Barbara Howard, MD

Sometimes you can feel the bristles in the air when a family comes in for help with their child with attention-deficit/hyperactivity disorder. Not only the child, but you also are in trouble!

As a group, individuals with ADHD are more likely to have oppositional defiant disorder, school retention, and school failure; they also are more likely to drop out of school, and eventually to have multiple job changes and broken marriages.

Are these serious problems really inevitable for your patient? In fact, the outcome of ADHD ranges widely, from exceptionally creative, energetic, multitasking, wealthy CEOs to felons in lockup. Is the difference between these outcomes a flip of the coin? Or is there something we as clinicians can do to shift the odds?

Optimizing medication use and teacher input makes the greatest difference in current symptoms, and IQ and absence of learning disabilities are the strongest intrinsic predictors of outcome. But support and acceptance are the protective factors most within the family’s control. Support clearly includes ensuring appropriate medical and educational services, and structuring family routines and homework time. But acceptance is more subtle, and is determined by many personal and family factors worth eliciting.

How can you begin to promote acceptance of a child with ADHD? When you think about it, most people do not know that their child has ADHD before being told by a medical professional. Teachers are generally not even allowed to mention the "A[DHD]" word to parents. How we give this news and relate to the issues over time can make a significant difference in the family’s basic perception of their child, in the child’s perception of him- or herself, and even in outcomes.

We are not helped in setting a positive perception for the family by the official name: attention-deficit/hyperactivity "disorder." I explain to families that although differences in attention and activity are normal, a disorder is defined by symptoms that interfere with day-to-day activities. The fact that daily life is harder for their child than for other kids comes as no surprise to this family, and eases the impact of these words.

When I explain ADHD to parents, I find that relating the "wiring difference of ADHD" to different breeds of dog can reduce judgmentalism. Suggesting that they got a Jack Russell terrier rather than a Labrador sometimes makes acceptance easier than a conversation about the abstract concept of temperament. After all, who is surprised when a terrier jumps on a visitor? But training a dog does not engage all the emotions, hopes, dreams, fears, and altered perceptions of parenting. Even parents who raised a dog together in preparation for parenthood lose that valuable objectivity when the developing creature is their child.

Helping families see ADHD symptoms as including assets such as energy, creativity, spontaneity, sometimes athletic or musical talent, and joyfulness can be a big contribution to developing a positive perception of their child. Finding and fostering their child’s talents may be the most important thing parents can do in the long run. You may need to brainstorm together over the years to figure out what might work for each child, especially because academics is often not a strength in a child with ADHD. My patients have grown to be good at drawing anime, leading hunting trips, doing karate, participating on rock-climbing teams, drumming, providing lawn service, singing, programming, baking, doing construction, working in theater, doing videography, volunteering with the elderly, and providing child care, among other things.

Start this conversation early in your management of ADHD, both to make sure a talent is found and to foster optimism about the child’s adult future. Asking the child (and parents) "What are you best at?" or "What would you like to do after you graduate?" can open this topic. Children with one real ability to distinguish themselves as capable have the seed for self-esteem that can sustain them over time. Try to find a talent that might work before they hit middle school, when kids need to have a social standing but are already reluctant to try something new. Otherwise, they may choose unproductive ways to be a big shot, like hanging out at the mall rather than being a musician or athlete. Did you hear what was said about one hyperactive kid who ended up on the Olympic team? When Jonathan Horton climbed to the ceiling of a store as a 4-year old "some parents might have scolded him; his parents gave him gymnastic lessons." He competed in the 2012 Olympics as part of the men’s gymnastics team. Michael Phelps, winner of the most Olympic medals ever, took up swimming as a way to handle his ADHD.

Why is it often so difficult for parents to accept their child with ADHD? ADHD symptoms can create a daily grind on family functioning. Getting from bed to table without a stop at the toy box, then to school with that science report, then through homework under 70 decibels, and finally to sleep with fewer than three curtain calls can feel more like mere survival than the victories those daily milestones really are. Parents who are positive by nature find spontaneous praise of tiny accomplishments easier, but others can learn to do this when its power is pointed out.

