Part 3 of our interview with child neurologist Dr. Sara J. Dorison provides tips for child care center educators dealing with ADHD behaviors.

OwnADaycare: Could you give a few tips to help preschool teachers or daycare providers help manage ADHD behaviors?

Dr. Dorison: It is often difficult for a preschool teacher to know how to manage an ADHD child.  This is especially true of the teacher has a large class, an assistant who is not highly trained or if there are several ADHD children together in one class.

1.  Set expectations that the child can meet.  For example, insisting that a child sit for extended periods of time is likely to be unattainable and for this reason a teacher would be wise to allow ADHD children a bit more leeway in terms of physical activity.  If the child is not able to meet expectations, then the expectations need to be changed or accommodations can be made such as allowing a child to run class errands or hand out snacks (instead of trying to wait quietly).

2.  Identify one or two “problem behaviors” to target.  For example, if an ADHD child is physically aggressive, then the teacher and child can sit down and talk about “angry hands don’t touch.”  If all behaviors are targeted at once, the child will be confused and unable to meet the demands.  This will result in frustration and poor cooperation.  Other behaviors such as not cleaning, fidgeting, etc. should be dealt with after the aggression has resolved.

3.  Set up a positive reward system that might be done at first every hour (depending on how bad the problem is).  So, a child might receive a sticker every hour if she did not push/hit another child.  Then, the system would be changed to a sticker for before lunch behavior and after lunch behavior.  The important thing is that the child feels that the teacher feels warmly towards her and that the teacher be encouraging with comments such as, “Well, this morning did not go well since you pushed Jacob, but let’s try this afternoon to have no angry touching.  I know you can do it!”

4.  It is essential that the teacher comment positively at unexpected on times regarding good behavior.  “Catching” an ADHD child being good and complementing her will help tremendously in terms of increasing the positive behavior and the child’s interest in complying.   It will keep the child motivated to succeed.

5.  Keep close communication with parents without a negative overtone.  So many times parents come to pick up their children and the teacher starts to run down a full list of negative behaviors the ADHD child had during the day.  A simple, “She had a tough day today, but tomorrow will be better!”   Negative comments should be written in a note or discussed over the phone and not in the presence of the ADHD child who will feel confused and sad to hear his teacher convey negative comments.  Frequent negative remarks from a preschool teacher often result in school anxiety and worsening of ADHD symptoms.

6. A preschool teacher might ask for a professional behavioral consultant to come and help make a behavioral plan for an ADHD child.   This might be a psychologist that works in the school or the community.

7. The teacher should keep the class feeling positively towards an ADHD child.  Often the other children in the class feel negatively towards a child that hits and gets reprimanded by the teacher. When an ADHD child has a good day, the teacher can say to the class, “Let’s all cheer for Jane since she had a great day with no angry hands touching!”

8. Give intermittent and unexpected rewards.  If an ADHD child has a good morning, for example, perhaps she can be the line leader to recess or pass out the snacks.  Compliments and positive reinforcement are the best ways to increase good behaviors.

9. Make the ADHD child feel special.  Often days are full of frustrations for ADHD children since they can elicit so many negative interactions from other children and teachers (as well as parents).   Parents frequently report that 90% of their verbal interactions with their ADHD child is negative.  A preschool teacher should be sure to give the ADHD child a special hug in the mornings and special compliments when the child does something well.  The teacher should make an effort to recognize something in which the child excels such as art, athletics, helping, etc.  Increasing an ADHD child’s confidence will decrease anxiety, frustration and improve her behavior.

10.  Avoid telling parents that you feel the child has ADHD and definitely do not mention the possibility of medications. Most parents feel upset when a teacher suggests a medical diagnosis and even more upset when a teacher suggests that the parents begin medication.  Even though the experienced preschool teacher will likely recognize ADHD, most parents appreciate a discussion of the symptoms with a suggestion to discuss it with a pediatrician.

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Part 2 of our interview with child neurologist Dr. Sara J. Dorison details the important aspects of managing ADHD in the preschool setting.

OwnADaycare: What are the symptoms of ADHD in preschool children?

Dr. Dorison: Preschool children with ADHD often have difficulty sitting still during story reading (“happy circle”), finishing little projects and waiting their turns.  Often they have low frustration tolerance which can lead to impulsive aggression.  For example, an ADHD child is more likely to push another child when that child grabs for a toy.   Due to impulsivity, many children with ADHD have a hard time following the rules.   Often it is hard for the ADHD child to “keep his hands to himself” since impulsivity is such a prominent feature.   Transitions such as going from the playground to the classroom can be difficult for them and they have a great deal of difficulty waiting quietly.   They might have difficulty learning their letters since paying attention in class is hard for them.   Low frustration tolerance can lead to tantrums.

OwnADaycare: What can parents or early childhood educators do if they suspect children are exhibiting ADHD behaviors?

Dr. Dorison: Parents must educate themselves and seek professional advice.  Reading about ADHD is very helpful so that parents can see whether their child indeed meets the typical profile of an ADHD child.  Pediatricians are generally able to guide parents in the right direction which is often towards a psychologist, child neurologist or child psychiatrist.  In general, a preschool child with ADHD does not need medication.  They can be helped significantly with behavioral management techniques that stress consistency, positive reinforcement and encouragement.  They must be given adequate exercise and reasonable expectations should be set.  An ADHD child might not be able to sit quietly so teachers and parents must tolerate a degree of fidgetiness. A preschool child that suffers severe ADHD where the impulsivity is dangerous (running in parking lots, running across the street, climbing onto the cooktop, jumping from high places) or where aggression is a prominent feature (hitting other children),might need medication.

Parents must be careful when consulting professionals to seek those who know about ADHD.  Many young children with ADHD are incorrectly diagnosed with Oppositional Defiant Disorder (ODD) and Bipolar Disorder.  Incorrect diagnosis can lead to damaging labeling of children and inappropriate use of medication.

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Our interview with child neurologist Dr. Sara J. Dorison details the important aspects of ADHD in the preschool setting.

OwnADaycare: What is ADHD?

Dr. Dorison: Attention Deficit Hyperactivity Disorder is a syndrome characterized by the presence of clinically significant levels of hyperactivity, impulsivity, disorganization, difficulty staying on task, short attention span, and difficulty waiting on line, interrupting, and low frustration tolerance. The diagnosis is based on the DSM-IV criteria which outline the criteria necessary to make the diagnosis.  It is felt to be present in about 5% of children.

OwnADaycare: How is ADHD diagnosed?

Dr. Dorison: ADHD is a clinical diagnosis and is made by taking an appropriate history and physical examination of the child and their behavior.  Unfortunately, there is no blood test, genetic testing, brain wave test or brain imaging test that can currently make the diagnosis.  The diagnosis is often made with the assistance of psychoeducational testing, or with a clinical interview, generally with a child psychiatrist or child neurologist.  The clinical features must be present in at least two settings and over a period of time.   Often doctors or psychologists use the Connor Rating Scales which ask parents and teachers to fill out forms regarding behaviors.   It is important to rule out other disorders that can present similarly in a young child.  These include Asperger Syndrome, Developmental Delay, Pervasive Developmental Disorder, Autism, deafness, lead poisoning and severe anxiety.

OwnADaycare: Many times, diagnosis of ADHD comes sometime after the age of 6. Can you please explain why? In other words, why is early diagnosis difficult and when is the earliest that a child can be diagnosed with ADHD?

Dr. Dorison: Toddlers and very young children normally exhibit many of the features of ADHD.   Two year olds, for example, are impulsive and disorganized.  They can’t sit for an hour listening to a lesson.  So, it is difficult to discern whether a young child has a “normal” amount of impulsivity or disorganization or a clinically significant amount of these features.   Over time, however, children without ADHD mature and gain more control in these areas and the ADHD children are left behind in terms of their difficulty with their symptoms.   As their peers mature, children with ADHD generally become more obvious to both the teachers and the parents.   Also, as the academic demands of school increase, children with ADHD often begin to lag behind their peers and not perform to their potential.

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Children may cry and cling to parents at daycare center drop-off time, need a carry a security item throughout the day, and/or cry at pick up time. Separation anxiety typically peaks between the ages of 12 months and two years.

Our interview with Dr. Shannon Ayers, assistant research professor at the National Institute for Early Education Research, discusses the issue of separation anxiety in the daycare and preschool setting.

OwnADaycare: Can you define separation anxiety in preschool aged children and some of its characteristics? At what age range is separation anxiety most common?

Dr. Ayers: Separation anxiety is at its highest intensity between 6 months and 3 years.  It is when the child’s relationship with their caregiver has become more intense and exclusive.   Resistance to separation occurs, but the child should exhibit happiness upon reunion.  With preschool children, they are beginning to understand other persons’ intentions and can often cognitively understand that a parent will return.  It is reassurance that this will occur that is important as the child struggles and that this plan is followed through consistently to build trust.  For example, a parent should not suggest that she will pick the child up after snack and then get held up and not come until after rest time.   A child may feel anxious, nervous, and/or scared about the new environment and fear being alone.  Over time, with appropriate interventions and environment, this fear should become less intense.  However the child may have some relapses such as when he or she is sick, tired, after a vacation, or if there is a big change in the family like a new sibling or a move.

OwnADaycare: What is the difference between separation anxiety and separation anxiety disorder?

Dr. Ayers: I see the separation anxiety as a part of normal development for some children (not all children experience separation anxiety and there are varying degrees as well).  I believe that it will decrease in intensity and duration over time with appropriate intervention and environment.  The child should be able to be consoled.  However, depending on age, a disorder is more intense, prolonged, and the child may not be able to be consoled.

OwnADaycare: What are some factors that contribute to separation anxiety? What factors can reduce separation anxiety?

