March 2, 2010

A First-Grade ADHD Story, Part 2

write100times When parents ask me about ‘discipline’ they are generally thinking of ‘punishment.’ Though they might feel very uncomfortable with the concept, they associate a child’s naughty behavior with a supposed need to have the child associate their impulsive or destructive actions with some kind of negative consequence. The way I see it, this is very close to an eye for an eye metaphor of proportional response. If your kindergartener is jumping on the bed, that would presumably require a different consequence than if you found him at a pool table in a bar having just lost your next mortgage payment to a particularly unkempt-looking group of motorcycle enthusiasts with tattoos that seem somehow less decorative than meant to convey some kind of threatening message.

My patient Sean, a bright first-grader who is bored and distractible in class, is a thorn in his teacher’s side. He’s not difficult, exactly. He’s polite and helpful and isn’t a problem student. But every time the teacher turns his back, giggling erupts and it usually seems centered on Sean. His homework is usually 100% and he does well on both in-class tests and standardized tests. But the teacher doesn’t know how to punish him. Every time he takes away a thing or a privilege, it just doesn’t seem to matter to Sean.

Sean’s mother knows this, of course. In their crowded house with Sean and his 3 older siblings, the kids have learned that becoming too attached to specific things like toys is a setup for frustration and disappointment as ownership gets vague very quickly amongst the children.

There are children, just as there are adults, who are particularly attached to specific things. In helping a child establish a sleep ritual, for example, I often recommend finding a transition object--like a teddy bear or doll--which can provide some comfort and help the child relax. I bring this up at this time because it is one of the deep errors parents sometimes make when they are angry. If you must punish your child, temporarily take something away. Never take away the one thing that gives them comfort. When you do that, you leave them helpless against the world, which at that moment is you.

Just like many parents struggling with discipline, Sean’s teacher was blinded by the fog of action and consequence. Here’s a medical example. A person in an emergency room says that they have chest pain. Should they get some pain killer? The right answer is that it depends. The first thing we try to do is find the cause of the pain or problem and deal directly with that.

Parents (and teachers) often try a discipline method that doesn’t appear to work. The kid either ignores the discipline, or it doesn’t have any impact on the behavior they want to change. Under these circumstances, it’s a mistake to do more of what’s not working. In my line of work, if I try some sort of medication or treatment and it’s not helping, should I just give more of it? Maybe I should change the treatment.

Sean’s teacher tried taking stuff away from Sean, but Sean wasn’t attached to material things and this didn’t work. So his teacher took more stuff away. This just appeared as wacky to Sean, who was amused by his bare desk. His teacher felt that he had no other options but to place more and more restrictions on the child. These didn’t really control his talking in class. Without even a piece of paper or pencil at his desk, Sean had nothing to do except talk with his classmates. This appeared to Mr. Dickson as overtly defiant, requiring ever more intensive punishments and restrictions.

I haven’t spoken directly to the teacher, but it certainly seems that it was much easier for the teacher to escalate the situation than it was to try and figure out why it was happening.

I’m not proposing that you even try to do some kind of forensic psychological analysis when one of your kids smacks the other. A simple NO HITTING! will do. But if it keeps happening, it is absolutely your responsibility to figure out why. Besides, it will only increase your frustration with the child and the child’s frustration with you when you keep pouring on more of whatever it is that isn’t helpful.

What about ADHD medication? It might help some of Sean’s symptoms of distractibility and impulsiveness, as well as what looks to be a short attention span. But I just couldn’t get past the idea that he was doing great until this teacher showed up, and suddenly he needs psychoactive medication. As my readers know, I have no philosophical problem with trying to help a child with medication, if it’s appropriate. But if Sean’s ADHD was well managed by non-pharmaceutical intervention, maybe we should try that first.

So I came up with the following plan, for his mother to review with the teacher.
  1. Stop punishing him in ways that are not effective.
  2. If he says he’s bored, and his rapid and excellent schoolwork suggests he might be bored, and he’s acting like a kid who’s bored, consider the possibility that he is, in fact, bored.
  3. Like the tree branch that bends with the wind, find a way to support his attention. For him, I have invented #4.
  4. The Bored Bag
    a. Let Sean pick out not one but at least 3 or 4 or 5 projects that can be worked on quietly and by himself. Give him plenty of choices.
    b. He can work on these without permission.
    c. When he is bored, he can get materials out of his Bored Bag and work on them by himself.
    d. Avoid projects with many pieces or requiring power tools.
    e. Some choices could be reading or drawing something or looking something up or writing about something or working on problems that the rest of the class doesn’t get to do yet.
  5. Sean’s doctor will write a letter stating, pretty much, the above. I will write that I have evaluated him, and suggest that in his particular case, the best remedy for his distractibility is likely to be distraction. Hopefully, the Bored Bag will allow this to occur without disrupting the class.


  1. This is an interesting story, Dr. N., and I appreciate the care in which you observe and relate it here. All of your points make perfect sense to me.

    To play devil's advocate, though, here are some alternate explanations:

    1. I grew up in an Italian family with seven children. I know what it means to have "communal property" and to consider sharing a way of life. Still, each of us had possessions that were particularly special to us, and no one else messed with them. None of us has ADHD.

    (That said, I had to watch my brother on Fried Chicken night; if I did not make a show of quickly licking my piece of chicken, he might grab it off my plate. Yes, momma's fried chicken was that good.)

    I wonder if Sean is unattached to things because he is simply detached in that ADHD kind of way -- as my husband calls ADHD (which he has) "a disorder of disconnection."

    Maybe one of the parents has ADHD, too, and the household is one that does not respect and enforce boundaries. That happens often enough.

    The point: Association might not be causation.

    2. Yes, his new teacher sounds a bit of a dullard. But then again, just because the other teacher didn't have problems with Sean doesn't mean Sean doesn't have problems. Maybe she was too lax, setting up Sean for a lifetime of bad habits.

    This is first grade. He is obviously a bright kid and can compensate on tests, etc. But demanding is first grade?

    What happens by third or fourth or fifth grade, when his inability to stay focused without being the center of attention has profound consequences (assuming it's not already)?

    Make no mistake: I'm not suggesting that he be given medication. Not only am I not a physician, but I also don't know all the details of his diet, home life,. Perhaps behavioral strategies will help him stop distracting other children (who have a right to learn without his "self-medicating" via clowning around) and develop the habit of paying attention. After all, aren't the adults supposed to help children "wire" their prefrontal cortex?

    It seems highly possible that at some point -- when he hits the wall --his parents will be looking back and asking why they didn't see the signs earlier and do something.

    I watched Charlie Rose's show on the brain -- last night it was child development specialists with the host Eric Kandel, the Nobel Prize winner. And it impressed upon me even more profoundly the importance of kids with developmental disabilities such as ADHD getting all the help they need in meeting developmental milestones in language, reciprocity, abstract thinking, etc.

    I see too many adults who did not meet these developmental milestones and who often feel like they will never catch up in some areas. Given the human brain's massive restructuring during the teen years -- when early-learning pathways are stripped away and adult pathways are configured -- maybe they are right.

    Gina Pera, author
    Is It You, Me, or Adult A.D.D.?

  2. I think you are a very smart person......I wish you had been my doctor when I was a child.....maybe it's not too late?????


Please let me know what you think. Do you know a child or situation like this?