How is ADHD Treated?
by Mary FowlerLike many medical conditions, ADHD is managed, not cured. There's no "quick fix" that resolves the symptoms of the disorder. Yet a lot can be done to help. Through effective management, some of the secondary problems that often arise out of untreated ADHD may be avoided. In the majority of cases, ADHD management will be a life-long endeavor. It may be helpful to think of ADHD as a challenge that can be met. Recently, the National Institute of Mental Health (NIMH), in combination with the U.S. Department of Education's Office of Special Education Programs (OSEP), completed a long-term, multi-site study to determine which treatments had the greatest positive effect on reducing ADHD symptoms. This study is known as the MTA study (The MTA Cooperative Group, 1999). MTA stands for multi-modal treatment study of children with ADHD.
The recommended multi-modal treatment approach consists of four core interventions:
1. patient, parent, and teacher education about the disorder;
2. medication (usually from the class of drugs called stimulants);
3. behavioral therapy; and
4. other environmental supports, including an appropriate school program.
Each of these core interventions is described in more detail below. These approaches are your tool chest.
Often, the first treatment step begins with learning what ADHD is and what to do about it. This knowledge will help you understand that the way your child thinks, acts, and feels has a lot to do with circumstances outside his or her control. When we understand the nature of the challenge, we are better equipped to meet the challenge.
Understanding ADHD also changes the way in which a child's behavior is viewed. When we know more about ADHD, we come to understand that the child has troubles and is not the cause of those troubles.
There are accommodations that can help your son or daughter adapt reasonably well. It is critical to learn what these accommodations are and to work to see that they are put in place across different environments-school, home, community. Children with ADHD need strong advocates. They also need to be taught self-advocacy skills if they are to successfully manage their symptoms throughout life. Self-advocacy should begin early in life. Help your child understand and identify his or her difficulties. Teach him or her how to ask for help and accommodations.
The MTA study found medication to be very effective in the management of ADHD symptoms. Since ADHD is a neuro-biochemically-based problem, it stands to reason that medication that gets to the core of the problem would be effective. The medication most often used is stimulant medication, especially methylphenidate. Most people know this medication as the drug Ritalin. There are other stimulant medications-Concerta, Metadate, Dexedrine, Cylert, and Adderall, an amphetamine compound.
These medications are believed to work by stimulating the action of the brain's neurotransmitters, especially dopamine. With the brain's systems working more efficiently, attention, memory, and executive functions, including inhibition, are improved. The result is better concentration, increased working memory capacity, greater recall, less hyperactivity, and more impulse control. Stimulant medications do not tend to help with symptoms of anxiety or depression (Barkley, DuPaul, & O'Connor, 1999).
The decision to place a child on medication may not be an easy one, especially given the controversy that surrounds the stimulants, specifically Ritalin. There have been many reports that medication is overprescribed for treatment of ADHD. However, according to the American Medical Association's Council on Scientific Affairs (Goldman et al., 1998), "There is no widespread over-prescription of methylphenidate by physicians" (p. 1100). By following good diagnostic procedures, the chances of overprescribing this medication are significantly reduced. Some children cannot take stimulant medications. In these cases, the physician knows what other medications can be helpful in relieving ADHD symptoms. Medication may not be the right approach for every child.
Always discuss any medication treatment thoroughly with your child's physician. He or she should explain the benefits and the drawbacks of medication to you and also to your child, if appropriate. When medication is first prescribed, the physician should start with a low dose and then gradually raise it until the symptoms improve. You will need to dispense the medication as prescribed and closely monitor its effects, including any side effects. With stimulants, most side effects are quite mild and go away over time. Since your child spends a large portion of his or her day at school, you will also need to be in contact with your child's teachers to determine positive effects and side effects. Communicate with the physician often, especially when medication is started. Call immediately with any problems or questions.
Also be aware that during adolescence many teens actively resist taking medication. If this happens, it's wise to discuss the situation with your child's doctor. While medication cannot be forced on an unwilling patient, the doctor may have some ideas of how to work with your son or daughter about any resistance to taking the medication.
Some parents are reluctant to place their child on medication for fear that doing so may lead to later substance abuse. Researchers have looked into this concern quite seriously. A recent study supports previous findings that stimulant medication treatment may actually prevent later substance abuse (Zametkin & Ernst, 1999). As with any medication, though, parents must carefully monitor its use to be sure that the medication is taken as prescribed.
