirl. Seating the adolescent near the teacher and surrounding him or her
with positive role models (helpfirl, successful students) is another strategy. Group work and
discussion teams with positive role models is another. Acting out and fighting may occur in the

cafeteria because of noise, confusion and distractions. Planning to avoid this can include

Adolescents with ADD 16

pleasurable activities during lunch break such as athletic activities, opportunities to work with
computers or auto mechanics (Diacon, 1992).

Working with the school to plan for decreased stimuli and distractions can help the student
with ADD/ADHD to be more successfirl (Amen, 1997). Seating the student near the front of the
room but away fi'om the window minimizes distractions. Printed instructions for assignments that
the student can refer back to are also helpful. The teacher who makes fi'equent encouraging eye
contact with the ADD/ADHD student will also help in keeping him/her focused on the classroom
activities.

A day planner is helpfirl in organizing tasks and assignments. Some students enjoy
electronic organizers. A variety of classroom presentation styles including demonstration, role
play, and computer programs helps engage the ADD/ADHD student. Preprinted lecture notes or
sharing notes of good students helps the ADD/ADHD student learn. Instructions should be given
in short simple steps and reinforced by written directions. Timed assignments or timed tests
should be avoided or modified for the ADD/ADHD student. Major assignments such as term
papers are especially difficult but can be managed if they are divided into stages and each stage
has a timeline and is reviewed (Amen, 1997). Frequent feedback to the ADD/ADHD student is
an important tool. Behavioral modification techniques should be used. Clear rules, positive
reinforcement for desired behavior and natural consequences without argument for undesired
behavior are as effective for teachers as for parents.

Stimulant use has been studied extensively (at least in male children), but more studies are
needed to document the benefits of behavioral modifications, parenting support, and

teacher/classroom modifications. A study that followed 100 adolescents over a three year period

Adolescents with ADD 17

showed sustained academic improvement and improved social adjustment for boys who received
multimodal treatments including pharmacological and behavioral therapies (Satterfield, et al.,
1981). This study is promising but limited by its all male population. Children treated with a
combination of stimulants and social skills training along with collateral parent training showed
more improvement in school performance than children in groups with only medication or only
social skills training (Frankel, Myatt, Cantwell, & Feinberg, 1997). Additional studies
documenting the benefits of behavioral therapy are needed to support the multimodal approach
Psychosocial/Developmental Issues

More studies are appearing on the long term psychosocial effects of ADD/ADHD on
adolescents. Studies have shown high rates of conduct disorders, anxiety disorders, and
substance abuse among adolescents who were diagnosed with ADD/ADHD in childhood (Foley,
Carlton & Howell, 1996; Lambert, et al., 1987; Homer & Scheibe, 1997). These studies had a
small sample size and were more likely to be retrospective, focusing on adolescents who were in
treatment for disorders rather than following larger groups of children with ADD/ADHD to
compare outcomes between groups whose treatment continued through adolescence and those
who stopped treatment.

Some research has recently examined other risks associated with ADD/ADHD. The
diagnosis was strongly associated with increased rate of driving offenses (N ada-Raja, Langely, &
McGee, 1997) and with early initiation of cigarette smoking (Millberger, Biederman & Faraone,
1997). A strong relationship between childhood ADD/ADHD and later arrests for delinquent
behavior was found in a study of 110 boys with ADD compared to a control group of 88 boys

without the diagnosis (Satterfield, Satterfield & Cantwell, 1982). Other outcome studies are

Adolescents with ADD 18

being reported of adolescents who were followed over time after a childhood diagnosis of
ADD/ADHD. A group of 85 adolescents with ADD averaged two years less of formal schooling
and lower ranking occupations than a control group of 73 “normal” adolescents (Mannuza, Klein,
Bessner, Malloy & Hines,1997). None of the studies above indicated whether the subjects
continued treatment through adolescence into adulthood. Studies are needed that document long
term beneficial outcomes from continuation of therapy through adolescence and adulthood.
Limitations of Literature

The subject of attention deficit disorder with or without hyperactivity has been studied
extensively, yet many things remain to be learned. The overwhelming focus of past studies has
been on eflicacy of stimulant medications on pediatric male subjects. Little is known about the
efficacy of stimulants and other medications on females (more likely to have predominantly
innattentive-type ADD) or on adolescents and adults of either sex.

The literature clearly documents the effects of stimulant medications on decreasing
ADD/ADHD symptoms. These stimulant medications have become the gold standard based on
the extensive research against which other treatments are being measured. A weakness of the
available literature is its lack of balance in documenting the effectiveness of non-pharmacological
treatment. Behavioral modification and environmental interventions show promise in the few
studies which focus on those treatments, but much more research is needed to document their
effectiveness and ensure their place in standard treatment for ADD/ADHD.

Although the short term benefits of stimulant medications are well documented, long-term
outcome studies of children treated through adolescence and adulthood are needed. The

literature has strongly documented the negative effects of ADD/ADHD on adolescent males:

Adolescents with ADD 19

increased rates of substance abuse, arrests and incarceration, and decreased completion of
education. None of these studies indicated whether the adolescents involved had maintained
treatment with medication, behavioral modification or environmental interventions through their
adolescent years. The biggest gap in the extensive research into this condition seems to be the
lack of studies which compare outcomes of long term treatment to outcomes of adolescents and
adults who have not received continued treatment.
fitment

Based on the literature reviewed, there is a need for an educational tool that is tailored to
the specialized needs of the adolescent with ADD and parents. Needs of the parents have been
identified as: knowledge and understanding of the condition; reassurance that they are not at fault
for their child’s struggle with school, behavior, and relationships; knowledge about the potential
treatment options; and support and assistance with implementing the family decisions about
treatment. Needs of the adolescent are identified as: understanding of how ADD afl‘ects their
daily life, knowledge of potential treatment options, participation in treatment decisions, and
support and assistance with their choices in making changes in school performance and
relationships. The literature strongly documents the risks for those who are untreated. The goal
of this project was to create a tool that would help families gain the knowledge to make treatment
decisions consistent with their values and beliefs, and to improve their ability to follow through on
their decisions to prevent the poor outcomes documented in the literature.

CONCEPTUAL MODEL
Imogene King’s (1981) General Systems Framework and Theory of Goa] Attainment were

used to conceptualize the role that the APN can play in supporting the health of the adolescent

Adolescents with ADD 20

with ADD/ADHD and the patient/family health. King developed the General Systems Framework
fi'om data based studies related to perception, self and communication (Tomey & Allgood, 1998).
King deliberately set out to build a scientific fi'amework for nursing (Frey, 1989). King stated that
most studies have centered on technical aspects of nursing care rather than on patient aspects
directly. King used a systems approach to build her theories, using systems to comprehend and
respond to complexities in patient care (Tomey & Alligood, 1998).

King’s (1981) three interacting open systems include individuals as personal systems, two
or more individuals forming interpersonal systems, and larger groups with common interests and
goals forming social systems (Figure 1, page 26). Adolescent health can be conceptualized fi'om
King’s concept of health in relation to the individual personal system. King defines health as a
process of growth and development and the ability to function in social roles. ADD/ADHD
impacts the adolescent’s health in each realm as impulsive, inattentive behavior retards
intellectual/academic development and severely impedes social firnctioning.

Interpersonal systems can be viewed as the family unit and the adolescent’s relationships
with peers, which is of crucial importance in that developmental stage. F arnily health is viewed in
terms of functional ability to adjust to stressors in the internal and external environment and cope
with maturational and situational crises (King, 1981). The behavior of the ADD/ADHD
adolescent puts a severe strain on the family’s ability to cope with these stressors. The larger
social system includes both the adolescent’s interaction with the school system and the
adolescent’s and family’s relationship with the health care system. These three systems interact

with each having major influences on the other two systems, as diagrarnmed in Figure 2 (page 27.

Adolescents with ADD 2]

Each system includes concepts which King (1981) defined and described to demonstrate
how interrelated these systems are. Concepts in the personal system include perception, self,
grth and development, body image, learning, and space and time. Selfis a composite of
thoughts and feelings which constitute a person’s awareness of his individual existence (King,
1981). Perception is a key concept in building the awareness of self and is defined as organizing
and interpreting information that gives meaning to one’s image of reality (King, 981). Perception
is affected by the ability of the person with ADD/ADHD to focus on information, sort it out and
make sense of it. Decrease of that organizational ability results in distortions of one’s perception
and self concept. Body image is a person’s perception of their own body and is influenced by
others’ reactions to self (King, 1981). The impulsivity, aggressiveness and clumsiness of
adolescents with ADD/ADHD results in poor peer, school and social relationships which cannot
fail to damage his concept of self (Amen, 1997). Learning is a concept King added to the
Personal System in 1986, although it was not defined or described (Frey, 1993 ). Learning is
affected by the ADD/ADHD condition and illustrates another impact this condition has on the
Personal System.

Concepts in the Interpersonal System include human interactions, communication,
transactions, role and stress. Human interactions serve a purpose and are valuable in their own
right in building relationships. Transactions include both verbal and nonverbal behavior and are
goal directed (King, 1981). Children with ADD/ADHD often use inappropriate verbal and
nonverbal behavior and thus fail to accomplish their goals in these transactions (Barkely, 1990). A
key role for the APN is to help the adolescent to develop verbal and nonverbal behaviors that are

more effective in reaching the goals. The description of role includes the set of expected

Adolescents with ADD ' 22

behaviors, the rules and obligations for a person to perform in a certain situation (King, 1981).
These expected behaviors and rules must be clearly stated and reiterated to the adolescent with
ADD/ADHD, as impulsive behavior often takes them outside the boundaries of what is
considered appropriate for their role in the classroom and in social situations (Amen, 1997).
Stress in the Social System can be positive or negative, constructive or destructive. When
transactions are successfully made, tension or stress is reduced in a situation (King, 1981).

King’s (1981) goal of nursing is to help the individual maintain optimum health so he/she
can firnction in social roles. Social support for both parents and children is necessary to maintain
the health of the individual and the family. Social support is synthesized from King’s work by
Frey (1989) as the exchange of positive afi‘ect, a sense of social integration, emotional concern
and/or direct aid or services between two persons.

The role of the APN in primary care is to manage the interactions between the social
system of health care and both the family and the adolescent’s personal system so that the result is
social support that improves the adolescent’s relationship and interactions with family and society.
The plan for accomplishing this goal can also be derived from the Theory of Goal Attainment
(King, 1981). Figure 2 (page 27) shows an adaptation of King’s schematic diagram of goal
attainment theory with the addition of the parents’ sphere of influence to that of the nurse (APN)
and client (adolescent). The mutual goal setting and agreement on means of attaining goals are
crucial in working with adolescents.

The Goal Attainment Theory (figure 2, page 27) is helpful in visualizing the APN’s role in
facilitating communication between the adolescent and parents because it indicates how important

each party is in the communication transaction and illustrates how each individual reacts to the

Adolescents with ADD 23

other individuals in the transaction. Including the adolescent and the parent(s) in the goal setting
and planning is essential in order to achieve the desired outcome. The APN plays the roles of
facilitator and supporter in the communication process. The teaching tool developed for this
project will be useful in the step of exploring the means to reach the goals. Agreeing upon goals
for the family and adolescent is a likely to take time and effort for the family and for the APN.
Once that important step is accomplished, the APN should be ready with the tools for the family
to use to explore the options for treatment and meeting the behavioral goals.

Adolescents with years of poor school performance and troubled peer and family
relationships may develop feelings of helplessness and hopelessness (Laben, Dodd, & Sneed,
1991). King’s (1981) theory of mutual goal setting and goal attainment was used in one setting of
I troubled juveniles who had been charged with criminal offenses (Laben, et al., 1981). Goal
attainment theory stresses the importance of accurate perceptions of nurse-client communication.
When therapists working with juvenile offenders used the concept of mutually set goals,
continuously reflecting back on the adolescent’s perception of the transactions, positive impact on
behavior and group cohesiveness was achieved (Laben, et al., 1981).

Adolescents are particularly suited to the use of mutually set goals. Their developmental
tasks include rebelling toward independence, so their share of control of the goal setting process
is crucial in gaining cooperation with the plan. The theory of goal attainment encompasses the
steps of action, reaction, interaction, perception, and transaction (King, 1981). Perceptual
congruency between client and nurse is necessary to reach the step of a successfirl transaction
(Carter & Dufour, 1994). The role of the APN in applying King’s theory in the treatment of an

adolescent with ADD/ADHD lies in facilitating communication until there is perceptual

Adolescents with ADD 24

congruency between adolescent, parent and nurse regarding the mutually set goals and the
planned activities to attain them.

The teaching tool developed for this project assists the APN in presenting a selection of
options for treatment to the adolescent and parents. The information is presented in short simple
steps in a modular format to fit the learning style of the adolescent with ADD/ADHD. The
teaching tool can be used to assist the family in exploring the means to reach the goals they have
mutually agreed upon. The family can discuss which of the options they wish to learn about and
finally select to act upon.

