[Content]

Non-Medical Interventions for ADHD

Numbers in parenthesis refer to reference materials that are listed on a separate page.

Environmental Interventions

What can be done to the environment at school and at home to help reduce ADHD symptoms? Let's look at the three groups of problems—attention, impulsiveness, and hyperactivity. For attention, there are many things that can be done. The most important is to cut down distractions, both sights and sounds. People with ADHD can not ignore unimportant sounds and sights as well as everyone else. So reduce these distractions as much as possible.

Home and homework

At home, if you are asking a child with ADHD to do something ask it in front of his or her face. The child should be in a room with the TV and radio off. There room should be somewhat free of distracting or stimulating objects. This may mean actually taking him into another room before you tell him what to do. When doing homework, it means finding a place that is quiet and dull. Doing homework on a kitchen table with lots of stuff on it will just not work with kids like this.

School seating

In school, seating the child at a place in the classroom that is the least distracting. This usually is close to the teacher, away from other disruptive students, and facing away from windows, and doors.

Rehearsed listening

Another strategy is using rehearsed listening. When giving information to family member we may say, "Listen up! Dinner is in five minutes, go wash your hands". With children who have ADHD you need to be much more formal and more consistent. EVERYTIME you want the person to pay attention, you should first start with some well learned cue words such as—"Listen up. News Flash! This is important!". Sometimes this will make the difference, and sometimes not.

Combine written and oral instructions

Another strategy is to combine written and oral instructions. At home, you might tell the child with ADHD to go clean their room and put away their clothes then write it down on a little blackboard in their room and say it at the same time. In school write those words on the whiteboard, the student's notebook, or on the paper itself and say them.

Interactive listening

Rather than using worksheets to practice addition problems use simple computer programs they hold a child's attention much better and generally provide instant feedback! any computer program that has a lot of action combined learning can be very useful.

Make life more structured at school and at home.

Structure and routine are very beneficial to the child with ADHD. