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ADHD: Establishing Routines

The procedure

ADHD: Establishing Routines One of the first steps in reducing household chaos is to establish routines. That means determining what situations occur regularly and then establishing a structure or sequence to be repeated every single day. Routines mean repetition and repetition means practice. Practice allows a child to become proficient (or at least better) at completing the basic requirements by himself. This is helpful to all children, essential for some.

The process for establishing a routine or changing a specific behavior requires answers to three questions: What do I want the child to do instead of what he is doing? How can I put it in a visual format so he doesn't have to rely on me telling him what to do? What will make it worth his while?

Quick Tip
To establish routines or change behaviors, answer these questions:

• What do I want him to do instead of what he is doing?
• How can I put it in a visual format so he doesn't have to rely on me telling him what to do?
• What will make it worth his while?

Without an answer to all three questions you will have failed to clarify your expectations in a way that allows your child to check what you wanted and double-check his progress toward those expectations. A visual format gives him the ability to do that without you reminding him. Moreover, it provides the necessary incentive to keep him going.

Step 1: Deciding on tasksSteps Toward Establishing A Routine

Step 1: Decide What Tasks Must be Done
To establish a routine you first have to agree on what tasks are truly important--not your idealized vision of what your child ought to do. What absolutely must be included as a part of the daily routine? The school will allow any child to attend whether or not he has made his bed, but a teacher will frown on children arriving buck-naked. Decide what tasks are necessary and in what sequence you want them to be done. If your child is over four, try to include him in the decision making process. What does he think is important? Ask how much time he thinks he needs to get ready in the morning. Seek your child's input but keep in mind that very young children have no concept of time, and many challenging children have no inner clock; therefore they have no accurate sense of time passing. Furthermore, they may never develop one. Now is the time to teach them to rely on watches and timers.

Steps Toward Establishing a Routine

1. Decide what tasks must be done.
   • Separate the desirable from the truly essential. Ignore the unessential--you can expand the routine once your child has fully mastered the essential tasks.
   • Prioritize the important tasks.
2. Develop a written checklist and post it where your child will see it every time he needs to use it.
3. Reinforce routines with incentives for performance.

Quick Tip
Make decisions about routines with your child's input, especially older children and adolescents. They can better adhere to a routine they have helped develop.

Ask how many reminders your child thinks he needs to get out of bed. An adolescent will often say "none" and accede to one. Agree on a sequence, prioritize what's really important, develop a checklist, and post it.

The checklist becomes the standard, so that both you and your child use it as a reference point. Place the checklist where your child will see it every time he needs to use it or give him a new copy to use every day.

Quick Tip
For any new routine, develop a written checklist and post it where your child will see it every time he needs to use it.

Some children benefit from a short checklist attached with Velcro to their backpack. The list includes things like homework, assignment book, forms, and lunch money, which the child checks off as he fills the backpack. To help a child learn to use the list, the parent's responsibility is to reward the child for using it.

Parents need to establish a rule that "if it's not in the backpack and down by the door, it doesn't go to school." For the child to make the connection and take responsibility, he may have to bear the consequences a few times of having forgotten to put his homework in the backpack.

Parents must make sure that their expectations are realistic and reasonable. "Realistic" means that the child actually has the skills to perform those behaviors on his own. "Reasonable" means that parents are not asking too much. Can they reasonably expect their child to complete all that's being asked? Even with parental or external prompts, however, they cannot count on perfection. They can expect, given a limited number of tasks, that with practice, the child will be able to get through the list, Therefore, an effective checklist should not be more than three to eight items long, depending on age and abilitiy to follow through on things.

Get Ready the Night Before

1. Have your child pack his backpack (according to a list) the night before.
2. Place it by the front door. (very important)
3. All homework, schoolbooks, paper, pencils, permission slips must be in backpack the night before.
4. Reward the child for completing all aspects of the routine with minimum of support.

