Management of ADHD

Admin Jan 29, 2021 1,862K 8

Management of ADHD

Comprehensive Treatment for ADHD should always include a strong psychosocial component. Most professionals believe that effective psychosocial treatment is the backbone of good treatment for ADHD. Apart from pharmacotherapy, following psychosocial modalities are found most effective in the treatment of ADHD.
(1)   Behavioural Intervention:
There are three parts of effective behavioural interventions for ADHD children—
(i)                 parent training,
(ii)               school interventions, and
(iii)             child-focused treatments.

Four points apply to all three parts:
(1) Always start with goals that the child can achieve and improve in small steps (e.g., “baby steps”);
(2) Always be consistent—across different times of the day, different settings, and different people;
 (3)ADHD is a chronic problem for the individual and treatments need to be implemented over the long duration—not just for a few months; and
(4) Teaching and learning new skills take time, and children’s improvement will be gradual with behaviour modification.
(i) Parent Training:
The first session is often devoted to an overview of the diagnosis, causes, nature, and prognosis of ADHD. Thereafter, in group or individual sessions, parents learn a variety of techniques, some of which they may be already using at home but not as consistently or correctly as needed. Parents go home and implement what they learn in sessions during the week, and return to the parenting session the following week to discuss progress, problem solve, and learn a new technique.
The topics covered in a typical series of parent training sessions include the following topics in sequence.

1. Establishing house rules and structure
Ø  Posted chore lists
Ø  Posted morning and evening routines
Ø  Posted House Rules
Ø  Review until child has learned them
2. Learning to praise appropriate behaviours (praise good behaviour at least five times as often as bad behaviour is criticized) and ignore mild inappropriate behaviours.

3. Using appropriate commands
o   Obtain the child's attention: say the child's name first
o   Use command not question language (“Don’t you want to be good” is a bad command!)
o   Be specific, describing exactly what the child is supposed to do (at the grocery checkout line “be good” is not a good command! “Stand next to me and do not touch anything” is more specific!)
o   Be brief and appropriate to the child's age
o   State consequences and always follow through (praise compliance and provide consequences for noncompliance)
o   Have a firm but neutral (not angry) tone of voice
4. Using when………..then contingencies
o   Give access to desired activities when the child has completed a less desired activity (e.g., ride bike when finished homework; watch TV when finished evening chores, going out with friends after completed yard work)
o   For younger children, important to have rewarding activity occur immediately
5. Planning ahead and working with children in public places
o   Explain situation to child before activity occurs
o   Establish ground rules, rewards, and consequences
6. Time out from positive reinforcement
o   Assign short times away from preferred activities when the child has violated expectations or rules
o   Give time off for appropriate behaviour during time out and lengthen time for noncompliance with time out
o   Base times on children's ages—shorter for younger children—e.g., one minute for each year of age
7. Daily Charts—Point/token systems with rewards and consequences
o   Make charts with home rules/goals and post prominently in house
o   Establish system for rewards for following home rules and consequences for violations
o   Nickel jar for noncompliance or talking back (e.g., put a nickel in for each compliance, remove two for noncompliance)
o   Home Daily Report Card (see target list and creating a Daily Report Card for the home
8. School-home note system for rewarding behaviour at school and tracking homework (see description below in School Interventions)

There are many other techniques that are part of a good behavioural parenting program. Those listed above are included in almost all of the good programs. Some families can learn these skills quickly in the course of 8 or 10 meetings, while other families—often those with the most severely impaired children—require more time and energy.

