ADHD Parent Skills Training Manual

PARENT SKILLS TRAINING FOR FAMILIES OF CHILDREN WITH
ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER
Department of Psychiatry,
Postgraduate Institute of Medical Education and Research, Chandigarh, India

PARENT SKILLS TRAINING FOR FAMILIES OF CHILDREN
WITH ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER
Ruchita Shah
Akhilesh Sharma
Sandeep Grover
Diksha Sachdeva
Subho Chakrabarti
Ajit Avasthi
This manual is meant for use by psychiatrists, psychologists and other trained mental health
professionals who serve children with attention-deficit/ hyperactivity disorder (ADHD) and
their families.
Copyright @ Authors
Shah R, Sharma A, Grover S, Sachdeva D, Chakrabarti S, Avasthi A. PARENT SKILLS TRAINING

FOR FAMILIES OF CHILDREN WITH ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER.
Department of Psychiatry, Postgraduate Institute of Medical Education and Research
(Chandigarh), India, 2018
PARENT SKILLS TRAINING FOR FAMILIES OF CHILDREN WITH
ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER
Developed as part of the Departmental project ‘Telepsychiatry enabled

Group Parent Training Intervention for children with Attention Deficit/
Hyperactivity Disorder: A pilot study’
Investigators
Ruchita Shah
Ajit Avasthi
Subho Chakrabarti
Akhilesh Sharma
A note to the Therapists
Skills training not because they lack skills, but because they are
dealing with a difficult situation
Attention-deficit/ hyperactivity disorder (ADHD) affects children and their families in more
than one way. Children have not only difficulties in studies, but the behavioural
manifestations affect their friendships, peer relations and relations with adults in their lives.
Parents and families have to deal not only with the direct manifestations of the disorder, but
also blame, stigma and severe criticism. Parents try disciplining, explaining, advising,
showering love and attention and often keep alternating between these strategies with the
hope that something would work out. Guidance to seek medical help usually comes their way
late in the course. So, when these families finally reach the clinicians, there are ambivalent
perceptions and views regarding need for professional help, guilt and blame, caregiver burn-
out, and often a crisis situation such as suspension from the school.
Before moving any further, it is important to emphasise that many of these parents have
raised another child in the same household who is doing fine. Children’s behaviours often
mould parents’ reactions and then build vicious coercive cycles. Hence, it is imperative on the
part of the clinicians not to blame parents, but to empathise, acknowledge their efforts and
offer help.
Involve extended family

Even when our child resides in a nuclear family, parental perceptions regarding diagnosis and
treatment are often influenced by the extended family. It is common for parents to take
treatment decisions, especially the application/implementing of behavioral strategies jointly
with grandparents and other members of extended family. Also, behavioural management
strategies are dependent upon the consistency shown by all the significant adults in the child’s
life. Behavioral management through parent training may fail, if grandparents who stay in the
same household are not involved pro-actively. Finally, involving other members may mitigate
blame and conflict amongst them.
Structure and flow

This manual shall assist psychiatrists, psychologists and other mental health professionals
providing clinical care to the children having ADHD and their families. This manual describes
parent skills intervention spanning across 10 weekly sessions. It sets out to impart knowledge
and skills to parents and families to deal with the manifestations and dysfunctions associated
with ADHD. This intervention can be provided to a single family or a group of families.
Throughout the manual, the words are phrased in a manner as if a therapist is communicating
with the parents. So, the words ‘you’ and ‘your’ pertain to the parents and not the therapists.
Since this manual aims at providing and enhancing skills, there are exercises during the
sessions such as brain-storming, role playing, etc. and homework assignments between
sessions for parents to practice those skills.
The chapters are sequenced to cover psychoeducation followed by environmental modifications

to enhance the performance or reduce problematic behaviors, and later the core behavioural
strategies are described. Towards the end, strategies to deal with problematic behaviours in
public places and for establishing liaison with teachers are outlined. However, depending
upon the individual’s needs and priorities, the therapist can alter the sequence and also
emphasise on certain sections more than others. For milder severity of symptoms, psycho-
education and environmental modifications alone may suffice. Attention enhancing tasks
outlined in the appendix are not part of parent skills enhancement, but these exercises for
the children may be of some benefit.
Many a times, parents are already quite stressed and some of them themselves have
symptoms of ADHD making it difficult for them to participate. Also, some parents over-
generalise or try to implement the same skill across many behaviors at once and feel
frustrated as such efforts invariably fail. Help parents choose a few target behaviors to start
with, practice the same, and then continue or modify the same as per the outcomes.
practising their skills. Also, it is important to tell the parents to keep the expectations from
themselves and the child to be realistic.
Authors
INDEX
TOPIC PAGE NO.
SESSION 1: PSYCHO-EDUCATION 1
SESSION 2: EFFECTIVE COMMUNICATION: 3 Ps AND 4Cs OF 13
PARENTING
SESSION 3: ENVIRONMENTAL MODIFICATIONS (PART I): 23
DEALING WITH HYPERACTIVITY
SESSION 4: ENVIRONMENTAL MODIFICATIONS (PART II): 26
DEALING WITH INATTENTION AND DISORGANISATION
SESSION 5: INCREASING COMPLIANCE 30
SESSION 6: PARENT-MEDIATED NEURO-COGNITIVE 35
TRAINING
SESSION 7: HOME POINT (TOKEN ECONOMY) SYSTEM 56
SESSION 8: PENALTY OR RESPONSE COST AND TIME –OUT 64
SESSION 9: ANTICIPATING AND PREPARING IN ADVANCE 70
SESSION 10: LIAISING WITH THE SCHOOL 72
APPENDIX 1: Problem Behavior Chart 74
APPENDIX 2: Sample ready-to-use Earning menu Chart 75
APPENDIX 3: Sample letter for communication to the 76
School
APPENDIX 4: How teachers can help a child with ADHD? 77
Some reading resources & Bibliography 78
SESSION 1
PSYCHO-EDUCATION
For therapist: Before you start with psychoeducation, ask parents about their understanding
about the child’s problems, what they think has caused these problems, what in their opinion
will benefit their child or will harm their child?
Remember that some of these parents may themselves have symptoms of ADHD, and the
family may need individualised intervention.
What is Attention-Deficit/ Hyperactivity Disorder (ADHD)?

Attention-Deficit/ Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD) is a
neuro-developmental disorder; i.e. a state arising out of problems in development of the
brain. It affects around 5-7% of children world-wide. The characteristic symptoms of ADHD
are difficulties in attention and organisation, excessive amount of activity (hyperactivity,
difficulty in sitting still for long) and a tendency to ‘act without thinking’, also called
impulsivity. The central problem is that of a difficulty in inhibiting responses, i.e. poor
behavioural or response inhibition. Hence, these children find it difficult to stop or suppress
themselves when needed. We need such response inhibition to carry out tasks meticulously
without being distracted.
Task to demonstrate role of response inhibition:

Till now, you were reading this (or listening to me in case of the therapist carrying out the
session). Now focus on noises and activities around you. Give about 2 minutes to the
parents to appreciate what is going on around them. Ask them to tell you about it.
You may then tell,
The same level of noises and activities were going on even earlier. However, you were
focused. You did not get distracted by most of it before. And even if you took note of the
door opening and shutting, you were able to get back to what I was saying. So, how did that
happen? Your brain automatically inhibits its response to such extraneous sounds and
sights, and helps you to focus on what you are doing. On the other hand, in case of ADHD,
the brain does not inhibit such responses effectively; hence, the child with ADHD responds
to such distractions and may jump from one distraction to another instead of focusing on
the task at hand.
Such response inhibition is equally important in helping us to plan and organise our day, think
ahead of time and chart our course for future actions. Children with ADHD therefore, have
marked difficulties in carrying out tasks that need sustained attention or in tasks involving
multiple instructions that need sequential execution. They are frequently overactive and
disruptive, without realising that they are being so. It is common for adults to label their
behaviours as deliberate and in need of stricter disciplining.
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The problems related to ADHD are seen mostly since early childhood. However, in milder
cases the child may present at a later age. This usually happens when demands exceed his /
her capacities. Take for example, an adolescent who has to deal with increasingly complex
and lengthy work assignments or has project deadlines.
Symptoms
Difficulty sustaining attention
These children have problems sustaining attention and are easily distractible.
They often fail to pay close attention to details while doing class or schoolwork or any other
work, and make careless mistakes.
They get bored or lose interest much faster than other children.
They have difficulty remaining focused during lectures or lengthy reading, lengthy or boring
conversations, or games that need sustained attention. So, they tend to often leave a boring
or a tedious task incomplete and get onto something that has caught their attention.
Many a times, the child appears to be lost; physically there but mind somewhere else
The child often does not complete his school tasks or other chores (may have started but then
got side-tracked to something else)
Children have difficulty organising and planning. Their rooms may be messy, belongings and
materials often not in place or order, work may be disorganised. They have difficulty
managing time. These children often procrastinate and fail to meet deadlines.
Several times, children with these difficulties avoid work that needs sustained attention or
mental effort (e.g. school/homework)
They are often forgetful and frequently forget to remember important things (e.g. teacher’s
oral instructions, telephone message) and frequently lose their belongings
They seem to be more attracted to rewarding or fun parts of activities.
Their work performance is quite variable and depends on the immediate surroundings,
motivations and rewards.
Difficulty controlling impulses

