Transcript of Webinar: ADHD - Navigating the Maze

Watch Webinar

Panelists:
Dr Merrilyn Clancy - Speech Pathologist
Dr Paul Joshua - Developmental Paediatrician

Questions asked and answered:

• What is ADHD?
• What strategies will help manage unwanted behaviours?
• How can you get the most out of these settings and surroundings like school?
• What is the difference between ADHD and autism spectrum disorder? 
• What is the role that genetics plays in ADHD? 
• What is the link between ADHD and the sensory system? 
• When should parents consider medication as the treatment option?
• What strategies can parents and teachers implement to help the children with unwanted behaviours?
• What are some of the practical things that we can actually do to help children with unwanted behaviours?
• Behaviour management tools versus medication? 
• Parenting suggestions for a 13 year old who's defiant?

Transcript

Nicole: Hi everyone, and welcome to our webinar, ADHD - Navigating the Maze.

My name is Nicole Gamerov, and I'm the founder of MyCareSpace - which is an online community that creates meaningful connections and resources, so that people can make better informed health and lifestyle choices.

Thank you to everyone who's registered for this webinar and sent your questions ahead. We literally received 100's of questions from hundreds of you. It would be impossible to answer all the questions in the time that we've allocated. And we know that your time is precious, so we are going to stick to less than 1 hour. Because of this, we have-- We are launching a new service, which is called, "Ask the Doctor." And this forum will allow people to send in their questions and receive responses from our experts. So watch out for that.

At this point I'd love to introduce our panellists, and we're very fortunate to have 2 people who have spent a lot of time thinking and working on the topic of ADHD. So first of all we have Dr Paul Joshua. Paul is a developmental paediatrician who has a particular interest in ADHD and behavioural disorders. Paul is a Fellow of the Australasian College of Physicians and is also a member of the Neurodevelopmental and Behavioural Paediatrician Society. Paul practices across a number of different private practices. In terms of a quirky fact about Paul - well Paul has 4 children, all of which are sons. Crazy or quirky, I don't know?

Then I have Dr Merrilyn Clancy here with me. Merrilyn Clancy is a trained speech pathologist. She has worked both in the US and in Australia. Merrilyn has worked with ADHD children in a range of different environments - including both in a research environment, in hospitals, in private practice and in schools. Merrilyn's goal is to work with parents, families, carers and teachers to help build people's skills so they can have the best functional outcomes for their children. So thank you Paul and Merrilyn for joining us.

At this point, I'd just like to emphasise 3 things about this webinar. The first is that there's no quick fixes, and neither should we be trying to fix these beautiful, gorgeous ADHD kids of ours. These are the children that are going to become the future entrepreneurs, the creative designers and the leaders of Australia.

The second important point is that not everything that we talk about today is going to apply to you. So one size does not fit all. And the third point is, take this - take note of this, that basically understanding your child and the triggers is what is going to lead to the best outcomes for your child. So the objective of today is really to provide you with a framework of thinking that will allow you to support your child in lots of different situations.

So with that in mind, we've looked at the questions that you've sent in - and there are really 3 key things, and there will be 3 key sections to our webinar:

The first will be "What is ADHD?" And this will cover the diagnosis and questions around medication.

The second section will talk about the strategies that will help manage unwanted behaviours.

And the third section will really look at other situations and other settings - like school, and helping you get the most out of these settings and surroundings.

So without further ado, we'll start with the first section, which is, "What is ADHD?" And really to a large extent, this covers the medical side of things. So Paul, I'm going to ask you the first question, which is really-- A couple of parents asked this question, and this is - in terms of the definition of ADHD, what is the definition of ADHD and how does a child with ADHD differ compared to a neurotypical child?

Paul: Sure. Well first of all, thank you for having us on this webinar and giving us the opportunity to discuss this important topic and help kids and families.

In terms of ADHD, I usually have a conversation with the families that I see - around the fact that on the one hand ADHD is a real disorder, which has evidence scientifically of biochemical differences - structural, functional differences in the way the brain works. Which translates into real effects in terms of attention, in terms of behaviour. But at the same time, it is part of the spectrum of what normal-- I use the word "spectrum" in terms of the normal range of what normal childhood behaviour is.

