Building an ADHD Treatment Plan Around the Whole Day, Not Just School Hours

For many families managing attention-deficit/hyperactivity disorder (ADHD), the hardest parts of the day aren’t during school, they’re before and after it. Michael Morse, M.D., MPA, director of Psychiatric Services and director of the ADHD and Anxiety Center at Alvord Baker, says mornings and late afternoons come with less structure, more transitions and, often, no medication coverage at all, a combination that can look like defiance or carelessness but usually isn’t.

For ADHD Awareness Month, The Educated Patient spoke with Morse about why those specific windows are so difficult, how parents can start recognizing patterns instead of blame, and what it actually looks like to build a treatment plan around a child’s whole day rather than just the hours spent in a classroom. To learn more, visit Start Talking ADHD.

Mornings and late afternoons seem to be especially hard for kids with ADHD and their families. What’s happening, developmentally or neurologically, during those transition times that makes them so much harder than the rest of the day?

Michael Morse, M.D., MPA: There are several reasons mornings and late afternoons are so hard. School gives kids with ADHD a lot of structure, with clear expectations about what to do and when. Mornings and late afternoons have much less of it, and they’re full of transitions from one thing to the next. A lot of people with ADHD are night owls, so even younger kids can have a hard time waking up early, because their brain just doesn’t boot up easily or quickly.

The morning transitions are also boring: eating breakfast, brushing teeth and packing the backpack all have to happen in quick sequence against hard deadlines like the bus. That’s especially hard for kids with ADHD, who do much better with tasks that interest them. By late afternoon, many kids with ADHD are fatigued from keeping it together all day, working harder than other kids to stay focused and manage their behavior. And stimulant medications, the most effective medications we have for ADHD, often cover the school day but leave mornings and evenings uncovered, which is a shame, because that’s when families have their time together.

ADHD symptoms don’t stay contained to school hours; they show up in routines, relationships and daily life at home. How do you help parents connect the dots between what they’re seeing at 7 a.m. and 6 p.m. and what’s going on with their child, rather than reading it as defiance or carelessness?

MM: I ask parents to look at when the trouble happens, not just what happens. If the hard moments cluster at 7 a.m. and 6 p.m., that pattern is telling you something. Those are the times when there’s less structure than during the school day, the child is tired and there often isn’t any medicine working. So a child who holds it together at school and then falls apart at home usually isn’t choosing to. They may just be out of fuel.

I really start from the idea that kids do well when they can. If a child isn’t doing well, my first assumption is that something is getting in the way. Often, it’s a mismatch between what the child can do in that setting and what the setting asks of them. That points to two kinds of help: changing the setting so it asks less or gives more support and building the skills the child doesn’t have yet. Kids don’t choose their mornings or their schedules, so it’s ultimately the adults’ job to do both. Seeing it that way helps the adults in a child’s life move from blame toward a plan.

You’ve talked about treatment needing to account for a child’s individual symptoms, schedule and needs, not a one-size-fits-all approach. What does that look like in practice when you’re working with a family to build a plan?

MM: When I'm working with a family, I start by asking what a day actually looks like for their child. One of my first questions is about mornings, because for roughly half the kids and adults I work with, the morning is a really difficult time. Stimulants are generally the most effective ADHD medicines, but no ADHD medication kicks in immediately.

A pill taken in the morning has to pass through the stomach into the intestines, then be absorbed and carried to the brain. So it usually isn’t working in time for the morning chaos. When mornings and evenings are the priority, prescribers often choose a nonstimulant because it can work around the clock.

But depending on the medicine, a nonstimulant may be only two-thirds as effective as a stimulant, and some are as little as half as effective. That’s a big trade-off, so a nonstimulant isn’t always the best option. There’s only one stimulant, Jornay PM, that you take at night. It’s already working when the child wakes up, and for many of my patients, it’s been a real game changer. Then I think about the afternoons and early evenings. A child with afternoon sports or other activities who struggles with teammates and peers likely needs medication coverage into the evening. That need often extends well beyond the school day. The plan has to fit the child’s whole day and what matters most to that child and family.

What does it look like for a parent to effectively partner with their child’s provider, and what should they be tracking or bringing to appointments to help set their child up for success throughout the day, not just during school hours?

MM: I think the most useful thing a parent can bring to an appointment is a picture of the whole day, not just the school day. I usually ask parents to think about three windows: the morning, the school day and the stretch from after school into the evening. Then I ask them to notice which of those is most trying for their child and the family, and when the medicine seems to kick in and wear off. The teacher’s observations are really helpful too, though school can miss a lot, especially with girls. Girls with ADHD are, on average, less disruptive than boys, so they may be suffering in silence. An anxious, conscientious girl can hold it together at school and look fine to her teachers. But she can look very different in the morning, when the dread of another day of keeping it together is building, and after school, when she’s exhausted.

Partnering also means paying attention to the foundations of a child’s health: sleep, exercise, nutrition and social connection. Without those, kids don’t do as well, and the medicines we prescribe don’t work as well either.

What’s the most common misconception or source of stigma you still see families dealing with around ADHD, and what would you want a parent who’s exhausted and second-guessing themselves to know?

MM: The most common misconception is that kids with ADHD somehow struggle with planning, organization, behavioral regulation or emotional regulation on purpose. Why would anyone do a worse job managing these things than they’re able to do? Kids, like adults, are usually doing the best they can with what they’ve got.

People also tend to think of ADHD as either only a problem or, especially on social media, only a superpower, but the reality is that it cuts both ways. So many of the creative people I meet have ADHD. But it’s also harder for a person with ADHD than for a person without it to do tasks that aren’t rewarding, like certain homework assignments, or taxes.

To an exhausted parent who’s second-guessing themselves, I’d say that raising a child with ADHD is genuinely harder work, so being exhausted isn’t the same as failing. And put on your own oxygen mask, too, because taking care of yourself is part of taking care of your child. Many parents of kids with ADHD have ADHD themselves, and many also struggle with depression, anxiety or burnout. Making time for your own self-care, and getting mental health treatment when you need it, helps you be the parent you want to be.

Disclosure: Morse has a paid speaker and consulting relationship with Collegium Pharmaceutical, which manufactures Jornay PM, a medication he discusses above. Start Talking ADHD is an educational resource hub created and published by Collegium. Collegium did not have editorial input into the content of this interview.