In addition to being distractible, these children respond immediately to various stimuli in
their environment.
They do not tend to think before acting.
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Often, parents wonder why ‘he does not learn from his past mistakes’. It is so because they
are unable to reflect back in time and modulate their responses. They actually ‘live in the
moment’.
These children prefer immediate, small rewards as compared to delayed bigger rewards. So,
a toffee after some work is preferred over waiting till the end of the day for a pizza.
These children often blurt out answers even before the questions have been completed.
They want to tell their thing first – they cannot wait for their turn. They want to take a ride
on the slide first – may push other children to get ahead, again, because they cannot wait for
their turn.
These children frequently interrupt others or intrude on others. For example, they may butt
into others’ games or activities. They are often disliked by peers because of such impulsive
behaviors.
They may start using others’ things without asking or waiting for permission, such as pencils
or crayons of a classmate.
Overactivity
These children are hyperactive besides being impulsive.
They often fidget with or tap hands; hands are never still is a common complaint
Even while seated, they may squirm a lot or appear restless. They are often considered to be
disturbing by their bench mates and others in the class.
They may often leave seat in situations when remaining seated is expected. For example, the
child may leave his seat, walk across the class to look out of the window or go to a nearby
classmate
They are often quite noisy, described as very talkative
These children frequently run about or climb in situations where it is inappropriate, like at a
relative’s house, in a market or mall or when a relative is visiting the child’s place.
These children often appear as if they are driven by a motor. Parents often feel that they get
exhausted but the child doesn’t feel tired.
They are unable to remain still or quiet for a long time, like in a restaurant or on a road journey
These children find it difficult to modulate their behaviours according to the situational
demands. For example, after a playground break, on returning back to classroom, children
with ADHD do not settle down as easily or quickly as their classmates.
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These problems are quite persistent and are almost always present across different situations
such as in the classroom, on playground, at home or when outside (e.g. market, temple,
relatives’ house). However, the manifestations may change with situations, with these
children doing better in newer situations such as a new academic year or a new teacher. They
may also do well in more structured situations.
Due to these symptoms, these children often perform poorly in their studies, have incomplete
assignments, submit assignments late, need considerable supervision to complete
homework. Their sense of time is poor. Also, due to their disruptive behaviours, they are often
disliked and rejected by peers. Often these behaviours embarrass the parents, who in turn
avoid social situations such as a visit to a relative’s place or attending a wedding ceremony.
This in turn leads to lost opportunities for social development of the child.
Case vignette
A is a 10 year old boy studying in the 4th Class. A’s mother complains that he is always on the
go, runs and jumps about, climbs here and there, and often falls, but just does not stop. He
has hardly played with a game or a toy for more than 5 minutes, frequently dismantled the
whole toy and left it ‘just like that!’ He is very noisy and absolutely disruptive – ‘there is no
calm in the house”. To keep him occupied, his mother often makes him sit in front of the TV.
Left to himself, he does not finish his homework, even if he has started (which is usually after
repeated instructions given in an increasingly threatening tone). This is in stark contrast to his
brother. Of late, he has become very demanding and moody. For the slightest of things, he
throws a tantrum and often blames others for his mistakes. Also, mother thinks that he
deliberately does the opposite of what she would have told him, just to annoy her. So, she
often lets him be, or he starts throwing things.
At school, his teachers often complain that he behaves as if he has not heard her, just does
not pay attention in the class and disturbs other children with his constant naughtiness. He
keeps fiddling with his things and often drops something or the other. He also frequently hits
other children in the class. In the playground, he is good at running, but often falls and injures
himself. He is quite careless about his things and has lost many pencils, erasers & water
bottles since the time he has started schooling. His work is messy as is his almirah. Parents
and teachers find him completely irresponsible.
If my child has ADHD, how can he sit for so long watching videos and playing
mobile games?
This is a frequent question that parents ask of themselves and their doctors. Children with
ADHD may spend hours in front of a screen (smartphone, tablet, television, etc). Videos, video
and mobile games, and several television programs have very rapidly changing stimuli (bright
colours, sounds, images, etc), so child does not need to hold attention for too long on
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something that is monotonous or boring. Also, many of these programs or applications (apps)
are interactive with frequent rewards (for e.g. scoring points while hitting the target).
Some parents often use gadgets to settle the child while they can go on with other household
responsibilities. This calm is however temporary and increases the risk of screen addiction.
Watching programs with violent or aggressive content can increase the risk of aggressive
behaviors.
Excessive time spent on these gadgets can negatively affect capacity to sustain attention on
tasks requiring sustained mental effort or are not very interesting or monotonous for the
child.
So, it is not a good strategy to use screen time for managing hyperactivity or disruptiveness.
Screen time can be used effectively as a reward (See chapter on Home Point system)
He’s just irresponsible and careless. Otherwise how come sometimes he does
his work much better and gets better marks?
Our capacity to sustain attention is not the same all the time, it gets affected by so many
factors. Our concentration is far better when we have slept well, are not tired, the work is
interesting, etc.
Likewise, the attention span and hence the performance of these children also fluctuates to
some extent (though problem of inattention and difficulties with performance are present
more often than not). These children do better when the work is interesting and the child
feels motivated. Attention improves when the workload is manageable, there is one to one
adult supervision, the teaching environment has less distractions, when they receive praise
or tangibles for their work. The attention also fluctuates with fatigue and time of the day
What causes ADHD? Whose fault is it?

Though what exactly causes ADHD is not known, what has been fairly established through
scientific studies is that functioning of the frontal part of brain is affected in this disorder.
There might be no gross abnormalities in the structure (shape and volume) of the brains if
seen on CT scans or MRI. Like many other psychiatric and developmental problems, the
problems are at the level of neuro-chemicals and neural connections between different
regions of the brain. There is increasing volume of research data proving the same.
Also, though no one single factor has been implicated in the genesis of the disorder, a myriad
of genetic and environmental factors have been shown to be related to ADHD.
ADHD can run in many families, though not in all cases. Often siblings or a parent also have
or had symptoms similar to that in the child, though these may not be as severe. Such findings
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implicate heredity as one factor. Just as we inherit certain traits like geniality; self-control or
novelty seeking are other traits that we inherit. Abnormally low or high levels of a certain trait
produce symptoms.
Maternal smoking and alcohol intake, infections and fever during pregnancy, low birth weight
and obstetric complications have all been found to be associated with the risk of ADHD. Lead
(which is often found to be high in certain toys) is another toxin that has been implicated for
development of ADHD.
There has been controversy regarding the role of food preservatives or additives and high
sugar intake; and these seem unlikely to cause ADHD.
However, it is important to understand that it is the combination of the above factors, which
is responsible for symptoms of ADHD, and presence of one or two factors does not always
lead to ADHD.
It is equally important to know what does not cause ADHD. Before scientific studies refuted
the same, it was believed that the problems are simply due to faulty parenting. In other
words, parents were blamed squarely for their child’s behaviours. On the contrary, parents
are often at their wits’ ends to understand and manage their child’s hyperactivity,
carelessness and impulsive behaviours. Parents can in fact, help children mitigate their
difficulties and alter the course of the disorder.
Vitamin deficiencies and general weakness do not cause ADHD. Neither does physical or
sexual abuse per se cause ADHD. Watching excessive TV or playing on mobiles do not cause
the symptoms, but have a definite role in increasing the problems. Bad company does not
cause ADHD, though peers with disruptive behaviours may get together and engage in high
risk behaviours such as use of drugs/alcohol and other substances.
In the end, children with ADHD do not voluntarily or deliberately behave as they do; rather
they are quite unaware of doing so. However, with time in some children with ADHD,
oppositional behaviours do appear, which complicate the picture as much as increase the
difficulties.
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I/ my spouse / grandparents have spoilt the child – Parenting inconsistencies
in the family
As parents and adults, we tend to respond differently to the child’s tantrums at different
times. It is common that a parent lets off the child easily after a bad behavior one day, and on
the next day may harshly scold or punish for something similar or even lesser. Parents’
reactions are frequently based on their own moods, stressors, how tired they are and how
busy they are. So, when a parent is busy with his important work, he gives the smartphone to
the child so that he doesn’t disturb him. After a while, the same parent takes the smartphone
away while reprimanding the child for spending so much time on the internet. These are
inconsistencies that we show in our handling of our children.
Then there are inconsistencies between different adults in the family. Take for example,
father scolds the child for disturbing others, while the grandmother sides with the child. One
family member advises the other on how to handle the child’s tantrums. On several occasions,
it is helpful, and mitigates extreme harshness from one adult. However, it is also possible that
adults argue or discuss about how to handle the child in his presence.
In any case -
Remember the motive of all members is still the same – get the best behavior from the child!
In case a child has ADHD, parents and other members of the family are constantly struggling
to handle the disruptive behaviors. In such a scenario, the inconsistencies can become more
marked. When there are inconsistencies in handling the bad behaviors, the chances that
those behaviors increase in frequency and severity is much higher.
The impulsivity and overactivity of ADHD are not deliberate, but parenting consistencies can
help the child manage the symptoms. Moreover, parenting inconsistencies can lead to
development of defiance and severe behavioral problems beyond that seen in ADHD. The
opposite is true if parents’ (and other family members’) responses are more or less consistent
over time and between each other.
He is like this because our home environment is very disturbed.

Family or marital problems do not cause ADHD, but can worsen the course of ADHD. Just like
parenting inconsistencies can worsen behavioral problems in any child, and especially a child
having ADHD; disturbed home environment can increase severe behavioral problems.
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ADHD is a brain developmental disorder. It has neuro-biological basis.
Psycho-social factors do not cause ADHD, but can alter the further course.
Positive parenting can affect the course of ADHD positively
The Child, Parents and the Family struggle with symptoms of ADHD
Parents and the Family can make a difference by working together
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Are two children with ADHD the same? What other problems can a child with
ADHD have?
Symptoms of ADHD can vary from being mild, which often go undetected to severe that come
to attention usually in early school years. Also, pre-school children present with more
difficulties related to hyperactivity. As the child grows, hyperactivity may be represented by
fidgetiness, and the more serious difficulties are seen in academic performance.
Some children with ADHD have additional disorders related to brain functioning. Some of
these children have sub-average intellectual functioning. Clumsiness, motor co-ordination
disorders, tic disorders, speech and language disorders and specific learning disorders may
also be co-occur. Seizure disorder or epilepsy is found in some of these children.
As many of these children receive criticism and rejection from families, teachers and peers,
they may have a poor sense of self esteem and self-image. Some of these children, in a bid to
boost their self esteem may engage in high risk behaviours such as smoking or in bullying
others. Some of them have high levels of anxiety and depressive symptoms. It is equally
common for these children to get bullied by peers.
Some children with ADHD also go on to show increasingly defiant behaviours, which are more
severe than what may be expected at their age. Such children appear irritable, spiteful and
hold grudges for long. Dissocial acts and substance/ drug use, reckless driving, and callousness
may be seen in a small proportion of these children as they grow up. These are often those
individuals whose symptoms were unrecognised and untreated, had families with marital or
family discord, family histories of such dissocial behaviours and drug or alcohol use.
Does ADHD improve with age?

The course of ADHD is quite variable. In about one-third of children, the symptoms of
hyperactivity abate as they grow up. However, they still have difficulties in attention and
organisation. It has been seen that some of these impairments persist even into adulthood
and reflect in problems at work and in relationships. However, in some children the course
may be more severe and marked with development of oppositional and dissocial (anti-social)
behaviours. Overall it has been seen in long term scientific studies, that untreated ADHD has
a worse course as compared to that of treated ADHD.
How is ADHD diagnosed? Are there any tests?