The Role of the Advanced Practice Nurse in Primary: Care

The role of the APN in primary care in managing adolescents with ADD/ADHD may start
with a family crisis intervention. Plans and therapies that were previously successful in the child
often become ineffective as the child passes through adolescence. The advanced practice role of
counselor assists the family in this instance by providing support and helping the parents and
adolescent to understand and cope with the impact of adolescent development on the treatment
plan. In assessment of families who present in conflict over the adolescent’s school and social
performance, previous history of learning disabilities is an important component. Both child and
parent may consider the previous diagnosis of ADD/ADHD to be “outgrown” and may not
mention that history unless asked. Once the assessment includes the former diagnosis of
ADD/ADHD, the APN can share with both parents and child the recent research that shows how
ADD/ADHD continues to affect adolescents and adults even after the hyperactivity abates.
Sharing that information, plus the fact that there are treatments available specifically for

adolescents may be enough for the first visit for this problem. Discussion between parent and

Adolescents with ADD 25

child over what treatment options should explored, what goals can be agreed upon, and what
interventions are best to accomplish the goals can be facilitated during fixture visits. The
consultant role of the APN will be to assist the family in developing their own knowledge base
from which they can develop a treatment plan. The APN can ofl’er the available treatment options
for medications, behavioral modifications, and environmental manipulation fi'om the teaching tool
developed in this project. The role of educator is key in using the teaching tool to help family
members to understand the available options. When facilitated discussions result in mutually
agreed upon goals, the APN as a clinician can assist the family in setting up intervention plans,
performance contracts, rewards and consequences, and alternative plans.

Throughout the process, the APN firnctions as a facilitator, evaluator, and monitoring
clinician (Buncher, 1996). The teaching tool enables the APN to serve as an information source
in the process of exploring the means during the goal attainment process, as well as a referral
source for support groups or more extensive counseling and family therapy if needed.
Background knowledge of the increased risk of accidental injuries and substance abuse should
guide the APN in using anticipatory guidance with the family as part of the plan.

Advanced Practice Nurses can contribute to the body of knowledge on the subject of
Attention Deficit Disorder in adolescents by following the current standard of treatment and by
collecting data on outcomes. Research needs identified by this project include long term
longitudinal studies of clients with ADD who are treated through adolesceince and into
adulthood. Outcome analyses to show the percentage of those treated who have substance abuse

problems, incarceration, and conduct disorders should be compared with the previous studies of

Adolescents with ADD 26

untreated youths. Graduation rates fiom high school and college would be another significant
outcome.

There is also a need to study clients treated through adolescence and adulthood with
stimulant medications to verify that ultimate height is not afi’ected by the more long term
treatment. Advanced Practice Nurses in primary care have an excellent opportunity to study the
effects of behavioral modification and environmental adaptations on the outcome of clients who
choose that form of treatment. That information is needed to substantiate the value of those
therapies and ensure their place in standard treatment for ADD/ADHD.

Use of the tool developed for this project will facilitate the APN’s ability assist the family
in selecting the treatment plan tailored to their needs. The tool will also enable the APN to use
the chosen interventions more effectively. Understanding how medications work can improve
compliance. Simple step by step directions can assist parents and adolescents in use of behavior
modification techniques.

Evaluation of the effectiveness of the tool should be on multiple levels. A simple
satisfaction survey can be used with parents and adolescents to ask for their level of agreement on
a five point scale with the statements:

“I found the education materials easy to read”

“I was able to use the information in the material”

“Reading this material helped my family to choose how we wanted to
plan for treatment”

“I found a suggestion that I was able to use to help meet my goal”

Adolescents with ADD 27

On another level, long term outcomes should be measured on each client. Those
outcomes would be based on the goals selected by the family. They may include improvement of
grades to a specified level, family disagreements handled without arguing and shouting, or ability
to complete a semester of school without expulsion for misbehavior. A compilation of the
percentage of client families who meet their goals would be another indicator of the effectiveness

of this tool.

Adolescents with ADD 28

Table 1. Diagnostic Criteria for Attention Deficit/Hyperactivity Disorder

A. Either I or 2: of the following symptoms of inattention have persisted for at least

1.

6 months to a

Six (or more) degree that is maladaptive and inconsistent with developmental level:

a. Often fails to give close attention to details or makes careless mistakes in
schoolwork, work or other activities

b. Often has difliculty sustaining attention in tasks or play activities.

c. Oftm does not seem to listen when spoken to directly.

d. Often does not follow through on instructions and fails to finish schoolwork,
chores or duties in workplace (not due to oppositional behavior or failure
to understand instructions).

e, Often has dificulty organizing tasks and activities.

f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained
mental efl‘ort (such as homework or schoolwork).

g. Often loses things necessary for tasks or activities (e. g., toys, school assignments,
pencils, books or tools).

b. Is often easily distracted by extraneous stimuli

i. Is often forgetful in daily activities.

2. Six (or more) of the following symptoms of hyperactivity-hnpulsivity have persisted

for at least 6 months to a degree that is maladaptive and inconsistent with
developmental level.
Hyperactivity
Often fidgets with hands or feet or squirms in seat.
. Often leaves seat in classroom or in other situations in which remaining seated
is expected.
Ofien runs about or climbs excessively in situations in which it is inappropriate.
. Often has dificulty playing or engaging quietly in leisure activities.
Is often “on the go” or acts as if driven by a motor.
.Ofien talks excessively.
Impulsivity
g. Often blurts out answers before questions have been completed.
h. Often has dificulty awaiting turn.
j. Often interrupts or intrudes on others.

0"!”

recap

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present

before age 7 years. A

C. Some impairment fiom the symptoms is present in two or more settings (e.g., at school or
work and home).

D. There must be clear evidence of clinically significant impairment in social, academic, or
occupational functioning.

E. The symptoms do not occur exclusively during the course of a Pervasive Developmental
Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by

another mental disorder (e. g., Mood Disorder, Anxiety Disorder, or Personality Disorder).

From DSM-IV, American Psychiatric Association, 1996.

Adolescents with ADD . 29

Figure l
ADAPTED FROM

A CONCEPTUAL FRANIEWORK FOR NURSING

 

 

BY IMOGENE KING

/ ————————————————————— W
l . l
I Social Systems I
: idysthtemcm (Society) School - :
l ___________________ \ l
l l

Interpersonal Systems | [x l
I ( Gro ups) ' r
l T—M ;
j P , If A Personal Systems \_.—:I> l l
I ”my I (Individuals) I I . I
I l " ' I j ,. 'l
I Adolescent I l l
l . ~ > 1
l - I r l l
: 2331p i l— — — — — J I . :
I l _ _ l . p l
i K ____________ J I
l l
l l
K _____________________ J

' DYNAMIC meme SYSTEMS‘

From I. M. King; A Theoryfor Nun-trig: Systems, Concepts, Process. New York Job:
Wiley & Sons, 1981, p. 11. .