Explaining that ADHD inherently includes trouble with judging time helps families understand why children with ADHD are "creatures of the moment." This means that giving praise immediately after tiny accomplishments is most effective in shaping the desired behaviors. Some parents find a strategy of constant praise to smack of coddling or bribery, and reject it; this can be especially true as children get older. But recommending a 3-week trial of bits of reinforcement can show the doubter that the improvement in behavior and tone in the household is worth the compromise. "Brief praise immediately" is a good mnemonic.

Eliciting details of a typical day, both at the initial diagnostic visit and at each follow-up, gives you the chance to ask how the family facilitates the "transitions" that are characteristically sticky in ADHD, as well as a source of conflict and frustration (a.k.a. anger). For example, although parents may be forgiving of their child’s trouble in attending to schoolwork, they may then be livid when the child shows perfect attention to a video game. It is helpful to educate the entire family that the child’s tendency to inattention is relative to his or her interest in the task.

Then, once engaged, kids with ADHD have more trouble than do others in moving on to something boring, like brushing teeth or eating dinner. This makes parents judge the child as "stubborn" or "only doing wants he wants to do." Our challenge is to help parents see the "transition difficulty" objectively as part of the deficit of ADHD.

Part of the solution to transition trouble is installing positive routines and habits (which come from a different part of the brain) through cheerful repetition. Cheerleading a young child through tooth brushing with a song eventually makes it an automatic behavior that doesn’t stress the weaker memory/transition functions.

Getting up, going to school, moving to the dinner table, engaging in homework, and going to bed are the major transition culprits. Some techniques that help include turning off electronics before a transition, setting aside extra time, using timers and alarm clocks to build time awareness, and singing songs or playing music to lighten the mood. Other helpful techniques involve rewarding with praise, marks, points, chips, or nickels for doing "a little better than before" at "moving on." Making the child and family more mentally aware of these trickier moments so that they take transitions on as a project is an important intervention in itself.

Although parents know they should not play favorites, this is harder to do when one sibling has ADHD. Sarah’s correct perception that Mom doesn’t yell as much at her mild-mannered brother Jason exacerbates jealousy and increases the squabbles. It can help to coach parents to find a specific activity or interest to share with each child, and to be sure to talk at home about how each person is special.

Parents are never alone in their own heads. It is hard for a parent not to criticize the way her son taunts his sister when the parent hears the voice of her own father from the past, echoing in her brain about the same behavior. This pattern can carry over even when the memory is of a correction to her brother and not herself. Reflecting with the parents, "Does this remind you of something from your own life?" may bring out this connection so that it is open to conscious control. Try asking, "How would your parents have handled this?" to reveal the origins of a strict, demanding, or even harsh reaction pattern that a parent himself learned from experience with his own parent as a child. It is possible that he himself was the hyperactive one?

What two parents don’t have different experiences and reaction patterns? Differences can spark innovation, but also can lead to discord over what to do. When parents argue about management, it is an opening for the child both to slip out from under their gaze and also to feel guilty for the fight he is leaving behind. It is more difficult for a parent to be accepting of the child if one party feels (or says), "We wouldn’t always be late if it weren’t for the ADHD on your side of the family!" With 25% of parents of a child with ADHD having ADHD themselves, they may not have to look far for the blame. Helping the child get organized, planning out those long-term projects, and focusing on the positive are all harder if the parent has the executive dysfunction of ADHD him- or herself. Instead, any residual parental low self-esteem or anger at a tendency to lose things can contaminate that parent’s opinion of the child. Even the spouse may displace irritation with the parent’s "messiness" onto the offspring, and overdo the criticism. Sometimes, referring a parent who you suspect may have ADHD for their own diagnosis and treatment can be the biggest contribution to the family you can make.

We all tend to parent the way we were parented. Some parents may react to that pattern from their past by rejecting it, but then may have no good parenting plan of their own, and may explode at the end of the day from the infinite number of "wrong" things that their child with ADHD managed to fit into the past 12 hours. This accumulated rage is worse from the child’s point of view, because the ultimate size of the explosion seems undeserved by the last little behavior that finally set it off. Plus, with their time disconnect, children with ADHD probably couldn’t remember the last thing they did wrong, much less all their other faults for that day, making the explosion seem even more unfair. To the child, the parent’s outrage may have the impact of an undeserved assault, which is something that often provokes a tendency for opposition over time. It takes some work to convince parents that their conclusion (that is, that the huge number of little misbehaviors means the parents need to step up their correction) is backwards. Asking them to consider "ignoring more" presents a shift in how they thought family life was going to be, but it is good advice in setting a happier tone at home. And asking the nit-picking parent, "How is it working?" and ultimately, "What would you like your relationship with him to be like 10 years from now?" helps him or her reorient to the Big Picture.

