Lazy or “Demand Avoidant”?: Motivating Children with ADHD

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Dr. Sophie Westwood, Clinical Psychologist, LIH Olivia's Place Shanghai

Dr. Sophie Westwood, Clinical Psychologist, LIH Olivia’s Place Shanghai

An article that recently caught my eye, on ADHD and motivation, was written by a guest blogger, Sherry Cramer, an Educational Therapist, and posted on Anne-Marie Morey’s ‘Bay Tree Blog’. Anne-Marie is also a North American educational specialist. She has a great blog and often posts interesting and useful articles and resources. I strongly recommend educators and parents to take a look at her ‘Bay Tree Blog’,

Difficulties regarding motivation and children and young people are common but there are some specific ways of thinking about this issue and tips and strategies for children with ADHD that can be helpful. Here is the link to the blog to read for yourself
I am going to outline some of the main points and a few other things that I think are important on this topic below. All of the research references can be found in Sherry’s blog post.

Sherry begins by explaining that researchers have found two major circuits of connections in the brain that are implicated in motivational behaviour: the reward and executive circuit. Both, or at least one of these circuits, function differently in the brains of children and young people with ADHD. The reward circuit doesn’t receive enough dopamine to keep children with ADHD focused on their goals and thus they become distracted by their own desires and things around them. A smaller, and less active and mature executive circuit in children with ADHD means that they struggle with ‘executive-function’ based tasks that enable us to plan, organise, pay attention and manage our time. Sherry goes on to describe a variety of tools that help to set up the right environment, details some of the benefits and controversies surrounding medications, and suggests reading for behaviour modification strategies, self-management and building executive functioning skills.

With these difficulties in mind, it makes it easier to see why children with ADHD often find it harder to complete the tasks required of them. In addition to these underlying brain-based skill deficits, other factors such as level of interest (we all like certain things over others), complicated ‘hidden’ social rules, the consequences or rewards of doing something, and the fact that repeated failure of a task can raise anxiety and/or lower self-esteem, commonly influence motivation. Taking these and other factors into account can help to shift the perspective of ‘laziness’ to think about why the child or young person is avoiding the demands of the task. Take for example Jack (a fictional character with realistic difficulties). Jack is an 11-year-old boy living with his parents and sister at home in Shanghai. He has a diagnosis of ADHD and takes medication when he goes to school. Jack’s parents are concerned because he has always loved soccer and plays in a team with his friends at weekends. Lately though, Jack has been playing videogames more and says he ‘can’t be bothered’ to play soccer. When his parents do manage to get him out the door and on the way to soccer practice he moans about going and doesn’t put much effort into the game. Jack’s parents have been sensitive to his needs as a young person with ADHD but are unsure whether this behaviour is laziness or more related to the issues described above. What factors might be contributing to Jacks ‘demand-avoidance’? How do you think Jack’s parents could approach this situation? Is there anything Jack can do to help himself?

The last section of Sherry’s blog posts focuses on how parents and educators can plant the seeds for personal motivation to thrive, and the skills that they might need for nurturing this growth. I echo Sherry’s advice and encourage those that are interested to read the books that she has recommended: they are often books that I recommend in my clinical practice.


What is the Role of Medications in ADHD?

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by Susan Cadzow, MD, Director Developmental-Behavioral Pediatrics, LIH Olivia's Place

by Susan Cadzow, MD, Director Developmental-Behavioral Pediatrics, LIH Olivia’s Place

Children and adults with severe attentional difficulties are sometimes prescribed medications. This is generally only when their symptoms are having a significant impact on learning and general function.

Medications should only be considered after other non-pharmacological supports and strategies have been implemented and there are still major concerns that the child is functioning well below their ability level due to concentration deficits.

Before considering medications, a pediatrician will do a thorough medical history and examination. Co-existing medical conditions that might be affecting the child’s performance can be identified and treated if necessary. The evaluation will also focus on assessing the nature and the severity of the problem. Information will be gathered from parents, the child’s school, and the child him/herself if they are old enough. In some cases, another referral may be made during this process, for example, to a psychologist to undertake formal assessment of the child’s learning profile and abilities).

Regarding ADHD medications, it’s important to recognize that they are aimed at reducing specific “target symptoms,” namely hyperactivity, impulsivity, and distractibility. They generally do not have specific action in terms of behaviours such as defiance and aggression. However, there can be some positive benefits for behavior and social skills if the problems are resulting from impulsivity or poor self-regulation.