There are no laboratory tests to diagnose ADHD. The diagnosis is made on the basis of
information gathered from parents, teachers and the child himself or herself. There are
specific diagnostic criteria that govern the diagnosis and ADHD is diagnosed accordingly. In
children where sub average intelligence or specific learning disorders are expected, specific
psychological tests are carried out. In case any hearing or visual deficit is suspected, hearing
or vision tests may be ordered.
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Some famous people with ADHD
Michael Phelps – 28 Olympic medals for swimming! He was diagnosed with ADHD when he was 9
years old. His mother encouraged him to swim. Swimming help him to develop self-discipline
Walt Disney – Founder of the Disneyland. He too was diagnosed with ADHD. His creativity gave
birth to the most popular product
Jim Carrey – A popular Canadian American actor, producer and comedian
There are many more …….. the channelised energy and creativity have helped them achieve in life
Can ADHD be treated?

As stated earlier, there was a time when symptoms of ADHD were thought to be either due
to sheer laziness or deliberate mis-behaviors on part of the child or due to inefficient parents
or most likely both. Naturally, the treatments were harsher and stricter punishments.
However, the present state of knowledge has shown beyond doubt that ADHD is a brain
disorder, with specific problems in self –control and self –regulation. There are drug and non-
drug modalities of treatment that have been well researched and established.
Medications: These include medications that are called stimulants, and another group of
medications that are called non-stimulants. Medications are usually started for moderate to
severe symptoms of ADHD, which are associated with significant difficulties at school and
home.
Behavior therapy: Behavior therapy focuses on increasing the good behaviors and decreasing
the bad/ undesirable behaviors through optimal and consistent use of rewards and
punishment.
Parents are the main elements of change for successful behaviour therapy. Parent training
program that impart knowledge and skills to the parents so as to help the children deal with
their core problems and to implement behaviour therapy have been found to be useful.
Further, parent-teacher liaison has been found to be useful in implementing many of the
principles and helping the child with ADHD.
There is no role of lay counselling for the child or the parents in the management of ADHD.
Other strategies like cutting down on sugar intake, avoiding food preservatives or food
allergens have not been found to be helpful consistently.
In case of depression or anxiety disorders, additional medication or therapy may be required,

besides the treatment for core deficits seen in ADHD. Many a times, with improvement in
inattention and behavioural response inhibition, there is improvement in academic
performance and peer relations, which in turn improves their self-esteem.
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What can parents expect from this program?
This is a 10 session intervention that will help the parents in developing and practising
skills to deal with the symptoms of ADHD and the ensuing impairments. Participation in
this intervention does not in any way imply that parents lack skills or are bad parents.
Rather parenting gets challenged sometimes by difficult behaviours, and this intervention
will help enhance positive parenting skills and develop new skills to deal with such
problems.
The intervention does not provide one single generic solution to all problems, but rather
provides the parents with knowledge and an armamentarium of strategies.
Like any other new skill that we learn, parents will need to practice these skills over and
over again and apply to different problems and situations.
We do not expect a rapid change. Rather, it is common that when parents start applying
the behavioural principles consistently, there might be a temporary escalation of
problematic behaviors by the child. Success of the intervention depends on the parents’
ability to persist through such times.
It is quite well established that if the behavioural strategies are applied effectively and
consistently, the effects last longer and the improvements are more sustained.
Last but not the least

Sometimes, there is a good side of the impulsivity... Many of these children are highly creative
and are known to have ‘out-of-the-box’ thinking. Many of them are good in sports especially
the ones that need high levels of energy. Some of these children are eloquent speakers. They
do not shy away from trying out new things, and this sometimes makes them take up
opportunities that others would have let go.
POINTS TO REMEMBER
1. ADHD is a brain developmental disorder
2. The core symptoms are hyperactivity, inattention and impulsivity, with a likely
central problem in self-control
3. Neither child’s fault nor parents
4. Long term course is affected positively by treatment and positive parenting; and
negatively by family or marital discord, drug or alcohol use in family.
5. Management mainly consists of medication and behaviour training programs
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HOME ASSIGNMENT
List out all the strengths and assets of your child
• Examples may be good verbal skills, being outgoing, obedient, good in sports
(need not be the best), popular with his friends
• None of us are champions; we are neither looking for champion-like qualities.
Rather, we are looking for those strengths that have been ignored or have got
submerged under the deluge of hyperactivity, impulsivity and poor academics.
A list by parents of their 9-year old’s strengths and assets
Social and friendly

Honest
Loves playing outdoors
Good in swimming
Participates in sports enthusiastically
Rationale of homework
It is to improve awareness and reflection amongst parents, so that they can understand their
child’s problems from a new perspective (brain disorder of self-control). It will help mitigate
guilt and blame.
Thinking of assets and strengths will help parents in recognising the goodness present
alongside the problems
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SESSION 2
EFFECTIVE COMMUNICATION: 4 Ps AND 4 Cs OF PARENTING
Feedback of Session 1 and Review of homework (around 15 minutes)
▪ Difficulties with sustained attention, impulse control and too much activity level
▪ Behavioral problems viewed from a new perspective: Disorder of self-control
▪ Brain disorder, neither wilful nor parenting defect
▪ Reflection: How have his/ her problems affected you as a family? Can the new
knowledge change the way you have handled the problems? (Discuss about guilt,
blame and burn-out)
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SESSION 2
EEFECTIVE COMMUNICATION: 4 Ps AND 4 Cs OF PARENTING

4 PS – PATIENCE, PERSISTENCE, PLAY TIME, PARENTS AS ROLE MODELS
PARENTS are the key, and informed and effective parent skills are at the heart of the
parent training program.
PARENTING (THE 4Ps)

▰ Parent self-care
▰ Patience & Persistence
▰ Play (Special) Time
▰ Parents as Role models
PARENT SELF-CARE
TAKE CARE OF YOURSELF
PRACTICE FORGIVENESS
PRACTICE YOGA / MEDITATION
DO SOMETHING THAT HELPS YOU RELAX
TAKE OUT SOMETIME EVERYDAY FOR YOURSELF
It is very important that you take care of yourself. Adopt a healthy lifestyle with good
nutritious food and daily physical exercise. Practice yoga or meditation or whatever helps you
relax (e.g. listening to music). Try to get some time for yourself. For this, both of you shall
have to help make free time for the other partner.
PATIENCE & PERSISTENCE

It is completely understandable that gradually parents lose their patience with the child, and
with each other. But, no change will come overnight. You shall have to nurture patience and
also practice forgiveness. It is important not to be snappy with or exceedingly demanding of
the child while you are trying to supervise or help out. For example, while packing his school
bag or getting his homework done. Your impatience may actually result in open defiance or a
tug-of-war between you and the child, each trying to defeat the other. Such interactions are
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rather counter-productive. Not being snappy does not mean that you cannot be firm with
your child.
Changes will come only after weeks, or sometimes, months of adopting behavioural
measures. Hence, it is very important to stay persistent with your efforts. It is expected that
initially the problematic behaviors will increase, when you are trying to be persistent. This can
be emotionally and physically draining for you. Please understand that this is actually an initial
sign of improvement and a reflection of the fact that you are changing your parenting skills
for the betterment of your child
The BIG P – PLAY TIME

It is time to strengthen the relationship with your child. Most parents struggling with ADHD
symptoms gradually end up spending most of their time with the child in supervising,
correcting or reprimanding the child. All interactions become a power struggle and full of
conflicts. Now that we understand that the child needs help, as a parent you need to practice
forgiveness and work on your relationship with the child.
An excellent way of cementing your relation with the child is by engaging in Special play time.
This special play time is a time, may be half to one hour that you have set aside to spend with
the child when the two (or three) of you can do things together; things that your child enjoys
doing. You can play a game of carom or ludo or cricket or badminton, or watch a TV program
together. You can even play video games with him. You have to strictly refrain from asking
questions, making demands from the child or passing critical comments. Do not bring up his
past bad behaviours during that time. Do not indulge in making him understand what he
should do or not do. Do not make this time an opportunity to advise him for correcting his
behaviours. Rather, enjoy the moment; indulge in praising him, reflecting on whatever he has
to tell during that time. Our children surprise us in more than one way; and sometimes these
surprises are rather pleasant.
Special play time will also give you an opportunity in re-discovering your child’s strengths
and assets.
In case the child indulges in any defiant or demanding behaviour during the special play time,
do not lose your temper or make angry remarks. Rather, ignore and let it go. You can also tell
the child that he can discuss the same at so and so time (be as specific as you can be). Make
it a point to hear him out at that time. To hear him out does not mean that you have heeded
to all his demands. Next day you can try some other activity and a different time slot for the
special playtime. For example, you can play an outdoor game instead of a board game that
he finds boring.
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PARENTS as ROLE MODELS
It often happens that while parents advise children not to behave in a certain way, they
themselves behave in that manner. Take for example, a parent talking rudely to elders,
parents screaming at each other while in disagreement, parent using smartphone excessively.
Children model or copy the behaviors of the adults. They copy their parents and teachers;
these are the most influential people for a child. So, if parents show unhealthy or maladaptive
behaviors, the child will copy that, and if parents model healthy behaviors, the child is more
likely to behave in that way.
So, as a parent you can influence your child in positive ways. If a parent stays calm in face of
a stressor, it is very likely that the child will also remain calm when stressed or frustrated. If
parents talk politely even when in disagreement, the child will also learn to behave similarly.
When you wish that your child brings down his screen time, it is very important that all adults
in the family also reflect on their screen time and cut it down.
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COMMUNICATION (THE 4CS)
▰ Clear, specific & short instruction
▰ Consistency
▰ Catch him/her good
▰ Cut down critical comments
THE FIRST C – CLEAR, SPECIFIC & SHORT INSTRUCTIONS

Why?
▪ Child’s attention span is short
▪ He can easily get lost in midst of long instructions
▪ He will have difficulty in following what exactly he is expected to do if the instructions
are vague (e.g. “stop being so bad”) or too broad (e.g. “clean your room”).
▪ Remember your child has difficulty in organising tasks especially when there are
multiple sub-components and needs sequential execution. So, an instruction “do your
homework” or “pack your bag” might not help the child
So how should your instructions be?

