The world is constantly changing. Today music comes on small CDs and video games can be played on telephones. Computers can fit in the palm of your hand. Just as electronics change, so does treatment for Attention Deficit Hyperactive Disorder (ADHD). However, unlike electronics, the study of ADHD is still in its infant stages, and there is still much to discover. At times, this can be frustrating to parents who expect instant cures. Until more research is done, parents need to be patient, willing to educate themselves, and practice a comprehensive approach toward ADHD treatment. The purpose of this handout is to help you learn more about ADHD and the comprehensive approach for ADHD.
If your child has been diagnosed ADHD, the best place to start is to learn all you can about this disorder and various treatments. There are literally a hundred books you can read on this subject. Many of these books conflict with one another. Maybe one reason for the conflict is that until recently, ADHD had not been viewed as a collection of disorders with a variety of possible causes. While one treatment approach was effective for one type of ADHD, it was ineffective for other types. Since you know your child better than any professional could, as you read, you can decide which treatment approach is most likely to help your child.
Assessment. The next step in successfully treating ADHD is a good assessment. ADHD is an easy diagnosis to give. All that is required is that the child meet certain behavioral symptoms found in the DSM-IV, a book that lists all the symptoms of psychiatric disorders. These symptoms include:
- inattentiveness (unable to maintain sustained attention to a task)
- easily distracted
- fails to finish tasks (e.g., when asked to take out the trash the child ends up watching TV with the trash can).
- often losing things necessary for tasks or activities at home or at school
- impulsivity (acting without much thought of the consequences)
- shifts from one activity to another
- excessive talking
- excessive motor movement (e.g., fidgeting, unable to sit still)
- unable to remain seated for a period of time
- these symptoms start before age seven
The difficult part in assessing ADHD is that there are many conditions that will cause these symptoms. The following is a partial list of causes of ADHD symptoms:
- genetic (e.g., Mom and/or Dad had ADHD and passed the trait to their children). It is estimated that 30% of ADHD children have relatives that are also ADHD.
- problems at birth (e.g., low oxygen, fetal alcohol syndrome, born premature, cocaine babies)
- environmental: some children from homes with little discipline often display the above symptoms
- allergic reaction: where ADHD symptoms are caused by intalerance to a food additive, sugar or certain foods (e.g., milk, corn, wheat)
- lead poisoning or other heavy metals
- a hyperactive thyroid
- history of abuse within the family (e.g., domestic violence, physical abuse, sexual abuse)
- developmental vision problems: children who do not process what they see close up
- auditory processing problems: children who do not process what they hear
- children with other learning problems (e.g., dyslexia, dysgraphia)
- manic-depression or bipolar disorder
- children who are oppositional and defiant (they do not mind)
- intellectual giftedness (children with I.Q. scores over 130)
- children who are dependent on constant supervision while doing school work
- hypoglycemic children
- children with iron deficiencies
Probably the most common cause of ADHD is a genetic cause. Many families with ADHD children report that at least one parent had similar problems in school as their child. Some argue that allergies are the most common cause of ADHD symptoms. Causes due to abuse (e.g., domestic violence, physical abuse, sexual abuse), environment, and birth problems are unfortunately very common also. ADHD symptoms due to lead poisoning, hypoglycemia, and hyperactive thyroid are less common.
One point needs further explanation. Depression, bi-polar, hypoglycemia and other disorders do not cause ADHD, but often produce symptoms similar to the symptoms of ADHD. While there are genetic and environmental causes to ADHD, the disorders that mimic the symptoms of ADHD are often completely separate and have causes of their own.
A child with ADHD symptoms may have one or more of the above conditions. Logically, knowing the cause of the symptoms will determine what types of treatment are necessary. For example, if the ADHD symptoms are caused by lead toxicity, treatment involves testing for the amount of lead in the child's body, removing the lead from the child's home, removing the lead from the child's body, assessing if any permanent damage has been caused to the child's nervous system, and the treatment of such damage. If a child has an overactive thyroid, medicine (thyroid hormone) can usually correct the problem.
Lead toxicity, iron deficiencies, and hypoglycemia can all be detected by your child's physician. The possibility of intellectual giftedness, environmental issues, domestic violence, and genetic influences can be assessed by a Psychologist through intellectual testing and a thorough social history. Finally, allergic reactions can be determined by an allergist who specializes in the behavioral reactions to allergies. Because these conditions are often overlooked, too many children are receiving the wrong type of treatment for their ADHD symptoms.
