How To Manage Behavior Challenges In Children With ADHD

Episode Transcript

Dr. Nicole Beurkens:

Hi everyone, welcome to the show, I am Dr. Nicole, and on today’s episode, I am answering a question from a listener. I get so many questions each week, and this is a great way to provide answers that many of you might find helpful. If you have a question you’d like me to consider answering on a future episode, email it to support@drbeurkens.com and you just might hear it on an upcoming show.

Now, onto today’s question, which comes from Audrey. She writes: “My son is six and has been diagnosed with ADHD. We struggle with managing his impulsive and disrespectful behavior sometimes at home. His pediatrician says we should use more rewards and punishments and specifically told me to use exercise as a consequence or punishment when he does inappropriate things, like make him do push-ups, run up and down the stairs, jumping jacks, those kinds of things. Something about that just seems off to me, but maybe it is the best thing to do. What do you think?”

Audrey, these are great questions, and first of all, before I answer the question and get to the issues involved, I want to say good for you for checking in with yourself about a recommendation that you got from a professional. Too often, parents get recommendations or suggestions, especially when it’s from a professional, particularly a medical professional, and feel like that’s what they have to do and it’s not okay to ask questions or to check in with yourself about whether that feels right to you. So I want to commend you for that. For all parents, it’s really important when a professional makes a recommendation, no matter how many degrees they have, how much experience they have, whatever the case may be, for you to check in with yourself and say “Does this feel right? Does this ring true? Does this align with my beliefs about parenting, about my child, about what would be helpful here? What does my gut tell me about that?” That’s really, really important because professionals can make lots of suggestions and they may not be the best thing for you or for your child. So Audrey, good for you for questioning, for pausing and saying “Let me check in with myself about this, and let me ask more questions.”

So now, let’s get to the big picture issue here, which is around what the best types of strategies to support kids with ADHD in terms of regulating their emotions and behaviors are, because that’s what you’re really talking about here. You have a son who tends to be impulsive, he is disrespectful, he is doing some acting out in ways that feel inappropriate or frustrating, and you’re looking at how to address that. So, this is a common thing that comes up with kids with ADHD, with kids with a whole wide range of neurodevelopmental and mental health kinds of issues. And it’s long been sort of thought or touted that the idea — what we need to be focused on here is really managing behavior. That we need to focus on the behavior itself and we need these systems in place like rewards and punishments that will get to the root of this that will just get a kid to finally learn what the right way to act is and what the wrong way is. So there is a lot that has been written. There certainly are studies that have been done showing that reward and punishment-based systems can be effective for helping kids behave a certain way or exhibit certain skills, and certainly behavior management systems like that can be helpful in some situations, but here is the concern that I have with that approach: It’s that it assumes that the primary problem is that the child knows exactly what they need to do, what they should do and how to do it and just isn’t. So let me say that again: It assumes that the real problem here is that this kid knows exactly how to respond to this situation and what the adult wants to have happen and they have the skills to do it and they’re just choosing not to. And the problem with that is that it tends to really not be true. Again, it assumes the problem is motivation to do the correct thing. If I use a rewards and punishment based system, I’m assuming that the real problem here is that the kid just needs enough motivation to make the right choice. That’s not true the vast majority of the time in my experience both with typically developing kids as well as kids with brain-based kinds of challenges.

We need to go back to the way of thinking that I’ve talked about in many different episodes over the last couple of years, which is this idea that kids do well if they can, which means that of course kids want to do the right thing. Why wouldn’t they? It makes their life easier, it makes our life easier, they want to please us. When kids know what’s expected and they have the skills needed to manage and respond to a situation in the “appropriate/right” way, they do. The issue is not that we have all these kids with ADHD and other issues running around in the world who know exactly how they’re supposed to do things and what they should do and they’re just not doing it because they’re not motivated. That’s just not true.

So, we need to go beyond this traditional idea of rewards and punishments and really instead look at what the proactive strategies that we can use are. How can we modify the environment? How can we use ourselves differently in these situations? And how can we teach the skills that are missing that are really leading to them having these challenges with managing their emotions and their behaviors. Teaching skills like how to stop yourself from doing something or saying something, things like listening comprehension skills, strengthening working memory, being able to tolerate and calm yourself when you’re having uncomfortable feelings. These are all skills. These don’t just magically appear for them. These are skills to develop and these are areas we know tend to not be strengths for kids with ADHD and related kinds of issues. So, we want to be thinking more about how we can proactively manage the environment and how we can teach skills.

