Overcoming Organizational Difficulties in Children with ADHD

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common mental disorders of childhood, and occurs in approximately 5% of children. There is a vast literature, spanning more than 50 years regarding interventions that focus on the symptoms of ADHD and/or the associated impairments in academic, social, and other aspects of functioning. However, until recently very little attention has been paid to a critical area; namely the treatment of organizational difficulties in children with ADHD.

Organization, time management, materials management and planning (referred to here as OTMP), comprise an important subset of abilities that clinicians often refer to as executive functions.   The exponential growth during the past few years in the number of digital apps intended to make us better organized is but one indicator of how important effective OTMP functioning is in our daily lives.  At various times, everyone, regardless of age, education, or occupation experiences some OTMP difficulties.  Misplacing one’s keys, forgetting to pay a bill on time, not setting aside enough time to complete a project, are common examples of such incidents. For the majority of children with ADHD, however, OTMP problems are not just infrequent, annoying events; rather, they occur with regularity, in multiple situations, and often impair their functioning at school, home, and with peers.  

The OTMP difficulties of children with ADHD typically become evident around third grade, when children are expected to show increasing ability to organize themselves and to rely less on others to do so.  These difficulties manifest in a variety of ways, and their negative effects are especially noticeable on school functioning.  For example, homework problems, which are common in children with ADHD, are often related to OTMP difficulties.  The following vignette illustrates how these difficulties can contribute to a missing homework assignment.

Teacher: “Jimmy, where is your math homework, it was due today?”

Possible contributors to the missing assignment

1)    Jimmy:  “I did the homework, but I forgot to bring it to school.”
                Or
2)    Jimmy: “I know I put it somewhere in my backpack, but I can’t find it.”
                Or
3)    Jimmy: “I thought that this math assignment was due next Wednesday.”
                Or
4)    Jimmy: “I forgot to write the assignment in my homework planner, and never did it.”
                Or
5)    Jimmy: “I started to do it last night, but I ran out of time, and didn’t finish it.”

Jimmy’s responses reflect how OTMP-related difficulties in managing materials, managing time, tracking assignments, or planning can result in a missing assignment (and the subsequent negative consequences they entail).  Because these difficulties tend to be pervasive, similar vignettes could readily illustrate the impact of deficient OTMP abilities on the functioning of ADHD children in other settings as well.  

Notably, OTMP problems tend to worsen over time, reflecting the escalating demands for organization and multi-tasking associated with secondary school, college, and the work place.

For more than a decade my colleague, Dr. Richard Gallagher, and myself have focused on therapeutics to improve the OTMP functioning of children with ADHD.  With funding from the National Institute of Mental Health and the Lowenstein and Lemberg Foundations we conducted programmatic research to develop and evaluate treatments designed specifically to target these organizational difficulties.  

Our treatment development efforts were informed in large-part by our clinical observations and experience, which suggested that many children with ADHD who had organizational problems lacked the knowledge and skills needed to be well organized.  The content and methods of the 20-session, twice weekly, clinic-based individually administered program that we designed (called “Organizational Skills Training”, OST), were derived both from our observations and from standardized, normed assessment measures we developed (the “Children’s Organizational Skills Scales”, COSS) that identified critical aspects of organizational functioning that tended to be impaired in many children with ADHD.  

As its name implies, OST is a skills-based intervention, which focuses on improving children’s organizational functioning, including their abilities to manage materials, track assignments, manage time, and plan. To this end, OST uses a variety of behavioral methods to facilitate skills building, including modeling and intensive practice with the child, in conjunction with parent and teacher prompting, cueing, and reinforcing the child for skills use.  We evaluated OST’s efficacy in a large, dual-site randomized controlled trial (RCT) at NYU and Duke University with 158 8-11 year-old children in 3rd-5th grade. The study found significant, sustained improvements in a number of important areas, including: children’s organizational functioning at school and home; homework problems; academic performance and proficiency; and family relationships (read the article here).  

Having met our first goal and establishing strong empirical support for OST, we embarked on activities to achieve our next objective – the implementation and dissemination of OST in real-world clinical settings.  First, closer to home, we initiated and continue to train and supervise the clinical staff at the Child Study Center in OST, and the treatment is now used clinically in our ADHD Service with youngsters with ADHD and organizational impairments.  Second, we developed programs to train clinicians from other settings in OST. Under the guidance of Dr. Gallagher, training can be provided in a variety of venues (e.g., webinars, workshops) and intensities (e.g., ongoing supervision of OST cases).  Third, we wrote a book for therapists to enable them to provide OST to children with ADHD and OTMP problems who are seen for individual treatment in private practice, child mental health, or school settings. (Find the book here.)

Relying on our extensive experience with OST, the book includes a number of features intended to facilitate therapists’ use of OST, including:

•    Information regarding the rationale, development and empirical evaluation of OST
•    A detailed, user friendly treatment manual that describes the guidelines, objectives, treatment methods, content, and activities for each session
•    Between-session activities to facilitate the child’s skills use
•    Instructions for parents and teachers regarding how to prompt, monitor, praise and reinforce the child at home and school for using the specific OTMP skills focused on in treatment
•    Treatment-related forms for therapists, parents and teachers that are tied to each treatment session
•    Guidelines for troubleshooting issues that may arise during treatment
•    Suggested treatment modifications when working with youngsters with other comorbid conditions.

Our hope is that the book will bring OST to the attention of a wide audience of child mental health professionals, and enable clinicians to provide an established organizational treatment to the many children with ADHD who can benefit from this approach.