Trouble with skill-building for ADHD? Here’s help

For kids who struggle with ADHD, building skills like executive function and self-advocacy can be difficult. 

In this episode of In It, hosts Gretchen Vierstra and Rachel Bozek welcome Dr. Andy Kahn. Andy is a licensed psychologist and the associate director of behavior change and expertise here at Understood. He’s also the host of the podcast Parenting Behavior with Dr. Andy Kahn. 

Andy discusses why skill-building is important for kids with ADHD. He also shares many ways families can help.

We love hearing from our listeners. Email us at init@understood.org.

• Understanding impulsivity in kids

• The 3 areas of executive function

• ADHD medication shortages: 8 ways to cope

• Listen: Talking through social struggles

• Listen: The power of self-advocacy for kids at IEP and 504 meetings

(1:27) Reasons why some kids do not take meds

(3:42) Areas where skill-building can help kids with ADHD

(5:33) Skill-building for executive function

(10:38) Skill-building for social situations

(15:40) Skill-building for impulsivity

(19:25) Understanding and working on self-advocacy

(23:00) The connection between access to medication and skill-building

Gretchen: Hello and welcome to "In It," a podcast for families with kids who learn and think differently.

Rachel: Here you'll find advice, camaraderie, stories of successes, and yes, sometimes failures from experts and from parents and caregivers like you.

Gretchen: I'm Gretchen Vierstra, a former classroom teacher and an editor here at Understood.org.

Rachel: And I'm Rachel Bozek, a writer, editor, and mom who has definitely been in it.

Gretchen: Rachel, we've talked a lot on the show about the benefits and challenges of trying out ADHD medication for kids.

Rachel: That's right. And for a lot of families, meds can be a real lifesaver.

Gretchen: But medication is just one tool in the toolbox when it comes to managing ADHD symptoms. And for some families, it might not even be an option.

Rachel: Right. So, today we want to talk about all of the other things you can do to help a child build the skills they need to thrive with ADHD. Skills to help with impulsivity, executive function, emotional regulation. All of the things.

Gretchen: All of the things. To do that, we're bringing back Andy Kahn, who at this point, is basically like a resident expert on "In It."

Rachel: Andy is a licensed psychologist and the associate director of behavior change and expertise here at Understood. He's also the host of the podcast "Parenting Behavior with Dr. Andy Kahn." Andy, welcome back to "In It."

Andy: Hey, guys. Thanks so much for having me.

Gretchen: OK. As you know, we're talking today about skill building for kids who aren't taking medication for ADHD. But first I want to ask you, what are some reasons a child might not be taking ADHD medication?

Andy: Oh, it's such a, such a sticky wicket for so many families. You know, so in my clinical experience, more common than not, it's parents are often reluctant to start with medications at the beginning. So, for a lot of parents, when they've come to see me for therapy, the idea is, "Hey, you know, can we do something in the interim? Can we do something to not take meds?"

Gretchen: Yeah.

Andy: Because people are just naturally reluctant, which is completely OK. Because obviously, like any medical intervention, there are risks and benefits that people want to consider. One of the things that's come up a lot in addition are the recent shortages.

Gretchen: Yes.

Andy: So, we've had stimulant shortages, what, since maybe the 18 months into Covid? We saw massive shortages and they've continued. So, parents are reluctant to engage because they don't want to chase the medication and have to call six pharmacies to see "Can I get the days of meds that my kid needs if they're on a stimulant?" So, those are really practical issues.

You know, and for some families, you can also think about things like they tried meds in the past and it didn't work. Maybe a bad side effect or they just really weren't comfortable with how it was going. Which again, very understandable. Nothing makes us more nervous and concerned than when our own kids are really uncomfortable physically as well as emotionally.

Gretchen: And might there be times when the child says, "I don't want to take this"?

Andy: Yeah. One of my most common topics with families is when their kids, or even their older teen, no longer wants to take medication or doesn't want to take it in the first place. You know, I often say to parents when, let's say, I've got a kid who's seven, eight years old and they're taking meds and they're doing their treatments and they're reluctant to do skill building.

One of the things I'll say to them is, "You know, one of the things developmentally, we can sort of predict is that a lot of our kids, as they want to become more strong individuals, one of the things they may grab on to is, 'Hey, I don't want to take these meds anymore.' And if you don't have the right skills in place and your child's not developmentally ready to handle this on their own, you know, that's something to be concerned with if you've had good med response."

Rachel: So, you mentioned skill-building. I want to talk a little bit more about that. What are some areas that a kid who has ADHD might need to do some skill-building in?