When assessing ADHD, parents should insure that a variety of measures are used. A complete assessment involves a clinical interview, medical tests, checklists, observations, a social history, and objective measurements (e.g., a computerized measure of attention). A psychologist and a medical doctor can help you obtain these tests. The resulting information will help determine the severity of the symptoms, the type of intervention to use, and measure treatment effectiveness. The latest techniques in assessment involve collecting information from the person’s brain. In 1996, R. J. Chabot identified eight subtypes of ADHD based on brain wave patterns. Dr. Daniel Amen has identified seven types of Attention Deficit Disorder (ADD) based on pictures of the brain using a technique called SPECT imagry. While these techniques advance the assessment of ADHD, they are too expensive for most professionals to use. However, Dr. Amen has made a checklist of the symptom characteristics of his six ADD subtypes. The checklist provides an inexpensive tool to identify the likely type of ADHD. Dr. Amen also recommends a comprehensive set of treatment methods to treat each ADHD subtype.
In summary, assessment involves not only determining if a child has ADHD, but also determining the type of ADHD, the likely causes and measures the amount of the symptoms. This information will be useful in determining what treatments to give and how to measure treatment success. If the treatment is successful, the number and/or intensity of the ADHD symptoms will become less. The following sections of this pamphlet deal with various treatments to consider for a comprehensive approach toward ADHD treatment.
Psychotherapy. Counseling or psychotherapy is a very important part to ADHD treatment. Psychotherapy is useful to teach children new skills to cope with and overcome the problems that arise with having ADHD. The goals of psychotherapy may include but are not limited to the following: increase attention span, increase self-esteem, effective parenting skills, effective communication, and decrease impulsive and aggressive behaviors, and excessive motor activities. There are several forms of psychotherapy that are beneficial and often crucial to the treatment of ADHD.
Behavior Modification. Probably the most beneficial form of psychotherapy for ADHD children is behavior modification. Done correctly, it can make a big difference. Behavior therapy involves targeting a desired behavior to change (increase or decrease), defining this behavior in measurable terms, counting how many times the behavior happens before any effort to correct it is done, making a plan to correct the behavior, following this plan, and then gathering more measures to make sure that the plan works. If the plan is good, the behavior will decrease or increase depending on what is desired. If the plan is not working, it can be adjusted or it can be thrown out and a new plan used instead. With behavior modification, parents play a major role in measuring the behaviors and working the plan.
Dr. David B. Stein developed a complete treatment program using prinicples of behavior modification applied by parents of children with ADHD symptoms. In a published journal article he demonstred the programs effectivness on 35 children diagnoses with ADHD. After a few short weeks of his treatment, all participants were symptom free and continued to be symptom free at their follow-up a year later. His program does not use medication, eeg biofeedback, nor supplements. The program is entirely based on behavior modification.
Parents should learn principles of behavior modification to help them better parent their ADHD children. Ask your therapist for more information about behavior modification. THIS IS VERY IMPORTANT.
Counseling. Counseling can help with the 'internal' effects of ADHD. This includes feelings of low self worth, depression, anger management and a variety of other concerns common to children with ADHD. A form of counseling called "self-talk" is a technique used to help reduce the tendency of an ADHD child to act without thinking. It also is used to increase a child's ability to remain on task at school. Other counseling techniques help children feel better about themselves. When children feel good about themselves, they are more likely to follow the advise of parents and professionals.
Play therapy. For young children, play therapy can be very useful. A therapist may use play therapy to measure children's skills, measure the amount of impulsiveness, or assess possible internal conflicts or struggles. Play therapy can also be used to help overcome conflicts caused by having ADHD. What is more important, therapists will often use play to establish a good relationship with children that encourages them to participate and return to therapy.
Exercises. Many exercises have been developed to strengthen attention, short term memory and other skills often lacking in children with ADHD problems. For example, relaxation exercises are often used to teach the child how be calm and cope with life's problems. The Memory Game is used to help ADHD children to remember verbal commands while self-monitoring helps them remain "on task" when completing their school work. (Consult with your therapist on using these exercises.)