What we are identifying as ADHD now, is a problem relative to the expectations that we place on children - especially in the school environment - where they have to be able to keep still, focus, sit and do their work. And not every child has a strength in that area, the same way not every child has a strength in sport or music. So because we don't have a blood test or a brain scan for saying what is and is not ADHD.

Like many disorders, the way we actually identify and define what is ADHD - which stands for Attention Deficit Hyperactivity Disorder, is based on a clinical definition. So it's based on a picture that we see whether a child fits. It's with-- Nowadays we talk about ADHD as the overall condition. And then we break it down into either predominately inattentive, which are kids that are - have problems with focusing, concentration, daydreaming kids. And kids that have got ADHD - predominantly hyperactive, impulsive. Hyperactivity - which is fidgeting, not being able to keep still. People often say "climbing the walls." And impulsivity - meaning a child that does things on impulse without thinking. Often manifesting as interrupting, doing things without thinking. And then there's combined type, which is also very common. Where they have both effects.

The way we define what is ADHD, is by looking at whether a child has enough symptoms of the condition - and there are set symptoms. There's actually 9 of each of inattention, which is attention problems and hyperactivity and impulsivity. And a child's got to have at least 6 out of 9 of those occurring often or very often. And this is all based on the DSM-5, which is a - essentially a rule book of behavioural and developmental conditions, and some psychiatric conditions. In ADHD, in addition to having those symptoms - it's also got to be having a significant effect on the child. Either academically, socially or behaviourally. It's got to have started from a young age, and it's got to be developmentally inappropriate. It also has to be present in more than one setting. So not just school, and not just home - but all across the child's experiences. And it's got to not be due to another cause. And each of these things is very important in actually making a diagnosis.

Because we have to look at everything to do with a child's experience. We have to look at their sleep, their diet, what's going on for the family? What's going on for that child emotionally and behaviourally? So that's how, that's essentially how we decide on whether a child has ADHD or doesn't.

Nicole: Great, thanks. So essentially, it's not necessarily black and white. Which, I'm sure a lot of parents have already experienced. So you mentioned DSM-5, and we also know that that's applicable in other scenarios where children are on the autism spectrum. One of the questions, and a few parents actually asked this question - is, what is the difference between ADHD and autism spectrum disorder? 

Paul: Okay, so they are very different conditions. And like ADHD, autism has certain criteria that have to be fulfilled to meet the threshold for a diagnosis. I will go in, I will explain now what the conditions are for diagnosing autism. But it's important to note that many children with autism have, also have ADHD as part of their behavioural profile. So it's not necessarily one or the other. We know that although there is a certain number of people that have ADHD when they're young who do grow out of it, autism involves an abnormality in the way the brain functions - and that leads to differences in the way children with autism experience the world and think. Which is not necessarily always a problem, it's just a different way of experiencing the world.

In autism, you have to have problems in 2 areas. And these are in social interactions, social communication - how you interact with other people in society and in your family. And then the other area is interests and behaviours, which are very repetitive and narrowed and fixated. That often manifests as repetitive movements or play. Being very inflexible and fixated. Being obsessive about particular interests. And having sensory needs which are either very averse to particular sensory experiences, or seeking out certain sensory experiences. I mean autism is a spectrum, because it can range from people with very high IQ, to people with significant intellectual disabilities. And the severity of the autism, autistic behaviours - can range from delightful kids in mainstream classes who might have a few social quirks, to kids that are significantly impaired and need to be in support classes. 

Nicole: Great, thanks Paul. So - and now that you mentioned the sensory system, and we actually got a question from a special needs teacher who asked - what is the link between ADHD and the sensory system? 

Paul: So when people are talking about sensory symptoms, and often the term "sensory processing disorder" is used. Firstly, there are some people for which a sensory difficulty is part of an underlying disorder - and autism is a perfect example of that. So whilst you don't have to have sensory integration problems to be on the autism spectrum, many children and young people do have them.

Now you can have sensory needs or sensory seeking behaviour, sensory aversions - and not have autism as well. So many people without any disorder have problems with the texture of food, have problems with the feeling of clothing on their bodies, sand on their feet, loud noises, smells - and that can be present in someone with ADHD, it can be present in someone with autism, it can be present without either of those. Looking at ADHD, I often think of these sensory problems as being a common comorbidity, which is a term we use for when there's other issues in addition to the main diagnosis we're focusing on. So in ADHD, comorbidities are the rule rather than the exception.