"Maybe if you just let him know who is boss" is the kind of input parents may hear from family and friends that can push them to feel that their management is lacking. Even teachers may subtly (or not so subtly) suggest that consequences at home "might make him act better at school," even when evidence is clear that the core features of ADHD are not improved by actions taken long after the time of the behavior. You can often find out about these pressures by asking parents, "What have others been telling you about your child’s behavior?" so that you can counter this notion with facts.

Do our patients deserve all the bad press we hear from their parents? Any clinician who has spent 20 minutes in the room with a hyperactive 7-year-old – protecting the box of medical gloves, catching him as he flies off the exam table, sweeping up the crumbs after she leaves – can identify with parental desperation. You can reflect that "she is a bundle of energy," but be sure to ask, "How are you and your partner holding up?" The stress is real and deserves to be addressed. Behavior management counseling has been shown to improve outcomes for the child, but don’t forget that parents also may need referral for themselves or their marriage to cope with the child with ADHD.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. E-mail her at pdnews@elsevier.com.

Sometimes you can feel the bristles in the air when a family comes in for help with their child with attention-deficit/hyperactivity disorder. Not only the child, but you also are in trouble!

As a group, individuals with ADHD are more likely to have oppositional defiant disorder, school retention, and school failure; they also are more likely to drop out of school, and eventually to have multiple job changes and broken marriages.

Are these serious problems really inevitable for your patient? In fact, the outcome of ADHD ranges widely, from exceptionally creative, energetic, multitasking, wealthy CEOs to felons in lockup. Is the difference between these outcomes a flip of the coin? Or is there something we as clinicians can do to shift the odds?

Optimizing medication use and teacher input makes the greatest difference in current symptoms, and IQ and absence of learning disabilities are the strongest intrinsic predictors of outcome. But support and acceptance are the protective factors most within the family’s control. Support clearly includes ensuring appropriate medical and educational services, and structuring family routines and homework time. But acceptance is more subtle, and is determined by many personal and family factors worth eliciting.

How can you begin to promote acceptance of a child with ADHD? When you think about it, most people do not know that their child has ADHD before being told by a medical professional. Teachers are generally not even allowed to mention the "A[DHD]" word to parents. How we give this news and relate to the issues over time can make a significant difference in the family’s basic perception of their child, in the child’s perception of him- or herself, and even in outcomes.

We are not helped in setting a positive perception for the family by the official name: attention-deficit/hyperactivity "disorder." I explain to families that although differences in attention and activity are normal, a disorder is defined by symptoms that interfere with day-to-day activities. The fact that daily life is harder for their child than for other kids comes as no surprise to this family, and eases the impact of these words.

When I explain ADHD to parents, I find that relating the "wiring difference of ADHD" to different breeds of dog can reduce judgmentalism. Suggesting that they got a Jack Russell terrier rather than a Labrador sometimes makes acceptance easier than a conversation about the abstract concept of temperament. After all, who is surprised when a terrier jumps on a visitor? But training a dog does not engage all the emotions, hopes, dreams, fears, and altered perceptions of parenting. Even parents who raised a dog together in preparation for parenthood lose that valuable objectivity when the developing creature is their child.

Helping families see ADHD symptoms as including assets such as energy, creativity, spontaneity, sometimes athletic or musical talent, and joyfulness can be a big contribution to developing a positive perception of their child. Finding and fostering their child’s talents may be the most important thing parents can do in the long run. You may need to brainstorm together over the years to figure out what might work for each child, especially because academics is often not a strength in a child with ADHD. My patients have grown to be good at drawing anime, leading hunting trips, doing karate, participating on rock-climbing teams, drumming, providing lawn service, singing, programming, baking, doing construction, working in theater, doing videography, volunteering with the elderly, and providing child care, among other things.

