How do early morning challenges impact your ADHD patient?

Assess your patients with the validated Before School Functioning Questionnaire (BSFQ). click here

ADHD symptoms occur from the moment a person wakes up and last all day. Early mornings, the time between waking up and leaving for school or work, can be significantly impacted in patients with Attention Deficit Hyperactivity Disorder (ADHD). Even people who are taking ADHD medications may struggle with symptoms in these early morning hours.

Pie Chart - 91%
91% of caregivers identified the early morning as a time when ADHD symptoms manifested in their children despite treatment1*†
Pie Chart - 79%
79% of caregivers had previously discussed their child’s early morning challenges with their doctor1*‡
Pie Chart - 48%
48% of caregivers indicated that they had woken up early in order to administer their child’s ADHD medication1*‡

"Many parents express that the morning routine sets the tone for the rest of the day; positive mornings result in a constructive, more focused attitude that lasts throughout the day."

—Andrea Marraffino, PhD

Video Series — Early Morning Challenges in Patients with ADHD

Ironshore Pharmaceuticals is proud to offer an educational, video-based series hosted by internationally recognized subject matter experts in the field of ADHD.

Dr. Greg Mattingly moderates the discussions with his three colleagues; Dr. Russell Barkley, Dr. Ann Childress, and Dr. Michele Novotni, about the challenges of the early morning routine in patients with ADHD.

Dr. Russell Barkley - Part 1

Russell Barkley, PhD, discusses the importance of early morning challenges in children with ADHD.

Dr. Russell Barkley - Part 2

In part 2, Russell Barkley, PhD, continues his discussion on the importance of early morning challenges in children with ADHD.

Dr. Ann Childress

Ann Childress, MD discusses best practices for using the Before School Functioning Questionnaire (BSFQ), a tool designed to assess before-school behaviors in children with ADHD.

Download the Before School Functioning Questionnaire

Dr. Michele Novotni

Michele Novotni, PhD, provides Tips and Tools on helping to improve working memory and organizational skills in children with ADHD.

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Download the results from a quantitative survey study regarding the impact of early morning challenges on primary caregivers:

Early morning challenges in stimulant-treated children and adolescents with attention-deficit/hyperactivity disorder, and its impact on caregivers.

Early Morning Challenges

Early morning challenges are a significant unmet need in ADHD

ADHD is among the most common psychiatric conditions, with behavioral symptoms fluctuating throughout the day. Existing therapies primarily focus on adequately controlling ADHD symptoms in school and more recently, extending the therapeutic effects after school or work.1,2

However, many home-based difficulties for children and adolescents with ADHD occur during the early morning routine (i.e. before the school day begins) that can cause stress within the household.3

Early morning challenges occur from the time of awakening until school or other morning activities.1,3

Despite advances in ADHD medications, early morning challenges remain an issue in many children and adolescents with ADHD. Caregivers report that children and adolescents with ADHD have difficulties immediately upon awakening until school or other morning activities.1,4

Accordingly, pharmacological management of early morning functional impairments remains a significant unmet need in patients with ADHD during the early morning routine.1,3

The early morning routine poses a significant challenge for patients with ADHD as it involves finishing a range of activities before the deadline of school or work, such as1,3:

Affected Activity - Getting out of bed
Waking and getting out of bed
Affected Activity - Getting dressed
Getting dressed
Affected Activity - Brushing teeth
Brushing teeth and self-hygiene
Affected Activity - Eating breakfast
Sitting down for breakfast and eating
Affected Activity - Going to school
Getting ready for school or other activities and remembering items
Affected Activity - Leaving house
Getting ready to leave the household

Completing these complex behaviors requires time management and working memory—skills frequently impaired by ADHD symptoms, even when patients are already on treatment.1,3
Research demonstrated that it's more difficult for patients with ADHD to gauge time compared to their non-ADHD peers.4
These deficits frequently manifest into disorganized patterns of memory recall and planning as compared to patients without an ADHD diagnosis. For example, patients with ADHD tend to have difficulty completing tasks because they underestimate the amount of time required to complete them as compared to their non-ADHD peers.4

Although it is known that preparing for school in the morning is a challenging time of the day for children and adolescents with ADHD and their families, few studies have evaluated the impact of early morning challenges on the child and their primary caregiver.1

Caregivers may experience increased stress while getting their child ready for school. Parents may experience tremendous stress around facilitating their child’s before-school behavior and/or be late to work on days when their ADHD child is late to school.1,3

"Despite treatment with a stimulant, children with ADHD still display early morning functional impairment—horrible mornings, children in grumpy moods, and difficulty getting out of the house on time."