Adolescents with ADD 3
0

FIGURE 2
ADAPTED FROM
SCI-[EMATIC DIAGRAM OF GOAL ATTAINNIENT THEORY

BY IMOGENE KING

 

 

     

Transactions

APN ‘ ADOLESCENT

 

 

PARENT

 

Adolescents with ADD 31

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Amen, D. (1997) Mdows mto the ADD Mind. Mindworks Press: F airfield, Ca..

Barkley, R. Attention deficit hyperactivity disorder: A handbook for diagnosis and
treatment. New York: Guilford Press, 1990.

Buncher, P. C. (1996), Attention deficit/hyperactivity disorder: A diagnosis for the 90's.
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Adolescents with ADD 32

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Adolescents with ADD 37

Using the Teaching Tool for Adolescents
With ADD and Their Parents

Attention Deficit Disorder is a relatively common condition in primary care, affecting
approximately 3-5% of children in the United States. It was formerly assumed that most children
outgrew the condition by adolescence, but it is now known that 50-7 0% of the children with
ADD are still afi‘ected through adolescence and into adulthood. Adolescence is a critical time of
growth and development, second only to the first year of life in the amount of physical change and
developmental tasks to be accomplished. Untreated attention Deficit Disorder causes severe
problems for adolescents and can result in diminished self esteem, decreased learning, and
increased risk of substance abuse and conduct disorders.

These adolescents may present to the APN in primary care under severe stress due to the
effects of the condition on their relationships and their performance in school. Both the
adolescent and parents may be under the assumption that the condition of ADD/ADHD has been
outgrown and is no longer contributing to the school and relationship problems. The first task for
the APN is to take a thorough history to determine the presence of a previous diagnosis of
ADD/ADHD. This may not be mentioned in the initial assessment without specific questioning if
the adolescent received childhood treatment by a pediatrician or child psychiatrist and assumed
that the condition was outgrown.

Once the previous diagnosis has been established, it is important to review the condition
with the adolescent and family. Emphasize that current research indicates that problems with

attention and irnpulsiveness usually continue through teen years and into adult life. The teaching

Adolescents with ADD 38

tool, “What is ADD and How does it Affect Teenagers?” is a helpful guide for this discussion and
can be given to the family to take home for later reference.

Ask the adolescent what he/ she would like to change about how he/ she gets along at
school and at home. The role of the APN is to facilitate communication by encouraging the child
and parent(s) to discuss until they agree on one or two priority goals. The teaching tool,
“Medications for ADD/ADHD” may be discussed and given to the family at this time if they
indicate they are interested in using the medication option to work toward the goals identified.
Behavioral modification and classroom interventions should be discussed briefly at this first visit
also, and if the family indicates they would prefer to pursue these options first, a handout from
each of these sections should be discussed in greater detail and given to the family instead of the
medication handout. It is important to not overwhelm the adolescent and parent(s) with written
information on the first visit, but to focus on initiating the family discussions on setting obtainable
goals and agreeing on the means to reach them. The various written handouts in the teaching tool
are intended to guide detailed discussions and give reinforcement to the options the adolescent
and parents agree are most workable for their situation.

A visit should be planned in two weeks to further discuss the options of medication,
behavioral modification and classroom interventions. A handout on a specific medication for
ADD can be given if the decision to use medication is used. Detailed handouts on behavioral
modification and classroom/homework strategies can be discussed and given out during
succeeding visits. Each visit should conclude with the APN seeking to obtain consensus with the
parent and adolescent about the long term goal and the specific steps being taken to reach the

goal. An expected outcome that details the steps taken by the adolescent and the parent(s) during

Adolescents with ADD 39

the next two weeks should be documented on the chart and also on a copy for the family, signed
by the adolescent and parent. This acts as a contract to encourage commitment to the plan by all
parties concerned.

Weekly phone contact is ideal to ask about academic progress, medication response and
side effects (if medication use is chosen) and family dynamics. Adolescents may choose to start
with medication and a home behavioral modification program and then work on school
interventions once they are comfortable with meds and home changes. Other adolescents may
wish to focus on classroom and behavioral interventions and use medication as a back up plan.
The decision that the family makes will guide the APN in selecting the specific sections of the
teaching tool that will be useful to the family. For convenience in selecting fi'om the appropriate
sections, they are color coded as follows: medication handouts (blue), behavioral modification

handouts (green), classroom/homework strategies (yellow).

Adolescents with ADD 40

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WHAT IS ADD AND HOW DOES IT AFFECT
TEENAGERS?

Attention Deficit Disorder (ADD) and Attention Deficit/Hyperactivity
Disorder (ADHD) has received a lot of attention in the news. Recent research
suggests ADD is a physical disorder where certain parts of the brain are under
active because of a chemical imbalance. The under active areas are the parts that
help us to concentrate and to think before we act. People with ADD are helped by
medicines that stimulate those under active parts of the brain. They also have to
learn to compensate by putting effort into focusing on their work and on keeping
organized. Many famous people have succeeded in spite of ADD. Examples:
Thomas Edison, Albert Einstein, Henry Ford, “Magic" Johnson, Suzanne Sommers,
Robin Williams, Whoopi Goldberg. The efforts they made to overcome the
impulsive, disorganized traits of their personality helped give them the drive to
succeed in life.

Scientists and doctors used to think that children outgrew the condition by
the time they were teenagers. We now know that over half of the children
affected by this condition continue to be affected as teenagers and adults.

How do we know if you have ADD/ADHD?

A health care professional diagnoses ADD/ADHD by getting information
from a child or teenager, the parents and teachers. This information must include
6 or more of the symptoms from the following list. The symptoms must be more
intense and troublesome than would be expected in someone of the same age and
must have lasted at least 6 months.

*Often fails to give close attention to details or makes careless mistakes

*Often has difficulty keeping attention on tasks or play

*Often does not listen when spoken to directly

*Often does not follow through on instructions and fails to finish work

*Often has difficulty organizing tasks and activities

Compiled fi'om written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 41

*Often avoids and dislikes tasks that require prolonged mental effort
(schoolwork and homework)
*Often loses things necessary for activities or work
*Is often easily distracted
*Is often forgetful in daily activities
*Hyperactivity - often fidgets with hands/feet or squirms in seat
*May leave seat and wander often when that is not appropriate
*Often has difficulty doing leisure activities quietly
*Often talks excessively
*Impulsiveness - may blurt out answers before questions are completed
*Has difficulty waiting turn
*Often interrupts others
*Seems always “on the go" or driven by a motor
Also: Some of these symptoms must have appeared before age 7
These symptoms must cause trouble in 2 places (school, home, work)
And: The symptoms are not better explained by another condition like mental
illness, anxiety, or stressful situations.