To get the most benefit from an exercise, choose one that you feel your child could use most. Practice the exercise for at least six of the seven days of the week. Usually most exercises will be mastered within a two month period. Every child is different and may master the exercise faster or slower. After the child has mastered the skill and is using it without your supervision, you can practice a different exercise. Again choose the next exercise that you feel will achieve the most benefit. With time and neglect of practice, children will sometimes lose skills they have learned earlier. Thus your child may need to review a previously learned skill by practicing the exercise again until it is re-mastered.
Support Groups. It's difficult to parent ADHD children. Special parenting skills need to be developed that match their special needs. Family therapy, parenting classes and support groups are the most effective forms of treatment for ADHD children whose symptoms were caused by earlier parental permissiveness, domestic violence and dysfunctional homes. Symptoms can be greatly reduced by parents learning how to discipline effectively and be consistent. ADHD children need a structured yet nurturing environment. Most parents need help in learning how to provide their children with a balanced environment. Some parents can provide nurture but lack the ability to provide structure or vice versa.
Domestic violence is a cause of ADHD symptoms and aggression within children. Women's support groups offer long term help for mothers learning how to have a structured yet nurturing environment. In addition, the groups teach mothers how to help their children deal with their anger and aggressive behaviors. These groups can help the family overcome the many negative effects of domestic violence.
Biofeedback. Biofeedback is simply giving children information about their body (e.g., skin temperature, muscle tension, electrical activity, heart rate) and having them control their body in some way. Several forms of biofeedback are useful for ADHD children. Temperature biofeedback can be used to teach children relaxation and self control. Children can practice these self control exercises at home and at school.
Probably the most impressive form of Biofeedback is EEG Biofeedback where children are taught how to change their brain wave patterns. To briefly explain, theta brain waves happen with inattention and day dreaming. Beta waves happen when you are concentrating and remaining on task. EEG biofeedback trains children how to decrease theta waves and increase beta waves. Each biofeedback session takes about 30 minutes. After 40 sessions, many children have increased attention and less hyperactivity. Research studies suggests that EEG biofeedback can raise IQ scores as much as 15 points and raise grades in school. These improvements seem to be long lasting.
EEG biofeedback is an expensive treatment. Total treatment costs can range from $1,300 to $5,000. Clinics with high success rates combine nutritional supplements with EEG biofeedback. With EEG biofeedback, many children will no longer need medication. Other children will still need medication but show improvement in concentration and school work that would not have been possible without the EEG biofeedback.
Medication. Many professionals agree that medication should be used as a last resort. None of the other described techniques have as many possible harmful side effects as medication. However, of all the techniques presented in this pamphlet, medication provides the quickest and often the most dramatic change. It is the treatment of choice for children with a genetic cause of ADHD and whose behaviors are so far out of control that they are failing in school. For children who have experienced domestic violence, inconsistent home environments, have a learning disorder, and poor motivation for school work, medication may also help the child's ability to concentrate and remain on task.
Today there are a variety of medications used to treat ADHD symptoms. Probably the newest and most used medication today is Strattera. It acts similarly to the new antidepressants. It has the advantage of not being addicting. Prior to Strattera, the stimulant medications (e.g., Ritalin, Adderall, Concerta, Metadate, Dexedrine) were the most commonly used medications. They have the potential to be addicting if misused. Today these medications are still used with great frequency. Other non addicting prescription medication used to treat ADHD symptoms include Wellbutrin, Catapres and Tofranil. Only professionals trained in medicine can prescribe these medications. Your physician can help you decide which medication is right for your child.
There are conditions where medication should be used with great caution. For example, children who have ADHD symptoms that are really caused by the first symptoms of manic depressive disorder ( an illness of extreme mood swings) or a psychotic disorder (an illness where the child looses touch with reality) may have their symptoms worsened with stimulant medication. Likewise, children who have trouble concentrating because they are depressed, do not need stimulant medication. Other types medications may be more appropriate for these children.
There are conditions where medication should not be used. For example, some parents do not have time nor an interest to correctly discipline their children and use medication as a means of behavioral control while the child is at school. In these cases, the medication is not appropriate because it does not address the real cause of the problem. Treating a child with stimulants who has lead poisoning would also not be wise. After the lead toxicity is out of the body, and the body has had a chance to heal, the need for medication could then be determined. Therefore a thorough assessment is needed before medication is considered.
