(p. 63) Module 3: Maintaining a Consistent Schedule and Time Management
(Recommended Length: 1 or 2 Sessions)
Materials Needed for the Module
Forms, parent summaries, worksheets, and handouts appear in Appendix A: Client Materials, located at the end of this therapist guide. You may photocopy this material for your clients, or you may download these items from the Treatments ThatWork web site at www.oxfordclinicalpsych.com/ADHDparenting. For a therapist outline of this and all modules, go to Appendix B: Therapist Outlines.
(p. 64) Home Practice Review from Module 2
Given the importance of home practice, it is critical to take a few minutes to review parents’ practice since the last session. Taking time for this review each week not only conveys the importance of home practice but also helps to troubleshoot any problems they encountered before covering new material. Note that this home practice review can be done in either individual or group formats.
Module 2 taught parents about the importance of increasing pleasant activities with their child (Special Time) and on their own (identifying specific activities that are important to them and can be added to their schedule). Review Worksheet 2.1: Special Time Record Form, Worksheet 2.2: Pleasant Activities, and Worksheet 2.3: Looking at Connections: My Mood/Stress, Caregiving, and Activities. If parents did not practice at home, spend time reviewing the rationale for home practice and help them to troubleshoot any problems they encountered. If needed, you can bring in MI to motivate behavior change (see Introduction). You can use some of the following questions to facilitate the home practice review:
■Were you able to practice Special Time last week? What activities did your child choose? What was your child’s reaction?
■How did you feel during Special Time? (Was it hard to relax? Did your mood change?)
■How did it go avoiding questions and directing? Did any challenges come up?
Monitoring Mood and Pleasant Activities
■Have you been monitoring your mood? Are you having any difficulty with this—remembering to do it, coming up with the mood rating, and so on?
■What pleasant activities did you do since we last met? Any trouble with this that I can help you with?
If needed, review what was discussed in Module 1 with Special Time as an example of a pleasant activity that can have a positive influence on the parent’s mood (draw the cognitive-behavioral therapy [CBT] triangle and arrow pointing from behavior to feelings to review this concept). If parents mention having unpleasant feelings during Special Time, refer to the CBT model and ask if they were aware of thoughts about themselves, their child, or parenting during Special Time.
Make sure to adjust the home practice review based on what was assigned in the previous session. If topics haven’t been covered yet, omit the questions about that content from the home practice review. Also, if this home practice review does not include content that has been covered and assigned for home practice (e.g., if you are doing modules in a different order), make sure to expand the home practice review to include all assigned items.
Overall Module 3 Goals and Rationale
During Module 3, parents learn to develop and maintain a consistent household schedule and daily routines, both with their child and for themselves. This involves learning to use a prioritized task list if they don’t already do so.
All children benefit from consistent structure and routines, but children with attention-deficit/hyperactivity disorder (ADHD) can be especially reactive when their environment is unpredictable or chaotic (think, orchid!). External structure can scaffold the child with ADHD’s own sense of organization. In other words, if children themselves feel internally disorganized, the adults around them can provide a sense of external structure and organization. Thus, being planful about how to structure the family’s daily routines (e.g., doing homework before the child is too tired and/or their ADHD medication has worn off), breaking down morning and bedtime routines into clear and manageable steps (e.g., brush teeth, change into pajamas, read for 10 minutes), and making sure the child gets adequate sleep will help to prevent child misbehavior and make it more likely that the child with ADHD will more easily (p. 66) follow through with the steps of their daily routines. Repeating routines consistently over the long term makes these routines automatic, ultimately reducing parent–child conflict.
In many families, parents of children with ADHD struggle with executive function or attention difficulties themselves. Teaching parents to implement a consistent daily schedule and to more effectively manage their time also serves to reduce parental stress and frustration, which can contribute to harsh or negative parenting and the negative sequelae of a dysregulated parent and poor parent–child relationship. Teaching parents to impose more structure onto their daily lives will also help them to be proactive versus reactive in their parenting. With your support, parents can think about other areas of their lives where routines can be helpful (e.g., reviewing and prioritizing a task list for the next day before they leave work so they may arrive home with less stress, hanging their keys on the same hook when they walk into the house, going to bed on time to get adequate sleep, etc.). An organized parent is going to be much better able to help their child with ADHD be organized and on top of things—and to do so more calmly! In this module, you will work with parents on the basics of scheduling and time management so that their households will run more smoothly and their children with ADHD will know what to expect. The ultimate goal, with practice, is for the child to be on “autopilot” when moving through the many steps of the morning, homework, or bedtime routines. This can lead to a more organized and harmonious household.
