Sean’s ADHD? Part 3: Dark Times in 1st Grade

Sean is a 1^st-grader who is bright and active and distractible. He’s also funny and talkative. Consistently finishing his classroom work before the rest of the class, he has been viewed as a behavior problem by his teacher. Even in my office, he is more fidgety than most kids his age. But I couldn’t get around the fact that for the first half of the term, he had a different teacher, with whom he never got in trouble. He didn’t sit quietly, exactly. The previous teacher gave him stuff to do to keep him occupied instead of bored. So even though I thought he might indeed have ADHD, I wasn’t ready to medicate him before figuring out why this became a problem as soon as the new teacher, Mr. Dickson, took over.

I re-evaluated Sean and he was just as before: fidgety, happy, talkative. But he never left the chair during a long discussion, and to each of my questions he responded with a full and articulate answer. As promised in Sean’s ADHD Part 2, I wrote a letter to the teacher. Here’s what I wrote:

Dear Mr. Dickson:

Sean’s parents asked me to evaluate their son, and to write you about some of my assessment. He’s a great kid and I enjoyed the time I spent with him.

As you know, Sean has been struggling somewhat in school. His distractibility, talking out of turn, and occasional disrespect have been issues for him. 

There’s no question that he’s an active child, with some of the motor traits of hyperactivity. He is also a bright child, who clearly understands and retains a lot of the academic material presented to him. It’s important to note that he is not uninterested in school work, and is curious and motivated to learn new things.

He has been disrespectful and sometimes even disobedient. Even so, he absolutely does not meet any of the diagnostic criteria for any disorder characterized by oppositionality, defiance, or conduct problems.

Though his hyperkineticism is longstanding, this has not caused problems for him until a recent change in his classroom situation. Thus even though he might be hyperactive when compared to most children his age, this hyperactivity does not mean that he has ADHD requiring medical treatment. In cases such as his, a behavioral approach will often result in the best outcome.

Sean has said that he is sometimes bored in class. He should be taken at his word. He is not very responsive to negative consequences, so these are of marginal value and might serve to frustrate him. A more effective approach would be to channel his energy in productive ways. If he’s done with his class work, for example, he should be able to access a ‘Bored Bag’ containing 4-5 quiet activities that he can do alone. It would be helpful if he chooses these activities from many choices given to him. 

From what Sean has told me, these might include:

• Some extra or more advanced math problems;
• Headphones and a recorded book;
• Coloring;
• Books.

It is essential that he be able to access these materials without permission, so he doesn’t interrupt you or the class. Ideally, he would also have the freedom to get out of his seat and walk quietly over to another spot, where he could work on some other task. I think he will be relieved to have this freedom.
These recommendations do not imply that he should be allowed to be disrespectful of teachers or disruptive to the class. Before starting this with him, you and his parents should meet with Sean and come up with a set of written rules. They don’t need to be extensive, but they need to be written. They should be simple and specific. For example, ‘you must not have a bad attitude’ is vague and difficult for a child his age to understand. ‘No talking during class,’ is something more likely to be understood. Taking away, as punishment, access to this Bored Bag or to recess—during which he gets to redirect some of that excess motor energy—would be particularly counterproductive. Those are the things that will keep him focused and motivated in the classroom. Try to enlist his help. If he’s fidgety and wanting to get out of his chair, there is no enforcement mechanism that will stop this. He doesn’t do it by choice and it not easy for him to control. Making a rule about him sitting still is setting him up to fail. If this is an issue, ask him to get up and do something helpful, then praise him for it. In this way, he will feel appreciated and not trapped.

There are certain things that ADHD medication can and cannot do. It can help some children sustain their attention, but it won’t do this if they have finished their work and are required to sit still with nothing to do. Indeed, none of us can do that.

Sean is a warm and kind child with a good sense of humor. He needs our help to plan what to do when he’s ‘bored’ and he needs the tools to work with that plan.

Please feel free to call me with your questions.

Only a day or two after mailing the letter, I received a forwarded email from Sean’s mother. She was active in the school, and received this note from a parent of one of Sean’s classmates.

Hello everyone,
I am sending this message because my son has reported to me some very disturbing comments that have been made to some of our children in the classroom.  I have not had an opportunity to speak with Mr. Dickson directly nor have I had the chance to inform the principal of this report because I was just made aware of this tonight. However, if these statements were directed to my child I would be very concerned! 

My son has reported to me that he (Mr. Dickson) told one child (Alice) that kids who talk too much in another country have their "tongues cut out". He said he told the child this because she was talking.    He also reported to me that he told one of the girls to sit her "fat butt" on the chair today when she was attempting to pick up her papers and color pencils off the ground.  He also told me that he often refers to two other boys (directly) as "rotten children" (Sean and Michael).  I am totally shocked that this man would speak to our kids like this!

I do not believe that this is a constructive way to reprimand children but it is a sure way to make them develop low self-esteem.

I am certainly not sending my child to school to be verbally abused by an adult.  I will be at the school bright and early Monday to speak with the principal about this.  The last thing we need is someone belittling our children.  Please speak with your children to confirm this. 

It is our responsibility to make sure that our children receive a good education in an environment that is conducive for them.

Suddenly, the pieces of this story started to fit together really well. More in the next post.

A First-Grade ADHD Story, Part 2

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.