Monday, March 10, 2014

Developing a Brain Filter How to Help Highly Impulsive Children and Teens Stop and Think Before Acting

HAVE YOU EVER MET A KID WHO LACKS A BRAIN FILTER? Usually, for such children, whatever is on their mind quickly comes out of their mouth with little or no regard for who is listening and who might be hurt by their cutting words. They often do things with little thought about the possible consequences of their actions. The inability to think before acting and to stop unproductive behaviors often plays a critical role in the lives of children and teens with ADHD. Poor response inhibition is one of the most difficult of the ADHD difficulties to address.

Three years ago, I met a fourteen-year-old with severe ADHD whose brain filter was like a flimsy butterfly net with holes big enough to drive a semi-truck through. At the time, Samuel was obsessed with online shooter games. During their second appointment, his mom handed me Sam’s English/Language Arts journal, which had a picture of a gun and bright red blotches drawn on the outside and on the inside included a number of gory detailed references to his most recent escapades while playing these games. Needless to say, Sam’s teachers were (appropriately) distraught. His principal had told his mom that one more incident like this would result in Sam’s being asked to leave the private school he attended.
Despite the huge lump in my throat, I managed to say something like, "The good news is we can help Sam improve his brain filter, but here’s the bad news: Addressing this most difficult of ADHD difficulties is going to require some patience and effort on your part and on the part of Sam’s educators." In other words, I was saying that this is not going to be a quick-fix!
Ask for help at school
By meeting with and collaborating with his educators, Sam’s mom and I were able to buy him some time: We helped his principal and teachers recognize that it takes time and effort to build self-awareness, develop strategies, rehearse alternative responses, cue appropriate reactions, rehearse, cue, rehearse, cue, and rehearse some more to develop improved impulse control. One of the best things you can do to help your child is meet with her educators to discuss how you will work together to meet specific needs in the classroom.
First, ask her educators to consider ways to increase external controls in the classroom. Initially, it may be helpful to ask her teachers to try to limit your child’s access to situations where she usually gets in trouble due to impulsivity. Educators can also encourage self-control through the physical presence of an adult nearby and reminders to use the strategies she has been taught to utilize in challenging situations.
Next, work with your child and her educators to select an alternative behavior for each of her usual impulsive responses by making sure it meets the same need. Practice using these replacement actions to improve her chances of success.
Finally, ask her educators to quickly reinforce your student for using the alternative behavior in the classroom. For example, we showed Sam that he could get better attention from his teacher if he wrote about anything but computer games. We brainstormed and developed a long list of ideas he could write about. His teacher helped reinforce his use of these alternative topics by commenting positively on anything he wrote about besides computer games, regardless of the quality of his journal entries.
If necessary, talk to your child’s educators about using a daily report card system to communicate with you on a regular basis regarding her most important needs. Use of this system allows you to reinforce every attempt your child makes to improve her impulsivity, and is detailed on the National Initiative for Children’s Healthcare Quality (NICHQ) website.
Develop awareness of ADHD and impulsivity
To help your child or teen with impulsivity, it is first important for him to know that all humans have impulses and temptations—there is no embarrassment in this. Impulsivity becomes a problem, however, when we act on our impulses without thinking and we or someone else gets hurt. It is imperative that your child knows that learning to control his impulses is a necessity in order to avoid a whole list of possible predicaments including losing friends, losing a job, serving time in detention, or serving time in jail, just to name a few.
Next, it is important that your child or teen understands why he or she has problems with impulsivity. Specifically, response inhibition centers in the frontal lobe and parts of the limbic system of the brain often fail to help even the smartest people to stop and think before acting or speaking. Knowing this helps your child understand that you understand that she is not purposely being oppositional or defiant. But you can’t just stop here; otherwise, you may unwittingly allow your child to turn her ADHD into an excuse or a crutch for her impulsiveness. When I talk to kids with ADHD about this and other common executive functioning challenges, I explain to them that, even though they did not cause the chemistry in their brain that causes impulsivity, they can and they must take responsibility for developing skills to reduce their impulsive responses.
Once your child understands that he did not cause his poor response inhibition, and that he can learn strategies to help better control his reactions, he is less likely to be hard on himself about this most difficult of ADHD difficulties, and he is more willing to start working toward improving his impulsivity.
Develop self-awareness
Developing self-awareness is a crucial first step toward self-control, so it is vitally important to try to identify the situations that lead to your child’s impulsive acting before thinking. For younger children, you may need to keep an impulsivity log at home, and you may need to ask his teacher for input about the circumstances that most often lead to problems at school. It’s important to identify when your child or teen is most likely to be impulsive, who else is around, what is happening, and what he is thinking and feeling right before he acts impulsively.
