Attention Deficit Hyperactivity Disorder (ADHD) manifests with symptoms of inattentiveness, hyperactivity and impulsivity, in varying combinations, and affects around five percent of the school-going population. Due to the pervasive nature of these symptoms in childhood, the diagnosis cannot be made unless there is significant functional impairment associated with the symptoms. Academic underachievement is perhaps the most obvious area of impairment cited, but in many cases it is the domain of social functioning which causes the most distress to the child. This article will focus on the impact of ADHD on peer relationships.
Children with ADHD are often gregarious and may have little or no difficulty initiating friendships, but over time they often have difficulties maintaining these relationships. Excessive impulsivity causes children to lash out physically and blurt out verbally. This is especially true of children with the combined subtype of ADHD, more common in boys, who present with significant hyperactivity and impulsivity. The normal ‘filter’ which assists in restraining impulses is inadequately developed in these children. They battle to take turns in games and their over-exuberance and excitability result in excessively rough play and an inability to know ‘when to stop.’ Without necessarily intending to be malicious or hurtful, hyperactive children easily become labelled as bullies, by both peers and teachers. In the preschool years it is often this impulsive aggression which causes the most impairment and can jeopardise a child’s school placement. They thus often become ostracised, which further erodes self-esteem and a vicious cycle ensues with ever-increasing desperate attempts to win approval.
The inattentive subtype of ADHD tends to be commoner in girls. In this subtype the prevailing symptoms are those of inattentiveness, without excessive hyperactivity or impulsivity. These children tend to have fewer social problems, but as a group they are by no means unaffected in this area. They struggle to maintain concentration whilst listening to their peers and thus often miss out on aspects of conversations, for example when the rules of a game are explained. There is also a growing body of research revealing more subtle social skills deficits in ADHD, for example recognising facial expressions and tone of voice. Taken together, these deficits leave the child and her peers frustrated and also result in alienation from the group. In addition, academic underachievement itself can impact on a child’s social standing; if she is always the last one finished she is less likely to be chosen for group activities and again can be excluded as a result.
ADHD commonly co-exists with other conditions, which are often themselves associated with difficulties forming and maintaining friendships. Depression, anxiety disorders, Autistic Spectrum Disorder and Oppositional Defiant Disorder may all co-occur with ADHD may all be more socially impairing than ADHD itself.
The quality of peer relationships is thus of paramount importance in assessing a child for ADHD, but is also a very important target symptom in planning and monitoring treatment. After initiation of pharmacological and/or behavioural treatment, social functioning usually improves along with the core ADHD symptoms of inattentiveness, hyperactivity and impulsivity; if it doesn’t we must question the effectiveness of our treatment. In fact, certain children become excessively quiet and subdued on ADHD medications and may be socially worse off than before the treatment, even if their academic functioning has improved. It is thus very important to monitor for this side-effect and take appropriate action, which might entail changing the dosage or switching the medication.
There are some interesting findings on self-esteem in ADHD. There is evidence that self-esteem is inherently low in those with the condition, and not exclusively mediated by repeated negative feedback. This may at least partly explain the correlation between ADHD and depression. Nonetheless, a child’s self-concept is a very helpful barometer in assessing the effectiveness of treatment of this condition, and whilst improved academic functioning is certainly important, it is often the quality of relationships – positive feedback from those at home and at school – which play a more decisive role in a boosting a developing child’s self-confidence and self-esteem.
Dr Brendan Belsham is a child psychiatrist and author of What’s the fuss about ADHD?
Last time I wrote about the harmful effects of excessive electronics on childhood development. That was the easy part. What follows is much easier said than done, but hopefully it will provide you with some tools for dealing with this problem in your home.
As mentioned previously infants and toddlers are especially vulnerable to the damaging effects of excessive screen time. And it is very easy to slip into the habit of using screens as babysitters from an early age. Too much sugar and salt in the diet will ruin a child’s appreciation for good food. In the same way, early and excessive exposure to electronic devices will interfere with her appreciation for the better things in life. This takes an investment of effort and time from an early age, but later on you (and your children) will reap the rewards.