—Ann Childress, MD

ADHD has been shown to have negative effects on caregivers and families as a whole. To learn more about how children with ADHD can impact their families, click here.

Early Morning Impact

The impact of ADHD symptoms on the early morning routine1,2

Caregiver Impact

Early morning challenges occur from the moment the patient awakens until school or work1,2

How caregivers rate the severity of ADHD symptoms1*

76% of caregivers reported that impairments in the early morning routine were either moderate or severe
Chart - Caregiver rating of EMF impairment severity from ADHD symptoms
Ratings based on a scale of 1–10, where 1 means "mild impairment" and 10 means "severe impairment"
Severe Impairment (8–10)
Moderate Impairment (5–7)
Mild Impairment (1–4)
Adapted from Sallee, 2015.

3 out of 4 caregivers reported that the most frequent ADHD symptoms during the early morning routine were1:

Icon - Getting Distracted
Getting easily distracted
Icon - Failure to Listen
Failure to listen
Early morning challenges affect patients with ADHD already on treatment1

Unwanted behaviors frequently occurring during the early morning routine1§;

Chart - Unwanted behaviors frequently occurring during the early morning routine
Adapted from Sallee, 2015.

Almost half of caregivers reported impulsivity and failure to finish tasks as behaviors that affect early morning routine.

§Information was obtained from primary caregivers (n=201) of children and adolescents with ADHD currently treated with stimulants, using a self-administered, anonymous, online, quantitative research survey.

SEE MORE results from a quantitative survey study regarding the impact of early morning functional impairments on primary caregivers:

Early morning functioning in stimulant-treated children and adolescents with attention-deficit/hyperactivity disorder, and its impact on caregivers
Floyd R. Sallee, MD, PhD – Journal of Child and Adolescent Psychopharmacology

Early morning challenges impact family dynamics

Caregivers of children with ADHD describe the early morning experience as generally chaotic.

Chaos is a result of the untimely actions or inactions of patients with ADHD from the instant they awaken to the moment they leave the household for school or work.1

Patients with ADHD frequently display behaviors associated with inattention, restlessness, disruptiveness, impulsivity, noncompliance to instruction and disorganization that affect those living in the same household.1,2

"Parents become so frustrated with their children who are off task, disorganized, and running late, that they end up yelling and getting the day off to a very stressful start for themselves and their children."

—Mary Ann McDonnell, RN, MS, CS, FPNP
   Child and Adolescent Clinical Nurse
   Specialist and Family Nurse Practitioner

 

"Many parents express that the morning routine sets the tone for the rest of the day; positive mornings result in a constructive, more focused attitude that lasts throughout the day."

—Andrea Marraffino, PhD
   
 

ADHD has been shown to have negative effects on families as a whole, causing2:

Affected Activity - Getting out of bed
Disturbed interpersonal relationships
Affected Activity - Getting dressed
Less perceived family cohesiveness
Affected Activity - Brushing teeth
Greater caregiver-child and sibling conflicts
Affected Activity - Eating breakfast
Higher incidences of divorce and separation

Because of the child’s ADHD symptoms during the early morning, caregivers of children with ADHD report2:

Affected Activity - Getting out of bed
Feeling overwhelmed and exhausted
Affected Activity - Getting dressed
Raising their voice more than they want
Affected Activity - Brushing teeth
Feeling constantly stressed
Affected Activity - Eating breakfast
Feeling inadequate as a parent
Affected Activity - Eating breakfast
Punishing more and praising less

"Many caregivers of children with ADHD describe the stress caused by early morning functional impairments as 'chronic' and 'severe.' Factors that contribute to this stress include sibling conflicts and failure to get ready in the morning, resulting in difficulty getting to school and/or work on time."