What I mean by that is that the majority of children that have ADHD will have one or more of the following things. And this list is not exhaustive. But they will commonly have learning difficulties or anxiety or oppositional defiant behaviour or tics - motor or verbal ticks, like twitches that kids often have. And there's, the list goes on. But sensory needs or sensory aversions are part of that list. The sensory system can also be a prism through which many people - and this is often the case with occupational therapists, a prism by which to understand and view what ADHD is. How it's affecting a child, and what interventions can assist.

I often will get referrals from occupational therapists where a child's difficulty with keeping still or sitting in a chair without fidgeting or their need to look out the window and get various sensory input, is viewed through a sensory prism - and then therapy is directed at that. And that can be very helpful in some kids, it doesn't help in all kids. And I think the main thing when we're looking at kids with ADHD and their sensory needs, is that we are very functionally focused, and we look at - in what way is their ADHD and their sensory needs impairing them at school, at home? What therapy can be directed to assist with those? And then we will review those goals periodically, so that we're making sure that whatever we're doing is helping and is useful. 

Nicole: Great. So we've covered a lot of ground, and I guess it's possible to go into a lot of detail for each of these different attributes. But another question which some of the parents asked, and actually contributed information - was around genetics. So a couple of parents said, "Well, I myself have ADHD, and my child has ADHD." One of the parents commented that her husband has ADHD and her child has ADHD. So how does genetic--? What is the role that genetics plays in ADHD? 

Paul: That's an excellent question. We don't have all the answers in terms of what causes ADHD. But we do know that it's very strongly genetic. We know that there's roughly 5 to 6% of people that have ADHD, and that doesn't change very much regardless of what country you're in, what the cultural background is, or whether it's people 100 years ago or kids nowadays. Obviously there's-- The world changes, and there's probably less tolerance for some of the behaviours which we now diagnose with ADHD, compared to the past. But some of the evidence that points towards a genetic cause of ADHD.

So we've got twin studies, and we know that there's identical twins and non-identical twins. And identical twins, genetically identical - and we know there's about a 92% rate of 1 twin having ADHD if the other does. We also know that ADHD is much more common when there's genetic, minor genetic abnormalities in a person's makeup - which we can test, even if we don't always understand exactly what those abnormalities are associated with. And it's very common that if a child has ADHD, that a parent was similar. But that doesn't mean that it's always the case. And ADHD can certainly occur out of the blue with parents that weren't at all affected by the condition. And one child can have it, without anyone else in the family having it. There are also environmental factors, and things like alcohol or drug use in the pregnancy. Prematurity can have a higher risk. Early infections. Early environment, environmental factors to do with the upbringing of a child - like significant abuse. So other things are also implicated.

Nicole: Great. So and that's a bit of a relief to know that it's not as a result of poor parenting. So I think there'll be a lot of relieved parents out there to know that ADHD is not the result of poor parenting. So thanks for that, Paul. That leads us on to the next area, and really there was a lot of questions around medication. So Paul, in your professional opinion - when should parents consider medication as the treatment option, and can you give them some indication as to when they've reached that point? 

Paul: Yeah. Well I think it's a very personal decision, so I don't think it's ever just up to a professional such as myself. I think it's a conversation to have with the family. And parents know their child best, and they're the ones that are entrusted with nurturing and raising that child in the world. And they will have had their own experiences at - with medical care, and with their child interacting with school, with friends. And so I think - first of all, I don't think it's up to a professional - including a doctor, such as myself - to say, "Your child needs to be on medication." It's not like having a infection that if you don't get antibiotics with some infections, where it can be very dangerous or even cause death - and then parents often shouldn't have a choice. But in this area, I think it's always something to discuss and look at the pros and cons. And that's especially the case, because all medications have side effects. And so - and each family have their own perspective on where they want their child to head. And in terms of school performance, what they find acceptable and what they don't find acceptable. So the types of things that families often discuss with me in deciding when their child, if their child should go on medication - is the severity of the symptoms. So in terms of academic performance - if they're having trouble concentrating, are they keeping up with their class curriculum? Or are they really completely falling behind? Is it affecting their self-esteem, are they not able to progress to the next academic stage because they've fallen behind so far? 

Nicole: Yes.

