His camp counselors call it "not using materials appropriately." But that doesn't begin to describe the frantic way a 10-year-old boy is pulling up a patch of lawn.
It's his third week at a summer camp designed specifically for children with ADHD, attention-deficit hyperactivity disorder, and like most of the other kids sitting in a circle this morning, he's wiggly and distracted. He's the kind of child who might suddenly turn to you and ask a steady stream of questions: Do you know what hair is made of? Do you know that Dove doesn't leave a residue on your skin? Are you married? Sitting in the shade of a playing field on Salt Lake's east bench, waiting for a game of soccer to begin, he wants to reach out in all directions and yank at the grass.
Life for a boy like this can be a constant barrage of negative feedback: Don't touch that! Stop asking so many questions! You're not paying attention! In fact, says ADHD expert William Pelham, a typical kid with the disorder will have a staggering half-million negative interactions a year.
Pelham is the founder of the Children's Summer Treatment Program, a therapeutic camp for children with ADHD. The program is now nearly 3 decades old and operates in seven states plus Japan, but this summer is its debut in Utah. The camp uses an elaborate point system to monitor and modify behavior while kids play sports, do schoolwork or simply stand in line.
Like ADHD itself, watching the camp in action is pretty exhausting. But as the seven-week program draws to a close, parents report they're seeing positive changes in their children.
Not all ADHD alike
Some children are fidgety, some defiant, some dreamy. Here's how 11-year-old Ryan describes what it's like for him: "I annoy everyone because I talk all the time." He's a slight, articulate, sometimes goofy child who is eager to discuss the novel he's writing about a man "who is well over 50."
Ryan's hyperactivity wears other children out, his mother says, so he has often been ostracized. At school he gets into trouble for not doing what the teacher asks. When he played on a soccer team he spent too much time staring at the sky or looking for bugs; the parent of another teammate called him a loser.
But at camp, for the first time in his life, there are 10 other kids with ADHD. "I don't feel alone," he says. At camp, finally, he feels like a success. Almost every day this summer he has won an award for High Point Kid, Best Social Skills or Best Sport. And he's doing great at soccer.
The life trajectory for children with ADHD can often be disappointing. More than half end up being expelled from school or dropping out, according to Pelham, who is professor of psychiatry and pediatrics at the State University of New York at Buffalo. About a third, according to recent research, end up committing a serious crime by the time they're 18. That percentage goes up even more if the child also develops oppositional defiant disorder or, worse still, conduct disorder. A child who follows this developmental pathway will often have lifelong problems with education, employment, relationships, substance abuse and criminal behavior, says David Groot, the Utah camp's clinical director and an assistant professor in the U.'s social work program.
Not all kids with ADHD develop these more serious disorders, but it's a common enough progression, and one that the intensive summer camp hopes to prevent.
The behavioral modification as practiced at the camp is intricate. Counselors try to be all-seeing, commenting on each child's every misstep or success. "Minus 10 for violating an activity rule," counselor Megan Pace might call out. Minus 10 for being a poor sport. Minus 20 for teasing. Plus 25 for ignoring someone else's teasing, plus 10 for paying attention.
Children who are aggressive or continually non-compliant are put in a time-out for 10 minutes, a penalty that is reduced to five minutes for good behavior, increased up to 30 minutes for continued non-compliance. At camp, every negative behavior has a consequence, every positive behavior has a reward. At the end of each activity there is a "point check." At the end of the day, for children who have earned the privilege, there is swimming; at the end of the week, a field trip.
The constant calling out of "minus 10" by the counselors (all are U. students in social work, psychology or special education) could easily drown out everything else. "The potential downside of any group treatment setting is that it's easy to have an environment where negative behavior is prominent, where it's heroic to be a negative leader," Groot explains, "so we work hard to have positive behavior honored and rewarded."
At one of the weekly evening parents meetings this summer, Groot reminded parents to "catch your children being good." Along with praise this might mean giving what he calls "no-brainer commands," the kind of thing a child will easily comply with and thus will earn positive feedback.
At its most basic, ADHD is characterized by difficulty staying on task or starting a task or stopping an annoying behavior; ADHD kids are impulsive and have trouble with what researchers call "working memory." Researchers don't fully understand what causes the disorder but believe it is largely genetic. It isn't caused by bad parenting, says Pelham. But bad parenting skills can make matters worse, and good skills can help turn things around.
Turning a corner
One afternoon earlier this month, a boy we'll call Joe was sitting in a tree on the edge of the athletic field at Rowland Hall-St. Marks Lower School, where the ADHD camp is housed this summer.
Joe has been the most oppositional of the camp's 11 children, a child who will deliberately do what he's not supposed to and then will tell the counselors "screw you." On this particular afternoon he is supposed to be in a time-out but has now climbed a tree.
Most of the other children by the fourth week of camp had earned a couple thousand points for good behavior. Joe was at minus 4775. But by the end of the sixth week, although he was still being put in several time-outs a day, they were for shorter periods, and Groot felt Joe's behavior had "turned a corner." Groot saw Joe holding a counselor's hand, something he was too defiant to do before.
Success for kids with entrenched oppositional behavior isn't easy or quick, requiring dogged strategies and constant immediate rewards and consequences. Sometimes it's also a matter of finding the right medications; the daily monitoring of behavior provides helpful information for psychiatric practitioners to know what medications and doses are working, says Groot.
The efficacy of medication is still controversial. Pelham's view is that ADHD meds have huge short-term benefits, but that to make long-term gains you need intensive behavioral interventions, plus parenting classes. There have been no controlled long-term follow-up studies for any behavioral treatment of ADHD, because studies like that are expensive, says Pelham.
Parents Susan McDonald and Steven Richter helped start the Utah camp, along with social worker Groot, because they felt there was nothing else specifically designed for children with ADHD. They're hoping to eventually be able to offer scholarships to meet the hefty tuition (this summer it was $2,500). Even at that price it's a bargain, says Richter. "It's like 8 hours a day of therapy."
McDonald, who is on the board of CHADD of Utah (Children and Adults with Attention-Deficit/Hyperactivity Disorder), says she doesn't expect her 11-year-old daughter to be completely changed because of a seven-week camp.
"But I think bits and pieces of it will be embedded. I already see her thinking before she does something." At the very least, she says, Naomi has had a positive experience, "not the drudgery of every day being the one in trouble."