—Floyd R. Sallee, MD, PhD

ADHD symptoms during the early morning have a negative impact on primary caregivers3‡

Aspect of caregiver’s life affected by child’s ADHD symptoms

Chart - Aspect of caregiver’s life affected by child’s ADHD symptoms

Proportion of caregivers having administered medication prior to child’s normal awakening time

Chart - Proportion of caregivers having administered medication prior to child’s normal awakening time
  • 47% of these caregivers did this at least 5 days a week
    • 24% of these caregivers did this every day
  • This approach is disruptive to the child’s sleep and caregivers would find an alternative option valuable
Results obtained from administering an online, 57-item survey to a total of 240 patients and/or caregivers of children with ADHD.

Caregivers value better management of their child’s ADHD during the early morning to:

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Reduce their and their families’ levels of stress and frustration
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Improve quality of life

Caregivers of children with ADHD are more likely to report:

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A lower overall quality of life
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Viewing their child as limiting their family's activities during the morning period and less likely to report that their child made them feel good as a parent, in comparison to caregivers with children without an ADHD diagnosis5*
* Results obtained from a study designed to map the challenges of everyday family life in a sample of children (27 with ADHD, 25 without ADHD). Children with ADHD included in the study were treated with stimulants. Across 7 days, mothers and children independently reported their moods, behaviors, and social contexts every 30 minutes during nonschool hours, using an electronic diary. After each day, morning and afternoon/evening summary diaries were also obtained from mothers.

Before School Functioning Questionnaire (BSFQ)

The BSFQ is a validated tool used by physicians to interview caregivers. It has undergone formal testing to demonstrate its reliability and validity.1

The BSFQ was developed by child and adolescent psychiatrists practicing at Massachusetts General Hospital and Boston Children’s Hospital.

This tool was designed to assess commonly reported difficulties in early morning activities associated with ADHD.

Previous research in children with ADHD have focused primarily on in-classroom behavior and little attention has been given to home-based difficulties during the early morning routine. The BSFQ is the first validated scale developed to capture naturalistic early morning functioning prior to school or other morning activities (approximately between 6 a.m. to 9 a.m.) in children with ADHD.1

The BSFQ contains 20 items that address early morning, before-school activities, including1:

Affected Activity - Getting out of bed
Overall organization
Affected Activity - Getting dressed
Breakfast
(not sitting down to eat, distracted while eating)
Affected Activity - Brushing teeth
Dressing
Affected Activity - Eating breakfast
Forgetfulness
Affected Activity - Eating breakfast
Hygiene
Affected Activity - Eating breakfast
Time awareness
Affected Activity - Eating breakfast
Procrastination
Affected Activity - Eating breakfast
Independence
Affected Activity - Eating breakfast
Getting to school

How to use the BSFQ1:

Caregivers should complete the questionnaire:

Icon - Checkmark
On school days
Icon - Checkmark
Either daily or weekly
Icon - Checkmark
Between the hours of 6 a.m. and 9 a.m.

Instruct caregivers to rate each item on a Severity Scale from 0 to 3 using the following rating methodology for symptom severity:

Chart - BSFQ Severity Scale

Caregivers or healthcare professionals can also record the following baseline and endpoint measures of early morning time management:

Time to wake up and get out of bed:_______(min)

Time to complete routines (from out of bed to leaving home):_______(min)

Start using the BSFQ

Click to download or print

Tips to help improve early morning functioning in children with ADHD

The early morning challenge

The following booklets contain tips that have been provided by Michele Novotni, PhD, to help children with ADHD stay focused throughout the morning routine. Each tip has been tailored for children of different age groups—young children (ages 6–8), pre-teens (ages 9–12), and teens (ages 13–17).

These tips are designed to offer caregivers strategies to handle specific behaviors that may prevent children from getting ready in the morning.

So whether children need help improving their listening skills or getting dressed for school, these tips can help children of all ages complete their morning responsibilities so that everyone can hopefully leave the house on time.