Lead by example
We cannot expect a standard of behaviour from our children beyond what we ourselves have attained. This is true for any behaviour, from picking up clothes off the floor, to punctuality, to the language we use, and yes, to our propensity to live in front of a screen. You may not be playing Minecraft, and you may rationalise it in various ways (‘It’s work, sweetie’), but your children are observing you all the time, and they learn more from what you do than from what you say. Your child needs to see that you are more interested in finding out about his day at school than your Facebook page. It is up to us as parents to create the culture we desire in our homes. We need to model to our children a lifestyle which prioritises the right things. In my family that includes spiritual growth, relationships, conversation, schoolwork, a love for nature, exercise and reading. Maybe your list is different, but have you articulated that list for your family? Perhaps a starting point is to do just that, and spend some time reflecting on how your own lifestyle matches up to those priorities.
Pay special attention to the holidays
It is natural to relax one’s parenting guard in the holidays, and who can blame you? You are also exhausted, and of course there’s cricket to watch. But childhood development doesn’t stop when school breaks up. On the contrary, there is compelling research which suggests that what happens on vacation is actually very important, cognitively and in every other way. We need to be intentional about how the holidays are spent. Endless hours on YouTube is not healthy for children even if there’s no homework to do. Of course we need to relax in the holidays, but rest doesn’t have to be mindless, for adults or children. How about having a mini family meeting each evening to discuss the following day? Each person gets a turn to choose from a reasonable list of activities. Even if there’s only one item planned daily, at least it punctuates the day with something wholesome.
Many parents need to continue working in the holidays, and are not readily available to supervise how their children’s time is spent. Here are a few suggestions:
- Enrol your child in a holiday programme. There are many excellent camps and sports clinics offered in the holidays.
- Enlist the help of grandparents or other family members. Sometimes they just need to be asked, and this quality time is beneficial for both the younger and older generations. Even your neighbours and friends can help. As the saying goes, ‘It takes a village to raise a child.’
- Join the local library. This often-neglected community resource is affordable, lots of fun and good for your child’s development.
- If you have home help, be intentional about communicating your expectations for the children to them. It is more important that the children are properly supervised than the shirts are ironed.
- Where possible, take a child to work. With a little planning, this can be a highly stimulating and educational experience for your child. It is also excellent parent-child quality time.
‘Doctor, how much screen time is appropriate for my child?’
As you can imagine, this is one of the more commonly asked questions in my practice these days. Of course this will depend on the age of the child their particular circumstances. Children under the age of two should not watch screens at all. Thereafter there should be a gradual relaxing of limits, commensurate with the increasing maturity of the child and with their increasing ability to make wise choices for themselves. For what it’s worth, here are my rules:
- No electronic devices in bedrooms. They are bad for sleep and also difficult to supervise if they are not in more communal spaces.
- A smart phone is a privilege, not a right, and even a teenager should understand that having one is subject to random parental checks.
- No electronics at mealtimes. The TV should be off and the phones put away. It is very important for families to spend at least one meal a week all together around the table, talking and making eye contact.
- Weekends: Not more than three or four hours, including family TV time. Of course this also depends on the day and on other priorities. Screen time should not be first thing in the morning; other things must get done first, including chores, exercise, family activities and the like. In this way, electronics can be used as an incentive, and a very useful one at that!
- Weekdays: Ideally nothing at all, but one hour at the most, subject to other tasks being done. Of course, the problem with a set time limit is sticking to it. Your child won’t, I promise, so you have to. You will have to set a timer, and monitor it, in the midst of your cooking, supervising the younger one’s homework and fetching the older one from ballet. Good luck with that…
Proactive versus reactive parenting
But there is a better way. If we focus our attention on the good stuff, and if from the very outset we are intentional about creating the right culture in our homes, then we will have less need to enforce rules in a legalistic manner. I firmly believe that playing board games, healthy conversation and outdoor activity is actually more fun than Pixel Gun, but as with many worthwhile pursuits, these are acquired tastes and have to be practised. When we first started taking family walks in the park, our children complained and grumbled. It was almost not worth it. Almost. But now we have created a family culture of walking on a Sunday afternoon, and (by and large) the kids actually enjoy it. Society needs rules, and so does every home. As with many aspects of parenting, it is easy to default to Thou shalt not… but when the better activity is more fun and more enticing than the prohibited one, the rules fade into the background. This is what we need to aspire to as parents. As with anything worthwhile, it takes planning, active engagement and, at times, downright hard work, but as with anything of value, it’s worth the effort!
