How do early morning* functional impairments impact your ADHD patient?

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

How do early morning functional impairments impact your practice?

  1. In what percentage of your ADHD patients (ages 6–17) are early morning functional impairments identified as a concern by a parent or caregiver?


  1. What percentage of caregivers of your ADHD patients (ages 6–17) are satisfied with their children’s/adolescent’s current medication’s ability to provide symptom relief during the early morning?

Do you have patients with early morning functional impairments?

register to receive the latest information about ADHD and early morning functioning as well as helpful resources that will support your patients and their families

Early Morning Functioning

Early morning functional impairments are a significant unmet need in ADHD

ADHD is among the most common childhood 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.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 functioning (EMF) occurs from the time of awakening until school or other morning activities.1,3

Despite advances in ADHD medications, EMF remains an issue in many children and adolescents with ADHD. Caregivers report that children and adolescents with ADHD have difficulties and impairments 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 children and adolescents with ADHD during the early morning routine.1,3

The early morning routine poses a significant challenge for children with ADHD as it requires children to adhere to a complex sequence of behaviors, 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
Affected Activity - Leaving house
Getting ready to leave the household

“Is it really that difficult for her to get dressed, eat, brush her teeth, pack up her stuff and catch the bus? She’s in middle school already. Why can’t she just remember and follow through? I shouldn’t have to tell her and remind her a million times!”

- Mother of 12-year child with ADHD
(Reported to Michele Novotni, PhD Psychologist)

Completing these complex behaviors requires time management and working memory – skills frequently impaired by ADHD symptoms, even when children are already on treatment.1,3
Research demonstrated that children with ADHD have impaired ability to gauge time and have a developmental delay in their gross sense of time as compared to their non-ADHD peers.5
These deficits frequently manifest into disorganized patterns of memory recall and planning as compared to children without an ADHD diagnosis. For example, children with ADHD tend to frequently experience difficulty completing tasks because they underestimate the amount of time required to complete them as compared to their non-ADHD peers.5

ADHD has been shown to impair early-morning activities, such as organization, self-care, preparation for the school day and transportation to school. These early morning functional impairments may put children at risk of 3,6:

Affected Activity - Being late for school
Being late for school
Affected Activity - Forgetting school materials
Forgetting school materials (books, homework, etc.)
These issues may lead to the development of academic and social difficulties, disability, and even death.6,7

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 functional impairments 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.

The impact of early morning functional impairments in children with ADHD1,8

“His medications have kicked in by the time he gets to school. At least they don’t see what I see when he’s home. But at times, I do feel like it’s unfair. I’d like to see that side of him too.”

- Mother of 9-year old child with ADHD
(Reported to Michele Novotni, PhD Psychologist)

Caregiver ratings of early morning functioning in children with ADHD

Early morning functioning (EMF) occurs from the moment the child/adolescent awakens until school.1,2

Caregiver rating of early morning functional impairment severity from ADHD symptoms1*

Chart - Caregiver rating of EMF impairment severity from ADHD symptoms
76% of caregivers reported that impairments in the early morning routine were either moderate or severe
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 functional impairments affect children and adolescents with ADHD already on treatment1

Unwanted behaviors frequently occurring during the early morning routine1*

Chart - Unwanted behaviors frequently occurring during the early morning routine
Almost half of caregivers reported impulsivity and failure to finish tasks as behaviors that affect EMF

Adapted from Sallee, 2015.

*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

The impact of early morning functional impairments on 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 their children from the instant they awaken to the moment they leave the household for school.1

Children 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

Caregiver reactions to ADHD symptoms that affect EMF2*

“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

Adapted from Sallee, 2015.

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

Reduce their and their families’ levels of stress and frustration

image here

Improve quality of life

Mothers of children with ADHD are more likely to report:

Icon - A lower overall quality of life

A lower overall quality of life

image here

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 mothers with children without an ADHD diagnosis4‡

* Information was obtained from primary caregivers (n=201) of children and adolescents with ADHD currently treated with stimulants, using a self-administered, online, anonymous, quantitative research survey. Results obtained from administering an online, 57-item survey to a total of 240 patients and/or caregivers of children with ADHD. 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 validated scale designed to capture naturalistic before-school functioning in children and adolescents with ADHD1,2

The Before School Functioning Questionnaire (BSFQ) was developed by child and adolescent psychiatrists practicing at Massachusetts General Hospital and Boston Children’s Hospital.2

This tool was designed to assess commonly reported areas of dysfunction in early morning activities associated with ADHD.2

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, including1,2:

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
Icon - Checkmark

Has been used in the assessment of morning functioning in at least two controlled clinical trials2,3*†

Icon - Checkmark

Has undergone formal psychometric testing and demonstrates both validity and reliability1

Icon - Checkmark

Is completed by a healthcare provider based on a structured interview with the caregiver1,2

How to use the BSFQ1,2:

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 and functional impairment:

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

* A randomized, crossover study of children with ADHD, aged 6–12 years (n=30) treated with either methylphenidate transdermal system or placebo.

A randomized, double-blind, placebo-controlled study of patients with ADHD, aged 6–17 years (n=461), treated with either guanfacine extended-release in the morning or evening, or continued current stimulant plus placebo.

About 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.

Tips to help improve early morning functioning in children with ADHD

The early morning challenge

Have parents and patients in your practice told you about their morning struggles?

Do your patients describe the early morning as a time of chaos?

It is especially hard for caregivers of children with ADHD to get them to stay on task and complete morning activities in order to get to school on time.

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-teen (ages 9–12) and teens (ages 13–17).

These tips are designed to give 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.

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.

Recommended Chore Monster

Caregivers should download Chore Monster:
A helpful app that will allow caregivers to create a schedule of chores and assign point values to each task. Whenever their child completes a task, caregivers can approve it and he or she receives the points associated with the task.

A fun way to get children to follow directions!

Resources

Frequently Asked Questions

What is Early Morning Functioning (EMF)?

Early morning functioning (EMF) occurs from the time of awakening until school or other morning activities. It involves 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 is EMF important?

The early morning is often described as a time of chaos and stress for family members of children/adolescents with ADHD. ADHD symptoms impair the child’s ability to get dressed, eat breakfast, brush teeth and prepare school materials. These early morning functional impairments can also negatively affect the rest of the child’s day as they may put them at risk of being late for school, forgetting school materials and sustaining unintentional injuries/accidents.1-4

Early morning functional impairments can affect children/adolescents already on treatment for ADHD.1,2

What is the Before School Functioning Questionnaire (BSFQ)?

The Before School Functioning Questionnaire (BSFQ) is a tool designed to assess commonly reported areas of dysfunction in early morning activities associated with ADHD. It contains 20 items that address early morning activities that is completed by a healthcare provider based on a structured interview with the caregiver.5

How can the BSFQ be used?

The BSFQ should be completed on school days, either daily or weekly and between the hours of 6 a.m. and 9 a.m.5

Caregivers are asked to rate each item on a Severity Scale from 0 to 3 using the following rating methodology for symptom severity and functional impairment4:

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.).2,5

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

Laptop Body Image