   Rule: If the item is not in there the night before, it doesn't go to school.
   Rule: If it's not in there, Mom or Dad won't bring it to school.

Step 2: Written checklistStep 2: Develop a Written Checklist and Post It

Checklists
Sharon: A short written list of two to six items not only establishes the steps of a routine, but conveys expectations and criteria for performance as well. The list's length depends on the child's age, as well as his level of distractibility. Limit lists for younger children to one to three items; three to six items for adolescents. Often parents send children to their rooms with the direction "Clean up your room." A challenging child can't break down this complex task into its component parts. To him it is overwhelming and he either "can't do it" or says, "I need your help." Remember too that for any child--not just challenging ones--the concept of cleaning differs substantially from yours. Yours is akin to House Beautiful and his is that he moves his socks. There's a big gap there.

A list clarifies expectations in clear, observable terms so that both parent and child know when the task is completed.

1. Trash in the trash can
2. Toys (books and papers) on the shelf and/or in toy box or milk crates
3. Dirty clothes in the hamper
4. Clean clothes in drawers and/or hung up

Write the list on an erasable white board, post it on a bulletin board in the bedroom, or put it on a Post-it Note that you stick on your child's door. Whatever you do, put the list where your child can't miss it. Remind him to check off each task as it is completed. Use picture cues for very young children. When your child says he's finished, you both survey the results as compared to the list. Acknowledge successful completion of each step. Call your child's attention to items still incomplete before he moves on to another activity. This way, the list defines "finished," not you.

Sharon: A list can also lay out a schedule. An afternoon checklist might be:

1. Snack
2. Homework
3. TV/free time
4. Dinner

If your child asks to watch TV, refer him to the schedule. That way, the list--not you--reminds him that the policy is homework before TV. Similarly, allow adolescents to decide which three of six chores they'll do by noon on Saturday and which three they'll complete before they go out Saturday night or Sunday afternoon. Implicit in this is that they must do all six before the weekend is over. In fact, they have to do them all before they earn the privilege of socializing on Saturday night or Sunday afternoon.

Picture Checklists for Younger Children
A younger child can work from a picture list or schedule. Have the child use a camera to take pictures that show "out of bed," "wash," "dress," "eat breakfast," etc. (Take an extra set. Your child may have photographed his toes.) Arrange the pictures in sequence on a Velcro strip. After he completes each step, he pulls a picture off and places it in an envelope. When he finishes the sequence, he brings you the envelope.

Checklists + Schedules = Predictability = Fewer Meltdowns
Schedules visually demonstrate sequence to a child, thus making his world more predictable. A child enters a situation with a preconceived notion about what the outcome will be. Often, some of the worst meltdowns occur when a child's concept of outcome does not match reality. Some children have particular difficulty making transitions. Knowing what will happen, as well as what will not happen, helps prevent those meltdowns.

Adults generally know what's on the agenda. They know the stops they intend to make (or don't intend to make) when they're running errands. It's not a state secret. But we generally don't share our agenda until the child demands to stop for fast food. ("We can't, we don't have time. It's not on our schedule." "What schedule?" the kid wails.) Or when your teen thinks a trip to the mall was to buy her Nikes. Try not to take this personally, but your children are not interested in going to the linen store. It isn't on their schedule. A list of intended errands that the child can check off or the teen can review to see that the shoe store is only one of the stops reduces fallout. Errand lists are especially successful if you include child-friendly stops, contingent on their behavior at other stops.

Step 3: ReinforcementStep 3: Reinforce Routines with Incentives for Performance
In most families, the reinforcer offered the child is the absence of parental wrath. "If you do this, I won't scream and yell at you." As any experienced parent knows, that doesn't always work. The list reminds the child what he's expected to do. Now the challenge is to find something to associate with it that is so important to the child that he will use the list on a daily basis. What works as a reward may change and needs to be reviewed on a regular basis. Determining what is an effective reinforcer is key.

