ADHD Treatment

What’s the best way to treat ADHD?

First, we need to understand that ADHD is a chronic disorder. It’s not like tonsillitis, where an effective antibiotic will take care of the problem and it’s gone, or a greenstick fracture in the wrist that will heal in four to six weeks and be back to normal. This is a problem that’s going to stay with your child, maybe for their lifetime. Hopefully, the symptoms will improve as they get older, but we need to approach this with a long view. The good news is that if treated appropriately, the symptoms of ADHD can be controlled and long-term prospects and potential are greatly enhanced. Now for the steps of treatment.

Since this is a chronic and complicated condition, the best approach is through a team. This will of course involve engaged parents, but also other family members and school teachers. We need to stress the importance of regular communication with your child’s teacher and will look at ways to effectively do that a little later. The “team” includes your pediatrician/family physician, perhaps a counselor, and maybe even a dietician.

The importance of the family being involved needs to be stressed as well. Your child (depending on their age), their siblings (depending on their age), and you as parents need to talk about the issue, understand it as much as possible, and discuss various treatment options and goals. Setting those goals, especially academic and behavioral, has to be a joint decision, and something that is reasonable and manageable.

Those target goals should be limited in number, with three to no more than six outcomes being addressed at any one time. Some of these targets might include:

• Improved relationships with siblings, teachers, and parents
• Improved academic performance
• Improvement in following rules (at home and at school)

Academic performance can be assessed with the regular reporting of grades, but these other areas can be “graded” as well, with the use of a report card. This can be designed by the “team” and used on a daily basis. This is where you want the child’s teacher involved, and willing to help with this reporting. And just so you know, your pediatrician or treating clinician will want your input into changed behavior and performance, but they will certainly want (and probably value more) the opinion of your child’s teacher. No offense, but that’s going to be more objective and dispassionate.

As we begin our treatment plan, we also need to search for the existence of coexisting conditions—things that could be making the ADHD worse, or even causing the symptoms instead of an ADHD condition. As many as one-third of children with ADHD may have one or more of these, and they include mood disorders, anxiety, opposition defiant disorder, learning disabilities, tics, and sleep disorders. We need to stress the importance of considering the presence of a sleep problem, evaluating it, and then getting treatment if needed. One thing is for certain—treating a coexisting sleep disorder will greatly improve our chances of success with the ADHD.

We have a variety of treatment strategies available to us, and the initial choice(s) will usually depend upon the age of the child. For instance, most experts would agree that preschool children (age 4 through 5 years) should begin with behavior therapy, rather than medication. These behavioral interventions include modifications in your child’s physical and social environment that will hopefully change behavior by using rewards and non-punitive consequences. Some of these include positive reinforcement, time-out, the use of a “token economy” (receiving small tokens for proper behaviors and responses that can be exchanged for specified items or activities), and response cost (losing privileges or withholding rewards with the occurrence of problem behavior). Seems like a lot here, and it is. We’re going to provide you with some references that will give you much more information and help you with the best behavioral and other strategies for you child. But here are some things that can be started right now:

• Develop and maintain a consistent daily schedule
• Keep unnecessary distractions to a minimum
• Provide easily accessible, specific, and logical places for your child to keep their schoolwork, toys, and clothes
• Reward positive behavior (you might want to look into the “token economy” idea)
• Setting small, understandable, and achievable goals
• Use charts and checklists to help your child stay “on task”
• Limit choices – activities, food, almost everything
• Find activities that you child enjoys and can be successful doing. We all need a “passion,”maybe a couple
• Examine your own behavior and identify any unintentional reinforcement on your part that might be affecting negative behaviors
• Make sure your discipline is calm (time out, removing your child from the aggravating situation, providing constructive distraction)

With that said, this is a great place to remind ourselves of what the Apostle Paul tells us in his letter to the Galatians. In chapter 5, verses 22 through 26, he lists the “fruit of the Spirit.” These are virtues that the Holy Spirit produces in the lives and hearts of believers. Thankfully, it’s the work of the Spirit that does this, since none of us has the inherent capability. There are nine of them, and they are:

• Love
• Joy
• Peace
• Patience
• Kindness
• Goodness
• Faithfulness
• Gentleness
• Self-control

Isn’t this what we all need? And isn’t each of these critical to how we approach our child with ADHD? We need to consider them one by one, and examine our own hearts.