Specific goals for this module include
■Goal 1: Teach parents about the importance of maintaining a consistent and predictable daily schedule for the child with ADHD and the family as a whole.
■Goal 2: Work with the parent to thoughtfully schedule daily activities, such as sleep and wake times, mealtimes, and homework time to optimize the child’s success.
■Goal 3: Work with the parent on developing consistent daily routines (e.g., breaking down the morning and evening routines into component parts).
■Goal 4: Introduce time management strategies (e.g., a prioritized to-do list) to help parents more effectively scaffold and model time management for their child with ADHD.
(p. 67) ■Goal 5: Help parents understand the value of consistent household structure while remaining flexible in the face of unexpected changes to help with their own and their child’s emotion regulation.
Module 3 Content (Divided by Goals)
Children with ADHD are more sensitive to their environments and tend to thrive on external structure and consistency given their own internal disorganization and difficulty maintaining attention. For all of the reasons outlined in the previous section, maintaining a consistent and predictable daily schedule for the child and family is an important “antecedent” that can improve the happiness and functioning of the entire family. In other words, if the child lacks internal structure and organization, parental scaffolding and structure can create an external sense of organization, structure, and predictability for the child.
You can say something like,
All children thrive with external structure, and children with ADHD are even more sensitive to the negative effects of inconsistent schedules and the stress of having essential tasks not done when needed (especially when parents need to have more time and energy to keep their child on track!). A therapeutic environment for children with ADHD is one in which routines and necessary tasks are clear and predictable. How is your family doing now with establishing consistent routines and completing necessary tasks?
Begin this part of the session by brainstorming with the parent their day-to-day tasks and activities (alone and with the child). Such tasks usually include waking up, getting ready for school/work, daytime (p. 68) tasks/responsibilities (work, caring for house and children, etc.), getting ready for and attending extracurricular activities, mealtimes, homework, and bedtime. A good general principle to apply throughout the discussion of routines is that we often underestimate the time it takes to do something. For example, people can be regularly late for activities because they “get ready” to leave the house at the time they need to actually be leaving! The act of “leaving” (actually beginning to walk or drive away) can take up to 10 (or more) minutes. Thus, if this time is not included in the schedule, one will always be late! This proactive, planful thought process will make daily routines go more smoothly.
Sleep is absolutely critical for children with ADHD and their parents! If you ask parents to remember back to when their child was an infant, they will likely remember the “mental fog” they felt when they were waking up several times per night to feed and change the baby. We know that many individuals with ADHD have more difficulty sleeping (which can sometimes be exacerbated by stimulant medication), and they are also more sensitive to “sleep debt” than the average person. Lack of sleep can affect mood, executive functioning, and overall health for everyone—making everything worse. Similarly, parents will be more irritable, less patient, and less effective when they are themselves sleep-deprived (as so many parents are these days). For all of these reasons, the best place to start when arriving at a daily schedule is to begin with ensuring that the child and parent are getting adequate sleep.
Refer to the American Academy of Pediatrics (AAP) sleep guidelines (see Box 3.1) to help facilitate the discussion of the family’s sleep schedule and the factors that contribute to insufficient sleep time. Working backward from the AAP guidelines on the amount of sleep needed at various ages, work with the parent to determine a consistent wake time and bedtime for the child. Help the parent consider what time the child has to leave for school/daycare and how long it generally takes them to get ready through the morning and evening routines. Ideally, this bedtime will be adhered to 7 days per week (i.e., including weekends) to reduce sleep debt and enhance the consistency of the routine. (p. 69)
Reducing Morning Stress
You may recommend that parents consider an earlier wake up time if they currently get themselves ready for the day while their child(ren) are awake. Getting up earlier reduces the demands for multitasking, and parents can focus on helping the child stay on track without the stress and distraction of getting themselves ready as well. Note that this will require the parents to go to bed a little earlier, too. Waking up a little bit earlier can also allow parents time for self-care (e.g., taking a shower, enjoying a cup of coffee, exercising, reading the news) that will put them in a better mental space to work effectively and calmly with their child(ren) during the morning routine.