Now let’s get into some specific strategies and let’s talk about movement since Audrey mentioned the pediatrician suggested using exercise as a punishment or a consequence for inappropriate behavior. I think movement is a great tool to use to help support regulation for kids, but I would never use it in a punishment or a consequence kind of way. So what’s being suggested here is that the parents say “Oh, you made the wrong choice/you disobeyed/You got in trouble/You didn’t follow my direction, so now you need to run up and down the stairs 20 times as a punishment so that hopefully you’ll think twice about that again and you’ll do the right thing next time.” Well, I find that very unhelpful and very inappropriate. Instead, we want to use movement in a proactive way. We know that structured movement, so not just chaotic running around, but structured movement, things like — maybe it is running up and down stairs or going for a walk or doing an obstacle course or jumping on the trampoline, movement with some boundaries to it is very, very regulating for the brain, particularly in children and particularly in children who have neurodevelopmental kinds of challenges. So, let’s use movement as a regulating tool for kids in a proactive way. So if we have this child who is really impulsive and struggling with regulating emotions and behaviors, let’s make sure we’re building enough movement into the day and let’s make sure this kid is having opportunities to get outside and be active, to have structured movement inside. Let’s build those opportunities in, in order to support their ability to reign in their impulses, to manage themselves better. So yeah, let’s use movement but in a proactive way. Now, maybe a kiddo has a falling apart moment. Maybe they’ve had a meltdown, maybe they have not managed themselves well. Maybe they’re just kind of in a funk, just kind of moody, being really snippy and disrespectful. Let’s use movement then as a positive tool to support them getting back on track, not as a negative punishment. So instead of “You’re being moody and disrespectful to me, that’s not appropriate, drop on the floor and give me 50 push-ups as a punishment”, no, let’s instead say “I noticed you’re kind of prickly. It seems like you’re not feeling so great, just kind of struggling right now. Let’s go outside and take a walk,” or “Why don’t you hop on your bike” or “Why don’t you go downstairs and do Wii Bowling for a little bit”, or whatever it is. To use it as a tool that we help model for them how they can then use movement to help themselves when they are not feeling so great, when they are struggling to regulate themselves. So yes, we want to use movement in a proactive and regulating type of way, not as a punishment.

Some other proactive strategies: Again, thinking about getting to the root of what’s really going on here, which is difficulty with processing and regulating emotions and behavioral responses and needing some skill development. I like to use a previewing strategy. I’m sure for Audrey and for any of you who have kids with these challenges, you’re really aware of the types of situations that are likely to bring about problems with impulsivity, with regulating behaviors, those types of things. So you can start to be proactive and preview some of those things even before they happen. “Oh, we’re going to be doing this in a little while. We’re going to be doing X/Y/Z type of thing in a little while. Let’s walk through what that might look like. Let’s walk through how you might feel. Let’s think about if you’re getting overwhelmed, what are some things that you can do? What are some ways that I can help you if that’s happening?” So you preview that and you’re helping the child to think through, ahead of time, what that might be like and what they can do so that you and they are more prepared in the moment if and when that happens, so that previewing strategy, very, very powerful. And that can be done well in advance and reviewed several times before the upcoming event or situation, or you can do it right before. “Oh, you’re getting ready to head outside with the friends from the neighborhood. Let’s think about how that might go. I remember last time this happened, yeah, that can be tough. Boy, if that happens again, let’s think about how that’s going to feel. Let’s talk about what it is that you can do”, and this can be a pretty quick kind of preview, but that can really, really be helpful in sort of slowing them down, getting them to think about that and then being better prepared and more ready for it if it does happen. So that’s an example of a helpful proactive strategy that actually works on the skill development that’s needed here.

And then we’ve got things like giving time warnings. Again, if you know that your child tends to be really resistive or struggle with transitions, giving some time warnings. That’s a really basic, but helpful strategy to sort of let them warm up to the idea of a transition, of stopping one thing, of starting another thing. You know, “We’re going to be getting ready to go in this amount of time” and kind of do a countdown. It helps them prepare, it helps them have some processing time to regulate themselves around that.