As parents and teachers know, ADHD can cause significant inappropriate behavior. Frequent complaints include failure to follow rules, listen to commands, complete tasks, delay gratification, or control impulse. In addition, some youth may be aggressive or anxious. These symptoms lead to their own set of problems, such as fighting or avoiding tasks. It is very easy for everyone involved-the child, the parents, and the teacher(s)-to be worn down into a pattern of negative, and sometimes hostile, interactions. This cycle, however, can be broken, and different, more positive interactions and behavior patterns can be developed. Knowing more about behavior and how to support behavior that is positive and appropriate is extremely useful information for any parent or teacher of a child with ADHD.
Researchers have identified effective strategies that parents can use. The following brief explanation gives you an idea of the types of help your son or daughter needs, along with some examples. You can find a lot more help through reading, talking to other parents, and working with a clinician.
You must consider the age of your child and his or her ability before using any strategy. A good rule of thumb is to provide interventions until your son or daughter demonstrates that these are no longer needed. If you withdraw interventions and problems re-occur, put the interventions back in place.
Think of the executive as the boss who creates a work environment in which all the workers know what they have to do to do their jobs appropriately. The boss also provides the necessary structure for them to do so. Performance expectations and company rules are clear. The executive supervises and directs but does not overmanage or micro-manage. Children who have difficulty with planning, thinking, organizing, concentrating, and self-monitoring need to have systems in place to guide and direct them. Parents and teachers need to be the executives in the child's life.
Examples:
Understand that you and your child's teachers will need to provide much more direct supervision than seems necessary for the chronological age. Remember, ADHD is a developmental disability, so these youth usually fall short of age expectations.
The main goal of all behavior management strategies is to increase the child's appropriate behavior and decrease inappropriate behavior. The best way to influence any behavior is to pay attention to it. Thus, the best way to increase a desirable behavior is to catch the child being good.
Children with ADHD receive a tremendous amount of negative feedback. Parents and teachers need to learn to give much more positive attention and feedback. That means you have to pick your battles carefully and let a lot of nonessential stuff slide. Otherwise, increased conflict and arguments between you and your child can result.
How do you make the bulk of your interactions positive and yet still provide discipline? With thought and planning. Effective parents (and teachers) know ahead of time what behavior is acceptable and not acceptable. They know what issues they are willing to negotiate and which ones, like safety, are non-negotiable. In a nutshell: Don't sweat the small stuff, and don't ignore the good stuff no matter how small.
Much of behavior management is about changing what you do. Your house rules (or the classroom rules) need to be carefully designed. First, you want to structure them so that your child or teen will be able to meet the expectations. In other words, you don't wait for a behavior to happen or not happen. You change what happens before the behavior-head it off at the pass, so to speak. For instance, if your child constantly forgets things for school, design a system for where to put things so they get picked up on the way out the door.
Your son or daughter needs to know ahead of time what behavior is expected. He or she also needs to know what the consequences will be for behaving (following the rules) or misbehaving (breaking the rules). Consequences are given as soon as possible. Give far more positive consequences and rewards than punishment. Children who hear too much negative feedback often become oppositional or depressed. Managing behavior thoughtfully, without a lot of reaction, especially undue punishment or criticism, helps to prevent unwanted side effects of poorly managed ADHD.
Some families need to use formal behavior management systems. These include charts or contracts. The difference between the two is simple.
Generally, contracts are used during early to mid-adolescence. In a contract, the involved parties (usually the parents and child, or teacher and student) talk about certain chores or obligations that the youth will fulfill. They draw up an agreement. The youth receives certain agreed-upon privileges or rewards for meeting the terms of the contract.
Charts are usually used for children ages 11 or younger. A chart lists behaviors that the child must display. Points are given or taken away depending on the child's behavior. Accumulated points may be traded for rewards.
If you decide to make a behavior modification chart, you may wish to follow these three simple steps.
In order for rewards to work, they must have value to the child. Since children with ADHD tend to become disinterested in the same thing over time, the rewards usually need to be changed frequently to have value. (For more detailed information on how to design and use charts and contracts, see the suggested books and videos in Section VI. Resources.)
About punishment: Children and teens with ADHD respond best to motivation and positive reinforcement. It is best to avoid punishment. When punishment is necessary, use it sparingly and with sensitivity. It is important that you and your child's teachers respond to the inappropriate behavior without anger and in a matter-of-fact way. Your child needs to be taught to replace inappropriate with appropriate behavior.
About time-out: When your child is misbehaving or out of control, time-out can be an effective way to manage the problem. Time-out means that your child is sent for a short period of time to a previously agreed-upon place-usually out of the main hub, like a special chair or area of a room. In general, he or she stays in time-out and must be quiet for three to five minutes. The time-out place should not be a traumatic place, such as a closet or dark basement. The purpose of time-out is to provide a cooling off place where your child can regain control.
Time-out works best with pre-adolescent kids. You can also use time-out with teens. Usually that means asking your teen to go to his or her room until he or she calms down.