Start this conversation early in your management of ADHD, both to make sure a talent is found and to foster optimism about the child’s adult future. Asking the child (and parents) "What are you best at?" or "What would you like to do after you graduate?" can open this topic. Children with one real ability to distinguish themselves as capable have the seed for self-esteem that can sustain them over time. Try to find a talent that might work before they hit middle school, when kids need to have a social standing but are already reluctant to try something new. Otherwise, they may choose unproductive ways to be a big shot, like hanging out at the mall rather than being a musician or athlete. Did you hear what was said about one hyperactive kid who ended up on the Olympic team? When Jonathan Horton climbed to the ceiling of a store as a 4-year old "some parents might have scolded him; his parents gave him gymnastic lessons." He competed in the 2012 Olympics as part of the men’s gymnastics team. Michael Phelps, winner of the most Olympic medals ever, took up swimming as a way to handle his ADHD.

Why is it often so difficult for parents to accept their child with ADHD? ADHD symptoms can create a daily grind on family functioning. Getting from bed to table without a stop at the toy box, then to school with that science report, then through homework under 70 decibels, and finally to sleep with fewer than three curtain calls can feel more like mere survival than the victories those daily milestones really are. Parents who are positive by nature find spontaneous praise of tiny accomplishments easier, but others can learn to do this when its power is pointed out.

Explaining that ADHD inherently includes trouble with judging time helps families understand why children with ADHD are "creatures of the moment." This means that giving praise immediately after tiny accomplishments is most effective in shaping the desired behaviors. Some parents find a strategy of constant praise to smack of coddling or bribery, and reject it; this can be especially true as children get older. But recommending a 3-week trial of bits of reinforcement can show the doubter that the improvement in behavior and tone in the household is worth the compromise. "Brief praise immediately" is a good mnemonic.

Eliciting details of a typical day, both at the initial diagnostic visit and at each follow-up, gives you the chance to ask how the family facilitates the "transitions" that are characteristically sticky in ADHD, as well as a source of conflict and frustration (a.k.a. anger). For example, although parents may be forgiving of their child’s trouble in attending to schoolwork, they may then be livid when the child shows perfect attention to a video game. It is helpful to educate the entire family that the child’s tendency to inattention is relative to his or her interest in the task.

Then, once engaged, kids with ADHD have more trouble than do others in moving on to something boring, like brushing teeth or eating dinner. This makes parents judge the child as "stubborn" or "only doing wants he wants to do." Our challenge is to help parents see the "transition difficulty" objectively as part of the deficit of ADHD.

Part of the solution to transition trouble is installing positive routines and habits (which come from a different part of the brain) through cheerful repetition. Cheerleading a young child through tooth brushing with a song eventually makes it an automatic behavior that doesn’t stress the weaker memory/transition functions.

Getting up, going to school, moving to the dinner table, engaging in homework, and going to bed are the major transition culprits. Some techniques that help include turning off electronics before a transition, setting aside extra time, using timers and alarm clocks to build time awareness, and singing songs or playing music to lighten the mood. Other helpful techniques involve rewarding with praise, marks, points, chips, or nickels for doing "a little better than before" at "moving on." Making the child and family more mentally aware of these trickier moments so that they take transitions on as a project is an important intervention in itself.

Although parents know they should not play favorites, this is harder to do when one sibling has ADHD. Sarah’s correct perception that Mom doesn’t yell as much at her mild-mannered brother Jason exacerbates jealousy and increases the squabbles. It can help to coach parents to find a specific activity or interest to share with each child, and to be sure to talk at home about how each person is special.

Parents are never alone in their own heads. It is hard for a parent not to criticize the way her son taunts his sister when the parent hears the voice of her own father from the past, echoing in her brain about the same behavior. This pattern can carry over even when the memory is of a correction to her brother and not herself. Reflecting with the parents, "Does this remind you of something from your own life?" may bring out this connection so that it is open to conscious control. Try asking, "How would your parents have handled this?" to reveal the origins of a strict, demanding, or even harsh reaction pattern that a parent himself learned from experience with his own parent as a child. It is possible that he himself was the hyperactive one?