Paul: For some families - the fact that their child is not meeting their potential alone, is something which is a significant consideration. Although it obviously makes a big difference whether they're not meeting their potential and they're performing at an average level. Or they're performing at a very low level, compared to the rest of the class. Whether their behaviour is resulting in a lot of discipline at school and at home, and whether that's affecting the child's self-esteem.

Obviously it's really important for children to have an environment around them which is celebrating their positives, and which is making them feel like they're getting runs on the board and they're winning in life - and not always being told that they're the cause of problems, and so that's a consideration. And because we know that there are interventions that can assist with ADHD - short of medication, it's always important to make sure that everything else has been tried first. So from the way I view things, and the way I view the evidence - the most important thing is looking at any underlying factors which can be contributing. So we're always looking at things like their diet and their sleep and their vision and their hearing. And whether they've got any symptoms of thyroid disease, or whether they've had concussion - and all these sorts of medical things which we need to rule out first. Next, we've got to make sure that we've really got an understanding of where that child is coming from behaviourally and emotionally and what's - what things are like for that family.

And often I'll involve a psychologist - sometimes a speech therapist or occupational therapist, depending on the situation. But we know that there's good evidence for classroom and home based behaviour interventions to help with the child. Whether it be sitting at the front of the class, whether it be making sure there are no distractions.Whether it's making sure they're getting short instructions, rather than a whole avalanche of instructions from the teacher. So we always like to make sure that all of those things are tried first before we look at medication. 

Nicole: Yeah, great. Thank you. And I guess it's one of those situations we know - one size fits all, it really depends on the particular set of circumstances. And Merrilyn, we're going to come to you. Paul mentioned therapies - but before we go onto therapies, I guess one of the questions that several parents asked were - are there any medications that don't cause drowsiness? So I'm not sure how difficult that question is to answer, but that was a common question that a lot of parents asked. 

Paul: No, it's a good question. And any medication, and not just for ADHD. Any medication - we're always weighing up what benefit is this child getting, and what side effects are we experiencing. Because there's no point in taking a medication that is not helping in the best interests of this-- Of the child, or adolescent.

So stimulants are the most common medication used for ADHD, and they - and that's because they have the best evidence, and in most cases they work the best. And we've got 2 stimulants on the market in Australia. There's Ritalin, otherwise known as Methylphenidate and Dexamphetamine. And long acting Ritalin's are Ritalin LA and Concerta. And long acting Dexamphetamine is Vyvanse. There's also compounded versions that sometimes are made up in pharmacies.

Now stimulants in any person at too high a dose will affect them in the sense that it will make them not quite themselves. They might feel a bit flat. They might even be really out of it if the dose is too high. And that's-- And those are side effects that mean that whenever we use stimulants, we always are very careful with the dose. And in most cases in my experience - if children are drowsy because of stimulants, it's because the dose is being mismanaged or the dose is too high.

So most paediatricians and psychiatrists will have a start low, go slow approach. Where we start with a very small dose - even at the risk of it not doing very much for the child's ADHD. Then we'll gradually increase it, watching carefully to make sure we're not changing all the wonderful things about that child and making sure they stay who they are. There are a couple of non-stimulant medications that are also used in ADHD. And really there's 3 common ones, I would say. There's Catapres or Clonidine, which can help with hyperactivity - not so much with inattention. That can cause drowsiness. There's Strattera, which is often used as an alternative to stimulants. And drowsiness can be a side effect of that. In my experience it's quite uncommon. And then there's a new one called Intuniv or Guanfacine - for which, again - sedation is the main side effect. However it doesn't happen in all children, probably only in about half - and it does improve with time. 

Nicole: Okay, great. So look, it sounds like that there's an element of trial and error. And judging from the questions, and a lot of them - it seems like a lot of parents maybe don't realise that there's a bit of trial and error involved, so--

Paul: Exactly.

Nicole: So thanks for clarifying that. So we've really covered off that main section - which is what is ADHD, and some of the medical issues associated with it. So I'd like to chat to Merrilyn, and you've been very quiet now - and I know you've got a lot of wonderful insights to share. So Merrilyn, we were chatting beforehand - and one of the quirky facts about you, you were saying, "People might not know this." But actually Merrilyn was - in her early part of her career, she was actually scared or nervous of children with ADHD - for fear of being struck at. But with years of experience, Merrilyn has found that learning to duck is a very important strategy. Is that true? 

