Organizational Interventions for Children with ADHD
I recently attended the annual meeting of the Canadian ADHD Resource Alliance (CADDRA) in Vancouver and was keenly interested in the work by Dr. Howard Abikoff on the importance of teaching organizational, time management and planning (“OTMP”) skills to children diagnosed with ADHD.
Dr. Abikoff carried out a randomized clinical trial studying the effectiveness of a 1-month OTMP training program in children ages 8-11 years old with ADHD who also had identified OTMP deficits. They compared the OTMP skills based-program to a performance-based training intervention. The performance based program did not include explicit skills training to the child. Instead, parents and teachers used a contingency-based system of rewards and punishments for when the child reached or did not reach OTMP goals. To assess the effectiveness of the programs, they measured academic performance, school-related behaviours & attitudes and family relationships. They found a statistically and clinically significant benefit of both interventions on the measures. Furthermore, the benefits were sustained over a one-year follow-up period. These results are promising and suggest that elementary children with ADHD can improve their OTMP skill deficits and this can positively impact their academic performance.
As a parent of a young elementary child, I can attest to the need for children to develop OTMP strategies at a young age. Luckily, my 6-yr old child enjoys keeping her backpack and desk neat. Her room, on the other hand is cluttered and disorganized. Other children struggle with many aspects of organization – they may forget to bring important papers home from school or when they do remember, they may stuff them haphazardly into their backpacks, alongside dirty Kleenexes and leftovers from lunch. Their desks might also be messy and their bedrooms at home cluttered and disorganized. Can these children be taught organizational skills? Can children learn to avoid misplacing or losing materials for school or extra-curricular activities? Who teaches them how to plan and follow-through on longer assignment and projects? If they are lucky, they have parents or teachers to show them and monitor their progress. Some schools do a nice job and help the children remember what to bring home so they can do their homework. However, many students never formally learn OTMP skills, or try to learn them only after they have already started falling behind and in some cases failing in school – this might not come apparent until the high school or college level — when there has already been an impact on their grades and anxiety levels.
At Vanier College in Montreal, there are formal requirements for teachers of first year psychology courses to review study skills and time management skills (also stress management, which is great). There is also a lovely student handbook packed full of tips on OTMP skills. However, anecdotal reports from students would suggest that the students who need the information probably do not read it or take it seriously. Moreover, for those who do read the material, it could be argued that it would have been more helpful if they had already learned and mastered the skills before college started as opposed to using a trial and error approach during the academic years when grades are particularly important.
I have worked with students with OTMP deficits who were able to use their smarts to “get by” in elementary school and in some cases, part of high school. However, things changed drastically at the senior high school level or at college or university when the demands become significantly greater and there is less accountability and structure. I have seen extremely bright students struggle and in some cases fail and drop-out because they were not able to effectively organize their time and manage their workload (some of whom have ADHD, other who do not). On the flip side, I have seen average students excel in university (and professional programs thereafter) in part, because they have learned early how to be organized, plan ahead, and effectively manage their time.
If a student starts to struggle at the high school level, many parents have great intentions and may then decide to jump in and earnestly try to help their teen or hire someone else to. Unfortunately, many parents may discover that their teen resists their help or becomes embarrassed by outside intervention since it may not be seen as “cool” to take advice from mom and dad or another adult. In other cases, a teen may think that it is “geeky” to carry around an agenda and fear being the target of ridicule from their peers. Technology can sometimes help in this regard (e.g. there are fantastic organizational and time management apps and e-agendas out there!), but there are other considerations with technology that parents are usually concerned about, but that is a topic for a future blog…
In working with adults with ADHD, the top goals that my clients choose to work on tend to be centered on time-management, organization, and procrastination. All of these factors have lead to turmoil in their lives, including feeling overwhelmed, stressed, inadequate, and achieving under their potential. In addition it has been associated with work related problems, relationship conflict, trouble managing finances, and problems with anxiety, depression and substance use/misuse.
What would these clients be like had they received instruction and practice with OTMP skills early in life?
Why not integrate a similar program into the curriculum at the elementary school level for all children? Why not formally teach children and practice OTMP skills at a young age, so that the skills become automatic and internalized before teenhood?
Let’s start teaching these skills early: Avoid the problems in the first place rather than try to fix the problems once they arise and have already taken their toll on a teenagers self-esteem, stress and anxiety level, and grades. An ounce of prevention is worth a pound of cure!
The Abikoff (2012) program involves teaching children how to (a) track assignments (i.e., how to record and monitor and record due dates), (b) manage materials (i.e., how to organize work in binders, and their desk and backpack, how to use checklists, how to get rid of what they no longer need, (c) manage time (accurately estimating time to carry out tasks); (d) task planning (learning to break down larger tasks (projects, assignments) into manageable steps and scheduling the work to be done). It uses five main treatment tools: (1) a daily assignment record (for listing materials needed to bring home and homework details), (2) a long-term assignment and test calendar, (3) an accordion binder for filing papers, backpack checklists and other checklists, and (4) “ready to go” (removing anything distracting or unnecessary from the work space). The program consisted of 20 sessions, where the therapist met with the child twice weekly for 1 hour after school.
For those interested, Dr. Abikoff’s program is manualized and will be published by Guilford Press sometime in 2013.
References
Abikoff, H. (2012, November 4). Organizational interventions for children with ADHD: Results from a randomized clinical trial, Plenary presentation, Presented at the Annual Meeting of CADDRA, Vancouver, BC.
Abikoff, H., Gallinger, R., Wells., K.C., Murray, D.W., Huang, L, Lu, F. & Petiova, E. (2012, August 13). Remediating organizational functioning in children with ADHD: Immedaite and long-term effects from a randomized controlled trail, Journal of Consulting and Clinical Psychology, Advance online publication. Doi:10.1037/a0029468