Jan: What incentive did Theodore have to follow his morning list? The immediate gratification of playing with LEGOs and reading books still afforded greater pleasure than did following a routine and getting out of the house, even if the new routine had reduced the volume of sound emanating from Mom and Dad. We decided that money was the incentive Theodore needed. We realized, however, that the list was too long for one reward to keep Theodore focused. At Sharon's suggestion, we split the list in half. If Theodore finished the first half by 8:00 A.M., he would receive ten cents. If he completed the second half by 8:20, he received another ten cents.

A little experience resulted in a refinement. The delay and then "hurry up and finish" syndrome particularly affected the second half of the list, so we redesigned the incentive. If he finished after the deadline, but before 8:25, he didn't get the second ten cents but he didn't lose anything either. But if he took until after 8:25, and we had to hustle him out the door by collecting his lunch box, combing his hair, etc., then he had to pay us ten cents.

Accounting for completion of the routine was the final step. I printed up multiple copies of his morning list on the computer. He kept them next to his alarm clock in his bedroom. When he finished the list, he stuffed that copy of it in an old mayonnaise jar on the kitchen counter. Every Sunday night, we added up what he had earned and that became part of his allowance. Although some children need the more immediate feedback of allowance money paid daily, for Theodore, watching the lists accumulate in the jar and getting paid on Sundays was sufficient.

The list--with monetary rewards--proved to be a surprisingly effective tool. The reward was an incentive, not a bribe. As Sharon reminded us, a bribe is payment for doing something wrong or outside the law. In this case, the incentive got him to do what we wanted, which was something he had trouble doing on his own. For the most part, we stopped nagging and yelling, and he assumed responsibility (mostly) for getting himself out the door in the morning.

Summary of Process for Establishing Routines

• Include the child in discussions whenever possible.
• Identify siuations that occur on a frequent basis.
• What do I want him to do instead of what he's doing?
  • Determine one to five things (depending on child's age) that need to be accomplished as part of that routine.
  • Discuss and decide on the number of reminders needed.
  • Determine the time frame for completing steps.
• How can I put expectations and progress in a visual format?
  • Develop documentation (chart, checklist).
• What would make it worth his while?
  • Decide on reinforcer for successful completion of retine within specified time.
  • Review steps of routine, tools (checklists, timers), and rewards with the child.

Other toolsOther Tools to Help Establish Routines
Calendars
Another useful trick for establishing children's routines is to use calendars. They provide visual documentation of daily activities and can be used to resolve conflicts between child and adult expectations. Almost every household has a calendar; many even have a family calendar. But it's rarely used by anyone other than the parent.

Calendars can supplement daily checklists. Once the child masters the list, your expectations can increase to cover day-to-day changes (the band instrument on Tuesdays, for instance). Use supplemental visual cues. One way is to color code items according to the day your child needs them. With masking tape and Magic Markers, tag each item with a small square of tape colored with a marker. Use the same marker and highlight the appropriate day on a calendar--blue for Monday, red for Tuesday, and so on. The child checks the calendar (posted close to the door) and takes the items coded for that day. (To make this system work--at least initially--keep all coded items by the door with the calendar close by.) This system not only increases a child's ability to act independently, it also acquaints him with a meaningful use for a calendar.

Once your child has developed proficiency with a daily checklist, you can combine the calendar and list in one format. The calendar can include a list of things needed daily as well as color-coded items. This reminds the child of what he's responsible for on a daily basis--homework, assignment notebook, lunch or lunch money--without relying on parental support. Parents need to update the calendar list and, at least initially, double-check and reinforce compliance. But once he gets it right, you don't have to keep reminding him.