Problem solving helps take the reaction out of parenting. It is results-oriented. If your child is mature enough, involve him or her in this process. Good problem solving has three parts:
Very often, people spend a lot of time solving the wrong problem. It's important to analyze problem areas. Pay attention to the facts and not the emotions of the situation. Brainstorm to find possible solutions. Put down all ideas that come to mind. Evaluate them. Pick the one that seems most likely to work. Go back to the drawing board if it doesn't. This approach helps to stop conflict from escalating.
For example: Suppose your child argues when you ask him or her to do a chore. While it appears as if arguing is the problem, actually that behavior might be the result of some problem with the request to do chores. Instead of focusing on the arguing, direct your attention to the chore and what that problem is. For instance, do you have a regular chore schedule? Are expectations clear? Does the child understand all the task expectations? Is there a definite time line? To some children, picking up the room means moving a couple of things out of the way.
Once you clearly define the problem, then you can brainstorm for a workable solution. Let's say your child understands all aspects of the chore, but it still doesn't get done without your nagging or threatening. Come up with a plan where the child knows exactly what to do by when. Decide if reminders will be given. Give a reward for on-time chore completion. Give a bonus if the chore is done ahead of time. Penalize the child if the chore is not done on time, but don't nag. Take action. Don't react. Make not doing the chore the child's problem and not yours.
Screaming, yelling, speaking through clenched teeth, stamping feet, throwing things, finger pointing, and making threats are violent forms of communication. These escalate problems, as do put-downs, sarcasm, lecturing, preaching, and name calling. When we are using good communication skills, we:
Problem solving and good communication help to eliminate some of the oppositional and hostile encounters that often accompany the disorder of ADHD.
One of the most critical areas in which to offer support is in the school arena. This is where most children with ADHD experience the greatest difficulty. That is because schools require great skill in the areas where students with ADHD are the weakest: attention, executive function, and memory. Although ADHD does not interfere with the ability to learn, it does wreak havoc on performance. Behavior problems, which usually get the most attention, may actually be by-products of the school environment and ADHD. These usually occur when tasks are too long, too hard, or lack interest. Many behavior problems can be avoided or lessened by adapting the school setting to fit the needs of the student.
In the school arena, ADHD is an educational performance problem. When little or nothing is done to help children with ADHD improve their performance, over time they will show academic achievement problems. This underachievement is not the result of an inability to learn. It is caused by the cumulative effects of missing important blocks of information and skill development that build from lesson to lesson and from one school year to the next. (It should be noted that a number of students with ADHD also have learning disabilities, and these do interfere with the ability to learn.)
Generally, ADHD will affect the student in one or more of the following performance areas:
Those teaching or designing programs for students with ADHD need to pinpoint where each student's difficulties occur. Otherwise, valuable intervention resources may be spent in areas where they are not critical.
For example, one child with ADHD may have difficulty starting a task because the directions are not clear. Another student may fully understand the directions but forget to follow all of them. Another may have difficulty making transitions and, as a result, get stuck in the space where one task ends and another begins. With the first child, intervention needs to focus upon making directions clear and in helping the child to understand those directions. The second child would need guidance to follow all the directions. The third child would need help in making transitions from one activity to another.
The sooner educational interventions begin, the better. They should be started when educational performance problems become evident and should not be delayed because the child is still holding his or her own on achievement tests. Specific suggestions for educational interventions are presented in Section III of this Briefing Paper. Other school issues, including special education, are discussed there as well.
Become Proactive. Knowledge is power. Gain knowledge about ADHD so you understand why and how this disability affects your son or daughter at home, in school, in social situations, and how it affects your entire family.
Change Your Belief System. Before your son or daughter can change his or her self- concept, the adults in the child's life have to change the way they view him or her. Separate the child from the behavior, and then separate the child from the disability. We don't have "ADHD children." We have children who have ADHD.
De-stress. Find positive ways to soothe yourself. For example, exercise, meditate, take long walks. Less stress means better self-control. Look for the humor in things, and enjoy a good laugh.
Act, Don't React. Emotional responses such as blame and anger lessen when you stop, look, listen, and then respond. Thoughtful parenting is needed here.
Catch the Child Being Good. The home atmosphere and the child's sense of self-worth change when the air fills with words of praise and encouragement. Pay plenty of positive attention to your son or daughter. Reward and show appreciation when he or she does what is expected.
Reprinted from National Information Center for Children and Youth with Disabilities (NICHCY) Briefing Paper, Revised Edition, April 2002. Contact NICHCY at P.O. Box 1492, Washington, DC 20013-1492; phone: 800/695-0285 or 202/884-8200 (Voice/TT).
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