Brendan Belsham MD is a child psychiatrist and writer. His book, What’s the fuss about ADHD? is available through Amazon (click here).
When I returned to work last Monday after the December holidays, I expected a fairly quiet, uneventful week. After all, the kids haven’t returned to school yet, many parents are still on leave, and the average home is relaxed and happy. Right?
Wrong, very wrong. It seems that many families have not had the happiest of times. Of course there can be many reasons for this, but the theme of my first consulting week of 2016 has been the scourge of electronic screens. One parent after the other has lamented the ongoing battle to keep their kids away from the iPad and/or computer, and engaged in more constructive activities. When limits are set, temper tantrums ensue, sometimes even involving physical violence. It’s often just easier to take the path of least resistance for the sake of peace in the home.
But what’s the big deal about screens anyway? If it keeps them happy (and out of our hair) why not let them play to their hearts’ content? Many parents intuitively know that it’s unhealthy for their children to spend hours on end in front of a screen, but here are five ways in which excessive screen exposure is impacting on your child’s development.
1. Gaming is addictive
If you don’t believe me, then consider the hallmark features of any addiction:
- you need more and more of it;
- you neglect other areas of your life to pursue it;
- when you can’t have it, you experience depression and anxiety (South Africans, think load-shedding);
- you battle to think of anything besides it.
Convinced yet? Scientific studies have also demonstrated that electronic gaming activates the same area of the brain (the nucleus accumbens, also known as the reward centre) as drugs of abuse such as cocaine. And internationally there is a burgeoning number of rehabilitation clinics specialising in internet and gaming addiction.
2. Electronic exploits produce a false sense of achievement.
This holiday my 8-year-old discovered Pixel Gun, which he played through my facebook account. I know this because, having recently looked at my page after some absence, I discovered to my surprise that I have been proudly broadcasting my Pixel Gun achievements to all and sundry. Contrast this rather hollow achievement with same 8-year-old’s experience at Acrobranch, an outdoor adventure centre involving zip lines and obstacle courses. His sense of achievement having conquered his fear and successfully negotiated this real life challenge was palpably different to that produced by any kind of virtual success. I just hope he remembers the feeling.
3. Screen time impacts on sleep
These days it has become commonplace for children to have TV’s, smart phones and tablets in their bedrooms. There is ample evidence from studies that the light emitted from these devices interferes with the physiology of sleep. Melatonin, a naturally-produced hormone which facilitates the onset of sleep, is suppressed by this light and insomnia is often the result. We then sometimes end up with the ludicrous situation of a child taking melatonin tablets to help overcome the melatonin suppression induced by Minecraft!
4. Excessive electronics makes kids moody
Have you noticed this? If the game is going well, there is no problem, but as soon as things go wrong, there is wailing and gnashing of teeth. Gaming seems to induce irritability in even the most placid children. These emotional effects are especially pronounced in the immediate aftermath of a screen session, where kids are moody, defiant and lash out at each other. They also complain of being perpetually bored with ‘nothing to do.’ The brain’s reward centre has been ‘spoilt’ by a glut of stimulation, and nothing else can fill the void. In children who are otherwise prone to depression or other mood disorders, this can be a recipe for disaster.
5. Time on the tablet is time lost to other activities.
This is what might be referred to as the opportunity cost of screen time. Even if one argues that electronic devices are innocuous in themselves, what about all the other things the child should be experiencing, learning and practising? Yes, even in the holidays. This is especially true for infants and toddlers, who are increasingly being given unbridled access to tablets or TV. These devices too easily become surrogate babysitters. In children as young as this, screen time interferes with attachment, the crucial developmental process by which children form secure emotional bonds with their mothers and fathers. Healthy attachment requires sufficient eye contact, physical touch, quality time and mother-tongue language stimulation. For all their other qualities, Barney and Bob the Builder can’t provide this!
Part two of this blog will suggest a ‘game plan’ for parents to deal with screens in the home.
Dr Brendan Belsham is a child psychiatrist and writer. His book, What’s the fuss about ADHD? is available through Amazon (click here).