1. Your instructions should be clear and short/ brief
2. It should specify what the child is expected to do exactly (e.g. “put your shoes in the
shoe rack”). Be precise.
3. In case of multi-step tasks, to begin with provide instructions for every step in a
sequential manner.
For example, instead of saying “pack your school bag”,
Tell him, “Take out/ Read your time-table (wait for him to do it). Okay. Check if EVS
book is there. EVS copy is there (wait at every step for him to complete). Hindi book,
etc.”
Remember: Parents can gradually increase the bulk of instructions (i.e. club more than one
steps) as the child progresses
4. Frame instructions in such a way that you tell him what to do, rather then what not to
do.
For example, Child is rolling on the floor and yelling.
Instead of saying, “Stop your bad behavior”,
Tell him “Stop screaming. Get up from the floor. Sit here.” (pointing to a chair).
5. Instructions or commands SHOULD NOT be phrased as requests such as “Would you
mind keeping your books back?”, “Can you water the plants?”
Effective phrasing: Ravi, keep your books back in the shelf." Or "Mohan water the
plants on the terrace"
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6. Instructions SHOULD NOT BE phrased as explanations or questions, e.g. “Stop jumping
otherwise you will fall and hurt yourself”.
Effective phrasing: "Ravi, stop jumping. Sit on the sofa. You can play with the fidget
toy."
Session tasks
1. Instructions for desirable behaviors (i.e. what we want him to do, such as putting his
things in place)
Tasks for discussion:
a. On returning from school
b. For arranging or cleaning his cupboard or room
2. Instructions in case of behavioral problems

Tasks for discussion
a. Child has pulled down all the toys from his almirah (not playfully; in response to
not being allowed a privilege such as TV time)
THE SECOND C – CONSISTENCY
Why?
▪ For a child to learn what he is expected to do, it is important that the results or
consequences are consistent. The rules should be clear and remain the same.
▪ If a child’s demand is not fulfilled and he is scolded when he keeps arguing, but the
same demand is fulfilled when he threatens to throw or hit, the child learns to increase
the tempo of his undesirable behavior to get his demands fulfilled.
▪ If father reprimands for a certain behavior, but the mother makes light of it or gives
into the demand, the message sent is ambiguous.
▪ You have allowed TV time after homework. But one day, when he did not score well
in a test, when he went to switch the TV on after completing the homework, you
shouted “no TV from today”.
▪ Consistent rules are an effective way of communicating to the child what is allowed
and what is not.
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THERE SHOULD BE CONSISTENCY BETWEEN WHAT YOU SAY AND WHAT YOU DO
How to do this?
1. Rules should be clear
2. Rules should define what he is expected to do, what happens if does not follow the rule
and if applicable, what he gains on following the rules)
3. If a reward had been promised on completion of a behaviour, it should be given without
unnecessary delay.
4. If a punishment or withdrawal of reward had been decided for an undesirable behaviour,
it should be carried out if the child behaves undesirably. Empty threats or warnings do not
help.
5. Rules should remain the same
a. across situations (e.g. home and market place)
b. across adult members of the family
c. across time
6. Rules should not be broken according to our moods or convenience
7. Be consistent, also between how you behave and what you expect from the child – e.g.
punctuality, use of abusive language

1. Spouse scolds / says it cannot be given and the child approaches you.
2. Your mood was not good. Child dropped milk vessel while opening the fridge.
THE THIRD C – CATCH HIM GOOD
Why?
▪ Praise and appreciation is the biggest reward
▪ It is common for parents to report that, ‘there is not a moment when he behaves well’.
But, in reality his good behaviours and assets are submerged in the deluge of bad or
challenging behaviours.
▪ One way of reducing challenging behaviours is to focus on these good behaviours and
re-inforcing, i.e. rewarding them.
▪ Also, rewarding good behaviours dissipates the sense of struggle in parent-child
relation and helps to strengthen it
How to ‘Catch him good’?

1. Use praise and encouraging words such as ‘well done’, ‘very good’ , ‘good’ for every
smallest good behaviour that he shows
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2. For this you should now be more focused on catching him good. While doing so, ignore
the bad behaviours if any, present around that time.
3. Use praise for things that he did on his own initiative or after your instructions. Do not
devalue when he does something after your instructions only.
4. Do not comment in a way that devalues your praise. There should be no riders, like,
‘it would have been better if you would have done it without my asking you” or “Now,
it is better” Such phrases makes the child feel that what he has done is after all is not
good enough to be praised. So, you actually foster discouragement instead of
encouraging the child to show more of such behaviours
5. Also, do not miss an opportunity for thanking the child when he has helped you in the
smallest possible way. Saying ‘thank you’ is a way of showing our appreciation.
Reflection: How do you feel when your spouse appreciates your efforts – bringing grocery
on way home, cooking a special meal?

1. He did not keep his shoes in the rack after returning from school. Then you instructed
him, “Keep your shoes in the rack”. He reluctantly got up and placed his shoes in the
rack”
Unhelpful dialog
P: Good, but you could have done that with a smiling face.
C (smirks): Now you have a problem with my face also.
P: I am just telling you there was no need to shrug and get up. It would have made me
happy if you would have kept your shoes on your own. Why do I have to tell you
everyday?
C (appears annoyed): There you go.
Helpful dialog
P: You have kept your shoes in the rack, Good. (looks in the direction of the shoe rack).
Would you like some water?
C: Okay.
P: How was your day?
C: Nothing much.
P does not enquire further.
2. Guests have come to your home. Child runs and greets them, then goes to the kitchen
and gets water.
Unhelpful dialog:
G: Thank you, child.
C: Welcome
P: Now, you can go to your room.
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After the guests have left,
P: When I come from the market, you never even ask me for a glass of water. You
become a good boy for others.
C (angry): I will not ask you when you come from anywhere.
P (angry): How dare you talk like that? Go to your room and finish your work. You
always leave your work incomplete......
Helpful dialog:
G: Thank you, child.
C: Welcome
P: Thank you, Beta.
C: That’s okay, mummy
P: You may now go to your room
After the guest have left, praising the child for their good behaviour with the guest, especially
for offering the water and also obeying them
THE FOURTH C: CUT DOWN CRITICAL COMMENTS
Why?
▪ These children receive criticism from all quarters, all the time.
▪ Excessive criticism can undermine their good qualities, make them feel discouraged,
despondent, affect their self image negatively and make them defiant
▪ We now understand that many of his behaviours are due to the lack of self- control
which is biological in nature. So, criticising them will not lead to any change.
▪ Most of their academic difficulties are due to their problems in sustaining attention.
So, being critical about his distractibility or comparing to a sibling or a friend only
damages the child’s sense of self esteem
▪ Sometimes, the so-called bad behaviours are actually age appropriate tantrums,
which can simply be ignored.
How to cut down critical comments & Ignore?

1. Catch yourself being critical. Spouses can help each other (but do not point out to each
other in presence of the child)
2. Remind yourself that your child is suffering from ADHD, a brain disorder, and many of
his behaviours that upset you are a result of this.
3. Learn to ignore small tantrums and fidgetiness, small amounts of defiance
4. The Ps will help you – practice patience and forgiveness
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Parent(s) to be asked the phrases that they often use and reflect if those are actually critical
of the child
1. You are no good.

2. Why can’t you just sit still?
3. You just do not pay attention.
4. Only you can make such silly mistakes.
5. Learn something from your sister.
HOMEWORK ASSIGNMENT
Practice 3Ps – Take care of yourself, practice patience and spend special playtime with your
child
Practice the 4 Cs of Communication
1. Be clear and precise in your instructions

2. Be consistent
3. Catch him/ her good
4. Cut down on critical comments and learn to ignore trivial misbehaviours
Practice instructing, praising good behaviours and ignore minor bad or undesirable
behaviours (e.g. tantrum, fidgeting)
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SESSION 3
ENVIRONMENTAL MODIFICATIONS (PART I):
DEALING WITH HYPERACTIVITY

Feedback of Session 2 and Review of homework (around 15 minutes)
• 3 PS – PATIENCE, PERSISTENCE, PLAY TIME

• COMMUNICATION (THE 4CS)
▰ Clear, specific & short instruction
▰ Consistency
▰ Catch him/her good
▰ Cut down critical comments
Re-visit the problems related to hyperactivity

• Central difficulty in regulating of self-control
• Biological in nature, brain disorder
• Long term course affected by environment and treatment
• Refer to Session 1 for symptom presentation
Environmental modifications include changes made in the environment (e.g. home or

school) to either decrease the symptom manifestations or importantly, to decrease the
impact of the symptoms. Such modifications should help enhance the performance and
functioning of the child
How to manage hyperactivity?

Children having symptoms of ADHD have excess of energy which needs to be channelized in
a constructive manner. If not done so, this energy can lead to much disruptive behaviour. On
the other hand, if used properly, some children do quite well in high energy activities such as
sports.
1. Give adequate time and opportunities for physical/ outdoor sports: Along
with your child plan for physical activities such as cycling, playing badminton,
running/ athletics, football, etc. Even guided play in a park is very helpful for
younger children. For example, you can ask them to race till a tree, you can ask
them to climb on the monkey bars and climbing frame, etc. Let the play be
supervised so that they do not inadvertently hurt themselves or others.
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Remember: Children with ADHD can get easily bored, so, they might soon lose interest in a
physical activity.
Make it interesting and fun. Participate with them whenever possible. If they have joined a
sports class/ coaching, ask them how it went when they return. PRAISE THEIR EFFORTS. It
is not necessary for a child to win or excel, it is essential to reward his efforts. Small rewards
can also be arranged to keep them motivated. These can be a favourite snack or extra TV
time.
2. Breaks while studying: These children start fidgeting after a few minutes of
having to sit for a boring or lengthy task like studying. Anticipate and give a
break. The break may be of around 5 minutes after every 15-20 minutes of
being on-task or lesser in younger children or when the adult senses increase
in fidgetiness. Ask the child to do some small chore like fetching water,
watering plants or handing a thing to someone or any task that helps the child
use his physical energy
3. Fidget toys: Use of fidget toys can help some children to concentrate better
on what they are doing. These can be particularly helpful while travelling.
4. Alternate activities while planning a meal outside or travelling: Carry age
appropriate materials such as crayons, activity sheets, Rubik’s cube, clay, etc.
to keep the child engaged in constructive activities while you dine out or you
are travelling
5. Limited screen time
6. Other environmental modifications: You may allow child to stand and study.
Tasks for discussion/ Exercise

Enlist physical/ outdoor activities you can think of for your child?
Think of things/ chores you can ask your child to do while giving him breaks during study time
Enlist activities that you can plan and arrange when you have to go out
HOMEWORK ASSIGNMENT
Practice 3Ps – Take care of yourself, practice patience and spend special playtime with your
child
Practice the 4 Cs of Communication
1. Be clear and precise in your instructions

2. Be consistent
3. Catch him/ her good
Cut down on critical comments and learn to ignore trivial misbehaviours
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Plan and implement strategies for managing hyperactivity:
• Plan a physical sport (discuss with your child while planning)

• Short breaks at regular intervals
• Allow activity during breaks to channelize the excessive energy
• Something to keep them occupied during long journeys
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SESSION 4
ENVIRONMENTAL MODIFICATIONS (PART II):
DEALING WITH INATTENTION AND DISORGANISATION

Re-visit the problems related to difficulty in sustaining attention and high distractibility
• Central difficulty in regulating of self-control