Another strategy to make mornings less hectic (an antecedent) is for the parent and child to determine which tasks can be done the night before. For example, getting the child into a routine of packing their backpack as soon as homework is completed reduces the child’s risk for misplacing the homework and/or forgetting to bring homework back to school, and it is one less thing to remember in the morning. Similarly, lunches can often be made the night before to ease the stress of the morning rush. Choosing clothes the night before can prevent stress about this decision in the morning. Depending on the child’s age/developmental (p. 70) level, they can be involved in these tasks because they will need to learn to independently complete such routines as they grow older.
It is helpful to consider schedules for eating as well. Hunger can be an antecedent to misbehavior (kids and parents can get “hangry”), and acting proactively to ensure that snacks and meals are predictable and available can help to prevent problems. When working on the meal schedule, consider any appetite suppression the child experiences related to stimulant medication. It is important that the child eats a high-protein meal before taking medication and when they have an appetite later in the day to avoid the potential growth suppression effects of stimulant medication. To avoid side effects of insomnia, the medication must be given on a consistent schedule (if the child takes it too late it will interfere with sleep), and thus medication times and meals need to be planned carefully.
There are many benefits to shared family meals, including healthier eating habits, better psychological well-being, and even lower risk of substance use and delinquency for teens (Musick & Meier, 2012). Identifying a time in the schedule when families can share a meal together (usually dinner) is therefore worth the effort, and this is another situation where proactive planning can make a big impact on stress. Scheduling time for meal planning and preparation (you can even suggest that the parent add these tasks to the schedule they are developing during this session) can make it much easier to eat family meals on a tight time schedule during the week. This is also a time when parental expectations (i.e., thoughts) can be identified if they lead to increased stress. Giving themselves permission to prepare simple and fast meals and to reduce accommodation for picky eating (instead of making multiple different meals) can help the parent gain some needed time in their schedule.
It can be difficult for all family members to sit down and eat at the same time each day, but with some creativity and persistence families can often find some time in their schedule where this is possible. Examples include family breakfast (some days this is easier than dinner, with work (p. 71) schedules, school events, and extracurricular activities), sitting when the kids have an afternoon snack or dinner even if parents aren’t eating at the same time (rather than using this time to get other chores done or have kids watch a screen while eating), or a ritual for a weekend meal (pancake breakfast on Saturdays, taco dinner on Tuesdays, pizza night on Fridays etc.). If you ask parents to share memories from their own childhood, they are likely to remember rituals like family dinners that were special because they were done consistently and they could count on them happening.
Homework is often a struggle for children with ADHD, so it is critical that homework is consistently done at a time that maximizes the child’s attentional capacity. For example, if the child does not begin homework until they are tired from a long day, that fatigue will negatively impact their attention and mood, thereby exacerbating ADHD-related homework problems and parent–child conflict. Homework should also be done in a quiet room with few distractions (e.g., no TV, little noise from others).
Another factor to consider for children taking ADHD medications is that homework needs to be done when medication is active. Parents should work with their prescriber to understand the duration of action for their child’s medication, which does vary somewhat by individual. For this reason, parents should observe and ask the child about their focus and ability to persist on tasks. This may require some experimentation with homework times over a few weeks.
Some parents report that their child needs a break after focusing all day at school, and this is a valid point. A snack and a brief rest after school is helpful for many children. However, caution the parents to not allow the child to engage in any activities (e.g., TV or video games) which can create a challenging transition. This is another situation where paying attention to antecedents is helpful—putting less desirable activities (homework, getting dressed) before more desirable activities (screens, toys) in the schedule can prevent misbehavior that occurs when kids have to leave a desired activity to do something less desirable. Putting (p. 72) things in the schedule in the right order helps to maximize child attention and cooperation. Breaks can be a helpful antecedent, but parents need to make sure the break is rejuvenating and doesn’t interfere with task completion.
The timing of activities like homework in your child’s schedule is important. Children will naturally choose to do more desirable activities first, and parents then have challenges with transitions and the child’s ability to focus on necessary tasks like homework. Children will sometimes say they need a break, and it is true that too many “have-to’s” in your child’s schedule will decrease motivation! However, the order in which things are done and choosing break times and activities that are rejuvenating (versus those that create conflict) must be considered when planning your child’s schedule.
Help parents understand that, in general, a “when-then” approach is often most effective (“when you finish your homework, then you can go outside to play/have screen time”). This can also have the long-term effect of teaching children to delay gratification, get the essential tasks done first, and then reward themselves with a more preferred activity and deserved break. You can note that this strategy works for parents as well, and many adults benefit at home and work from using the Premack principle: a behavior that happens reliably (more desirable behavior) can be used as a reinforcer for a behavior that occurs less reliably (less desirable behavior). You can ask parents how this principle might help them with tasks related to the schedule changes you’ve discussed today.
Children with ADHD often need support getting started, persisting, and/or completing tasks during homework. Talk with parents about skills that children need to complete homework (such as creating a to-do list, breaking larger tasks into smaller parts, estimating time needed to complete tasks, organizing materials, and designating a quiet work area) and how their child can be supported as they learn and develop these skills. Parenting skills reviewed throughout this therapist guide can also be applied to homework time. For example, parents should provide labeled praise (see Module 4) for getting started on homework, staying on task, working carefully, and putting completed homework in their folder). Parents can also actively ignore (see Module 5) complaining, tapping pencils, humming, or standing at the homework desk/table. (p. 73)
When children need to use the computer for school assignments, it can be difficult to stay on task. Help parents consider how to reduce access to other websites or computer games during homework if distractibility is a concern (see the Resources section at the end of this module). Parents may also need to communicate with their child’s school (see Module 8) about the child’s computer use at school to limit distractions and ensure appropriate use.
Bedtime is another challenging time because children rarely want to go to bed and miss all the fun! Parents should estimate the time it takes for the child to get ready for bed and even allow for some extra time given that things usually take longer than expected. Remind the parent that we often underestimate the time it takes to do something if we include the time needed for preparation and transitions. Sleep routines (including reading together) are essential for good sleep hygiene. Screens, on the other hand, can have a negative impact on sleep quality and should be avoided for 30–120 minutes before bedtime. (If relevant, refer to the Resources section at the end of this module for links with more information for parents about the effects of screen time on sleep.) For older children who may have their own mobile devices, these should be removed from the bedroom to avoid screen time after the parent leaves the room. There are also ways for parents to monitor and turn off devices remotely to limit conflict around screen time limits (see Resources). It can be beneficial to have the goal of everyone in the family following a calming routine in the hour before the children’s bedtime to put the whole house in “sleep mode,” taking the noise level and even the lights down a notch to prepare the child for bed.
Special Time and Pleasant Activities
Special Time (see Module 2) should be added to the daily schedule to increase the likelihood that it will happen each day. Thoughtfully consider (p. 74) with the parent how much time is possible (ideally 10 minutes) and the natural time of day this could most easily fit into the schedule (e.g., after dinner or at bedtime). The goal is to do Special Time most days of the week, although it may be truncated on nights when the child has an extracurricular activity, or it can be folded into another activity like bath time, riding in the car (e.g., parent can allow the child to lead the conversation), or giving positive attention during an extracurricular activity.
Finally, when considering their own schedules, remind parents to include on the daily schedule their own pleasurable activities that are mood elevating, such as exercise, calling a friend/family member, reading a book, or watching a favorite TV show/Netflix episode. If parents seem overwhelmed, preview that you will soon talk about ways to approach and prioritize tasks to help them protect time for self-care activities. You can also validate that, during certain parenting “seasons,” it is more difficult to practice self-care and that is why you will support them in finding ways to move in the right direction—it doesn’t have to be a perfect schedule, just one that considers parent needs and mental/physical health.
As parents write their schedule, if there are busy days with little unstructured time for the parents’ own pleasurable activity and Special Time, they can try to identify a short time where the parent and child can engage in a pleasurable activity together like doing a short yoga practice together at home (there are many free yoga videos online), watching a favorite TV show together, or playing a game of cards.
Children with ADHD benefit from spending time outdoors and engaging in physical activity (e.g., Gawrilow, Stadler, Langguth, Naumann, & Boeck, 2016). That can often be challenging to fit in, especially when the weather is not optimal for outdoor activities. If physical activity has not come up during the discussion of daily routines, ask about it and help parents think about where they can fit it in. It can be as simple as taking a walk after dinner, doing yoga together (may double as a parent pleasant activity), going for a bike ride, having a “dance party,” or running around the house! (p. 75)
Also, parents and children often have weekly activities that may change the daily schedule. This may include doctor’s appointments, sports, religious activities, or irregular parent work schedules. Think ahead with parents about how these activities may impact the daily routine and how to keep the daily routine as consistent and predictable as possible. Discuss with parents the benefits of previewing changes to the routine with their child as a helpful antecedent and learning opportunity for their child. In addition, encourage parents to think about the things that may get in the way of them maintaining their schedule and plan ahead for those things, too. For example, parents can put their mobile phones away if they think they may be interrupted during an activity chosen for relaxation. A theme here is to help parents be proactive (as opposed to reactive) in anticipating and planning for deviations from the daily schedule.
Each daily routine we have discussed thus far is actually a complex organizational task with multiple steps. Multistep routines or activities tax the attentional capacity of most children with ADHD (as well as parents who struggle with their own executive functioning deficits). Have the parent walk through the steps of their or their child’s morning routine: wake up, shower, brush/floss teeth, eat breakfast, get dressed, get backpack ready (ideally done the night before), get shoes (and coat) on, and get out the door (more or less!). Homework involves writing down the assignment, bringing home necessary materials, getting started, reading directions, completing the homework, checking one’s work, and putting it back in a folder and then in the backpack (not to mention remembering to turn it in!). That means homework consists of eight steps. This type of complex organizational task taps exactly the distractibility, forgetfulness, and disorganization that characterize ADHD. This is greatly compounded when caregivers themselves also struggle with attention/executive functioning difficulties.
Breaking down these complex, multistep routines is a challenging but essential skill for children with ADHD to learn, especially as they move toward greater independence in middle school, high school, and eventually college or other postsecondary settings. Working with the parent (p. 76) and child together (if the child can be present in session, or coaching the parent to work with the child later at home if the child is not present) is an important exercise.
We usually recommend beginning with one daily routine at a time (additional routines can be added after the family experiences success with the first one). Attacking all routines at once may be overwhelming for the parent, and success with the first routine can motivate and give the parent the confidence to add others. Brainstorming together, it is useful to create a step-by-step checklist that can be written on a whiteboard (dry-erase board) or printed on a paper/poster board that is hung prominently in the home. Give parents Handout 3.1, Sample Routines, and review it with them. This handout provides a good example of daily routines for a school-aged child, and you can talk with parents about how it would look different for a younger child. For example, pictures (rather than words) are helpful for younger children who cannot yet read. Involving the child in this process of breaking down and writing out steps (or finding the pictures) gives them more ownership of their routine. The child may write out the routine in their own words or decorate the poster with their favorite things. Then, as each step is completed, the child can check it off and move on to the next step.
Note that this is a good time to remind parents to praise the child for staying on task and completing each step of the routine (see Module 4 for more detail on this). Some parents are resistant to doing this because they may feel that the child should be doing these things on their own without praise; however, you can gently remind such parents that their child is currently not doing these things independently, and doing so requires more effort from the child than things they have mastered (or for peers of the same age without ADHD). You may also remind parents that ADHD is a brain-based disorder that makes it harder for their child to focus, and more frequent praise for each step of the routine is part of providing a therapeutic environment for their child.
Children may also receive a reward/reinforcer for completing their routine in a timely manner, such as a special treat with their lunch or the natural reinforcer of some time to watch TV or play on a tablet before they head out the door (although, as noted earlier, disengaging the child from these activities may become an issue, in which case this should be avoided). You can let parents know that, later in the program, you (p. 77) will discuss more structured ways of rewarding their child to motivate them during challenging times of day (Module 10). For now, try to help parents consistently use the skills suggested in this module to see if this resolves the struggle.
Managing a schedule and getting things done may not be an issue for every parent with whom you work, but for some parents who struggle with their own motivation, procrastination, or attention problems, scheduling and accomplishing goals is a major challenge. This is especially true for parents who suffer from depression or adult ADHD.
Some parents participating in this program may have told you at this point that they have a mental health disorder. That may be why they selected this program. Other parents may not have reported a mental health diagnosis, but you may suspect one. If a parent is experiencing mental health difficulties that require more than what is provided in this program, this could be a good time to gently provide referrals for an evaluation, medication (e.g., in the case of undiagnosed adult ADHD), or their own therapy.
All of the strategies discussed in this module involve scheduling. Parents have so many things going on in their day-to-day lives that it is nearly impossible for someone to remember everything without some type of calendar system. Some parents may carry a planner book or use an online calendar already (like Google Calendar or Tasks), but others will not be using such tools and will need more support with this.