Andy: Sure. So, there's some really key categories. And I think the one thing I want to emphasize here is that while we talk about categories, naturally, many of these categories will overlap, and that'll be more clear as we break them down. So, when we think about things like, you know, impulsivity, these behaviors our kids show us before they think through what they're doing and causes a lot of challenge in day to day life. Executive function challenges those day to day activities, how they plan, organize, and execute, whether it's messy rooms to failure to do homework, to coming home without your clothes. You know, these any number of things that can really be challenging for our kids.

Emotional regulation is a big one. Kids with ADHD are prone to having big emotions and in turn, from big emotions come big reactions. And this can be barriers to all kinds of daily activities in their lives. Social skills for many, many kids, not being mindful of and aware of aspects of the social environment that let them be successful. And you could see where that overlaps. Again, if you're not emotionally regulated, you're too impulsive, it's going to make friendships a little more challenging.

And one area that is always top of mind for me, particularly as kids are getting older, is self-advocacy. How do I say what I need? Say what's not working for me and get the things I need from my world. Through the things I do? And it's obviously skills kids will develop over time, but it's always something I'm thinking about. Even when you have little kids in terms of, you know, very few people listen to their voices or give them a voice to share what it is that they need and how that's going to work for them.

Gretchen: So, executive function. That seems to be a biggie, right?

Rachel: Yeah.

Andy: Absolutely.

Gretchen: So, what are some things you might tell kids to do to work on that? Or what might parents do to support their kids at home, like actual tangible things?

Andy: Sure. So, the key with executive function is the fact that kids with executive function disabilities or kids with ADHD, for example, tend not to organize, plan, structure, and engage in multi-step activities in a natural way, and I'll speak as an adult with ADHD. These are things that give me challenges even today. So the best way to start approaching executive function is to talk about concrete skills like setting rituals and routines that can help your child build together the steps they need to be successful in any number of daily tasks.

Let me start with an example here. So, one of my favorite sort of K successes, I had a nine-year-old boy I was working with for a period of time, and he had really severe executive function challenges. He would come home without his belongings, rarely completed work, and his space was just a catastrophe. And his parents were at wit's end because, you know, you're always chasing the thing that your kid isn't doing and you're cleaning up the mess.

Gretchen: Right.

Andy: And number one area of challenge, after school routines. He comes in the door and you hear him the second he comes in the door, the door slams, you hear the thud, you hear the shuffle, which is the bag hitting the floor, the shoe sliding across the vestibule, and he enters that kitchen half-dressed, you know, hand, the dirty hand in the cookie jar, and as happy and as lovely as can be, right? And we're happy to see our kids, but, like, you hear that tornado come through the door and you're like, "Oh, my lord, what do I have to go clean up now?"

So, we did something that I call, reverse fireman drills. And I'll, let me clarify. If you ever look at firefighters and how they get in and out of the fire station, they actually have to get be able to get out of bed into their gear and into that truck really quickly. So, they sort of create strategies where all of their clothes and their equipment is laid out in a stepwise order. They literally like, jump in the pants, get on the boots, pull on the coat, you know, grab the helmet, slide down the pole. Well, what if we do this for our kids, but we do it sort of in reverse?

When that child comes home, we were using tape lines and tags everywhere. First thing he gets in the door, there's a marker for jacket, a little picture jacket. Immediately to the right of that, a little tape outline of where his shoes and boots went, and then a little square for his backpack. And he places things in order from closest to, farthest from the door. Immediately, once he's got those things done, he's at least somewhat ready to be in that home, and his stuff is in the box, so to speak, in that limited area.

But you can see what we're doing here is we're first creating those really concrete cues that show the child "This is exactly where stuff goes. We planned it and practiced. It seems silly and we made a bit of a game of it." But you know, the kids like to do things like, "Oh, how quickly can I do this part of the routine." And in the game aspect of it, we were really able to add some steps and give that child a few little bits of independence. And from there, we have all kinds of step-by-step rituals, for things like navigating the backpack. What is a parent's worst nightmare? Looking in the kid's backpack after school. It is usually a pile of garbage, crumpled paper, spoiled food, you name it.

Gretchen: Fun discoveries.

Andy: Yeah. You know, awful when those discoveries are a week later and you come out with an an identifiable dark goo, right?

Gretchen: Yeah.

Andy: Which we've all done. But really having routines daily for disassembling and reassembling their materials, including my favorite folder for the backpack. I have folders for, work that came home today. Things that must go back to school. And the other one is things I don't know what to do with, my favorite folder, and it tends to be fairly large. Instead of shoving stuff, we have that folder because one of the goals for executive function is to use that folder to say, "OK, this is something that needs sorting and organizing.

Gretchen: Yeah.

Andy: The idea here is that we're creating really concrete steps and rituals that over time, while the child may not have this internally, they're going to see that "Wait a second. I'm not having as much conflict with my parent. I actually know where some of my stuff is because it always goes in the same place."

Rachel: Yeah.

Andy: For a parent who's dealing with a kid with ADHD, there's these 7000 cues we give, and then we're exasperated. So, give less cues, do more practice, and create steps. So, that's just like a little example of how we navigate some of the executive function for a fairly young child coming home from school.

Rachel: So, what about social skills? What are some skill-building things to do on that front. Because that I know is really hard for a lot of kids with ADHD.

Andy: Oh yeah. Yeah. And like as we said earlier, the idea of social skills, social skills, are generally things that develop more slowly for many kids with ADHD, primarily because they're struggling to pick up on the subtle cues and may not always be able to attend and focus on the things that other people want, or the things they're telling you with their body and how they're speaking to you. So, for a lot of kids, especially when they're young, we talk a lot about rehearsal. How do we do things like role-playing?

And again, it can be goofy and it can feel really funny. And it's OK to laugh with your kids about this, but the idea of like, practicing a greeting, the idea "Hey, how are you today?" And having just that one thing you're going to use to hook that conversation going a little bit more.

You know, teaching kids that great conversation starters are things about like, do you have a shared interest with that child? You see, oh, they have a Pokemon on their backpack, "Hey, I like Pokemon too. What's your, do you have a favorite Pokemon?" or you know, "What cards do you have?" Like any of these things that allows the kids to engage their peers in conversation. But these are things you need to practice.

Very oftentimes self-regulation and social skills are skills that come together. So, before they launch into an interaction with a peer who they're really interested in chatting with, we might do a practice of a little deep breathing. Get your body and mind a little more chilled out, take that breath and then start. It's funny because as I did that here, you know, on mic, I'm like, "Wait a second. My pace is slowing down a little bit because I'm excited about my, like, I've got my buddies here who I can sort of go deep with, right?" Like, we all nerd out on the same stuff.

So, when I get excited and have people who have share intense interests with me, what happens? I get a dopamine surge, I get a little more energetic, my words start to go fast. Then you take a breath, you're like, "Wait, OK, well, hang on, I can do both of these things. I can be a little calmer, and I can have these conversations about shared interests and topics."

The other thing that we do in terms of the role-playing and rehearsal is making sure that we have opportunities for kids, you know, to have a way to get out of a conversation if they need to know how to, "How do I finish this?" Sometimes the best social interaction is a brief one that's successful and ends naturally, the ones that sort of fade awkwardly, those are terrible. Those are not reinforcing for a future conversation.

Gretchen: Nobody likes those.

Rachel: Just walking away, mid-sentence.

Andy: Yeah. The classic middle school phrase that I remember hearing when I would go off the rails, was "OK, so I..." you know, and they'd like, and they'd go off. Like, and I remember thinking, "Oh gosh, did I just come across as like this golden retriever puppy who just has no control?" And, you know, it's, those were the things that happened. So, being able to keep those interactions short, successful, and sweet make them more likely to happen again.

And having conversations with your child from a positive slant like, "Hey, did you have any nice interactions today? Are there kids you really like talking to? How's that going?" For parents when you're asking your kids about their social skills, it's really easy to say, "So what's not going well?" And starting with"Hey, are you still having problem with that boy on the bus?"

Remember, our attention is the most reinforcing things we give our kids. So, if you bring up a negative topic and they want your attention, they may dive right into that and focus on negative topics. And that really sort of can trap you so that the next day they come home, they're talking about negative things because they knew what got your attention.

Gretchen: Well, that's interesting.

Andy: And that's something you can be really selective about. If your child brings up something like, "Yeah, you know, I really tried to talk to Johnny today in the playground and he just walked away in the middle of it." In those situations, the most important thing you can do for your child: be present and be empathic. "Oh, that must have felt really, really bad. Like, was that, were you really uncomfortable? OK." And then you can ask one of the most important questions "Hey, is that something you want me to help you solve, or did you just want to share that with me?" You know?

Gretchen: I try to do that. Sometimes it's hard to remember.

Andy: It is. Well, because we want our kids' distress to go away.

Gretchen: Yeah.