• Biological in nature, brain disorder
• Refer to Session 1 for symptom presentation
• How does it present?
➢ Messy work, careless mistakes
➢ Loses stuff
➢ Misplaces and forgets
➢ Keeps forgetting instructions or messages to pass on
➢ Generally confused
➢ Gets onto something else when I tell him some work
➢ Gets easily bored
➢ Has no track of time
ENVIRONMENTAL MODIFICATIONS
a. The first C of Communication: Clear, specific, short instructions
b. Helping him to make sense of time: Structuring the day
c. Helping in organising: Structure the physical environment (Home and room)
d. Helping in organising: Use of visual cues and prompts
e. Preparing in advance for daily routines
f. Helping in sustaining attention: Decrease off task distractibility, increase on task
stimulation
g. Helping in sustaining attention: External motivators and Immediate and powerful
rewards
a. The first C of Communication: Clear, specific, short instructions
Refer to Session 2.
• Always draw the child’s attention towards you before giving any instruction
• Avoid yelling.
• Immediately reinforce step or whole task completion (depending upon his
current abilities) with verbal praise or use of star stickers.
b. Helping him to make sense of time: Structuring the day
[
• Externalise the concept of time: Use a time-table, use of reminder (verbal

prompts to remind him how much time is left for a certain task)
26 | P a g e
• Make the daily routine regular and predictable: E.g. waking up; brushing,
drinking milk, bath, wearing shirt followed by trousers, etc.
• Use a daily and weekly planner. Paste it where he/she can see.
• Inform the child in advance of any changes in the schedule
• Prompts as per schedule: Use visual prompts by directing him to the planner/
time table that is pasted.
• Prompts during a task: These children often lose track of time. So, it is good
idea to let the child know for e.g. “5 minutes are left to complete this
assignment” or “after 5 minutes TV time gets over”.
c. Helping in organising: Structure the physical environment (Home and

room)
• A place for everything: Allot a fixed place for almost everything in the house,
but particularly for his/ her belongings.
• Visual cues: Paste labels indicating which things go where. For e.g. “School
books”, “Battery toys”, “Blocks” labels may be pasted over the respective shelf
doors. You may draw or paste a picture indicating the same
• Verbal prompts: Again use short, specific instructions/ commands as prompts
for helping him organise the physical space.
d. Helping in organising: Use of visual cues and prompts

• Paste a time table
• Paste house rules
• Paste labels
• Direct the child to view the planner or rules or labels as needed
e. Preparing in advance for daily routines

For e.g. preparing for school: Get ready the night before; packing school bag,
laying out clothes, polishing shoes. Make enough time for him in the morning
to get ready and have breakfast.
f. Helping in sustaining attention: Decrease off task distractibility,

increase on task stimulation
• Study environment:
o Not many things around the study table
o Study table preferably in a place with lesser noise
o Preferably only things required for a particular task should be laid on
the table (e.g. maths workbook and notebook, 1 pencil and an eraser)
o Preferably the table is placed in a corner of the room (with walls also
lacking any thing on it), which is away from the window, does not
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have anything over it (except for a green table top), except for the
things to be used while doing that activity
• Adult supervision helps - Re-direct attention by gently tapping on his
shoulder and saying “Do this sum” or “write here”. Immediately reinforce by
saying “very good” when child has been able to re-direct his attention to the
task
• Use of colored pens to highlight important or difficult parts of the work: You
may highlight for e.g. difficult words in a chapter, first explain those to the
child, and then direct him to start with the reading. Use a different colored
marker to highlight concepts, etc.
• Externalise ideas: While writing down an answer, these children may often
get lost. Ask them to jot down the points that have come to their mind. Ask
them to read through the points and add if anything else has come to their
mind. Direct them to expand one by one later on.
g. Helping in sustaining attention: External motivators and Immediate

and powerful rewards
• Praise and rewards will help.
• These should be provided immediately after task completion.
• Use “when-then”: Child will be allowed to do a desired activity after
completing a less desired task. When you finish reading this chapter, you can
watch TV or play on the mobile/pc/tablet for 20 minutes.
h. Attention enhancing tasks

Tasks for discussion/ Exercise
1. Describe changes you need to make in the study area

2. Chalk out a plan to structure the child’s room
3. Draw up a rough time-table and decide on places where it can be pasted
4. Role—play:
a. Child has to sit for studying Maths
b. Child has to write an essay and submit after 6 days
c. Child has to homework in English, Hindi and Science
Home assignment for parents
• Practice the 4 Ps and 4Cs

• Environmental modifications
i. Managing hyperactivity
ii. Managing inattention/ disorganisation
▪ Helping him to make sense of time: Structuring the day
28 | P a g e
▪ Structure the physical environment (Home and room)
▪ Use of visual cues and prompts
▪ Preparing in advance for daily routines
▪ Decrease off task distractibility, increase on task stimulation
▪ External motivators and Immediate and powerful rewards
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SESSION 5
INCREASING COMPLIANCE
Feedback and review of homework assignments
Strategies for improving compliance

1. Effective communication
2. Praise and planned ignoring
3. When...then.....
Before we begin, some basics of behaviour management
Behaviour Consequence
Good behaviour Good consequence/ reward/ privilege
Good behaviour/ stopping of bad behaviour Removal of bad consequence
Bad behaviour Removal of a privilege/ punishment
30 | P a g e
1. Effective Communication employing behaviour principles
We had already covered some basic principles of effective communication and instructions in
Chapter 2. (Therapist and parent should re-visit the Session 2 and also evaluate how much
the parents are is able to apply).
• All the instructions should be provided in an even, firm tone looking at the child and
addressing him directly. Be careful not to allow anger come through your voice or body
language. At the same time, you have to convey to the child that you are serious about
what you are saying.
• In case the child complies with the instruction, praise him immediately.
• In case the child does not comply with the instruction, repeat the instruction and tell
him that you will count till 5, and that if he does not comply till the count of 5, he will
lose some privilege (e.g. the toy he is playing with) for 5 minutes. Then start your count
till 5. If he complies, praise and if he does not, remove the privilege. Do not give it back
till 5 minutes are over, no matter if he throws a tantrum. In the latter case, give
another instruction stating that he should sit quietly in the chair. Repeat the same
steps.
• In case a child is about to enjoy a privilege (e.g. TV time), after doing the work you
have instructed him to do, you can make the privilege contingent upon the child
following your instruction. “You will pack your school bag. When you pack your bag,
then you can watch TV.” After that you can start giving smaller instructions for smaller
steps of the chore (depending on the age and capacity of the child).
Avoid
Negatively phrased statements
Emotional threats or pleadings
Empty threats or warnings
Promises that you don’t intend to keep
Changing stand from withdrawal of privileges to giving of rewards
Session task
Example,
Child does not keep his toys and games back after playing.
Ineffective communication
Keep all your toys back. Why can’t you keep it all in its place? Why I have to tell you everyday?
If it breaks or gets lost I am not going to buy you a new one. Stop making that face. And just
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remember, I am not going to allow your friend to play here tomorrow. (after the child does
not comply)..okay, get up, pack your toys, then I will make noodles (or a favourite snack) for
you.
Brainstorming – What were the contributors to ineffective communication?

Effective communication
Instruction to be given 10 minutes before playtime is to end and preferably before the child
is quite hungry or sleepy or tired.
It is 7:20. It is time to pack the toys. (you are externalising time for the child) Get up and pack
your toys. (short and specific instruction about what the child is supposed to do). (Child
whines and tries to negotiate for another 5 minutes). (You can ignore the whining and
complaining). Put this game on that shelf. (pointing and physically prompting the child if
needed). Good (when the child complies). Now, put the cards back in the box. Fine.... and so
on.
Suppose the child does not comply,
I will count till 5 and if you do not start packing the toys by the count of 5, you will not be
allowed to watch TV till it is 7: 45 (reducing 15 minutes of TV time). Carry out the warning.
Ignore all complaining, provocations (e.g. you cannot just boss me around) or protesting
(how can you do that)
2. Praise and planned ignoring

Praise is the most powerful reward. It should be specific, immediate and proportionate to the
behaviour.
Attention increases frequency or occurrence of any behaviour. This is more pronounced

with bad or undesirable behaviours. This happens irrespective of whether the attention is
positive or negative. Attention works as a reward.
For example, when a child is upto some mischief and other children in the class laugh, it
encourages him to repeat such behaviours.
When a child throws a tantrum and is lying on the floor, when the parent tries to cajole,
persuade or threaten the child to get up, it increases the likelihood of that behaviour.
Planned ignoring or taking your attention away from the behaviour decreases the frequency
of the behaviour.
How to implement planned ignoring?
1. Remember you have to ignore a specific undesirable or ‘bad’ behaviour

2. Ignoring should continue till the target behaviour stops
32 | P a g e
3. Do not ignore the child once the target behaviour has stopped
4. While ignoring a certain behaviour, you should continue with whatever
you were doing (e.g. Cooking, talking on phone, etc.)
5. You may as a next step turn your back to the child during the tantrum,
but continue with what you are doing
6. Only intervene if you think that the child will harm himself or someone
around (Other strategies such as time out or penalty will need to be
employed in such situations)
Session task: Applying planned ignoring

1. You have informed the child that TV time is over and have switched it off. You are
about to start with a household chore and it is child’s playtime. Child starts arguing for
more TV time and starts crying loudly when you do not yield
2. The child wants you to buy a doll/ car and you have told ‘no’. He starts yelling and then
lies on the floor and keeps kicking his legs
3. You have informed the child that you have to make an important call and the child
should not disturb you for 5 minutes. While you are talking on the phone, the child
repeatedly comes and asks you to give her a toy which is out of reach.
3. When....then....
Using the behavioural contingency principles, you can use the “when....then....” approach.
It simply means that when the child complies with a certain instruction, then he gets a
reward or a privilege.
For example,
“When you finish the maths assignment, then you can watch TV for 30 minutes”
“When you have put your books/ toys back, then you can go to the park”
For younger children,

“When you put your school bag and shoes in place, then you will get a star sticker.”
Many a times, parents have been already using such strategies, but find no consistent
improvement. So it is important to emphasise on the following for more effective
implementation:
1. The ‘then’ phrase or reward should be something that can be given or done
immediately after the behaviour.
2. Reward should be something that the child enjoys or likes
3. Rewards should be practical to deliver
4. Change the ‘then’ rewards from time to time
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5. Do not allow the child’s request of the reverse, i.e. “If ...only then...”. For example, the
child may say, “If you allow me to watch TV now for 30 minutes, then I promise I will
finish my Maths assignment”
6. Reward only and immediately when the child is compliant.
7. Do not reward if the child did not follow your instruction.
Session tasks: “When...then...”