Merrilyn: Yes, yes. The reason is that you can modify your own behaviour to help children do better. 

Nicole: Great. So I've got to learn to duck. So really moving onto the next section, which was strategies to help manage unwanted behaviours. So the unwanted behaviours that a lot of parents spoke about was - defiance, aggression, impulsivity, and this lack of concentration or emotional regulation. So Merrilyn - in your experience, what are some of the strategies that parents can use to help manage some of these unwanted behaviours? 

Merrilyn: So thanks, Nicole. Those certainly are quite a stack of what we consider things we don't like, unwanted behaviours. Like, "I can't believe my child just did that." "That can't possibly be my child, my child would never do such a thing. Yet there he is, or she is doing it right in front of me, and I don't seem to be able to control it." But what we need to do is to understand. And what do I mean by "understand?" I mean that we need to look at what the behaviour is, what are the contexts that it occurs in - and to try and kind of put a net around it, so that we can describe and list them in a simple way. And being able to do that, and being able to explain them - turns you into a navigator.

And so in terms of specific tips, it would really depend on the age of the child - and we're speaking now in kind of a general webinar. But a hallmark of the way that I work with children, is to build skills in the adults. Build skills in the parents, in understanding what is happening. The child's not bouncing the ball in the house to intentionally annoy you - even though you're certain that he is. Even though you're convinced the way he's looking at you while he's doing it - it's for the express purpose of ruining your day. But instead, understand that children love their parents. They look to their parents for safety and protection, and they want to please them. And so when they have unwanted behaviour, it's generally the overwhelming impulse that just seems to take over their entire brain in that moment.

Take for example a tantrum. The child might be inconsolable. At that time, consider that their entire brain might be fully occupied with this extreme emotion. And so giving orders or directions in that time - in that moment, the child cannot take information in. And so you want to calm the child by staying quiet and being - controlling your own behaviour and regulating your own behaviour, so that you can listen and understand what the words are the child is saying. So if they're saying, "I want this, I want that." Or, "You're terrible," etc. You just say, "I understand. I understand." So maybe inside you're feeling like, "I can't take this, it's too hard." But on the outside - you're responding in a calm way, in a navigational way. Because that impulse will pass. And once it's passed, then you can talk about what might have been a better strategy that the child - him or herself could engage with. And so by developing capabilities in adults of understanding what these behaviours look like, what are the boundaries. And it's going to be a process, because every year they get older. And so what today's behaviours are in say this particular month, they might vary next month. And so you want to be ready with your kind of navigator mindset, to be able to understand what these are and how they change over time. 

Nicole: So we really need to be like a mini compass that is trying to work out - I guess, which direction are we facing? And then steer ourselves in - I guess, in a different way. Okay, well note to self then, to remain calm when the ball is bounced inside. So Paul, just - we might jump to you, just in terms of talking about some of these unwanted behaviours and the therapies that may be applied. In your opinion, do you see medication working well in isolation? How do you see the interplay between the therapies that Merrilyn might be talking about, or some of the management tools versus the medication? 

Paul: Yeah well, I think they go - they go hand in hand. I tend to always like working with families in conjunction with a-- with someone with skills to help the child and the family in managing behaviours, and often that is a psychologist or someone with Merrilyn's skill set. We know from the evidence, the biggest study from looking at kids with ADHD - in this case, kids 7 to 10 - was called, "The MTA study, The Multimodal Treatment of ADHD." And that followed up about 600 kids over a number of years.  And they found that medication in combination with behavioural therapy was the best way of assisting with ADHD behaviours. And the behavioural interventions helped to lower the dose of medications, and the combination - led to better academic performance, parent/child relations, social skills, anxiety - than just routine care. So we do recommend both. And there's a saying that, "Pills don't build skills." So medication helps while the child is taking it - and hopefully while the child is taking it, is more receptive to therapy and more receptive to getting into a routine of focusing and a routine of appropriate behaviour and less impulsivity - that will translate into improvements. But both is best. 

Nicole: Important for parents to realise that maybe in isolation one treatment is not actually going to get the results that they would expect. So we've spoken a lot about some of the theoretical or high level strategies and treatment options. But Merrilyn, this question's for you. In terms of unwanted behaviours like impulsivity that could lead to dangerous situations, what are some of the practical things that we can actually do? 