Children and teenagers with ADD/ADHD need extra effort and help to
succeed in school and life. This condition affects 3-5% of children and teenagers in
the United States. There is much research on how medications help people with
ADD to function better. Most health care professionals believe that behavior
modification and school adjustments are just as important as medication. We will
talk about how each of these strategies may be helpful to you. To learn more
about ADD/ADHD, here are some resources on the Internet or in the library.

INTERNET RESOURCES

http://www.as.wvu.edu/-scidis/add.html
http://www.add.org
http://www.chadd.com
http://add.miningco.com/mbody.htm
http://www.nimh.gov/publicat/adhd.html

Compiled fi'om written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 42
BOOKS FOR TEENAGERS

Gramer, J. (1996). Succeeding in Collogo with Attention D_eficit Disorder.
Plantation, FL: Specialty Press.

Crist, J. (1996). ADHD: A Teenagor's Guide. King of Prussia, PA: Center
for Applied Psychology.

Nadeau, K. (1998). Hel ADD Hi h School. Bethesda, MD: Advantage
Press. .

Quinn, P. (Ed), (1994). ADD and the Collogo Student: A Guide for High
school and Collge Students with Attontion D_eficit Disorder. New York:

Magination Press.
BOOKS FOR PARENTS

Bain, L. (1991). A Parent's Guide to AtterntionJDeficit Disorders. New York:
Dell Publishing.

Barkley, R. (1987). Defiant Children. New York: Guilford Press.

Wender, P. (1987). The ractive Child Adolescent and Adult: Attention
Deficit Disorder Through the Lifesmn. New York: Oxford University Press.

 

Sources: Am, 1997; Diacon, 1992; Calandra, 1994

Compiled fi'om written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 43

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MEDICATIONS FOR ADD/ADHD

Medication is often an essential component to treatment for ADD/ADHD.
There are a variety of different types of medications and several specific
medicines within each type. Some people who do not respond well to one type of
medicine may do very well on another type. You, your parents, and teachers all
need to be alert to how you respond to the medicine so that changes can be made
if needed, and the best possible therapy can be selected.

GOALS OF MEDICATION
*Increase attention span and ability to learn
*Decrease distractibility
*Decrease restlessness or high activity levels
*Decrease impulsive behavior and increase thoughtful behavior
*Decrease irritability
*Increase motivation
*Improve functioning in school, at home, and in relationships

How will we know if the medications are working?
Patient, teacher and parent questionnaires and logs of behavior are helpful
and may be used to compare functioning before and after treatment. Evaluation

also includes how you are doing in school and how you feel you are getting along
with family and friends.

TYPES OF MEDICATIONS

Stimulants - most common type of medication used for ADD/ADHD
Examples: Ritalin, Dexedrine, Adderal, Cylert

Tricyclic Antidepressants - used in lower doses for ADD/ADHD than for
depression. May take up to one month to show effectiveness and need close
monitoring for side effects.
Examples: Norpramin, Tofranil, Elavil, Pamelor, Wellbutrin, Sinequan

Compiled from written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 44

Serotonin effecting medications - may take 1-3 months to show their benefit and
need close monitoring.
Examples: Zoloft, Effexor, Paxil, Luvox, Prozac, Remeron

Anti-Seizure medications - not first choice medications, but may help some people
who don't respond to other medications.
Examples: Tegretol, Depakote, Neurontin, Dilantin

Blood Pressure medications - sometimes used along with stimulants to help with
hyperactivity and aggressiveness.
Examples: Catapress, Inderal.

Sources: Amen, 1997; Diacon, 1992; Calandra, 1994

Compiled from written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 45

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STIMULANT MEDICATIONS FORADD/ADHD

n RITALIN (methylphenidate) [I oexeolune (dextroamphetamine)
[I ADDERAL (mixed dextroamphetamine salts)
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DOSAGE

How do these medications work?

These medicines stimulate the underactive areas of the brain that control
attention and concentration. They can improve attention span and ability to finish
tasks, decrease distractibility and restlessness and improve ability to follow
instructions. Better listening and improved communications in relationships can
result.

How long does the medication last?

Ritalin and Dexedrine usually last 3-4 hours but it can vary in some people
from 2 i hours up to 6 hours. There is a slow release Ritalin that lasts 6-8 hours
and may help you avoid a lunchtime dose. It works well for some people but for
others the release of medication is too irregular to be helpful. Adderal acts like a
slow release medication and usually last about 6 hours. For some people it has a
smoother onset of action and wearing off period

Everyone is different in their need for medication. Some people show
improvement on small doses once a day, others have to work up to higher doses 3-4
times a day to get a good effect. Close attention to your response to the medicine
and good communication with our office are necessary to make sure you get the
amount of medicine that is best for you.

These medicines start their action with the first dose, so you will see the
effects right away.

Compiled fiom written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 46

How will we know if the medicine is working?

We may need to have contact either by an office visit or phone every 2
weeks until your best combination of medicine, dosage, and timing is figured out.
We will talk about how you are doing at home, at school, and in relationships with
friends, and check for any side effects. We will keep a chart on your height,
weight, and blood pressure. We will also ask your teachers to fill out evaluation
forms at times.

What side effects can these medications have?

Stimulants have been found to be very safe and side effects that may occur
almost always go away when the medicine is stopped. Some side effects go away
after the lst 2-3 weeks of the medicine, so we may decide together to wait out a
side effect if it is not too troublesome. We will need to talk about ANY side
effect you may have so we can decide.

Common side effects
*lack of appetite
- take medication after meals rather than before
- plan a healthy afternoon and late evening snack
*trouble falling asleep
- afternoon doses can be decreased or stopped
- warm milk with vanilla and honey at bedtime may be helpful
- avoid caffeine (coffee, pop, chocolate)
*headoche or stomach ache
- use tylenol or ibuprofen for headache
- take medication with food
*moodiness/crankiness/emotional sensitivity
- minor personality changes usually go away after a week or two. If
not, a change of medication may be best.
*growth slowing
- growth is sometimes delayed, but you will catch up later

Rare side effects
*tics, twitches, or rapid eye blinking
- call if this happens

Compiled from written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 47

*rapid pulse or increased blood pressure
- call immediately if you have chest pain or fluttering feeling in your
chest
*nervous habits - picking at skin or hair or stuttering
- rare, but call if this happens so we can adjust medication
*allergy to medication
- call immediately if rash or trouble breathing

What happens if I stop this medication suddenly?

Moodiness, trouble sleeping, or hyperactivity can occur if you suddenly stop
this medicine after taking it for a long time. It is better to stop the medicine
gradually by taking less each day for a week or two.