1. Think of situations where you can employ the when/then strategy
2. Let us practice: Parents should phrase “when...then...” statements
Homework assignment
1. Continue applying the 4Cs of communication
2. Select 2-3 tasks/ chores that you want the child to do – Practice giving effective
instructions
3. Praise the child for desirable behaviours: Be specific and let the child know what has
pleased you
4. Practice ignoring for tantrums and intrusions
5. Select 2-3 tasks where you can practice “when...then...” You may use this strategy for
tasks selected under point 1
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SESSION 6
PARENT MEDIATED NEURO-COGNITIVE TRAINING
A. ATTENTION ENHANCING TASKS

Attention deficits in these children manifest in difficulty to sustain attention in academic tasks
and difficulty in remaining focused in class or when given instructions.
Attention enhancing tasks may help the child to sustain attention for required period of time.
Regular practice of these tasks will gradually help the child to increase concentration in
studies and classroom.
The parents are needed to engage their children in these tasks.
Note:
• Relaxation between exercises is crucial

• The younger your child, the more often he or she will need a break.
• The length of time children can actually concentrate on a single task is often
overestimated or over expected
On an average: ➛ 5 - 7 years of age: 15 minutes
➛ 8 - 11 years of age: 20 - 25 minutes
➛ 12 years + of age: 30 minutes
• These periods may be shorter or longer, depending on the time of day and energy level.
A break is the only effective way to restore concentration.
• Throughout the task, the adult should use verbal and physical prompts to bring back the
child on-task.
• For younger children or those with more severe problems, frequent praise and
encouragement (possibly, even for smaller steps of the task) may be needed.
• On completion of the task, there must be presentation of appropriate reward which
should be pre-decided.
• Attention enhancing exercises should be according to the age - According to the age,
developmental level and attention span, tasks of different levels of difficulty are to be
assigned.
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Attention enhancing tasks
1) Colouring (3 to 6 years)
Draw a shape with a thick border. Ask the child to colour the shapes inside the
border only. Remember not to criticize if the child does so. Reward whatever he is
able to do.
For example:
2) Bead making
Instruction to be given to the child: “Insert beads into the
thread one by one.”
Task should be changed and assigned according to different
patterns of size, color and shapes which will move from simple
to complex tasks as follows
o Random bead making
o Colour pattern
o Colour and shape pattern
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Patterns of bead making
a. Random bead making
Start from simple task, example: Randomly
inserting the beads into thread irrespective
of colour and shapes for a week.
b. Colour pattern
Add colour pattern as shown in image for another one or two weeks.
Instruction to be given: Insert same colour beads and then move to next. For
example, “Insert all green beads first, then insert red beads, and then yellow
beads.”
The child can insert beads of any shape, but of the same color
o Insert pattern of colour irrespective of shape: for example one red bead, one blue,
one green, one white. Same pattern will continue further. This may be followed
for 1-2 weeks
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II. Colour and shape pattern (Age above 11 years)
Specify colour pattern in same shape.
Instruction to be given: “Insert same shape with colour pattern of red, yellow,
white, green and blue. Then repeat the same colour pattern with other shapes.”
3) Grain sorting
For small children, (3 to 7 years) start from big size pulses (Rajma and Chana). Ask the child to
separate the both without any distractions. Start from small quantity to big quantity.
Note down the time taken and number of times child got distracted from the activity.
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For children above 8 years, size of pulses will be small but pulses should be of different
colour.
Instruction given to the child: “Separate the pulses one by one without any distractions.”
Note down the time taken and number of times child got distracted from the activity.
4) Mazes
Mazes enhances attention and visuo-motor coordination ability. Mazes worksheet can be
downloaded from internet or books can be purchased from stationary shops.
Instruction given to the child: “ Find out the route through this maze and get out of it.
Remember that you do not touch the pencil with the black lines”
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5) Letter cancellation
Single digit (for children 6 to 8 years)
Take a newspaper column or paragraphs from old book.
Instruction to be given: “Cancel (/) letter for eg ‘e’ in this paragraph. Go line by line
and do not miss any letter which is assigned”
Note down the errors (Omission: Missed the letter and commission: Wrong
cancellation) and time taken.
Double digit (for 9 years above children)

Take a newspaper column or paragraphs from old book.
Instruction to be given: “you have to Cancel (/) 2 letters for eg ‘e’ & ‘m’ in this
paragraph. Go line by line and do not miss any letter which is assigned”
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6) Join the dots
Join the dots exercise is for small children. According to the age, move from simple to
difficult task. Use numbers (counting) or alphabets (A to Z). these kind of worksheets
can be downloaded from internet or purchase books having these games.
Instructions to be given: ” Join the numbers/alphabets in sequence”
7) Crossword Puzzles and Picture Puzzles
Crossword Puzzles and Picture Puzzles are used for children above age of 10 years.
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B. WORKING MEMORY TASKS
1) Series of numbers
Child should be presented with a series of 3 random digits which are not
related to each other by any obvious mathematical equation. Digits should
be said at the rate of 1/ second and with intervals of 1 second.
For example, 1, 9, 4
[Examples of series to be avoided: 2, 4, 6 or 1,3, 5 (even or odd)

2,3,5 (addition), etc.]
He should be asked to repeat the digits.

Then, he should be asked about the position of different numbers in the
series. For example,
“Which is the 2nd number/ middle number?”
“What is the position of 4?” or “what is the position of 9?”
For all correct answers, say “very good” or “well done”, etc.
Gradually increase the number of digits in the series to upto 6-7 digits as per
the child’s progress.
Monitor the progress by maintaining a diary record.
2) Series of words
This is similar to the previous exercise. Here, say a series of three unrelated
words (in keeping with the vocabulary level of the child).
Examples,
water, pencil, boy
cat, eraser, happy
Ask the child to repeat the words, then ask the child the position of a
certain word.
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3) Spotting the picture
Show the child picture cards (3-4 cards for a young child, 9-16 cards to an
older child) placed as a single row of 3-4 cards or 2 x2, 2x3, 3x3, or 4x4
squares. See figures below
Ask the child to name all the cards while pointing at each. Ask the child to remember the
position of all the cards.
Now you turn the cards upside down.
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Ask the child where a particular picture card is? For example, “where is the picture of
umbrella?”
Give repeated trials. Start from lesser number of cards. If the child is able to manage 3-4
cards without errors, go to 6 cards, then 8-9 and so on.
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4 cards
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6 cards
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8 cards
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12 cards
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16 cards
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Note: Parents can make their own picture cards. It can be a fun joint activity with the child.
Otherwise parents may use flash cards or picture cards from any game. They may cut out
pictures from old books and paste them on cardboard to make picture cards.
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4) Matching the pictures
Here show the child 3 or 4 pairs of cards. See figure below.
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Ask the child to point and name the cards in pairs and ask the child to remember the position
of the cards.
Now turn the cards upside down.
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Ask the child to open any card.
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Now instruct him to open the matching card. Give repeated trials.
Homework assignment:
• Make the child do at least three exercises per day. Initially, supervision is needed.
• Monitor the record as given in the table.
• Praise the effort made by child.
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Example of how to record child’s progress
Date Grain sorting exercise Letter cancellation Mazes
No. of Time taken Error Time taken Error Time taken

Distractions
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SESSION 7
HOME POINT (TOKEN ECONOMY) SYSTEM
Feedback and review of homework assignments

▪ Attention enhancing tasks
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SESSION 7
HOME POINT (TOKEN ECONOMY) SYSTEM

The home point system (Token Economy) is used to motivate the child to do chores, follow
rules, or obey commands and decrease problematic behaviours.
Like a Bank!
Home point system is like the banking system. The child can earn, save and spend points or
tokens. He can earn by following rules, showing good behaviours and by not showing bad
behaviours (absence of bad behaviours).
He can spend by using these points to ‘buy’ things from a reward menu (a menu like in a
restaurant) or he can save his points and spend them later!
Caution: Points or tokens are not money or equivalent of money. These points or tokens
have their own value. For example, packing bag can earn the child 2 points, but not Rs. 2
and similarly 10 points can be spent to watch TV or play a mobile game for 30 minutes.
Remember: Although you’ll probably see quick results, the positive changes in your child’s
behavior are not likely to last if you stop using the program too soon, so plan on sticking with
this program for at least two to three months.
Taking the child on board

It is important to convey to the child that this system of points is going to be started. This
should be done on a positive note by introducing it as a banking game. We must bank on its
novelty!
The child can be told, “You have been doing many things on your own. I feel you should get
rewarded for the same. You can earn points and then also spend them to get something that
you like!”
For children from ages 4 years to 10 years, use stars (these stars can be colourful cut-outs
from a chart paper or scrap file or made from cardboard, or can be brought from the market,
or can be drawn with markers) and above 10 years, use points/tokens. A token can represent
different values, e.g. 2-point token, 5 point token, etc. You can involve the child in drawing/
cutting out the stars or tokens. Toy coins from an old game can also be used as tokens.
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You and your child should then make a bank from a shoe box, a plastic jar, or some
other container for storing the tokens (points) earned. Or these tokens earned can be
displayed on a board, for visibility, which can act as further motivating factor. Have
some fun decorating it with your child. For an older child, you can have a ledger book to
credit and debit the points.
For children till 8 years of age: Star system
For children above 8 years: Point system
1 3 5
Also for
5
1 the subsequent steps and overall effective implementation of this system, it is
important to keep the child interested and motivated. Involve the child in preparing the
menus, stars/ tokens, pasting the menu chart, etc. Also, keep updating the reward menu
periodically. Every 2-3 weeks may be alright.
How to implement home point system?