Merrilyn: So when a parent's concerned about safety, the automatic reaction is to jump in and kind of save the day. And again, it depends on the age of the child. But if you can recruit the child or the sibling - again, for their own understanding. And you can do this by asking questions or directing the sibling. Sometimes Johnny's brain has a mind of it's own, and it takes over. So when that happens, step aside. When that happens, don't engage. When that happens, try to make a different decision - a better decision for you. And likewise with the child who is doing the potentially unsafe behaviour. Try to stop it in the moment without using fear or anger, in as calm a way as possible. And then afterwards, address what the situation was with the child directly by asking him or her questions. "What were you thinking at the time? What was on your mind? Can you see that there are risks involved with that? I want to help you make better decisions for yourself." Again, "Sometimes your brain has a mind of it's own, it gets ahead of itself. Hands are not for hitting. So what made you feel that you wanted to reach out at that time and whack your brother? Was that a good decision?" These are, these questions might sound hard to implement in the moment - and that's because they are. You want to do these things after you have stopped the potentially dangerous situation. Because if you're not going to respond in a calm way - the alternative is, you're extremely anxious - and that is projected to everyone in the environment. And then it's not clear to people what you're actually anxious about. Are you anxious for the sibling that might be about to be injured? Or you're anxious because the other child is doing something bad. But it will kind of set everyone off. And so if you can-- As best as possible, separate the situation. And when people - when the children are calm, then explore - from their point of view, what was happening, and empower them to make better decisions for themselves. 

Nicole: So you're suggesting no screaming. 

Merrilyn: I am suggesting that using your regular voice will always lead to a better outcome. 

Nicole: Note to self, no screaming. Thanks Merrilyn. So defiance is one of those behaviours that some of us have to deal with or manage, and it's probably particularly difficult when you're dealing with a teenager. So we have a mum of a 13 year old, who asked the question - how do I manage, or some parenting suggestions for a 13 year old who's defiant? Merrilyn, that's for you.

Merrilyn: Yes, sure. Again, this is one of these things that we wish we didn't have to deal with. Because we don't like those behaviours. We don't like being opposed. We don't like it when someone doesn't like our ideas. Think of yourself in the workplace. If you make a suggestion and someone gets irritated by it and challenges you on it - as an adult, we don't like it. And so when a child has trouble with these behaviours, the number 1 thing you have to remember is - now you're on their turf. Because while they're being defiant, that's a comfort zone for them. And that's a kind of preferred activity.

So even though we don't like it and we feel compelled and drawn in to oppose it - we want to neutralise it as best as possible. And I often get asked, "What's the difference between ADHD style of defiance, and what's regular teen years?" And my answer to that is - it doesn't really matter. We don't like being challenged in that way, just the same as the child doesn't like it. So again, we want to come from the point of view of being a detective, being a navigator - and understanding. Like, let's not engage. Because likely the child is more skilled in this defiance situation because they are more comfortable with it than you are.

And so, again - you want to ask questions. If it's very, very strong defiance, you might want to explain that it's not working and so we're going to take a break from discussing it and discuss it later - and set a time. And when you set that time, you go through a checklist. So you have a kind of, an agenda. So everyone knows what's going to be discussed. But if it's a more mild thing, then you might want to use some detective strategies, like, "Huh, I'm surprised by that. Gee, you sound mad to me, I'm not sure what to say." Because you want the child to make better decisions. And so by giving them questions and leading them out of the fight, so to speak - you'll more likely have more success. But always remember that that type of back and forth, the tennis match - the child who is truly defiant is going to win in the moment. And so not engaging will help them get out of that. 

Nicole: And I know from my own personal experience, sometimes I have to remind myself who's the adult and who's the child. And generally, yeah - backing one's self out of a situation is the best way forward. 

Merrilyn: And then if it gets to the point where it escalates, and they're actually insulting you - you want to them just say something from the heart. Just say, "Wow, that really hurt my feelings. I'm going to need to take a break now. When you say that, that hurts my feelings. I don't like it when you say that, because I feel bad." And by reflecting something from your heart, that can also top the back and forth. 