While most parents' goal should be treating their child effectively without medication, some children will need medication. To date, the science of alternative approaches to ADHD is not advanced enough to guarantee success with every ADHD child. Medication combined with other techniques will do much to deal with the devastating effects of severe ADHD symptoms.
Before taking medication, parents should know the pros and cons about prescription drugs. No medication is completely safe. While a stimulant (e.g., Ritalin, Cylert, Dexedrine, Adderal) medication may be relatively safe compared to other prescription drugs, some children will have severe reactions if the wrong diagnosis is made. For example, some children could develop muscle tics or twitches, jerking movements and increased sadness. If your child has any of these side effects from medication, contact your physician immediately. An overdose of stimulant medication could cause convulsions followed by coma, delirium, and high fever.
You may want to consider using medication to treat your ADHD child if alternative methods have either failed or are not affordable and you believe the medication will significantly improve your child's life. For example, if medication can keep a child from failing school, from getting into fights with other children, and behavior modification has failed, then medication should be attempted.
Once you decide to try medication, do not stop giving the medication too soon. At first, most children on stimulant medication will have some side effects such as lack of appetite, trouble falling asleep, headaches, irritability or increased blood pressure. Most of these side effects will go away within two weeks. Too often children are taken off medication too soon because parents become fearful of these side effects. Parents should try their physician's recommendations for at least six weeks before deciding whether to keep trying the medication or not. Keep in regular contact with your doctor to inform her or him of your child's progress with the medication and report all side effects. If you do decide to stop giving the medication, always inform your doctor of what you intend to do.
To find out if medicine is working or not, your child's symptoms should be measured before medication is given. Such measurements can be obtained through checklists completed by parents and school personnel, observations from trained personnel such as therapists or case managers, and measurements from computer programs (e.g., T.O.V.A., I.V.A). By continuing to measure your child's symptoms, the physician can monitor treatment success. This information provides parents with information to judge the worth of the medication.
Many parents mistakenly believe that medication should be enough to treat ADHD. They fail to realize that medication does not cure ADHD. It only reduces the symptoms of ADHD. For most children on medication, at first, they will improve in their school grades. However, research shows that over time, their grades decrease to their pre-medication levels. Medicine alone, even when it helps the child to move less and pay attention more, does not help improve school grades after six months, and does not improve a child's self-esteem. But medication, combined with psychotherapy and special parenting skills can help children increase their self- esteem, improve social skills, improve study habits, and learn new skills to deal with their ADHD symptoms.
Nutrition. Even though much controversy exists over nutrition, scientific research does suggest that nutrition can be very helpful in treating ADHD children. For children with food allergies that produce ADHD symptoms, the right diet can eliminate all ADHD symptoms and aggressive behaviors. Children with lead poisoning can use certain foods and nutritional supplements to remove the lead from their bodies faster.
If your child as an infant had to be switched to different formulas, or if your child has had numerous ear infections resulting in tubes being placed in the ears, allergies may be causing some of the ADHD symptoms. Dr. Block developed a method to treat ADHD symptoms through nutrition. These techniques are desribed in her book, No More ADHD: Ten Steps to help Improve Your Child's Attention and Behavior without Drugs!
There are some ADHD children who have multiple causes of ADHD symptoms. For example, many genetically caused ADHD children may also have allergic reactions to certain food. Many parents report that their ADHD child will act worse when eating chocolate or too much sugar. For the child with multiple causes of ADHD, elimination of chocolate and other foods that create allergic reactions will not completely remove symptoms of ADHD. Other treatment methods must be used as well.
Research suggests that most children will improve in IQ (an average of six points) and behaviors with appropriate nutrition. The first step in proper nutrition is to reduce the amount of junk foods. Parents should not allow their children to drink caffeine or eat too much sugar. As you decrease the junk food, you need to increase the nutritional foods. For the majority of ADHD children, diet alone is not likely to cure ADHD, however a healthy diet will improve symptoms. Some will show only minimal improvements with a good diet while others will show more dramatic changes. Another good book on this topic that is backed by extensive scientific research is Improve your Child's IQ and Behaviour by Stephen Schoenthaler (ISBN 0563-361-93X).