STEP ONE
To set up a reward system at home, you will have to make two types of menus (or lists)
1. For earning: List of desirable (wanted) tasks and behaviours
2. For spending: List of rewards/privileges
Both the lists have to be individualised, depending upon the specific problems and
individual likes of the child.
1) List of desirable (wanted) tasks and behaviours:
This list may include the following three:
1. All the tasks/assignments which the child has to perform daily. For e.g.,
brushing teeth, getting dressed up, packing school bag, homework etc.
2. Problematic behaviours which are not expected from the child like fights with
children, screaming, shouting etc. Note all problematic behaviours using
Problematic Behaviour Chart (PBC). See Appendix 1. The problematic
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behaviour of the child may be converted into desirable/wanted behaviour. For
example: talking rudely (problematic behaviour) into talking nicely
(desirable/wanted behaviour)
3. House rules (e.g. waking up time, bedtime)
Always include some tasks and good behaviours that the child is already doing/ having.
BE REALISTIC in your expectations from the child while drawing up the list.
Each child will have a different list of behaviours. Here are some examples:
1. Brush teeth
2. Get dressed
3. Tuition/ study for 15 minutes (It is important that the study time is specified and
is realistic. So every 15 minutes of study can be rewarded, instead of rewarding
only when ‘homework is done’)
4. Attention exercise (each)
5. Put your utensils into sink
6. Clean room/books
7. Homework per 15 minutes
8. Pack up school bag/ hang the school dress
9. Talk nicely to everyone (from 5pm to dinner time)
10. No fights with children (from 5pm to dinner time)
It is important that the tasks or behaviours included are not vague or too general, but are
specific. Some examples,
Wrong way Correct way

Homework done Study work per 15 minutes
Behave well No fights with brother from 3pm to 6 pm
Tuition work sincerely Tuition work per 15 minutes
Do not put value judgment, for e.g. if points are only given if work is done sincerely. It
can lead to child feeling de-motivated and it will increase child-parent arguments
2) List of rewards/privileges: Reward menu
This list will include daily, weekly and long term rewards. The rewards should be based on
his likes, preferences or demands. Reward list will also be different for every child. Some
examples of rewards are given.
a. Daily rewards:
i. Play outside for 1 hour
ii. Use phone for half hour
iii. Watch T.V for half or one hour
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b. Weekly rewards:
i. Outside food (one item such as burger, sandwich, wafers/ chips, etc.)
ii. Pocket money
iii. Small toy (such as bubble maker, toy car)
iv. Hair bands or accessories of value less than Rs. 30 (or a similar
amount)
c. Long term rewards:
i. Movie
ii. Dress/ Game
iii. Visit to a place which child likes/ Going to a restaurant for a full meal
While making the reward list, allow the child to bargain and negotiate.
STEP TWO
Assign points to each task or behaviour in the first list and each reward in the second list.
Remember:
1. The more difficult the task for the child, the more points he should earn. For
example, studying for 15 minutes can be given more number of points than
brushing teeth if the latter is not so problematic in the child. Another example,
absence of shouting should be given more points if shouting is a concerning
problematic behaviour.
2. Daily rewards should be least expensive and long term rewards should be most
expensive. For example, watching TV for 30 minutes can cost the child 15
points, but going out to a restaurant costs him 700 points.
3. Bonus points: Let’s say, the child earns 2 points for brushing teeth on daily
basis, but if he does it consistently for 7 days, he gets 2x7=14, and an additional
4 points.
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Earning Menu
Keep 1 to 3 stars/points for small work and 5 stars/points for big or difficult task. Assign more
points for good behaviours or absence of bad behaviours. Chart for record can also be
maintained. It can be pasted on wall where it is most visible to family members.
SAMPLE Earning Menu
Behaviour Points/stars 22/12 23/12 24/12
Point
record
Brush teeth 1 1 1
Get dressed 3 3 3
Tuition/ study per 15 minutes 5 5,5,5 5,5
Attention exercise (each) 2 2,2 2,2,2
Put your utensils into sink 1 1,1,1 1,1
Clean room/books 3 3 X
Homework per 15 minutes 5 5,5 5,5
Pack up school bag/ school 3 3 3

dress
Talk nicely to everyone (full day)

Wake up to lunch 3 3
Lunch to dinner 3 X
Dinner to bedtime 3 3
No fights with sibling/friend
Breakfast to lunch 3 3 3
Lunch to dinner 3 X 3
Dinner to bedtime 3 3 3
Total points/stars
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Example for star chart
Behaviour Points/stars 22/12 23/12 24/12
Point
record
Brush teeth 1
Get dressed 3
Also see Appendix 2 for a ready-to-use Earning Menu Chart
Reward Menu
Set daily, weekly and special rewards contingent to points/stars earned. We generally suggest
that two-thirds of the child’s daily points be spent on common rewards and one-third be
saved toward the purchase of special rewards. If your child can earn about 30 stars/points a
day for doing daily work, for example, 20 should be spent on everyday privileges and 10 will
be saved to earn weekly or long term rewards.
SAMPLE Reward Menu
Reward list
Watch T.V (½ hr) 10 points
Game on phone (20 minutes) 10 points
Play time outside/ with friends/toys 10 points
Outside fast food 150 points
Pocket money (Rs.50/100) 300 points
Movie 500 points
Special toy/dress/game 1000 Points
STEP THREE
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Implement the Home point system
For the first 2 weeks, child can earn and spend. Do not deduct or minus points for bad
behaviours. That would come later. If penalty is applied too early during the
implementation, the child may lose motivation and the system will not take off.
Allow the child to earn enough, so that he can spend and may also save.
• Stars/points should be given immediately.

• Rewards should be given as per rules made
• Include verbal and non-verbal rewards while giving materialistic rewards
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SESSION 8
PENALTY OR RESPONSE COST AND TIME –OUT

Feedback

HOME TOKEN POINT SYSTEM
STEP ONE – PREPARING BEHAVIOR LIST AND REWARD LIST
STEP TWO – PREPARING EARNING AND REWARD MENUS
STEP THREE: IMPLEMENTING THE SYSTEM
NOW, STEP FOUR
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STEP FOUR
Penalty or response cost
Learn to Punish/decrease misbehavior constructively
Purpose and Goals:
The goal of this session is to decrease defiant behaviours, aggression, hitting, disobeying or
behaviours which were not managed in home point system.
Why do children with ADHD become defiant or disruptive?
• If the task assigned is lengthy, boring, repetitive, or otherwise tedious, they will show
defiant behaviour due to problem of inattention and distractability.
• All the criticism they receive for their lack of persistence
• They learn to balk/disobey in circumstances where they fear they’ll fail.
• The children learn that resistance, defiance, and negativity are effective means of
avoiding work
Process of implementing penalty:

Penalty means deducting (minus) points for misbehaviour.
Points deduction should be less than rewarded for same behaviour. If u are giving 5 points
for rewarding particular behaviour such as talk politely (no aggression), deduct 3 points if
child gets aggressive.
Decide any two misbehaviours for which you will deduct points or stars
The child should be informed before implementing this penalty.
NOTE: Do not threaten the child for deducting points randomly or spontaneously on any or
every behaviour.
Instructions for penalty
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1) If child disobeys or does not comply with your instruction, repeat
instruction for one more time firmly.
2) If child still disobeys, tell the child ‘I will count till 5 and if you do not obey,
you will lose 5 points or stars (for example; the actual number should be
pre-decided).
3) All instructions should be given in an even and firm tone. Remember not to
lose temper.
Remember: Not to deduct too many points in a day otherwise child will lose motivation for
the point system and will not follow it for long.
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STEP FIVE
TIME OUT
Time-out is a form of punishment for more serious misbehavior. Use time-out with only one
or two forms of misbehavior during the next week.
Choose a type of misbehavior that is more serious and not responding very well to the point
system.
What does Time-Out mean?
It can be understood as an extreme form of removal of privileges. In planned ignoring, we

remove attention, in response cost, child loses privileges and in time-out child loses all the
attention and privileges.
Time-out involves taking the child to a quiet place where he is made to sit on a chair facing
the wall. He loses access to his belongings, activities, privileges, as well such as T.V, Phone,
Toys or playmates/peers. Time-out should be for a period of 1 minute per year of age
(approximately); i.e. a time out of 3-4 minutes for a 3 year old is sufficient. The period can
be extended if the child does not comply or give up the undesirable behaviour. In that case,
it can additively last for up to 1 hour at a time.
Note: Child should be informed earlier about time out. Time out should not be used
spontaneously for any kind of behaviour.
Process of implementing time-out:
1) If child disobeys or does not comply with your instruction, repeat

instruction for one more time firmly.
2) If child still disobeys, tell the child ‘I will count till 5 and if you do not stop
screaming, you will sit on that chair for 5 minutes (for example).
3) All instructions should be given in an even and firm tone. Remember not to
lose your temper.
4) If the child runs away or pushes away the chair, restart the time. Gradually
child will learn to finish the time out early and go back to his activities.
Place where the timeout is to be practiced:
Choose a safe and boring place without toys or games for time-out. The child should not
have access to any fun or entertaining things during time-out. At the same time, the place
should be safe so that the child does not hurt himself inadvertently. Some examples of
places that may be suitable for time-out are -
• Spare room
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• Hallway
• Specific chair / sofa facing towards wall with no window in front
Note: Locking the child in store or washroom where he is totally unsupervised is absolutely
NOT recommended.
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REVIEW OF HOME POINT SYSTEM
It is important to review the Home point system periodically for effective implementation and
trouble shooting.
Common problems parents may face
1. Child is not following point system and has refused for collecting points/stars.
• Check if the activity schedule is not too heavy for child to initiate.
• Child may perceive that points provided are less, bargain with the child and increase the
points.
• Make sure that child has understood what he will get by collecting points. In other words
"Rewards will be given according to points only."
2. At time of penalty, child may show tantrums and scream or may even tear the
chart
This is called behaviour outburst- when you try to change behaviour pattern of the child, the
problematic behaviour may increase to avoid the change. Child may expect that you will not ask her
to change.
• Stick to point system and rules decided. Give point and rewards accordingly.
• Ignore the misbehaviour
• Have patience and don’t get involved emotionally at that period of time or situation
3. Child initiated with interest but has gradually lost motivation to follow it
• Relating points with rewards is necessary
• Inconsistency between mother and father or any other family member may be resolved by
proper communication among themselves
• Child must not get any kind of reward from anyone without getting points
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SESSION 9
ANTICIPATING AND PREPARING IN ADVANCE

When can you anticipate and prepare in advance?
Examples of when you should plan in advance:
Visit to the market
Visit to a mall
Visit to the doctor’s office/hospital
Visit to a relative’s place
Dinner at a restaurant
Long car drive/ bus ride
Why should you prepare in advance?

1. Children with ADHD tend to get bored easily. If there is monotony expected, it is better
to prepare
2. These children have difficulty maintaining calm and have excess of behaviour. In public
places this may become disruptive or dangerous.
How to handle behaviour problems in public places?