Nicole: Yeah. Well one of the favourites you told me the other day, is - when they say something that, I guess is defiant - you say, "Well that's the opposite to what I'm saying," and it worked the other day, so thanks Merrilyn. So moving on from some of the strategies to help these unwanted behaviours. The last section of our webinar really is around other areas of the child's life - and in particular, school. We all know that our children spend a huge amount of their day and week at school, and achieving those learning outcomes is really important. So Merrilyn, given that you've worked in a lot of educational settings and with schools - what strategies or what advice can you give parents to help their children get the best outcomes in a school environment? 

Merrilyn: I think the best advice I can give is - again, comes from this word, "understand." And I probably sound a little annoying, because I say it all the time. I want you to understand that schools have their own set up and the way that they run, and your child goes every day for many hours. Most of their day is spent in the care of school teachers and the school environment. And what is the school environment. It requires a child to get along with others.

First when the baby is born, this very young infant has to get along with immediate family members. Then get along with grandparents, aunts and uncles, cousins etc. But once you're in school - you really have to get along as a member of a community, a team player - and get along with strangers. And so the child who has some limitations in social skills - maybe an ADHD child knows the rules of social engagement, but just can't call upon them in the moment. And so you want to be an advocate for your child, but also understand that it's about your relationship with the teacher as well. And so you want to be supportive of that environment, rather than imposing knowledge on the teacher or telling the principal what to do. Instead, try to explore what the challenges are that the school staff sees. They can be your best ally in understanding how your child's getting along. Because these types of kids, they flunk socially a lot. So that means they'll flunk in the learning environment, in the playground. But they're going to have to go every day. So we want to build skills in them, but also support the school staff. And again, that comes from understanding. Like listening to - what are the aspects that the teacher is saying that I can assist with? Rather than being offended by saying, "Oh the teacher's always blaming my child. I believe my, I don't think my child really did that. He's always the one that's blamed. It's not always the case." This happens on a daily basis, but instead try to look at your child's strengths and impart those strengths with the teacher. And say things like, "He really does better sitting at the front of the classroom." Or, "He may do better if he sits left of Susan. He's mentioned a few things about working on the laptop, that it doesn't seem like he follows directions. Would it help if you used shorter instructions?" Or, "Can I reinforce something at home?" And what that's doing is creating an environment of relationships that you can help your child to move forward from. So you're improving your adult relationship with the teacher, with the school - and that in turn will have a long term effect on your child's school attendance. 

Nicole: Yeah, I guess kids model their behaviours off their parents. So walking in all guns blazing, and blasting the teacher's not going to help, as much as we sometimes want to do that. We have to just take a step back. So we've spoken about the school environment and the teachers are really an important part of that. But are there some strategies that we can offer teachers? And I know that we've got some teachers who have registered and have joined us in this webinar. What are some of the strategies we can offer for our teachers, to help them cope better? 

Merrilyn: I think teachers have a lot of responsibility. They have large numbers of children. And they're all different personalities. So I think the way to help the teacher is to know and understand your child, and to share that with the teacher when invited. In terms of things that you can do with your child - planning, organisation, packing the school bag, unpacking the school bag, having lists of things to do. Going through daily responsibilities, "Now today this is happening at school," etc. And then supporting the teacher. "I know on Thursday's there's a spelling test, and so we've had a little practice a couple of nights before." But, again - a back and forth exchange in the teacher's view of how the child can be supported in the classroom, will be a long term winning strategy for the teacher and for the child. 

Nicole: Okay, so obviously in school, one of the important things is children need to be able to concentrate. And sometimes they need to stay focused for longer periods of time. One of the questions many parents asked, is - my child has inattentive ADHD and finds it difficult to get started at tasks and staying focused and completing tasks. So this lack of focus or ability to stay on task, what strategies can parents and teachers implement to help the children in these situations? 

Merrilyn: So, again - it's, that's a general question and so it depends on the age of the child. Because some things I might say might be a little too straightforward for older children, and other things might be too hard for little kids. But you want to think of these main concepts - planning, organisation, routine. Again, as a parent you're the navigator. So you want to steer the boat. So frequent reminders. "Now Thursday is tomorrow. What's on the list for Thursday? Do you remember? Okay you've forgotten, let's go look at the list. This is on the list for Thursday. What needs to be done for that?" Okay, so let's get started with item number 1. Let's say it's a maths assignment. And you go away, and then you come back 15 minutes later and they haven't started - and they're chatting with a sibling or playing a game. You want to ask questions so that, to draw them back into initiate the activity. But sometimes you can just use the phrase, "I know it's hard, but just get started." Just get started. Just a small prompt like that, start at the beginning. It sounds a little bit obvious, but there's a - sort of an inertia. And instead of seeing this whole thing, "I've got to do this whole maths problem and I'd rather play a game," it's, "Just get started." Because once they get involved, they're more likely to be able to continue. We know their focus might wax and wane - but again, cue them back. "Just keep going, just get started." 