Dr. Ayers: Separation anxiety can be heightened because of a parent’s anxiety and/or reaction to leaving the child at preschool.  A parent should remain positive and upbeat about the experience.  If a parent is expressing anxiety about the situation the teacher should talk with the parent about his or her fears.

Concern for the unknown may also heighten separation anxiety and can be lessened by visiting the school and role playing the routines/schedule at home.   Post pictures of the children’s families in the room and encourage the children to talk about their families so they stay connected.

Young children do not understand time the way adults do so although they may understand that the parent is coming back, when may be a question.  The parent can practice leaving for short times and build up longer intervals so the child begins to feel confident in the return of the parent.  Also see the suggestion below about posting the schedule.

OwnADaycare: Can you provide a few tips to help preschool teachers or daycare providers manage separation anxiety in their students?

Dr. Ayers:

• Visitation assists children and parents with the unknown.  There should be a day where the child can meet the teacher and get to know the surroundings.  This should be done with the parent and in a relatively short amount of time.

• Encourage parents to establish a goodbye ritual and stick to it.  It should be something relatively quick like a special hug/kiss combination, secret handshake, or unique/silly exchange of words (i.e. see you later alligator, in a while crocodile).

• Following a schedule is also helpful.  The teacher should have the schedule posted in pictures and words for the children so they know what is coming next and can see when their parent will be coming to pick them up.  For instance, if a child knows that after lunch she hears a story, takes a rest, has a snack, plays around the room, sings a song and then her mommy comes it makes it much easier to move through the day.
• Teachers must respect the child’s feelings when he or she is missing the parent.  The teacher does not ever want to criticize the child’s feelings or label them as baby-ish or wrong.  Also, bribing the child is not good practice.  It is not a good choice to offer a reward (or punishment!)  in return for the child’s behavior during separation.
• Engagement in an activity, project or play scenario is also important for the struggling child.  The teacher should work with the child to enter play with other children, offer to paint together, or go to the dramatic play area where the child can engage in pretend play.  The child may choose to “phone” her mom or dad on the pretend phone and express his or her feelings.
• Read comforting stories such as The Kissing Hand by Audrey Penn to the whole class, small group, or one-on-one.
• Teachers and parents should be consistent in their approach.  Overall, the teacher wants to provide a sense of warmth and caring while encouraging independence.

OwnADaycare: What are some suggestions for preschool teachers or daycare providers for dealing with anxious parents?

Dr. Ayers: Communication with parents is key.  Parents should be aware of what their child will be doing during the day, what is expected of both them and their child, and should be given written information about the procedures and policies of the school.  Parents should also be invited and encouraged to visit the classroom for various reasons including reading a story, helping with a special snack, and/or sharing a special family or cultural ritual.   An additional support for a particularly anxious parent or the parent of a child that did not separate easily is to phone the parent shortly after the day begins to provide an update.  It is reassuring to hear, “Allison has stopped crying and is busy playing in the blocks.”

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Q: Is thumb sucking harmful for children?

A: Thumb sucking can be bad for children. Children who continue to suck their thumb may have dental problems.  Their teeth may be pushed outward or be poorly aligned which is called malocclusion.  The longer thumb sucking persists, the greater likelihood the child will need orthodontic treatment to fix the teeth.  Some children may have difficulty talking who have prolonged thumb sucking.  Some children may get skin infections of their thumb from thumb sucking.

Q: Are there any benefits to thumb sucking?

A: Thumb sucking helps babies soothe and comfort themselves when they are tired, scared, hungry, or even bored.

Q: How can I get my child to stop sucking his or her thumb?

A: After age 4-5 years old, it’s appropriate for parents to set limits about thumb sucking such when and where children are allowed to suck their thumb.

• Show your child in a mirror what she looks like when she sucks her thumb.
• Offer ways to distract your child during the day to keep his hands busy like doing crafts, drawing, coloring, or puzzles.
• Praise your child for not sucking her thumb! Setting up a sticker chart or other reward system for not thumb-sucking can be beneficial.

• Putting a bandage on the thumb can also help make the child stop sucking his thumb

Q: What about pacifiers? Are they harmful or beneficial and when should a child stop using a pacifier?

A: Pacifier use like thumb sucking also is beneficial helping babies soothe themselves.  Pacifier use has also been shown to reduce the risk of Sudden Infant Death Syndrome.   However, pacifier use is linked to an increase risk of ear infections and continued use can cause dental problems such as malocclusion which is seen with thumb sucking as well.

Q: What can parents do to help wean a child off of their pacifier once they become too old for it?

A: Initially limit the pacifier to naps, bedtime, and stressful situations.  Then limit the pacifier to only in bed.  Then get rid of it completely!  (This is usually the toughest step!!)  Parents need to be ready to put up with a struggle and a crying child for a few nights with this.  Usually a few nights is all it takes.  When parents start this, they should make sure they collect all the pacifiers around the house.  Sometimes kids hide them in toys and various places so parents shouldn’t be surprised if they find their child with a pacifier while playing later!

These tips should work well at home and at child daycare centers.

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