With some prompting, many tweens and most teens can easily identify the circumstances that cause them to get into trouble because of impulsivity. These situations often involve open-ended activities with very little structure, competitive events, holidays, interactions with older teens, interactions with abrasive adults, or activities undertaken when he or she is overtired, overstimulated, or overwhelmed.
On the other side of the self-awareness coin, impulsive children and teens struggle to learn from their experiences due to inconsistent recognition of the effects of their behavior on themselves and others. Therefore, it is essential to discuss what happens after they have acted impulsively—not to shame or blame them, but to help them learn to recognize the benefits of stopping their impulsive acts. Remind your child that the effects of impulsivity can include hurting someone’s feelings, hurting someone physically, destroying someone’s property, or hurting themselves.
Once you have identified some specific situations that cause your child or teen to act before thinking, then it’s time to start teaching him how to STOP, THINK, and then GO instead of his typical immediate response of GO, THINK, and then STOP.
Use a STOP-THINK-GO strategy
First, think about the situations you and your child identified as a result of your discussion about the cause and effect of her impulsivity. Use these to practice stopping and thinking before acting.
Next, teach your child how to STOP before acting on impulse. It’s important to know that saying, "Stop!" usually does not work, no matter how many times or how loudly you say it! Agree to a "key word" or phrase you can use to help your child or teen stop: often, the funnier the better so that you can quickly deflate any anger or other negative emotions involved. Over time, with practice and cueing, your child or teen can learn to stop herself before acting.
After your child stops, then she needs to THINK about her possible actions. Teach her to ask herself two simple questions:
 "Is it going to hurt anyone?"
 "Is it going to hurt me?"
It is crucial to make sure your child understands that "hurt" can include physical, emotional, and social injuries.
Finally, she should GO with the best choice. Once she has learned to stop and ask herself these questions, it becomes much easier to make good decisions. Encourage your child to tell someone and celebrate when she makes good choices. Similarly, urge her to ask someone, "How could I make a better choice next time?" in order to learn from her mistakes.
It can be helpful to role-play this process using real-life situations. On a weekly basis, it may be useful to talk about possible responses to any upcoming challenges that could cause your child to act impulsively.
Make a plan, set a goal, and take daily action
For situations that cause your child to respond impulsively, it is important to make a plan. For example, the teenager who impulsively loses his temper whenever he is tired needs to learn how to monitor his energy level, get some rest when necessary, and, in the meantime, use the STOP-THINK-GO procedure so no one gets hurt.
Next, you and your child should set a realistic and measurable goal to implement the plans you’ve made. First, it is important that you and she recognize that no one is perfect. An appropriate goal might be stated, "At least 75 percent of the time when I am faced with an impulse, I will reduce my response of acting before thinking and replace it with the strategies I have learned."
A critical part of the goal-setting process involves identifying the benefits of decreasing impulsive responding: recognizing these potential gains keeps the child or teen striving toward their goal when the going gets tough. Benefits of improved response inhibition are typically the opposite of the negative effects your child has suffered due to poor impulse control, and could include fewer notes sent home for talking out in class, less arguing with parents, and better relationships with friends.
Next, it is especially important for your child or teen to identify those who can help her reach her goal: parents, teachers, counselors, and/or an ADHD coach are typically good candidates. To avoid a problem turning into a complete disaster, it’s crucial for your child or teen to agree to how and when these individuals will assist her: If a helper does something unexpected when she is impulsive, the fall-out could quickly spiral out of control.
Finally, you, your child, and his educators must take daily action to implement the plan. It is important to remind everyone that making this life-altering change takes effort. Know that she will make mistakes and missteps along the way, and encourage her to learn from her errors rather than beat herself up over them. Remind her often of her goal and the benefits. Evaluate her progress on a regular basis, and solve problems as needed. It may be helpful to keep track of her progress in some visual way to encourage her continued enthusiastic participation in the process.
 The STOP-THINK-GO Strategy
Discuss with your child the cause and effect of impulsivity and identify situations in which he or she acts impulsively. Use these to practice stopping and thinking before acting. Teach your child to:
STOP before acting on impulse. You might agree upon a key word or phrase, the funnier the better, to quickly deflate any anger or other negative emotions involved. THINK about possible actions. After stopping, the child asks him/herself two simple questions:
 Is it going to hurt anyone?
 Is it going to hurt me? GO with the best choice.
by Monte W. Davenport, PhD

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