1. Keeping the child engaged: While going for a long journey or going for dinner at a
restaurant, take along things and activities that can keep your child engaged. Examples
are coloring sheets and crayons, hand spinner, Rubik cubes or puzzles. Take the child’s
interests into account. Also encourage the child to pack the stuff in his or her own small
bag. Make the whole exercise interesting and exciting for the child.
2. Home point system: Home point system can be very useful while going to public places
and for different kinds of social situations such as dinner party, functions, market, malls
etc.
Steps for implementing in public places

a) Anticipate and choose 2 problematic behaviours which occur in public places.
b) For absence of a problematic behaviour or if an instruction is complied, set tokens/
points for the child. Give clear instructions regarding the same. For example, "If you
hold my hand during the 30 minutes in the market, you will earn 5 points.” Or “If you
do not run around in the shop, you will get 5 points”.
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c) Also, penalty system can be used. For example, “If you leave my hand or run around
in the shop, you will lose 5 points”. D
d) You may combine reward and penalty
3. Use of time out: Time out can also be used in public places. Here the child should be
made to stand for a specified period in an isolated corner or corridor or steps (fire exit)
facing the wall.
Remember and apply 4Cs throughout
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SESSION 10
LIAISING WITH THE SCHOOL
Communication with School

Rationale:
Child's academic and behavioral problems often leads to blaming of the child as well as of the
parents. Equally true is that often parents perceive that the School is unable to handle the
child and teach him effectively. This leads to a no-win sitaution and the greatest sufferer is
the child.
Parents can form a bridge between the treating agency and the School.*
Effective and cordial communication between the parents and teachers can lead to
compounding of benefits.
Strategies
1. Maintain a cordial and non-provocative approach towards the teachers. Their
observations are invaluable.
3. Meet the Class teacher and subject teachers at a time separate from the regular PTM at
teachers' convenience
4. Arrange more frequent meetings to begin with. Seek collaboration. Be open to
suggestions.
5. Appreciate the specific efforts of the teachers, however less you feel those might be.
6. Sandwich approach: While communicating always start with highlighting what you
appreciate about the school/ teacher. Then, you may raise your concerns and give your
suggestions. Always seek their suggestions. End with genuine appreciation.
(*Note for therapists: A sample letter for communication to the School is provided in
Appendix 3)
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SCHOOL ENVIRONMENT AND ACCOMODATIONS
1. Ideal class strength should be around 12-15. It may not be easy to find, but class strength
of not more than 20-30 would serve better.
2. Awareness of School Principal and teacher about ADHD: Here, you may have to play a
significant role by increasing their awareness by mediating communication between
doctor and school.
3. Certain classroom accomodations can benefit the child. These are listed in Appendix 4.
PARENT TEACHER COMMUNICATION THROUGH DAILY DIARY NOTES

1. Talk to the teacher and request daily to and fro communication.
2. Teachers usually dictate a diary note every day to children mentioning about homework
and important timelines (e.g. maths revision test on 14.11.2019).
3. Request teacher to check the child’s diary note for correctness and completeness. If not,
she may make the child wait an extra 10 minutes to complete the diary note.
4. Further, if the teacher can mention the class work done, it shall help. There can be other
alternative ways to confirm class work – such as meeting teacher when the school
finishes for the day. You may also ask the teacher to mark the most essential work or
prioritise the work.
1. Extra time should be set out at home for completion of class work. An adult must
supervise the child and re-direct him while studying (Refer to Chapter on environmental
modifications (Part II).
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APPENDIX 1
Problem Behaviour Chart
Date क्या हुआ बच्चे का व्यवहार आपने कैसे बच्चे की

संभाला प्रतिक्रिया
Situation What child did?
How you How the child
handled the responded
child
19/12/17 टी.वी बंद करने को नहीं बंद क्रकया डांट के टी.वी बंद बच्चा मारने लगा
कहा करने को बोला और ज़िद्द करने
लगा
19/12/17 पढाई करने को ध्यान से पढाई नहीं कर बोला “ध्यान से पढाई छोड़ के
बोला रहा था पढाई करो” खेलने भाग गया
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APPENDIX 2
Menu Chart
Sample ready-to-use Earning menu Chart
Behaviour / Chores Points/stars for Date Date Date

completed task
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APPENDIX 3
Sample letter for communication to the School
(Note: All communication to and fro with the School must be through parents, and if direct it
should be only after explicit permission of the parents)
Office No.:
Dated:
Principal,
Name of School,
Place
Dear Madam/ Sir,
This is in reference to Miss/ Master ......X........., son of Smt. ....... and Sh. .................., student of Class ..... in your
School. At the outset, we thank you for the referral and the accompanying Teacher’s Observation Report. It was
of great help to us.
X presented with difficulties in attention, levels of activity and academic performance. He has been diagnosed
to have attention deficit/ hyperactivity disorder (ADHD) with average intellectual capacity. ADHD is
characterised by difficulty in sustaining attention, getting easily distracted, making careless/ silly mistakes, being
forgetful, having excess of activity and difficulty in maintaining calm where it is required. These children often
come across as inattentive, fidgety, restless and are often impulsive and have difficulty waiting for their turn.
These symptoms often lead to poor academic performance, inter-personal problems with peers and adults, peer
rejection, low self-esteem, being a bully or a victim of bullying.
Master….’s learning problems seem to be secondary to inattention. Specific learning disorder can be assessed
after improvement in symptoms of ADHD (depending upon the kind of chief symptoms and functional
impairments; another focus can be that of peer rejection and bullying). Child has been on regular follow up, and
has been advised drug treatment and behavioural management through parent skills training and counselling
(as applicable). We expect improvement in all his symptoms with treatment.
With this background, we believe that the School can help the child by following certain techniques for teaching
and accommodation that take into account his attentional and behavioural difficulties. Please find attached with
this letter some of the easy and effective strategies for the teachers (See Appendix 4).
We are definitely hopeful that a liaison between the teachers and the treating team shall be of tremendous
assistance in helping the child.
Thanking you.
Yours sincerely,
Doctor’s name
(Handed over to parent)
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APPENDIX 4
How teachers can help a child with ADHD?
It is important that the teacher looks for strengths and assets in the child, which can be useful
resources and reinforcers. E.g. many of these children are good in sports, sport activities help in
venting energy and also provide opportunities for praise and positive reinforcement.
1. Teaching methods
a. Starting a lesson: Establish eye contact with the child; list the activities of the lesson
on the board
b. Conducting a lesson: Give brief instructions and one instruction at a time. Repeat if
necessary.
c. Use visuals: charts, pictures, color coding
d. Vary the pace and include different kinds of activities. Many students with ADHD do
well with competitive games or other activities that are rapid and intense.
e. Have an unobtrusive cue set up with the child, such as a touch on the shoulder or
placing a sticky note on the student’s desk, to remind the student to stay on task.
f. Immediately re-direct the child’s attention with the above mentioned ways
g. Help child organize assignments (e.g. : system for writing down assignments and
important dates)
h. Allow time for the student to organize materials and assignments for home
2. Behavioral management
a. The most important and effective strategy is verbal reinforcement of appropriate
behavior. It works better than punishment for inappropriate behavior.
b. Praise using phrases such as “good job”. Vary the statements given as praise.
c. Give praise immediately and define the appropriate behavior while giving praise.
d. Effective teachers praise children with ADHD frequently and look for a behavior
to praise before, and not after, a child gets off task.
e. Selectively ignore inappropriate behavior.
f. Remove nuisance items (distractions)
g. Allow for “escape valve” outlets (allow to leave the class)
h. Use activity reinforcement. Students receive activity reinforcement when they are
encouraged to perform a less desirable behavior before a preferred one. E.g.
finishing classwork before playtime. Decrease playtime if undesirable behavior
occurs.
i. When talking to a child, move to where the child is standing or sitting
3. Classroom accommodations
a. Seat the student away from windows and the door, right in front of your desk
b. May be seated with a work buddy
c. Allow a student with ADHD frequent breaks (you can send him on errands or ask him
to distribute or collect books). A break after every 15-20 minutes may be needed.
d. Create a quiet area free of distractions for test-taking and quiet study
e. Reduce the number of timed tests. Test the student in the way he or she does best,
such as orally or filling in blanks; give frequent short quizzes rather than long tests
f. Accept late work and give partial credit for partial work
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PARENT SKILLS TRAINING FOR FAMILIES OF CHILDREN WITH

ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER

Postgraduate Institute of Medical Education and Research, Chandigarh, India

Shah R, Sharma A, Grover S, Sachdeva D, Chakrabarti S, Avasthi A. PARENT SKILLS TRAINING

Developed as part of the Departmental project ‘Telepsychiatry enabled

Involve extended family

Structure and flow

The chapters are sequenced to cover psychoeducation followed by environmental modifications

What is Attention-Deficit/ Hyperactivity Disorder (ADHD)?

Task to demonstrate role of response inhibition:

They seem to be more attracted to rewarding or fun parts of activities.

Difficulty controlling impulses

They are often quite noisy, described as very talkative

What causes ADHD? Whose fault is it?

He is like this because our home environment is very disturbed.

Positive parenting can affect the course of ADHD positively

Parents and the Family can make a difference by working together

Does ADHD improve with age?

How is ADHD diagnosed? Are there any tests?

Jim Carrey – A popular Canadian American actor, producer and comedian

Can ADHD be treated?

In case of depression or anxiety disorders, additional medication or therapy may be required,

Last but not the least

A list by parents of their 9-year old’s strengths and assets

Social and friendly

EFFECTIVE COMMUNICATION: 4 Ps AND 4 Cs OF PARENTING

Feedback of Session 1 and Review of homework (around 15 minutes)

EEFECTIVE COMMUNICATION: 4 Ps AND 4 Cs OF PARENTING

PARENTING (THE 4Ps)

TAKE CARE OF YOURSELF

PRACTICE YOGA / MEDITATION

DO SOMETHING THAT HELPS YOU RELAX

TAKE OUT SOMETIME EVERYDAY FOR YOURSELF

PATIENCE & PERSISTENCE

The BIG P – PLAY TIME

THE FIRST C – CLEAR, SPECIFIC & SHORT INSTRUCTIONS

So how should your instructions be?

2. Instructions in case of behavioral problems

THE SECOND C – CONSISTENCY

Tasks for discussion

THE THIRD C – CATCH HIM GOOD

How to ‘Catch him good’?

Tasks for discussion

THE FOURTH C: CUT DOWN CRITICAL COMMENTS

How to cut down critical comments & Ignore?

1. You are no good.

Practice the 4 Cs of Communication

1. Be clear and precise in your instructions

ENVIRONMENTAL MODIFICATIONS (PART I):

DEALING WITH HYPERACTIVITY

• 3 PS – PATIENCE, PERSISTENCE, PLAY TIME

▰ Clear, specific & short instruction

▰ Catch him/her good

▰ Cut down critical comments

Re-visit the problems related to hyperactivity

Environmental modifications include changes made in the environment (e.g. home or

How to manage hyperactivity?

Tasks for discussion/ Exercise

Practice the 4 Cs of Communication

1. Be clear and precise in your instructions

Cut down on critical comments and learn to ignore trivial misbehaviours

• Plan a physical sport (discuss with your child while planning)

ENVIRONMENTAL MODIFICATIONS (PART II):

DEALING WITH INATTENTION AND DISORGANISATION