Also use calendars to schedule all family members' commitments in one place. When a child comes home and asks, "Will you take me to get poster board for my project?" (which, by the way, was assigned three weeks ago and is due tomorrow) and you have to take his brother to a piano lesson, the calendar can convey the bad news--so you don't have to. Your reply is "I don't know. Check the calendar to see if I have to be someplace else." So, too, when Maria comes home and asks if Anna can spend the night tonight (something you are the last to know since she and Anna have made all the plans), let the calendar convey the decision. If your household policy is, "Ask two days in advance; if the answer is yes, it goes on the calendar. If it's not on the calendar it doesn't happen," the calendar communicates the response. One last example: Your younger child asks to go to the park on Saturday. You say, "We'll see," which by Saturday morning becomes interpreted as "You promised!" If the family policy is, "If agreed to, it goes on the calendar. If it's not on the calendar ..." To make this system work you need to wean yourself from that parental cop-out "We'll see," which usually means "probably not" to you and "yes" to your child. If it's "no," say so; if you're not sure, set a definite time by which you will tell your child one way or the other.

Quick Tip
Use calendars to document family activities and privileges. If it's not on the calendar, it doesn't happen.

Calendars are also great for recording interim objectives and deadlines for long-term projects. Many children, especially those with ADHD and some learning disabilities, have difficulty breaking down large tasks into their component parts. Calendars provide a visual format for taking those parts, once established, and, working back from the final due date, determining short-term objectives and deadlines for each step. Children need this skill as they get older and the assignments' complexity increases. By middle school, teachers assume children have the ability to organize, work, and complete tasks independently. Therefore, introduce these tools as early as possible.

TimersTimers
Timers provide visual and auditory cues to document time. Time has no meaning for young children and most kids with ADHD. To them, it is something controlled by adults. "It's time for bed." "Who says?" Or, "Let's get going, we're in a hurry." "Who's in a hurry? I'm not in a hurry." To them there is always more than enough time to do things they don't like to do and not enough time to do things they enjoy. When you stop a fun activity, they want to shoot the messenger.

The timer says "time is up" so you don't have to say it. Before your child turns on the television, sits down at the computer, or starts talking on the telephone, set a timer to determine when time for that activity has expired. Have the child set the timer, or at least get him to acknowledge what happens when the timer rings. When it rings, and he appeals or complains, your response can be: "I'd like you to have more time, but the timer rang." You can be on his side and still make clear that time is not something you control.

Quick Tip
Use a kitchen timer to determine when "time's up" for your child's activity. The timer enforces the rule--not Mom or Dad.

It is essential that you reinforce the timer's decision (even if your child strenuously objects). As long as you adhere to the policy that something happens every time the timer rings (and "that something" does not include resetting it) the timer will become the enforcer.

Pointer for Effective Parenting
Something happens every time the timer rings but that does not include you or your child resetting it.

Timers are even more effective when paired with incentives. Reinforce compliance with the timer and/or completing the task before the timer rings. An incentive gives the timer special significance, giving him a reason to respond. Simply keeping a tally of times when your child complies with or beats the timer gives it greater importance. Each success can earn a timer credit that your child can accumulate and cash in for privileges. Set a minimum for each day. A half hour of television requires six timer credits; ten credits keeps the light on twenty minutes later at bedtime.

Quick Tip
Provide an incentive for your child to respond to the timer. He can earn it by ending an activity when the timer goes off or by completing a task before it rings.

Quick Tip
A watch with one or more alarms enables a child to take on more responsibility for managing his own time and obligations.

Sharon: The timer can also be a tool that protects the child's interests in his struggle against you, the timekeeper. In the past, when he wanted your attention, often his request was met with that maddening response: "In a minute." But how long was that minute? No wonder your child reacts so negatively to hearing that now. As far as he knows, it's that dreaded adult minute and you'll never show up. A timer can hold us to the same standard we impose on our children. When you respond to their request for time and attention with the suggestion to "get the timer and I'll set it for fifteen minutes. When the bell rings, I'll stop what I'm doing and come into your room," a child can accept this answer. If you adhere to the timer whenever it is used, your child can trust it to get you to stop, as promised.