Some other tools: Things like making sure that we’re communicating effectively. What’s going to happen or what the expectation is. So with a child with ADHD who tends to be impulsive and dysregulated, instead of just giving instructions or letting them know something and hoping that they catch that, which they probably won’t, to say “Let me be more intentional about my communication here. Let me get down on my child’s level”, if they’re young and they’re small. Or “Let me physically get closer to my child and stop and wait for them to shift their attention to me so I know that they’re now thinking about what it is that I’m about to communicate. They’re tuned into me. They’re aware.” Maybe that’s putting a hand on their shoulder, waiting for them to orient to you, to stop what they’re doing and put their attention on you. Then you tell them what it is that you want to tell them. Maybe it’s what they need to do at that moment, or you’re giving them information about something. But that’s something that we can control and do on our end to make sure that we’re communicating effectively so that they have the message. So stop, get down on their level or get closer to them, wait for them to turn their attention to you, then deliver the information and maybe even say “Tell me what you heard me say”, or “Let’s do a check here: What are the two things I asked you to do?”, or “What’s the thing I told is going to happen in 5 minutes?” So you’re checking to make sure: Was the message received? And a lot of these kids, the reason everything seems to be so chaotic for them or they seem so resistive or disobedient in the moment is because they didn’t really process what was happening leading up to it. They didn’t really pay attention to or make sense of the instruction that they were given or the expectation or the time constraint, or whatever it might be. So these are simple but really effective communication tools that we can use.

Another proactive strategy? Making sure that we’re giving them some processing time with things, not expecting them to respond immediately. Sometimes I hear parents using these countdown kinds of techniques, “I’m going to count to 3, I’m going to start at 3 and count to 1 and you need to do what I say by then.” Well, for many kids, that does not leave enough processing time for them to make sense of what it is that they’re supposed to be doing, and then also manage the big feelings that may come up for them with that, so we need to be thinking about leaving that processing time. So those are just some examples of those proactive strategies that we can use, that not only help smooth the way for these types of things to go better for them, but also start to help teach the skills and the regulatory capabilities that are really lacking here.

Other skills that we can work on, things like how to stop yourself mid-action, you have an idea or you have an impulse to act, maybe to reach out and hit your sister or to run away or whatever, how do we practice slowing down and stopping ourselves, that space between “I have a thought” and “I act on it” and really practicing that, and we can do a whole other episode on that, but that’s an example of a skill that often needs to be taught to these kids. How to manage big feelings that come up. These kids often just get totally overwhelmed by uncomfortable feelings, whether it’s embarrassment or shame or frustration or hurt or whatever it might be. Those can be difficult for any kid to manage, but especially if you have a child with a neurodevelopmental or mental health issue, they can really just get knocked over quickly by those big feelings, and then they act out as a result, and let me tell you: All of the punishing push-ups in the world after an episode of them blowing up because of uncomfortable feelings, it’s not going to teach them how to understand and regulate those big feelings the next time, so we need to work on the skills for that. So hopefully that is helping you see that there is a lot more to these situations with kids than just “They’re not motivated to do the right thing here.”

Now, if a challenge arises, okay, Audrey or any of the rest of you, you’re in a situation, you’re using these proactive strategies, your child does react in a very big way or a disrespectful way, or there is impulsive behavior — okay. Then you slow down, you stay with them, you keep yourself calm, you stay with them until they’re calm, and then you talk about what could be done differently. You work on talking through reviewing what happened. “Wow, you were feeling really mad about that and then here is what happened, and this is what I did, and ugh, that was really tough. Here is a way that I could help you with that next time/Here is something that you could do next time,” We’re doing, again, the reviewing of it and the teaching on the back end of that. Much more effective than giving some kind of consequence or punishment on the back end of that. It’s helping them through that period of dysregulation, which teaches them we are a model for them during those times of how to stay calm and regulated during those situations, so there is teaching happening there, and then there is teaching on the back end of “Man, that was tough! Let’s think about how we could approach that differently”, and there is teaching there too. So that’s really where we want our focus to be, it’s on identifying what the real issues going on here are, and then how we can teach the skills, how we can model the things that are needed, and move away from this idea that motivation is the problem and we need to do rewards and punishments. And again, rewards can be really helpful for certain things. We can all use a little bit of reward-based motivation for certain things in our lives, right? So I’m not saying that’s never the approach to take. But when we’re talking about these kinds of things with kids with brain-based challenges, it’s much more effective and appropriate and important in the short and the long-term to take this approach of really identifying what the missing skills are, what really is happening here, and then how we can help them develop and strengthen the skills that they need to manage big feelings and to respond to things that happen in life more appropriately.

So, I hope that this is helpful for Audrey and for any of you who have been wondering about the best way to support a child with ADHD or related types of issues. Remember, if you have a question you would like to hear answered on a future show, email it to support@drbeurkens.com. You can put “Podcast Question” in the subject line, that will help my team sort through that, and we’d love to hear from you and maybe answer those questions on a future episode. Thank you as always for listening. And I will catch you back here next time.