What two parents don’t have different experiences and reaction patterns? Differences can spark innovation, but also can lead to discord over what to do. When parents argue about management, it is an opening for the child both to slip out from under their gaze and also to feel guilty for the fight he is leaving behind. It is more difficult for a parent to be accepting of the child if one party feels (or says), "We wouldn’t always be late if it weren’t for the ADHD on your side of the family!" With 25% of parents of a child with ADHD having ADHD themselves, they may not have to look far for the blame. Helping the child get organized, planning out those long-term projects, and focusing on the positive are all harder if the parent has the executive dysfunction of ADHD him- or herself. Instead, any residual parental low self-esteem or anger at a tendency to lose things can contaminate that parent’s opinion of the child. Even the spouse may displace irritation with the parent’s "messiness" onto the offspring, and overdo the criticism. Sometimes, referring a parent who you suspect may have ADHD for their own diagnosis and treatment can be the biggest contribution to the family you can make.

We all tend to parent the way we were parented. Some parents may react to that pattern from their past by rejecting it, but then may have no good parenting plan of their own, and may explode at the end of the day from the infinite number of "wrong" things that their child with ADHD managed to fit into the past 12 hours. This accumulated rage is worse from the child’s point of view, because the ultimate size of the explosion seems undeserved by the last little behavior that finally set it off. Plus, with their time disconnect, children with ADHD probably couldn’t remember the last thing they did wrong, much less all their other faults for that day, making the explosion seem even more unfair. To the child, the parent’s outrage may have the impact of an undeserved assault, which is something that often provokes a tendency for opposition over time. It takes some work to convince parents that their conclusion (that is, that the huge number of little misbehaviors means the parents need to step up their correction) is backwards. Asking them to consider "ignoring more" presents a shift in how they thought family life was going to be, but it is good advice in setting a happier tone at home. And asking the nit-picking parent, "How is it working?" and ultimately, "What would you like your relationship with him to be like 10 years from now?" helps him or her reorient to the Big Picture.

"Maybe if you just let him know who is boss" is the kind of input parents may hear from family and friends that can push them to feel that their management is lacking. Even teachers may subtly (or not so subtly) suggest that consequences at home "might make him act better at school," even when evidence is clear that the core features of ADHD are not improved by actions taken long after the time of the behavior. You can often find out about these pressures by asking parents, "What have others been telling you about your child’s behavior?" so that you can counter this notion with facts.

Do our patients deserve all the bad press we hear from their parents? Any clinician who has spent 20 minutes in the room with a hyperactive 7-year-old – protecting the box of medical gloves, catching him as he flies off the exam table, sweeping up the crumbs after she leaves – can identify with parental desperation. You can reflect that "she is a bundle of energy," but be sure to ask, "How are you and your partner holding up?" The stress is real and deserves to be addressed. Behavior management counseling has been shown to improve outcomes for the child, but don’t forget that parents also may need referral for themselves or their marriage to cope with the child with ADHD.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. E-mail her at pdnews@elsevier.com.

Sometimes you can feel the bristles in the air when a family comes in for help with their child with attention-deficit/hyperactivity disorder. Not only the child, but you also are in trouble!

As a group, individuals with ADHD are more likely to have oppositional defiant disorder, school retention, and school failure; they also are more likely to drop out of school, and eventually to have multiple job changes and broken marriages.

Are these serious problems really inevitable for your patient? In fact, the outcome of ADHD ranges widely, from exceptionally creative, energetic, multitasking, wealthy CEOs to felons in lockup. Is the difference between these outcomes a flip of the coin? Or is there something we as clinicians can do to shift the odds?

Optimizing medication use and teacher input makes the greatest difference in current symptoms, and IQ and absence of learning disabilities are the strongest intrinsic predictors of outcome. But support and acceptance are the protective factors most within the family’s control. Support clearly includes ensuring appropriate medical and educational services, and structuring family routines and homework time. But acceptance is more subtle, and is determined by many personal and family factors worth eliciting.

How can you begin to promote acceptance of a child with ADHD? When you think about it, most people do not know that their child has ADHD before being told by a medical professional. Teachers are generally not even allowed to mention the "A[DHD]" word to parents. How we give this news and relate to the issues over time can make a significant difference in the family’s basic perception of their child, in the child’s perception of him- or herself, and even in outcomes.