While we’re still talking about preschool children, we need to consider those circumstances where medication might be added to behavioral strategies. Some examples of those might be:

• Your child poses a significant risk of injury to other children or caregivers
• Expulsion (or threatened expulsion) from preschool or daycare
• Suspected or documented central nervous system injury (some of these could be prenatal, such as alcohol or cocaine exposure, and prematurity- less than 32 weeks gestation)
• The existence of a strong family history of ADHD
• The symptoms of ADHD remain uncontrolled and interfere with other therapies

With school-aged children (older than 6 years) and adolescents, initial management is probably going to include stimulant medication along with behavioral therapy. Parental and family preferences will weigh heavily here, and need to be thoroughly discussed.

As we’ve noted several times, ADHD is a chronic disease, and needs to be monitored regularly. We’re going to be looking for the response to our therapy, adverse reactions to medications (if given), and adherence to our treatment plan. If we fail to see a satisfactory response, the two most likely causes are not adhering to the plan or our failing to identify one of the co-existing problems noted earlier. At that point, we should call a time-out and reevaluate things.

The frequency of follow-up visits depends on several things, including the age of the child, whether or not they are receiving medication, and how well the core symptoms and target behaviors are being controlled. It might be once or twice a year, monthly, or even more frequently, especially during the initial stages of treatment. Every child needs to be individualized.

Measuring the response to treatment can be done through teacher interviews and reports, use of the daily report cards we previously discussed, and review of academic performance. It’s not going to happen overnight, but we would like to see a positive response over the first few weeks of treatment.

What about other stuff, like “elimination diets” and chelation? Do they work?

If you search the internet, you’ll find lots of things that promise improvement for ADHD—some even a cure. Beware. Most of these are unproven and potentially dangerous. Let’s consider a couple.

Elimination diets have not been proven to be of benefit, and the influence of diet on hyperactivity, attention, and behavior is controversial. Dietary factors such as food additives, food intolerance, or food allergy usually don’t impact behavior and are not a significant contributing factor in the majority of cases of ADHD. But if you believe something your child is eating or drinking is making things worse, eliminate it and see what happens. One thing at a time though, so you’re making a correct identification. You don’t want to overcomplicate yours or your child’s life. It’s complicated enough already.

Essential fatty acid supplementation has been recommended, but no concrete evidence exists that supports its use. It won’t be harmful, but you can save your money.

Stay away from “chelation therapy” and megavitamins, since these have the potential for serious side effects. They, along with other complementary and alternative medicines such as herbal and mineral supplements, St. John’s Wort, and several forms of visual training have not been proven to be of help. Stick with what we know works and is safe.

The more you know about ADHD the better you’ll be able to help your child. Here’s a list of useful resources. There’s a lot of information here. However, the better we understand this problem, the less intimidating it will seem.

• The National Attention Deficit Disorder Association (ADDA) – www.add.org
• The American Academy of Child and Adolescent Psychiatry (AACAP)
  • aacap.org/AACAP/Families and Youth/Facts for Families/FFF-Guide/Children-Who-Cant-Pay-Attention-Attention-Deficit-Hyperactivity-Disorder-006.aspx
• Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD) – chadd.org
• National Institute of Health – nimh.nih.gov/health/publications/adhd-listing.shtml
• The American Academy of Pediatrics – aap.org

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This is an excerpt from the new book I wrote with pediatrician Dr. Robert Alexander. Ask the Family Doctor addresses questions from parents regarding their children’s health. Feel free to email us with questions: askthedox@yahoo.com