How long will I need to take this medicine?

Each person is different so that is hard to predict. We used to think people
outgrew ADD/ADHD in their teen years, but recent research shows even adults
can continue to function better if they stay on medication.

How does this medication affect other medications I might take?
*Check with your pharmacist or this office before taking any other
medications.
*Caffeine intake (from coffee, pop, chocolate) should be very limited.
*Avoid antihistamines and decongestants. Saline nasal drops can be used or
a nasal spray for one or two days if needed.
*Never take this medicine with MAO inhibitors (a type of antidepressant)

Please write down your questions, concerns, and any possible side effects you have
so we can discuss them at your next office visit or phone conversation!

Sources: Amen, 1997; Diacon, 1992; Calandra, 1994

Compiled from written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 48

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flTofranil (imipramine) [INorpramin (desipramine)

[lElavil (amitryptyline) [JPamelor (nortriptyline)

[ISinequan (doxipen) flWellbutrin (buprion, similar to tricyclics)
DOSAGE:

 

How do these medications work?

These medications affect chemicals in the brain that affect mood, attention
and concentration. In larger doses they are used to treat depression, smaller
doses decrease impulsive behavior, distractibility, anxiety and hyperactivity. The
effects may take several weeks to appear so you must take this medicine for 4-6
weeks before deciding that it doesn't work for you (unless you experience side
effects that are too troublesome to continue). These medicines are usually taken
once or twice a day.

How will we know if this medication is working?

When taking these medications, it is important to keep in close touch to
make sure the medication is helping and that side effects are not a problem. We
will talk about how you are doing at school, at home and in relationships with
friends. Your parents‘ impression of how things are going are also important, and
periodic evaluation forms from your teachers.

A blood level of the medicine or an ECG (heart test) may occasionally be ordered.

What side effects can this medicine have?
The following side effects may occur within the first few weeks of
treatment and then may go away if treatment with the medication is continued.

Some people may have some of these effects so severely that the medicine may
have to be stopped.

Compiled from written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 49

*Dry mouth - sugarless gum may help. Brush your teeth frequently to
prevent increased cavities.

*Weight gain or loss. These medications may effect your appetite either
way. Be aware of how your appetite changes and plan for healthy eating.

*Sleepiness - when first starting this medicines and if this side effect
continues, DO NOT drive or operate machinery.

*Irritability - this usually improves after a few weeks, but if it is too severe
or lasts, the medicine may have to be changed.

*Nightmares - same as above.

*Stuttering - again, if this lasts or is severe, the medication may have to be
changed.

*Constipation - drink 8 glasses of water a day, use a fiber supplement like
Metamucil

*Dizziness when you first stand up - this usually goes away after a few
weeks, but in the meantime stand up slowly and give your body a few
seconds to adjust before walking.

Call immediately if you have:

*Blurred vision

*Trouble urinating

*Heart fluttering or pains in chest
* High or low blood pressure
*Severe nausea or vomiting
*Convulsions (seizures)

What could happen if this medicine is stopped suddenly?

Stopping the medication suddenly or skipping doses is not dangerous but it
could be uncomfortable. Headache, muscle aches or nausea could occur.
Nervousness, sadness, or trouble sleeping could also happen. If you have been on
this medicine for some time and you decide you want to stop, we should talk about
how to taper it off.

What else is important to know about this medication?
An accidental or deliberate overdose of any of these medications is very
dangerous! They need to be taken under close supervision.

Compiled fi'om written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 50

Drinking alcohol or using other drugs with these medications can also be very
dangerous. We should discuss any prescription or over the counter medicine you
use when you are taking these medicines.

You should not become pregnant while taking these medications.
Unprotected sex should always be avoided, but especially while on these
medications. If you think you may be pregnant, call immediately so we can discuss
what to do.

Please write down your questions, concerns, and any possible side effects you have
so we can discuss them at your next office visit or phone conversation!

Sources: Amen, 1997; Diacon, 1992; Calandra, 1994

Compiled from written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 51

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Some of these medications are known as “SSRI” meds - Selective Serotonin Reuptake Inhibitors.

flEfl'exor (venlafaxine— []Paxil (paroxetine)
flProzac (fluoxetine) [ISerzone (nefazodone)
flDesyrel (trazodone) DLuvox (fluvoxamine)
[IZoloft (sertraline) flRemeron (mirtazapine)
DOSAGE

 

How do these medicines help?

These medicines cause increased levels of serotonin, a chemical in your brain
which affects mood, anxiety, and behavior. It may take several weeks to feel the
effects of these medicines, so it may take some time to adjust to the right dose to
improve attention span, irritability and restlessness.

How will we know if this medicine is working?

When taking these medications, it is important to keep in close touch to
make sure the medication is helping and that side effects are not a problem. We
will talk about how you are doing at school, at home and in relationships with
friends. Your parents' impression of how things are going are also important, and
periodic evaluation forms from your teachers.

What side effects can occur with this medication?

Any medicine can have side effects, including allergy (rash, trouble
breathing). Let us know right away if the medication is causing you any problem.

Compiled from written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 52

The following side effects sometimes occur. They usually decrease after a few
weeks, but if they are severe the medication may have to be stopped or decreased.
* Increased sweating
* Dizziness (stand up slowly and give your body a few seconds to adjust)
* Headache - use tylenol or ibuprofen
* Nausea or diarrhea - take medication with food
* Unable to sleep - if this occurs, take the medicine in the marning
* Dry mouth - use sugar free gum and brush teeth frequently to prevent
cavities.
* Sleepiness - don't drive or operate machinery if the medication makes you
sleepy
* Increased or decreased appetite - be aware of the effect and plan for a
healthy diet
* Sexual problems - usually delayed orgasm

What could happen if this medicine is stopped suddenly?
Stopping these medicines suddenly or skipping doses is not recommended,
and may cause depression. Call if this occurs.

How will this medicine affect other medicines I might take?

You should discuss any other medicines with me or with your pharmacist. It
is especially important not to take MAO inhibitors (a type of antidepressants) with
these medicines.

Do not use alcohol or take any street drugs with these medicines.

You should not become pregnant while taking these medications.
Unprotected sex should always be avoided, but especially while on these
medications. If you think you may be pregnant, call immediately so we can discuss
what to do.

Please write down any questions, concerns or side effects you may have while on
this medicine so we can discuss them at your next office visit or phone contact.

Sources: Amen, 1997; Diacon, 1992; Calandra, 1994

Compiled from written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 53

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flDepakene (valproic acid flDepakote (divalproex sodium)

[ITegretol (carbamazepine) [lNeurontin (gabapentin)

[lKlonopin (clonazepam) [lDilantin (phenytoin sodium)
DOSAGE:

 

How do these medications work?