Some people use nutritional products to help calm the symptoms of ADHD. Before trying any nutritional product, educate yourself as much as possible to understand how the supplements are proposed to work. When you decide which supplements to take, contact your physician to insure that the supplements will not interfere with any medical treatments that are being performed with your child. Be careful and not give your child too much of the nutritional supplement because some supplements can be toxic at too high of levels. Also monitor for side effects, just as you would with medication. For example, some children develop motor movements (i.e. motor tics)with Vitamin B6, just as they would with a stimulant medication. What may be helpful to one child with ADHD symptoms, may be detrimental to another. Learn all that you can about nutritional products before you use them. Most professionals agree that the majority of nutritional supplements are safer than medication.
Many nutritional products have the potential to make a difference in reducing ADHD symptoms. Today a common nutritional supplement is Focus Factor by Vital Basics (www.focusfactor.com). It contains a combination of vitamins and minerals belived to help idividuals with ADHD symptoms. Some parents and professionals feel that Pycnogenol (Pine Bark Extract) to help children concentrate better. When considering vitamins and minerals, a complete Vitamin B complex has been suggested as a good place to start along with "colloidal minerals". Many parents swear by omega-3 fatty acids in the form of fish oil. Depending upon which of his seven types of ADD a person has, Dr. Amen recommends L-tyrosine, St. John's wort, 5-HTP, L-tryptophan, Inositol L-tryrosine, GABA, ginko biloba, phosphatidyl serine, vitamin E, Piracetam, DL-phenylalanine, SAMe, and Rainbow Light Brain and Focus MultiVitamin for Teens and Adults; and Barlean's Flax Oil. Both of these products contain no stimulants and can be purchased at most health food stores. Flax oil contains omega-3 fatty acids which is thought to be needed in most children with ADHD symptoms. Sound nutrition works well with behavior modification, exercises, and biofeedback. These techniques encourage brain cells to grow "dendrites" to other brain cells. As these dendrites grow, the child is able to overcome problems with attention, concentration, memory, etc. Vitamins and minerals supply the body with the raw materials to grow these needed dendrites. Vitamins and minerals also help the whole body to become more healthy and the mind to have a better attitude. Research has shown that giving children vitamins and minerals can decrease their aggressive behaviors by 50%. Another study, double blind control study, found that Vitamin B6 was more effective than the leading stimulant medication (methylphenidate or Ritalin)in reducing ADHD symptoms. Adding nutrition to your ADHD treatment plan is important.
Parenting Skills. Parenting children with ADHD can be difficult and frustrating. Because of frustration, some parents can cause damage to their ADHD children by yelling at them or putting them down. If parents yell at children when frustrated, they can injure their already fragile self-esteems. ADHD children often receive many negative statements by their teachers, peers, and outsiders. Parents need to learn how to help the child cope with ADHD and give them positive statements that build their self-esteem.
Another important concern is the way parents raise their ADHD children. Disciplining too harshly and not disciplining enough can both cause harm to ADHD children. Through being inconsistent and permissive, ADHD children become very manipulative and unpleasant to be around. ADHD children have special needs that require specialized parenting skills. These special skills include nurture and structure.
Nurture is the ability to give love to your child no matter what your child does. Some parents show love only when the child is behaving well. Nurturing your child also involves encouragement, understanding, and a strong emotional bond between parent and child. Structure involves being consistent, having set rules with consequences when rules are disobeyed, and having a routine around the house (e.g., consistent bedtimes, morning chores). It's rare that a parent will have both of these qualities naturally. What is more common is for a parent to be great at nurturing but poor at providing consistent structure or visa-versa. Parents need to work at developing both skills.
A good parenting program for parents with ADHD children is Dr. David B. Stein's Caregiver Skills Program. It is a comprehensive treatment program designed to address all ADHD symptoms within a few weeks. Another helpful parenting program is 123 Magic by Dr. Thomas W. Phelan (ISBN 096-338-6123). The book teaches parenting skills that work with ADHD children. Using these skills will help you not to yell at your children thus damaging their self-esteem. Most parents find the program very helpful.
Parents will need to get continued parenting education when the ADHD child reaches adolescents. ADHD adolescents need a new set of parenting rules. These new rules include grounding, setting limits, ignoring the child's tactics that get the parent side tracked, and explaining the rules without lecturing. Since a high number of ADHD children turn to drugs, alcohol, or criminal behaviors, parents need to have effective skills to prevent these possible results.