From Michele Novotni, PhD,
Counseling Psychology,
Licensed Psychologist,
Senior Certified ADHD Coach

Michele Novotni, PhD, is an internationally recognized expert and thought leader in the field of ADHD.

As a parent of a child with ADHD, she is dedicated to helping individuals with ADHD be successful in school, in interpersonal relationships, and in the workplace.

She is an inspiring speaker, best selling author, psychologist, ADHD coach, and the former president and CEO of the national Attention Deficit Disorder Association (ADDA).

She currently serves on the Scientific Advisory Board for ADDitude Magazine and has been on the Professional Advisory Boards for both ADDA and for the ADHD Coaches Organization (ACO). Inspiring individuals to unlock their potential is her passion, whether it is one-on-one or speaking to thousands.

See more tips by using the links below. Access and share tips with parents/caregivers of children with ADHD to help everyone get a good start to the day.

Badge - A Sneak Peek Inside!

Children with ADHD often have trouble following directions during the morning routine.

Share the following tips from Michele Novotni, PhD, with caregivers to help their children get back on track:

Personalize with photos

A photo timeline may serve as a fun reminder for young children. Instruct caregivers to take pictures of their children during each step of the morning routine, including:

  • Getting dressed
  • Eating breakfast
  • Brushing teeth
  • Putting on their backpack
Icon - Photographs

Posting the photos on the wall will provide children with a personalized reminder of what they need to do each morning.

Resources

Frequently Asked Questions

What are early morning challenges?

Early morning challenges occur from the time of awakening until school or other morning activities. They involve performing activities such as getting out of bed, getting dressed, brushing teeth, sitting down for breakfast and getting ready to leave the household.1,2

Why are early morning challenges important?

The early morning is often described as a time of chaos and stress for family members of people with ADHD. ADHD symptoms affect a patient's ability to get dressed, eat breakfast, brush teeth and prepare for the day. Symptoms can also negatively affect the rest of the day as they may put patients with ADHD at risk of being late for school or work, or forgetting things.1-3,5

Even patients already on treatment for ADHD may be affected in the early morning hours.

What is the Before School Functioning Questionnaire (BSFQ)?

The Before School Functioning Questionnaire (BSFQ) is a tool designed to assess behaviors and activities associated with the early morning. It contains 20 items that address early morning activities and is completed by a doctor based on a structured interview with the caregiver.4

How can the BSFQ be used?

The BSFQ should be completed on school days, either daily or weekly and between the hours of 6:00 a.m. and 9:00 a.m.4

Caregivers are asked to rate each item on a Severity Scale from 0 to 3 using the following rating methodology for symptom severity and impact on activities4:

0 = None
1 = Mild (Somewhat different from peers/siblings; some days)
2 = Moderate (Different from peers/siblings; most days)
3 = Severe (Different from peers/siblings all days; all settings)

Has the BSFQ undergone formal psychometric testing?

The BSFQ has undergone psychometric testing and demonstrated2:

  • Reliability
    • High internal homogeneity and good test-retest reliability
  • Validity
    • Significant concurrent validity in investigator-rated BSFQ scores as measured by its correlations with current functioning, ADHD symptoms and behavioral measures of executive functions

What scales assess before school behaviors, functions and/or ADHD symptoms?

The Before School Functioning Questionnaire (BSFQ) is the first validated scale developed to capture naturalistic functioning in children with ADHD in the morning, before they go to school or other morning activities (approximately between 6 a.m. to 9 a.m.).2,4

The Parent Rating of Evening and Morning Behavior Scale, Revised (PREMB-R) is a validated questionnaire given to caregivers to assess the behaviors of children with ADHD during the morning (AM) and late afternoon/evening (PM) time periods. The PREMB-R AM is comprised of three questions about early morning behaviors that has been derived from a survey of expert clinicians. The questions are as follows: (1) How much difficulty did your child have getting up and out of bed this morning? (2) How much difficulty did your child have getting ready this morning (e.g., getting washed, dressed, eating breakfast, and getting to school) because of being distracted and inattentive (not because of arguing or refusing to do things)? (3) How much was your child arguing or struggling excessively with you this morning? Caregivers can review the questionnaire with a healthcare provider.6

Online Resources

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