If parents are already using a calendar system, take some time to learn about their system, how well it is working, and difficulties they experience. Troubleshoot with them any pitfalls of their current system, and ask if they are interested in your suggestions to help with scheduling (p. 78) (using motivational interviewing [MI] style). Common issues are that parents have a calendar but forget to check it (or forget to add items to it), have multiple calendars (which can be very confusing and result in double booking), or are simply inconsistent in using the system.
Online calendar systems are ideal because they are with us all the time (given that most people use smartphones) and they allow us to enter recurrent activities and set alarms to remind us when to leave, etc. These online calendars can be shared with the co-parent, babysitter, or even with older children who have their own devices. Again, by using these strategies and incorporating the child in the process, the parent is teaching the child critical life skills that they can adopt on their own as they get older.
As you are working through the daily schedule, spend some session time entering the daily routine you worked out together into the parent’s calendar system and set reminders. (You can often set multiple reminders, for example 15, 10, and 5 minutes before an activity.) Remind parents that previous skills/strategies learned in the program should be added to the calendar, including Special Time with the child and the parent’s own pleasant activities (Module 2). Prepare the parent by setting the expectation that most systems for scheduling need some adjustments and to consider this a trial period when they will get good information to identify what works for them and what doesn’t.
Prioritized To-Do Lists
With all of the competing demands on parents, it can be hard to keep track of everything they have to do. Also, there is not enough time in the day for parents to do all of these things! That is why keeping to-do lists and prioritizing tasks is such an important skill (and another skill that is useful to teach and model for the child). Many of the online calendar systems and scheduling apps have corresponding to-do lists that include an option to put in a deadline (e.g., Google Calendar and Tasks).
Many parents relate to the idea that too much time is spent on distracting (or delayable) tasks rather than having true priorities determine where our time goes. This is natural! However, many parents (p. 79) feel overwhelmed and guilty with thoughts of never doing enough. The Eisenhower Matrix (also known as the Urgent-Important Matrix) can be used to help parents view tasks based on their importance and urgency. This matrix stems from a quote by President Eisenhower: “I have two kinds of problems, the urgent and the important. The urgent are not important, and the important are never urgent.” Tasks can be sorted into four quadrants—important and urgent, important and not urgent, urgent and not important, and not urgent and not important—that help us make decisions about how to spend our time. Give parents Worksheet 3.1: Categorizing Tasks, located in Appendix A, to complete as an in-session activity during this discussion.
Examples of the Urgent-Important Matrix include
■Important and Urgent: Comforting your child when they are hurt (do this right away)
■Important and Not Urgent: Teaching your child something (can be added to the schedule)
■Urgent and Not Important: Going to the store because you are out of milk (can be delegated if you don’t have time or delayed)
■Not Urgent and Not Important: Making the bed (can be left undone)
Most parents find that there are not enough hours in the day to get everything done! When parenting a child with ADHD, your ability to effectively manage your time and energy is especially important given your child’s needs for more support compared to their same-age peers. To reduce stress and increase feelings of accomplishment, using a system like the Eisenhower Matrix can help you to determine which tasks are most important for your family and which tasks may be distracting or able to be delayed. As you think about your daily schedule and the things we discussed today, can you think of any tasks/activities that get in the way of your priorities?
[Examples: If calls or emails are distracting, some parents find it helpful to put their phone away during certain parts of the routine (e.g., from 6 to 8 pm or 7 to 8 am). If parents are very stressed about getting chores done when their child needs their support, seeing the task as delayable (or able to be delegated) can help parents prioritize what is most important in that moment.]
Indeed, parents may need to learn to accept that not all tasks will be completed each day and to be kind to themselves about the things that do not get done. They may need to adjust their standards (e.g., giving themselves permission to have a messy family room or to order take-out once in a while) or call in supports (co-parent, neighbor, babysitter, or cleaning person) if possible to get everything done with less stress. For a parent who has rigid thinking about expectations for themselves and their family (“I should be able to do this without help”), use the CBT model (thoughts-feelings-behaviors) to help them identify more helpful thinking to change how they feel. Module 4 gives more specific ways to help parents with changing their thinking, including their expectations of themselves and others that lead to feelings of stress, resentment, or anxiety.