(ii) School Interventions
The following list includes typical classroom behavioural management procedures. They are arranged in order from mildest and least restrictive to more intensive and most restrictive procedures. Some of these programs may be included in Individualized Educational Programs that may apply to ADHD children
Typically an intervention is individualized and consists of several components based on the child’s needs, the classroom resources, and the teacher’s skills and preferences.
1. Classroom rules and structure
o   Typical classroom rules:
Ø  Be respectful of others
Ø  Obey adults
Ø  Work quietly
Ø  Stay in assigned seat/area
Ø  Use materials appropriately
Ø  Raise hand to speak or ask for help
Ø  Stay on task/complete assignments
o   Post rules and review before each class until learned
o   Make rules objective and measurable
o   Number of rules depends on developmental level
o   Establish a predictable environment
o   Enhance children’s organization (folders/charts for work)
o   Evaluate rule-following and give feedback/consequences consistently
o   Tailor frequency of feedback to child’s developmental level

2. Praise appropriate behaviours and ignore mild inappropriate behaviours that are not reinforced by peer attention
o   Use at least five times as many praises as negative comments.
o   Use commands/reprimands to cue positive comments for children who are behaving appropriately—that is, find children who can be praised each time a reprimand or command is given to a child who is misbehaving.

3. Appropriate commands (clear, specific, manageable) and private reprimands (at child’s desk as much as possible)—same characteristics as for good commands for parents described above.

4. Accommodations and structure for individual child (e.g., desk placement, task sheet)
o   Structure the classroom to maximize the child’s success
o   Sit by teacher to facilitate monitoring
o   Pair with peer to help copy assignments from board
o   Break assignments into small chunks
o   Give frequent and immediate feedback
o   Require corrections before new work

5. Increase academic performance
o   Focus on increasing completion and accuracy on work
o   Provide task choices
o   Peer tutoring
o   Computer-assisted instruction
Such interventions have the advantage of being proactive (i.e., could prevent problematic behaviour from occurring) and can be implemented by individuals other than the classroom teachers (e.g., peers, classroom aide). When disruptive behaviour is not the primary difficulty, academic interventions sometimes lead to improvements in behaviour that are equivalent to gains associated with more intensive classroom behavioural strategies.

6. When…….then contingencies (e.g., recess time contingent upon completing work, staying after school to complete work before dismissal, assigning less desirable work prior to more desirable assignments, require assignment completion in study hall before allowing free time) (same guidelines as for parents described above)

7. Daily School-Home Report Card - Means of identifying, monitoring, and changing classroom problems

o   Tool for parents and teacher to communicate regularly
o   Individualized target behaviours determined by teacher
o   Teachers evaluate targets at school and send DRC home with the child
o   Parents provide home-based rewards; more rewards for better performance and fewer for lesser performance
o   Continually monitor and make adjustments to targets and criteria as behavior improves or new problems develop
o   Always used in the context of other behavioral components (commands, praise, rules, academic programs)
o   Cost little and take minimal teacher time

8. Behaviour chart/reward and consequence program (point or token system) for the target child
o   Establish target behaviours and ensure child knows behaviours and goals (e.g., list on index card taped to desk)
o   Establish rewards for meeting target behaviours
o   Monitor child and give feedback
o   Reward immediately for young children
o   Use points, tokens, stars that can later be exchanged for rewards

9. Class wide interventions and group contingencies
o   Establish goals for the class as well as the individual
o   Establish rewards for appropriate behaviour that anyone in class can earn (e.g., class lottery, jelly bean jar, wacky bucks)
o   Establish reward system in which whole class (or subset of class) earns rewards based on entire class functioning (e.g., Good Behaviour Game) or ADHD child’s functioning (e.g., class earns reward if ADHD child makes goals)
o   Encourages children to help one another because everyone can be rewarded
o   Easier for teacher than individual programs because improves whole class
o   Tailor frequency of rewards/consequences to children’s developmental level
10. Time out (classroom, office); a program in which a child is removed from the ongoing activity for a few minutes (less for younger children and more for older) when he or she misbehaves (same guidelines as for parents described above)
11. School-wide programs—e.g., discipline plans that are school-wide can be structured to minimize the problems experienced by ADHD children at the same time as they help manage the behaviour of all children in a school.
(iii) Child Interventions

Nonspecific talk or play therapy in a therapist’s office is not a form of treatment with scientific support for children with ADHD. Instead, child-based treatments for ADHD with a scientific basis are those that focus on peer relationships and that typically occur in group settings outside of the therapist’s office. Very often, children with ADHD have serious disturbances in peer relationships, and those problems are very strong predictors of long-term outcomes. Children whose difficulties with peers are overcome will have considerably better long-term outcomes than those whose peer relationships remain problematic. Thus, intervention for peer relationships is a critical component of treatment for children with ADHD and it is the focus of child-based treatments.