If everyone agrees that a trial of medications may be helpful and is appropriate for the individual child, generally a 1 to 2 month trial of a stimulant medication will be started as the “first line” treatment. If stimulant medications are prescribed appropriately, approximately 70-80 % of people show a beneficial response (that is, significant reduction in the target symptoms).

In general stimulant medications are very safe and have been in use since the 1980s for treating children with ADHD. Reduction in appetite during the day is a common side effect of stimulant treatment. Children must be monitored carefully to ensure intake is adequate and growth is not affected. The pediatrician will follow up on a regular basis to assess dose adequacy, ongoing effects, and side effects. ADHD medications do act on chemical transmitter levels in the brain so there are many other possible side effects involving the neurological system but fortunately these are very rare and normally immediately reversible when the medications are stopped.

Since the main time that the medication effects (improved concentration, planning, and focus) are needed is the school day many families choose to not give the medication on weekends and school holidays. If for any reason stimulant medication is not effective or not well tolerated there are some alternate medications that can be tried. For example, Strattera (atomoxetine), is one that is often used and which is also available in China. Occasionally this may be tried first, particularly in children with significant anxiety symptoms as it also has an anti-anxiety effect.

Key Points

1. ADHD medications should normally be considered only in children with severe symptoms who have already tried non-medication therapies.
2. Medications are only part of the treatment plan for children with ADHD. Behaviour management, school support, classroom strategies, and counselling are also very important.
3. Children need to be assessed thoroughly before a trial of medications and monitored closely during treatment.
4. The main aim of medication is to reduce specific target symptoms in order to allow the child to reach their learning potential. Improvements in social skills and relationships may be seen if impulsivity and self-regulation have been a problem.
5. Approximately 70-80% of people with a diagnosis of ADHD respond positively to treatment with stimulants.
6. Stimulant medications have been used in ADHD since the 1980s and are well-researched and generally very safe.

Family Education Support through a Growing Partnership

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The Neurology Department of Beijing Children’s Hospital (BJCH) is one of the leading pediatric neurology departments in our country, which has been existed for more than forty years. This department has complete professional disciplines with advanced technical skills. They have accumulated rich clinical experience in both common and rare diseases of pediatric neurology. The outpatient service is filled with patients of varying difficult cases. In 2013, there were more 110,000 outpatient visits to the department. . This Department is responsible for training and teaching doctors of pediatrics for Capital Medical University and the Inpatient Department of Beijing Pediatric Hospital. To provide parents with more knowledge and improve the communication and exchange of information between BJCH and LIH Olivia’s Place, we decide to carry out joint training for parents.

LIH Olivia’s Place specializes in children’s development, behavior, and rehabilitation for children and adolescents ages birth to 18 years of age. The Beijing clinic offers an international multi-disciplinary team (developmental behavioral pediatricians, pediatric neurology, pediatric rehabilitation physicians, clinical and educational psychologists, and an therapy team composed of physical therapists, occupational therapists, speech-language therapists, and behavioral therapists.

In order to give full play to the respective advantages of both BJCH and LIH Olivia’s Place and provide the highest quality medical services for children and parents, we established a team of experts to organize public scientific knowledge training, take advantage of technical experts, create a platform to provide parents with training and knowledge about their child’s diagnosis, how to support their child’s independence and education, and other aspects of growth and development. This training model allows for organic interaction between medical intervention and family education support for children.

BJCH Partnership 1In 2015, the partnership successfully implemented three training activities. The first was a physical therapy presentation in March by Dr. Lisa Kenyon(PT, associated professor, Grand Valley State University, who provided case-based teaching with three children. The second was for parents of children with autism spectrum disorder (ASD) in April; the presenter was Edna Elisabeth Nyang(CCC-SLP, Speech- Language Pathologist, LIH Olivia’s Place), Finally, Dr. Mease (Developmental-Behavioral Pediatrician, LIH Olivia’s Place) presented additional information for parents of children with ASD in June. The initial three training events were very successful, with both doctors and parents speaking highly of their experience.

In 20016, LIH Olivia’s Place and the Neurology Department of BJCH are planning to continue this partnership to empower parents through training. The training plan for the first six months of 2016 includes 21 training sessions, with topics covering autism spectrum disorder (ASD), attention deficit/hyperactivity disorder (ADHD), and cerebral palsy.

To learn more about this program or to obtain information on the training schedule and registration, please contact Yangshaoun at