Visual cuesAdditional Visual Cues
In many households, "trespassing" is the basis for a lot of arguments. Siblings invade each other's space and take things without first asking permission. What belongs to you, the parents, belongs to everyone. These infractions don't include the times when children get into things that are potentially dangerous. This is another opportunity to use visual cues. Colored dots (available at office supply stores) are perfect for color coding items to show ownership. Use red and green dots to mark areas or rooms that are either okay to enter (green) or are off limits (red). Put red dots on cabinets that hold "you need permission" or "these aren't yours" items. Label free-access cabinets and closets with green dots.

Quick Tip
Use red and green colored dots (available at office supply stores) to mark areas or rooms that are either okay to enter (green) or are off limits (red). This is especially useful for young children.

Labeled or color-coded milk crates can be the basis for organizing and marking ownership of possessions. A milk crate or carton in the front closet is the perfect place for shoes. Use a set of crates to hold different items--shoes in red, hats in blue, gloves in green. Their presence reminds everyone of the proper place to drop their things. (If all shoes are left there when family members come home, the box limits the scope of that last-minute, mad search for missing shoes.) Alternatively, colored crates can distinguish who owns what--Tommy's things in blue, Joe's in green.

Quick Tip
Use different colored milk crates in the front closet to organize or mark ownership of personal possessions.

Quick Tip
Using a milk crate, carton, or box in the front closet or by the front door to store all shoes eliminates that last-minute, frantic search for missing shoes.

Letter boxes on the homework desk labeled "finished" and "questions for later" act as visual cues that improve both organization and materials management. Completed work goes directly in the "finished" box rather than being shuffled (and lost forever) among other papers for later placement in a homework file or a student's notebook. The "questions" box allows a student to move on to something else rather than get up to seek help or sit and do nothing until assistance is offered. A child who needs a great deal of adult support will rarely get back on task once he's up and wandering the house.

Quick Tip
Use letter boxes labeled "finished" and "questions for later" for your child's homework. Completed work can be transferred later into the child's notebook or file folder for transport to school.

Of course, these visual prompts are only as successful as your support for their use. If you don't reinforce your child's use of the tools, it probably won't happen.

Structure and predictabilityBuilding Structure and Predictability through Routines
All children need structure in their lives. Some can develop it for themselves, but most--especially challenging ones--need adults to provide that structure for them. Similarly, most kids prefer predictability. They like to know roughly how the day will go, what will happen if they misbehave, and that there will be no school on holidays. For some children, however, predictability isn't merely desirable or preferable--it's essential.

Theodore: I like to know what's going to happen because then I can prepare myself. I need to know ahead of time exactly what's going to happen and for how long. Otherwise, I get upset if things don't go the way I expect them to. For example, when we're down at the beach, we used to have a lot of arguments because I got fidgety not knowing how we were going to spend the day. I'd think to myself that I'd be able to play Game Boy for much of the day, but I'd get mad when my parents would make me go for a walk on the beach. I'd get upset because I hadn't expected to do that. I had too much free time down there. Sometimes, partway through the week, I'd want to go home. Once we began drawing up a daily schedule for me, I did much better because I knew what to expect. If I knew I was going to take a walk on the beach because it was on my schedule, that was OK.

Sharon: Kids like Theodore, and that includes almost all challenging children, whether they have ADHD or not, need to know what to expect ahead of time. This information helps make their life predictable, giving them a sense that they can navigate their world successfully. Otherwise, they feel out of control or overwhelmed by the moment. When they feel out of control, they may act that way. They need structure and predictability. Without this, it is difficult for them to make lasting changes in their behavior.

Providing structure and establishing routines is easier than you think. Although children have difficulty doing so on their own, you can help them if you remember to ask the following:

• What do I want him to do instead of what he's doing?
• What are the behaviors and/or steps that are most necessary to the situation?
• How can I put that in a visual format so he doesn't have to rely on me telling him what to do?
• What would make it worth his while?