There are five forms of intervention for peer relationships, listed below.
1. Systematic teaching of social skills
o   Cooperation
o   Communication
o   Being positive and friendly
o   Participation
o   Helping/sharing
o   Giving compliments
o   Coping with teasing
2. Social problem solving
o   Identifying problem
o   Brainstorming solutions
o   Choosing best solution
o   Planning implementation
o   Evaluating outcome
3. Teaching other behavioural competencies that other children consider important
o   Sports skills
o   Rules of sports
o   Board game rules
o   Good sportsmanship and good team membership
4. Decreasing undesirable and antisocial behaviours
o   Target bossy, intrusive, aggressive, and other disruptive behaviours that children with ADHD exhibit with peers
o   Establish reward/consequence program to reduce these behaviours and to replace with prosocial behaviours taught in social skills training
5. Developing a close friendship
o   Develop program to help child with ADHD develop a close friendship with another child
o   Work with family and teacher to facilitate the relationship
o   May serve an important role in improving long-term outcomes
(2)   Working memory training
Many of the problems shown by children with ADHD are linked with deficits in working memory (or short-term memory). Training this memory may diminish some of symptoms of ADHD. In a study by Klingberg et al., children with ADHD who completed a computerized training program for working memory reported a decrease in ADHD symptoms and performed better on working memory tests than the control group. Some researchers attribute this to an improvement in working memory generally, while others believe it is merely the natural effect of practice.
(3)   Timers
Timers have been found to be effective for allowing people with ADHD to concentrate more effectively on the task at hand. When a target is set, one method is to only turn the timer on whilst working on the given task. A physical stopwatch or an online timer may be used.
(4)   Neurofeedback
Neurofeedback (NF) or EEG biofeedback is a treatment strategy used for children, adolescents and adults with ADHD. The human brain emits electrical energy which is measured with electrodes. Neurofeedback alerts the patient when beta waves are present. This theory believes that those with ADHD can train themselves to decrease ADHD symptoms.
No serious adverse side effects from neurofeedback have been reported. Research into neurofeedback has been limited and of low quality. While there is some indication on the effectiveness of biofeedback it is not conclusive: several studies have yielded positive results, however the best designed ones have either shown reduced effects or non-existing ones.
(5)   Aerobic fitness
Aerobic fitness may improve cognitive functioning and neural organization related to executive control during pre-adolescent development, though more studies are needed in this area. One study suggests that athletic performance in boys with ADHD may increase peer acceptance when accompanied by fewer negative behaviors.
(6)   Massage Therapy
For children and adolescents with ADHD, pediatric massage therapy has been found to improve mood and increase on-task behaviors, while reducing anxiety and hyperactivity.
(7)   Art Therapy
Art is thought by some to be an effective therapy for some of the symptoms of ADHD.
(8)   Media
Preliminary studies have supported the idea that playing video games is a form of neurofeedback, which helps those with ADHD self-regulate and improve learning. On the other hand ADHD may experience great difficulty disengaging from the game, which may in turn negate any benefits gained from these activities, and time management skills may be negatively impacted as well.
(9)   Nature:
Children who spend time outdoors in natural settings, such as parks, seem to display fewer symptoms of ADHD, which has been dubbed "Green Therapy".
(10)                       Dietary supplements:
Omega-3 supplementation (seal, fish or krill oil) may reduce ADHD symptoms.
Magnesium and vitamin B6 (pyridoxine) - In 2006, a study demonstrated that children with autism/ADHD had significantly lower magnesium than controls, and that the correction of this deficit was therapeutic. Mousain-Bosc et al. showed that children with ADHD (n =46) had significantly lower red blood cell magnesium levels than controls (n =30). Intervention with magnesium and vitamin B6 reduced hyperactivity, /aggressiveness and improved school attention.