Assertiveness (Saying “No” and Feeling OK About It)
For some parents, assertiveness skills (taught and practiced in Module 6) will need to be used so they do not overcommit and take on too many obligations. You can normalize that many people need practice to say “no” when they have the desire to help others and contribute. Being mindful of the limits of our energy and time can help us to make the commitments that are most important and to say “no” or “not at this time” when we need to. If this is particularly difficult for a parent, suggest a small step toward having more boundaries that can help with stress: have the parent practice saying, “I’ll need to get back to you” when a request is made to give them additional time to decide if they can/want to add something to their to-do list and schedule. Adding a “pause” or waiting 24 hours before agreeing to something is a good rule of thumb. Co-parents may also need to think about the current division of responsibilities and changes that can help with times of day that are most stressful for the family. For example, sharing or delegating a task to a co-parent can make the morning or evening routines more manageable for both parents.
Maintaining enough energy to support your child and your own self-care will require saying “no” to requests and not doing things even though you would like to do them if time and energy were limitless. We will talk later in the program about assertiveness skills that can also help with managing your time and delegating. For this week, is there any (p. 81) boundary you can set (even a small one) that can protect you from taking on too much?
Schedules, routines, and prioritized to-do lists are extremely helpful when they are approached with the flexibility needed for the realities of day-to-day life with children. When parents are too rigid, they are less likely to use good problem-solving skills and model good flexibility for their child.
You can ask, “What things may influence your family’s ability to follow a schedule or complete ‘to do’s’ on any given day?” Examples include illness, a co-parent traveling, a new activity starting, a large project due, and visitors.
Parents and children alike may have difficulty when there are changes to the schedule (especially if these changes are last-minute). Understanding that changes/challenges will occur in life and that not everything is in our control can help us calmly and strategically problem-solve when these things do happen. It helps to understand one’s priorities (e.g., sleep, homework) and to consider what is not absolutely necessary to achieve on any given day (tidying up or other household chores). Sometimes dinner will need to be later (or frozen) to adjust to these changes, and that is OK! Remember, a calm and well-grounded parent helps the child to stay well-regulated.
In addition, schedules may need to change as activities are added or as children’s needs change over time. Let parents know that if the schedule or routine isn’t working at a later point, they should review the routine and make course corrections as needed.
Group Options: Here are a few questions to jump-start group discussion:
■Can a few people share what has worked for them in terms of a daily schedule for your child/family? What has worked and not worked?
■What type of calendar system do you use and why do you like it?
■Does anyone use particular apps for a prioritized to-do list?
Some parents resist the idea of having a consistent daily schedule because they prefer to be more spontaneous and flexible. It is possible that this style worked for them in the past when they had fewer responsibilities and things to juggle. Given what we know about how children with ADHD thrive with structure and routines, we expect that instilling some consistency in the day-to-day routine will reduce family stress and conflict.
MI might be helpful in these instances. You can say something like, “On one hand, you prefer to be spontaneous and unplanned, but on the other hand you notice that your child has more difficulty with less structured situations . . . (silence). . . . What do you make of this?”
The goal is for such parents to give these skills a try and to know that you will work with them to ensure that whatever you set up fits with their lifestyle and goals.
At the end of each session, distribute the Parent Module Summary and reinforce the fact that the information discussed today will now be practiced at home. Home practice for this module includes:
■ Implementing a daily schedule or routine
■ Practicing using at least one of the time management techniques discussed in this session
■ Completing Worksheet 3.2: Looking at Connections: My Mood/Stress, Caregiving, and Activities
■ Completing Worksheet 3.3: Special Time Record Form
Remind parents about the schedule/routine that you worked on in session and encourage them to test it out before the next session. Also, ask parents to identify one time management strategy they would like to try this week that they are not currently using (a calendar system, a prioritized to-do list, delegating or not doing a task that is not a priority, saying “I’ll have to get back to you” or “Not at this time” to a request for something that will take time and is not a priority, etc.). Ask parents (p. 83) if they anticipate any problems with the home practice this week and troubleshoot.
When presenting the two worksheets for home practice, parents may need you to explain why they need to do those home practices again this week. Although these skills were not discussed much in Module 3, practicing them until they become routine is essential to the success of this program. As parents incorporate pleasant activities and Special Time into their schedule, they will see a more positive mood and improved child behavior. If parents reported feeling better over the past week or noticed an improvement in their child’s behavior, remind them of that and link it to their home practice completion. If they stop doing these things, they will not experience the full benefits of the program.