Andy: So, our first parent instinct is "How can I fix this for you?" Which, which isn't always our best instinct, right? It's you know, our kids actually should be uncomfortable, have experience of discomfort and be able to navigate through it which builds them resiliency and stamina and problem-solving skills. If we always make the stress go away, you get a lot of really whiny kids who don't really achieve anything cool or have the ability to do something that is difficult, and that's ultimately, none of us want to do that, it's just a trap we fall into, you know?

Gretchen: I want to ask about another tricky area for kids, with ADHD, which is one of the things you mentioned early on, impulsivity. Like, are there actually skill-building activities you can do around impulsivity? Because that seems really hard to me.

Rachel: Yeah.

Andy: Yeah. I think the answer is complicated, which is always is in my line of work. Impulsivity in and of itself is a developmental skill, you know, so if you had a toddler, you would expect that, you know, you're going to need to childproof because they're mobile, curious, and they don't really have the ability to think through things. So, when you get a toddler plus, which is your, you know, your young school-age child who has all the same interests, mobility, and mischief-making abilities, sometimes you need to just take away access to some of the things that would be problematic for you.

I'll give you an example. So, there's a kid I was working with, about eight years old, you know, right in that sweet spot of old enough to know what we want them to do and when they shouldn't have certain things, but impulsive enough to know that, "Hey, I can sneak things I want when my parents aren't paying attention." So, this child was routinely during times when it wasn't allowed, sneaking their gaming system, their portable gaming system, and going in to hang in the bathroom or put it under their pillow so that at night time when everyone was in bed, they were staying up in gaming.

And, you know, the parents were consistently saying, "Yeah, this is really impulsive. He can't stop this behavior." And then I asked a question and I said, "It might sound stupid, but like, why aren't you locking up the system? Like, is there a place you can put it that he can access it?"

Gretchen: Right.

Andy: And their response was, "Yeah, we really, like we really don't want to do that." And I'm like, "Do you want the behavior to change? You've been doing the same thing over and over again and you have the same result. So, my instinct is that your child isn't able to control that impulse yet." So, we set a schedule for game times. When the game times weren't going on, we would put the item away and that child couldn't access it.

As they started to manage their gameplay and be appropriate and ask for it when they should, and you know, and show us that they were able to do a little more of what they needed to. Then they started to take some time to leave it in a common space where the child should know, "Hey, this isn't time for it, but it's here for during the times when it's on your schedule."

And give your child the opportunity to show they can control themselves. If they don't, you say, "Oh well, you know, we were trying it, but it didn't work. You know, we're not going to give a massive consequence here unless there was some deception. We put the thing back away and we'll try again in a couple of weeks or a month." In those situations, kids need eventually to have opportunities to be tempted and still make the choice. So, impulsivity can also be managed with again, some emotion regulation skill.

So, here, think about it from this perspective: What do we want kids to do? We want them to think before they act. So, in daily activities we do things like we plan a pause. So, before we start eating dinner, before we start an activity, we say, "OK, time out, stop, take a pause. Take a deep breath. OK, now we're going to do the activity.

Just practicing pausing between things that aren't super, super high stakes, gives your child the opportunity to sort of interrupt the automatic. Impulsivity is the urge to do something in the moment without consideration? So, by putting in these natural pauses can be really helpful for some kids and some families.

Again, some of these things are just, they're not ready, right? They're not ready and the skill isn't going to be internal for them. But over time it's something that we can train and we can practice.

Gretchen: I like the pausing. Yeah.

Rachel: So, what about self-advocacy? Because I feel like that one's a little different from, like, all of the rest of these.

Andy: Yeah. Self-advocacy at its core, is a pretty advanced skill. Self-advocacy is the idea that we ask for the things that we want, and we try to help the world be aware of us and what our needs are. So, for some kids, the beginnings of self-advocacy are things like teaching them about what's different about their brain. When kids have ADHD and they're struggling and they get frustrated, those are great education opportunities for parents to say, "You know, this is part of how your brain is wired. It's really difficult, but we're going to develop strategies for it."

In the meantime, for example, if a child is in school and let's say they've got a 504, they've got an accommodation plan and they're struggling with something, parents can talk to kids about what's on their plan. So, like, "Oh, wait a second, this space is too noisy or, I need to put on my noise-canceling headphones." In those situations, we practice that at home with our kids. They're doing homework, and we notice they're struggling, "Hey, here's your skill."

Now, for kids who aren't verbally able to do this for themselves, a great way to build self-advocacy is to start writing down on little cards the skills they need are the things they need. So, headphones or, extra time or a break. And kids who have access to little cards might be more willing to step up and put that on a teacher's desk, or to pull that input on the kitchen table while doing homework. The idea here is we want to take the internal process that they're going through and create a way for them to engage with "This is what I need. This is what will help me."