These medications calm overactive areas of the brain that may cause
depression, anxiety, restlessness and aggression. They are NOT first choice
treatment for ADD/ADHD but sometimes help people who do not respond to other
medications. They may be combined with stimulants in some cases.

How will we know if this medication is working?

When taking these medications, it is important to keep in close touch to
make sure the medication is helping and that effects are not a problem. We will
talk about how you are doing at school, at home and in relationships with friends.
Your parents' impression of how things are going are also important, and periodic
evaluation forms from your teachers.

A blood level of the medicine or a blood test that measures liver function or a
blood count may be ordered depending on which medication you are taking.

What side effects can this medicine have?

The following side effects may occur with some of the above medicines and
should.be reported right away.

*High or low blood pressure or rapid heart rate

* Rash

Compiled fiom written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 54

*Sleepiness - when first starting this medicines and if this side effect
continues, DO NOT drive or operate machinery.

*Decreased coordination.

*Confusion or memory problems

*Nausea/vomiting.

*Dizziness when you first stand up - this usually goes away after a few
weeks, but in the meantime stand up slowly and give your body a few
seconds to adjust before walking.

*Hair loss (with Depakene or Depakote)

*Swollen gums (with Dilantin)

What could happen if this medicine is stopped suddenly?

Stopping the medication suddenly or skipping doses is not recommended, so
contact this office if you feel you need to stop taking the medicine after taking it
for a period of time.

What else is important to know about this medication?

If you are taking birth control pills, they may be less effective while you are
taking some of these medications. You should not become pregnant while taking
these medications. Unprotected sex should always be avoided, but especially while
on these medications. If you think you may be pregnant, call immediately so we can
discuss what to do.

Do not drink alcohol or take any street drugs while taking this medication.

If you are taking antacids that contain aluminum or magnesium, you should
wait 2 hours after taking the antacids before taking these medications.

Please write down your questions, concerns, and any possible side effects you have
so we can discuss them at your next office visit or phone conversation!

Sources: Amen, 1997; Diacon, 1992; Calandra, 1994

Compiled from written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 55

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DOSAGE:

 

How do these medications work?

Antihypertensive medications control blood pressure by affecting the nerves
that control the heart rate and size of the blood vessels. They can also have an
effect on the central nervous system, decreasing anxiety, aggression and other
ADD/ADHD symptoms. They are not the first choice of treatment, but can be
helpful in combination with other medications or when other medications don't
work.

How will we know if this medication is working?

When taking these medications, it is important to keep in close touch to
make sure the medication is helping and that side effects are not a problem. We
will talk about how you are doing at school, at home and in relationships with
friends. Your parents' impression of how things are going are also important, and
periodic evaluation forms from your teachers.

Your blood pressure and heart will also be monitored.

What side effects can this medicine have?

The following side effects may occur with some of the above medicines. As
you adjust to the medication, the side effects may go away or lessen. If they are
too severe, the medication may have to be decreased or changed.

*Low blood pressure or slow heart rate

* Rash or skin reaction

Compiled from written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 56

*Sleepiness - when first starting this medicines and if this side effect
continues, DO NOT drive or operate machinery (may happen with
catapres).

*Nausea or abdominal cramps.

*Dizziness when you first stand up — this usually goes away after a few
weeks, but in the meantime stand up slowly and give your body a few
seconds to adjust before walking.

*Constipation - try a fiber supplement (Metamucil or Citrocel) and drink 8
glasses of water a day

What could happen if this medicine is stopped suddenly?

Stopping the medication suddenly or skipping doses is not recommended, so
contact this office if you feel you need to stop taking the medicine after taking it
for a period of time.

What else is important to know about this medication?

You should not become pregnant while taking these medications.
Unprotected sex should always be avoided, but especially while on these
medications. If you think you may be pregnant, call immediately so we can discuss
what to do.

Do not drink alcohol or take any street drugs while taking this medication.

If you are diabetic, Inderal may mask the symptoms of low blood sugar.

Please write down your questions, concerns, and any possible side effects you have
so we can discuss them at your next office visit or phone conversation!

Sources: Amen, 1997; Diacon, 1992; Calandra, 1994

Compiled from written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 57

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Classroom Strategies
Classroom environment

*Seating - best for a student with ADD/ADHD to sit up front, near the teacher
but away from the door, window or high traffic areas

*Try earphones during quiet study time to block out auditory distractions

*At times the student may need to leave the classroom to work on complicated
concepts or to get special one to one tutoring

*Share resources on ADD/ADHD with the teachers

*A daily or weekly progress report from each teacher lets the student and
parents know how things are going

*For special assignments, get written step by step instructions

*For term papers and big projects, break the project into short steps, each with
a time frame and get feedback from the teacher at each step

*Try using a sectioned 3 ring binder or a planner for different subjects so all notes
and instructions for one class can be kept together

*Read assigned reading into a tape recorder and listen to it several times -
sometimes the spoken word sticks with you better than the written word

*Typed lecture notes from the teacher that you can refer to are helpful - or
you may share notes from another good student
Sources: Amen, 1997; Diacon, 1992; Calandra, 1994

Compiled from written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 58

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HOMEWORK STRATEGIES

Some common homework problems that are more common in students with ADD:

1. Failure to write down homework assignments
Tips: get a day planner or electronic planner. Plan with the teacher to
review it at the end of class to make sure homework assignments
are written down correctly. Also get the phone number of a good
student you can check with later.

2. Forgetting assignment book, or not bringing home needed materials.

Tips: Post a reminder on your locker door. Consider obtaining an extra set
of textbooks for home. Have a folder/notebook or assignment book
that you always carry with you. A multisectioned folder or binder
with sections for each subject works well.

3. Taking hours to do a short assignment

Tips: Break the assignment into chunks. Set a timer to give yourself 15
minutes to work on the lst set of 5 problems or questions. If you
complete on time, give yourself a break - 10 minutes for snack or
music or phone call. When the timer rings after your break, start
on the next chunk. If the assignment is assigned reading, try
reading the material into a tape recorder then listening to it several
times. Sometimes the spoken word sticks with you better than the
written word.

4. Forgetting to take homework to school or losing it before you turn it in.

TIps: Always put your homework in the same place when you finish it - a
bright colored sectioned folder is good. Pack your homework and

Compiled fi'o‘m written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 59

books the night before and put them by the door. Tape a note at
eye level on the door you go out of “get homework!“

5. Putting the work off til “later,“ but later never comes.

TIps: Set a routine. You need 115' hour after school to relax. Set the timer
for i- hour, when it rings set up your study area with books, paper,
assignment book, everything you will need. Have the same start time
every day. Plan for breaks and plan to be done in time to watch a
TV show you like. Have a deal with your parents - after the homework
time starts, no TV, phone or other distractions til the homework is
done. Wear a set of headphones if necessary to avoid distractions.