Nicole: Really it requires the parent to remain focused. At the end of the day, the parent needs to remain focused. 

Merrilyn: And that's hard for all of us. 

Nicole: And that's hard, because doing homework and making dinner and looking after a baby just doesn't really happen. So we all need to apply this to our own circumstances and see what works best for us. 

Merrilyn: We do. Sticking to a routine, even if it kills you - or even if Johnny's not participating in the routine. Dinner's at 6, it's always at 6 - no matter what. And it's over at 6:30, and then we're onto the next activity. And so maybe there are some challenges around that. But we can't steer the ship in the direction of the turbulent wave, because we're disturbed by the turbulent wave. We have to head for the lighthouse. So planning, routine, fixed routine - even on weekends. So no sleeping in on weekends, get up at the same time, go to bed at the same time. And these are the things that are helpful for adults, as well as children. Things like doing chores, doing chores helps children do orderly things. Children, as young as 3 can sort laundry by colours. 5 year old's can wear socks on their hands and help dust. So children who are 10 and 12 years of age who aren't making their bed or doing things to contribute as a team player, are not learning to-- Are not learning the skills that we need to get along with others outside the house. So it's not about child labour or, "We have a housekeeper," so much, "We don't have to do that." Chores are, they're mind setting. They get us on the right pathway. So if everyone has their chores, it doesn't matter that you prefer to sleep in a messy bed - your day will be better navigated if every morning, child gets up and straightens their bed - however that is in your home. 

Nicole: Yeah, and I think from my own personal experience - you have to try things. And some will work, and some won't. But certainly from my own personal experience - having a routine and trying as much as possible to stick to that routine really, helps the child. So really - as a wrap up - our job's to equip our children with the skills that they need to get on in life and to be happy. And often our happiness depends on the quality of our relationships. So what we should be trying to do is really help our children get along with others and develop the skills that are going to achieve those positive relationships, whether they're at home or at school on the playground. So in terms of - we've spoken about a lot of different things, and Paul and Merrilyn - I suppose you've both got your areas of expertise. But if I could ask you to think about your 1 top tip for today that you could share with parents - Paul, would you have 1 top tip that you could share?

Paul: I like this quote from Andrew Soloman, who wrote, "Far From the Tree," which is a book about parents and children when they're coping and accepting difference. And the quote is, "All parenting turns on a crucial question. To what extent parents should accept their children for who they are, and to what extent they should help them be their best selves." And I think that's a really important thing for every parent to consider. Accepting the children, so that they can celebrate their strengths and not focus so much on any deficiencies they perceive in their ADHD behaviours. But also helping them to be the best they can. And that's why having a team that you trust and is advocating for child and helping you with your child is really important. 

Nicole: Great, and Merrilyn, what's your tip?

Merrilyn: My tip would be that your child has only you, and your child loves you and looks to you for safety, protection - and looks for you to be the navigator. And so if you can stay on a steady course that is planned and organised and less anxious and goal directed - then those things will learned by your child. And perhaps a child with ADHD has some struggles in learning these things in the same time line that you learn them - but they will learn them. And they'll also learn to understand their limitations. So that they can then have a language to describe their limitations, but focus on their skills and strengths to move forward. Because they're certainly valuable members of the community, like all of us. 

Nicole: Thanks Merrilyn. And certainly at MyCareSpace, we celebrate brain diversity and that is something that we will always promote. So thank you to Paul and to Merrilyn for sharing generously of your time and your insights. We hope and really do look forward to parents taken some of what we've spoken about today into the home or into the classroom and implementing that. We will be sharing this webinar, recorded version on our website - which is www.mycarespace.com.au. We'll be sharing some useful links that Merrilyn and Paul have shared with us, so that you have the tools and the resources to go to after this webinar. And then just to reiterate, that we will be launching our new service - which is, "Ask the Doctor," in a week's time. And you can send in more questions, or similar questions that we haven't answered today. So thank you everyone and goodbye. 

End.

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