And parents and teachers can support this in their kids because as kids get older, one of the things that we see a lot of, and this was a big factor in my life, was masking. I would do everything I could to look like it wasn't a problem, but I wasn't being effective. And if someone gave me a way to access one of my skills, but I wasn't going to be embarrassed by it, that was a game changer. I wanted to avoid shame and embarrassment at all cost, and I think that's a big factor as kids grow up with ADHD, if they're diagnosed a little older, they're teenagers, they're going to say, "I don't want my 504. I don't want to look different."

Rachel: Right.

Andy: So, we have to figure out how to look less different, you know?

Rachel: Yeah.

Andy: So, self-advocacy really comes from you have to have an understanding a little bit about how your brain works and what you need, and then whatever level of willingness to ask for that, then giving them permission and praise. So, when kids self-advocate, you know, if they do that in class, the parent might say, "Hey, if my kid uses their self-advocating cards, let's say a couple of times a day, can you drop me an email? And I'm going to give him a reward at home." In those situations, you know we want to give them a little bit of indication this is great. The best way to do that is to praise.

If you can, you know, in a subtle way say "I'm really proud of you for using your skills. It's a really big deal. And look what and look what happened. You got your work done." Why do we do that? Because that's really the reward. You were able to, on your own, see what you needed, ask for what you needed, and be successful. Because remember, these differences in ADHD aren't things we're necessarily going to outgrow, but we can accommodate it, we can develop skills. And that's why we want our kids to be independently accessing what they need to thrive and be successful.

Rachel: In cases where someone who is taking medication for ADHD suddenly can't access that medication. What is a kid and their family in that situation to do? Like, we can't assume that they're going to just learn all of these skills overnight. What advice do you have for, you know, families who find themselves there? You know, in panic.

Andy: Yeah. Well, I mean, don't we all? I mean, certainly. I think for the last two years at least, this has been a common conversation with parents. You know, in terms of problem-solving, skills are the key. We're going to be saying, "Listen, what we've learned based on what the availability of medications are, is that we need to be building these skills, and then we need our crisis plan, which is if my child doesn't have their medications, what are we going to share and how are we going to make this navigate and bridge this with places like coaches and teachers and friends."

So, in those situations, you know, pre-teaching teachers saying, "Hey, you know we're struggling sometimes getting our meds. So, if we're struggling at the end of the month I may send in a note to you saying, this is where my kid's at right now. Could we try to navigate this with, you know, a little more movement time or being aware of upping those accommodations a little bit because they're not can internally be as able to do it?"

Rachel: So, it sounds like from what you're saying, the key is that kids on meds should always be doing skill-building at the same time, right? The two go hand in hand?

Andy: That's always my bias.

Rachel: Got it.

Andy: It's that, you know, why not maximize? And again, if kids are naturally going to want to age out and say "I don't want meds anymore," and they've really developed great self-advocacy and good independent skills, you know what? There is nothing wrong with them taking that approach, particularly as they're in adulthood and thinking about, you know, what works for them.

I think the conversation always is this: "We try strategies, we develop skills so that you can be as independent as possible." And I would begrudge no young person that opportunity. I would just say that if we're going to, if they're on meds and they're coming off, let's take some data. Let's keep track of how this is going. Because if it's not going well for you and you're failing or you're having a lot more impact, we want to be mindful of "Do we come back to this conversation again at some point in the future?" Make it a collaboration instead of a declaration, so to speak.

Gretchen: Great advice Andy, as usual. This has been so helpful.

Rachel: Yes, thank you so much.

Andy: Glad to be here, folks. Thank you so much for having me.

Rachel: Thanks so much for listening today. If you have any thoughts about the episode, we'd love to hear from you. You can email us at init@understood.org.

Gretchen: And check out the show notes for this episode, where we have more resources and links to anything we mentioned.

Rachel: This show is brought to you by Understood.org. Understood is a nonprofit organization dedicated to empowering people with learning and thinking differences like ADHD and dyslexia. If you'd like to help us continue this work, donate at Understood.org/give.

Gretchen: "In It" is produced and edited by Julie Subrin, with additional production support from Cody Nelson and Samiah Adams. Justin D. Wright mixes the show and Mike Errico wrote our theme music. Briana Berry is our production director. Neil Drumming is our editorial director.

Rachel: From Understood.org, our executive directors are Laura Key, Scott Cocchiere, and Seth Melnick. Thanks for listening.

Gretchen: And thanks for always being "in it" with us.