6. Putting off long assignments or term papers because you don't know where to
start.
Tips: Break the project into steps as soon as it is assigned. Make a list of

the steps and put a date by each one so you can work on it a little at

a time. Example:

1. Get resources from library, internet, etc.

2. Read the material and write notes of what you want to use with
the references. Keep these notes together in a special folder.
Discuss the resources you are using with your teacher.

3. Make an outline of how you want to use the notes to set up your
paper. Show the outline to your teacher.

4. Review your notes and dictate a rough draft using notes and
outline into a tape recorder.

5. Play the tape back and type what you dictated into a word
processor (or hand write if necessary). Triple space it so
you can write in changes or additions. Get feedback from
your teacher on this draft.

6. Revise the rough draft using teacher comments and your own ideas.
Have a parent or friend who is a good student check for
sentence structure and clear ideas.

7. Retype and turn in by deadline!

Sources: Amen, 1997; Diacon, 1992; Calandra, 1994

Compiled from written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 60

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FOR PARENTS:
BEHAVIORAL MODIFICATION STRATEGIES

Being a parent is not easy and parenting a child with ADD/ADHD is even
more challenging. Some parents have found parenting classes or books helpful.
Below is a summary of points from a parenting class:

1. Be focused. Set clear goals for yourself as a parent and agree with your child
on goals for him or her. Then make sure you act in a way consistent with those

goals.

2. Relationship is key to success in discipline. Relationships require time and a
willingness to listen. Plan for time daily with your child and listen to what he/she
thinks before giving your opinion or advice. Ask for more details ‘tell me more
about why you think that" 'I'd like to understand how you feel about that.“

3. Be clear about what you expect - a few written rules that the family can agree
on are helpful.

4. Notice the things you like about your child and praise them. Try to give 10
times more praise than criticism each day.

5. Decide in advance on a consequence for breaking the important family rules.
Enforce the consequence firmly without yelling nagging or arguing. “You can't go
out this weekend because you didn‘t complete your homework. I hope next week
you'll do better so you can enjoy the weekend."

6. Present a united front - agree with your spouse on rules and consequences.
Supporting each other is good for you and helps your child feel more secure.

Compiled from written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 61

7. Avoid the guilt trap. Don't let your child get away with breaking rules because
you feel guilty you haven't had enough time to spend with him/her lately. If you do
explode with anger over a situation, apologize for over reacting then go back to the
logical consequences for what he or she did.

8. Use the 5 step approach to modify behavior:

1. Clearly state the behavior you want to encourage and the behavior you
want to stop.

2. Establish a baseline period. List 2-3 desired behaviors and 2-3 undesired
behaviors. For a week, check off the numbers of these behaviors you
see. This way you will know if the things you do to encourage good
behaviors (praise and rewards) and to discourage undesired behaviors
are making a difference.

3. Clearly communicate the rules and expectation. Keep the rules in writing
and post on the refrigerator or in the family room. Keep the rules
simple and in line with the behavior you most want to see.

4. Reward the desired behavior. Children who only get attention (even if its
negative) when they misbehave usually continue to misbehave.
Rewards can be social (praise, a hug), material (a new CD or cash for a
movie), activity (a trip to the mall or a sporting event), or a token
system (you get a point for each good behavior and when you have 50
you can go to an amusement park with a friend).

Some guidelines for using rewards:
*Use many more rewards than punishments
*Reward as soon as possible after a child exhibits positive behavior
*Focus your energy on catching them being good - then reward!
*Reward your child with something he or she particularly likes
*Be consistent
5. Use clear, unemotional consequences for negative behavior
Components of effective discipline:
*A good relationship is necessary for discipline to work. Remove
privileges but don't withhold love or affection
*Discipline when you are in control. If you need to step out of the
situation briefly, take a few slow deep breaths or even take

a short walk Return and explain the consequences in a firm
Compiled fi'om written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 62

calm voice.

*Don't yell, nag or belittle. Your strength is in a soft, calm voice -
with a firm message.

*Have a goal in mind. Let your child know how he could have handled
that situation differently.

*l-lave a plan for discipline. Try using the STARAR approach: Tell
the child the specific Situation or Task they handled poorly.
Tell the Action you observed and the Result of the action.
Then give them an Alternative action and the Reason it would
have been better. Then add “because of the action you took
which broke the family rule of , you will not watch TV
tonight (or go out this weekend, etc.).

*Use natural consequences when possible

 

Privileges, money, phone time, use of the car, even computer time - all make
good rewards for teenagers. They are equally effective when they are withheld as
a consequence of negative behavior. A child has a right to food, shelter, clothing
and love. Other things are privileges and can be used to influence behavior. If you
feel powerless to influence your child, you may be surprised to find how powerful
controlling these privileges is.

Sources: Amen, 1997: Diacon, 1992; Calandra, 1994

Compiled fiom written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 63

FOR TEACHERS:
SCHOOL ADJUSTMENTS FOR STUDENTS
WITH ADD/ADHD

Physical Room Arrangement
*Seat student near teacher
* Seat student near positive role models
*Increase distance between desks
*Avoid distracting areas - near door, window or high traffic areas
*Stand near the student when giving directions or explanations - make eye
contact
*Allow use of ear phones during quiet study time

Lesson Presentgtion

*Pair students to check work and share notes

*Provide written outlines for note taking

*Break long presentations into shorter segments - use supporting activities
as a break

*Use multiple sensory modes of teaching with a variety of activities including
demonstrations and hands on techniques

*Allow tape recording of lecture and assignment directions

*Encourage peer tutoring

*Avoid timed tests

*Use frequent short quizzes rather than one long test

*Consider oral testing for essay questions

*Consider take home tests with student giving answers on tape recorder

*For term papers and big projects, break into steps, each with a due date

and give feedback to student at each step

Behavior Manament

*Praise positive behaviors

*Keep classroom rules simple and posted in room

*Contract with student and parents for specific behaviors to encourage and
discourage

Compiled from written and Internet resources by Donna Strawser, MSN Candidate

Adolescents with ADD 64

*Use short checklist form to give students and parents daily or weekly
feedback

*Give immediate feedback for positive behaviors and immediate
consequences for negative behaviors

*Allow short breaks during class time for students to stand and stretch
quietly

*Plan for close supervision during nonacademic times — lunch, movement
between classes

Sources: Amen, 1997; Diacon, 1992; Calandra, 1994

Compiled from written and Internet resources by Donna Strawser, MSN Candidate

 

 

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