We are not helped in setting a positive perception for the family by the official name: attention-deficit/hyperactivity "disorder." I explain to families that although differences in attention and activity are normal, a disorder is defined by symptoms that interfere with day-to-day activities. The fact that daily life is harder for their child than for other kids comes as no surprise to this family, and eases the impact of these words.

When I explain ADHD to parents, I find that relating the "wiring difference of ADHD" to different breeds of dog can reduce judgmentalism. Suggesting that they got a Jack Russell terrier rather than a Labrador sometimes makes acceptance easier than a conversation about the abstract concept of temperament. After all, who is surprised when a terrier jumps on a visitor? But training a dog does not engage all the emotions, hopes, dreams, fears, and altered perceptions of parenting. Even parents who raised a dog together in preparation for parenthood lose that valuable objectivity when the developing creature is their child.

Helping families see ADHD symptoms as including assets such as energy, creativity, spontaneity, sometimes athletic or musical talent, and joyfulness can be a big contribution to developing a positive perception of their child. Finding and fostering their child’s talents may be the most important thing parents can do in the long run. You may need to brainstorm together over the years to figure out what might work for each child, especially because academics is often not a strength in a child with ADHD. My patients have grown to be good at drawing anime, leading hunting trips, doing karate, participating on rock-climbing teams, drumming, providing lawn service, singing, programming, baking, doing construction, working in theater, doing videography, volunteering with the elderly, and providing child care, among other things.

Start this conversation early in your management of ADHD, both to make sure a talent is found and to foster optimism about the child’s adult future. Asking the child (and parents) "What are you best at?" or "What would you like to do after you graduate?" can open this topic. Children with one real ability to distinguish themselves as capable have the seed for self-esteem that can sustain them over time. Try to find a talent that might work before they hit middle school, when kids need to have a social standing but are already reluctant to try something new. Otherwise, they may choose unproductive ways to be a big shot, like hanging out at the mall rather than being a musician or athlete. Did you hear what was said about one hyperactive kid who ended up on the Olympic team? When Jonathan Horton climbed to the ceiling of a store as a 4-year old "some parents might have scolded him; his parents gave him gymnastic lessons." He competed in the 2012 Olympics as part of the men’s gymnastics team. Michael Phelps, winner of the most Olympic medals ever, took up swimming as a way to handle his ADHD.

Why is it often so difficult for parents to accept their child with ADHD? ADHD symptoms can create a daily grind on family functioning. Getting from bed to table without a stop at the toy box, then to school with that science report, then through homework under 70 decibels, and finally to sleep with fewer than three curtain calls can feel more like mere survival than the victories those daily milestones really are. Parents who are positive by nature find spontaneous praise of tiny accomplishments easier, but others can learn to do this when its power is pointed out.

Explaining that ADHD inherently includes trouble with judging time helps families understand why children with ADHD are "creatures of the moment." This means that giving praise immediately after tiny accomplishments is most effective in shaping the desired behaviors. Some parents find a strategy of constant praise to smack of coddling or bribery, and reject it; this can be especially true as children get older. But recommending a 3-week trial of bits of reinforcement can show the doubter that the improvement in behavior and tone in the household is worth the compromise. "Brief praise immediately" is a good mnemonic.

Eliciting details of a typical day, both at the initial diagnostic visit and at each follow-up, gives you the chance to ask how the family facilitates the "transitions" that are characteristically sticky in ADHD, as well as a source of conflict and frustration (a.k.a. anger). For example, although parents may be forgiving of their child’s trouble in attending to schoolwork, they may then be livid when the child shows perfect attention to a video game. It is helpful to educate the entire family that the child’s tendency to inattention is relative to his or her interest in the task.

Then, once engaged, kids with ADHD have more trouble than do others in moving on to something boring, like brushing teeth or eating dinner. This makes parents judge the child as "stubborn" or "only doing wants he wants to do." Our challenge is to help parents see the "transition difficulty" objectively as part of the deficit of ADHD.

Part of the solution to transition trouble is installing positive routines and habits (which come from a different part of the brain) through cheerful repetition. Cheerleading a young child through tooth brushing with a song eventually makes it an automatic behavior that doesn’t stress the weaker memory/transition functions.

