Strong Relationships are Crucial in Treating ADHD

The missing part of many treatments

This blog is the third in a series on attention-deficit/hyperactivity disorder (ADHD) and youth development. Read part one: Development or Diagnosis? and part two: Asking the Hard Questions about ADHD.

Source: Être et avoir (2002)

My two recent pieces about ADHD were in response to a study in the New England Journal of Medicine focused on the age of school enrollment and ADHD diagnoses. In my posts, I offered ways we can counter the mind-boggling increase of diagnoses and the practice of putting children, even very young ones, on long-term medication. You may recall that the CDC and the American Association of Pediatrics recommend a combination of behavioral treatments (such as special seating arrangements, verbal cues and other reinforcers) and medication to treat ADHD. In reality, the ease of obtaining medications often makes it the only intervention children receive. In this post, I will argue for a third, crucial element for successful treatment of ADHD: positive relationships with trusted adults. Interestingly, this element is not part of the typical treatment recommendations for ADHD. Parents, teachers, guardians, and other caretakers can all become a stable bedrock for a child’s development. By deploying a three-pronged approach where relationships are emphasized as much as behavioral therapy and medication, parents and teachers alike can help young people navigate the challenges of ADHD.

ADHD is often especially visible and troubling in classrooms, and the typical teacher often has very little training to handle multiple children who need behavioral support including those with ADHD. To help make these ideas concrete, I want to offer an example of how a positive student-teacher relationship led to the significant developmental advancement of a student who would be diagnosed with ADHD today. The acclaimed 2002 French documentary Être et Avoir (To Be and To Have) focuses on the connection between a teacher and a challenging child, as well as the effective pedagogical methods utilized by the teacher. The documentary takes place over a school year in a one-classroom country schoolhouse which combines very young students with adolescents.

The teacher in the film is a kind, middle-aged man, who holds a great deal of authority without being authoritarian. He does not give of himself easily, but is always there at the right time and has a very good hold of the classroom. In his class is a young boy called Jojo, who is full of fantasy and loves playing outside during recess. He is charming and funny, but has problems concentrating and often distracts others. Children with similar behaviors are often rejected by their peer group, but this teacher deliberately creates positive connections among the students.

The teacher does not do everything right, however. In one scene, Jojo is expected to complete a mind-numbing coloring exercise, which takes him a great deal of time because the teacher does not understand that his expectations are beyond the child’s capacity. This misunderstanding leads to Jojo losing his playground privileges and staying inside with the teacher, but what develops out of this misunderstanding is excellent. Though initially a punishment, the teacher takes the time to engage with Jojo, and their relationship is strengthened by this time together. Another example of their connection is a scene where the teacher helps Jojo wash his hands after painting. This gesture shows the attachment between teacher and student, which creates a feeling of safety that advances many aspects of Jojo’s development including the confidence to try new things.

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These two examples illustrate an important point: When teacher and student step out of their roles and engage as human beings, they can both feel competent and empowered. If the child is asked for too much, they will get frustrated and shut down. If the child is too comfortable, they will struggle with challenges and have diminished learning. There must be a positive tension between what is known to a child and what is discovered, something I call a developmental space.

Near the end of the school year, it is clear that Jojo has made immense progress in his learning. He can count to hundreds, thousands, and even billions, while earlier in the year he was learning how to write up to the number six. He has also shown improvement in concentration, which is most prominent when the teacher gives him gentle encouragement. Would medication have helped? In my experience with children like Jojo, probably only marginally. However, what did help was his teacher viewing the problem first and foremost as a matter of developmental maturation where Jojo’s skills had to be honed.

The structure and support Jojo received from his teacher made the biggest difference and were just what he needed: A positive relationship with an educator who saw the whole person in front of him. When tackling ADHD and other challenges, expanding our lens to include positive relationships would create a more comprehensive view of development. In that context, medication and behavioral approaches can have a very central place. If there is one thing that this cinematographic delight should teach us, it is that nothing will replace a transformative relationship between a child and their teacher.



Founder of The PEAR Institute: Partnerships in Education and Resilience at McLean Hospital, Faculty Member at Harvard Medical School. All opinions are my own.

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Gil G. Noam

Founder of The PEAR Institute: Partnerships in Education and Resilience at McLean Hospital, Faculty Member at Harvard Medical School. All opinions are my own.