Optimism. While ADHD can be harmful to children in many ways and left untreated could have many bad consequences, there are some positive ways to look at ADHD. Simply treating the child with optimism and in a positive way can help change negative outcomes. How we view and treat a child is often what they believe about themselves.
There are some positive characteristics common to most children with ADHD. These children usually have great enthusiasm, can concentrate on activities in which they are very interested (e.g., video games, hunting), do well outdoors, are independent, and willing to take risks when necessary. Some have special gifts at conversation and can talk to anyone. These skills should be developed into productive skills for a successful life. A recommended book that explains in more detail the positive characteristics of genetic ADHD is Attention Deficit Disorder: A Different Perception , by Thom Hartmann (ISBN 0-88733-156-4).
It is unfortunate that many schools are not more tolerant to the special needs and special gifts of ADHD children. Parents working positively with school officials can help children adjust better to the demands school places on them. Parents can often help teachers understand the positive characteristics their child has and suggest ways for their child to behave better in class. For example, some ADHD children do better at the front of the class. Others need notes signed by the teacher and parent to encourage them to complete and turn in their work. Working positively with teachers is one of the best ways to improve your child's progress at school.
While there is much that professionals do not know about ADHD, the scientific base of knowledge is expanding. Twenty years from now looks very positive for effective treatment of ADHD. Until then, a comprehensive technique to treat ADHD will be most effective. There is enough data to suggest that professionals and parents should not be content in just dealing with the symptoms of ADHD. They should be more positive and attempt to help the child outgrow or at least compensate for their ADHD symptoms. Even with the best of treatments, some ADHD children will carry their disorder into adulthood. For those that do, they can live a more productive and enjoyable life by applying a variety of treatment approaches to overcome problems related to ADHD.
A healthy view of ADHD is to realize that everyone has certain weaknesses to deal with. Some physical weaknesses such as being near sighted are easy to overcome (e.g., wear glasses), while other disorders are more difficult. Severe ADHD is certainly a difficult disorder to overcome, but it can be dealt with. If parents believe this, then children are more likely to believe it as well. With this belief the entire family is more motivated to get the most out of their comprehensive treatment.
Summary and conclusions. Attention Deficit/Hyperactivity Disorder in children is often difficult to deal with. Left untreated it can seriously affect a child's self-concept, self-esteem, performance in school, social development, and ability to function in society. With treatment these problems can be avoided.
A combination of treatments is needed to help children learn skills to overcome ADHD effects. Medicine alone, even when it helps the child to move less and pay attention more, does not help improve school grades after six months and does not improve a child's self-esteem. Other treatments should be used that will improve school grades after six months and improve a child's self-esteem.
The first step in choosing treatments is to obtain a complete assessment. This means more than using a checklist completed by a teacher or parent. A complete assessment involves a clinical interview, medical tests, checklists, observations, a social history, and objective measurements. A psychologist and a medical doctor can help you obtain these tests. After the diagnosis is made, then a theory of what is causing the ADHD symptoms can be formulated. This theory or hypothesis will be useful in making a treatment plan that lists the types of treatments to be used. The types of treatment needed depends on the likely cause for the ADHD symptoms. Below are some guidelines to help you decide which treatments will be most helpful.
If the use of medication can be avoided, it should. Dr. Stein's Caregiver Skills Program is offered as a self help book and is the least expensive treatment option presented in this article. If you can afford a variety of treatments, then you may consider EEG Biofeedback with nutritional supplements, psychotherapy, and family therapy. If you are limited in financial resources, you may wish to consider psychotherapy, support groups, and medication. Some cases of ADHD cannot be handled successfully without medication. When you decide to try medication, be active by asking your physician questions, learn about the medication's possible side effects, report any side effects that you see, and help the physician decide the correct dosage. Whatever forms of therapy you try, keep a journal of what works best with your child. This success journal will help you monitor your child's improvement and will help you explain what works with your child to professionals.
While the effects of ADHD can cause much suffering to the child, parents, school teachers, and society at large; there are reasons for hope. Many symptoms can be reduced by helping the child compensate for them through a variety of techniques. In many cases, ADHD children will outgrow the disorder. Even those who do not outgrow their symptoms can improve performance in school, family and society by utilizing various treatment methods. There still is much to learn, but we are learning fast. Working with various professionals, much progress can be made with your child.