Getting up, going to school, moving to the dinner table, engaging in homework, and going to bed are the major transition culprits. Some techniques that help include turning off electronics before a transition, setting aside extra time, using timers and alarm clocks to build time awareness, and singing songs or playing music to lighten the mood. Other helpful techniques involve rewarding with praise, marks, points, chips, or nickels for doing "a little better than before" at "moving on." Making the child and family more mentally aware of these trickier moments so that they take transitions on as a project is an important intervention in itself.

Although parents know they should not play favorites, this is harder to do when one sibling has ADHD. Sarah’s correct perception that Mom doesn’t yell as much at her mild-mannered brother Jason exacerbates jealousy and increases the squabbles. It can help to coach parents to find a specific activity or interest to share with each child, and to be sure to talk at home about how each person is special.

Parents are never alone in their own heads. It is hard for a parent not to criticize the way her son taunts his sister when the parent hears the voice of her own father from the past, echoing in her brain about the same behavior. This pattern can carry over even when the memory is of a correction to her brother and not herself. Reflecting with the parents, "Does this remind you of something from your own life?" may bring out this connection so that it is open to conscious control. Try asking, "How would your parents have handled this?" to reveal the origins of a strict, demanding, or even harsh reaction pattern that a parent himself learned from experience with his own parent as a child. It is possible that he himself was the hyperactive one?

What two parents don’t have different experiences and reaction patterns? Differences can spark innovation, but also can lead to discord over what to do. When parents argue about management, it is an opening for the child both to slip out from under their gaze and also to feel guilty for the fight he is leaving behind. It is more difficult for a parent to be accepting of the child if one party feels (or says), "We wouldn’t always be late if it weren’t for the ADHD on your side of the family!" With 25% of parents of a child with ADHD having ADHD themselves, they may not have to look far for the blame. Helping the child get organized, planning out those long-term projects, and focusing on the positive are all harder if the parent has the executive dysfunction of ADHD him- or herself. Instead, any residual parental low self-esteem or anger at a tendency to lose things can contaminate that parent’s opinion of the child. Even the spouse may displace irritation with the parent’s "messiness" onto the offspring, and overdo the criticism. Sometimes, referring a parent who you suspect may have ADHD for their own diagnosis and treatment can be the biggest contribution to the family you can make.

We all tend to parent the way we were parented. Some parents may react to that pattern from their past by rejecting it, but then may have no good parenting plan of their own, and may explode at the end of the day from the infinite number of "wrong" things that their child with ADHD managed to fit into the past 12 hours. This accumulated rage is worse from the child’s point of view, because the ultimate size of the explosion seems undeserved by the last little behavior that finally set it off. Plus, with their time disconnect, children with ADHD probably couldn’t remember the last thing they did wrong, much less all their other faults for that day, making the explosion seem even more unfair. To the child, the parent’s outrage may have the impact of an undeserved assault, which is something that often provokes a tendency for opposition over time. It takes some work to convince parents that their conclusion (that is, that the huge number of little misbehaviors means the parents need to step up their correction) is backwards. Asking them to consider "ignoring more" presents a shift in how they thought family life was going to be, but it is good advice in setting a happier tone at home. And asking the nit-picking parent, "How is it working?" and ultimately, "What would you like your relationship with him to be like 10 years from now?" helps him or her reorient to the Big Picture.

"Maybe if you just let him know who is boss" is the kind of input parents may hear from family and friends that can push them to feel that their management is lacking. Even teachers may subtly (or not so subtly) suggest that consequences at home "might make him act better at school," even when evidence is clear that the core features of ADHD are not improved by actions taken long after the time of the behavior. You can often find out about these pressures by asking parents, "What have others been telling you about your child’s behavior?" so that you can counter this notion with facts.

Do our patients deserve all the bad press we hear from their parents? Any clinician who has spent 20 minutes in the room with a hyperactive 7-year-old – protecting the box of medical gloves, catching him as he flies off the exam table, sweeping up the crumbs after she leaves – can identify with parental desperation. You can reflect that "she is a bundle of energy," but be sure to ask, "How are you and your partner holding up?" The stress is real and deserves to be addressed. Behavior management counseling has been shown to improve outcomes for the child, but don’t forget that parents also may need referral for themselves or their marriage to cope with the child with ADHD.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. E-mail her at pdnews@elsevier.com.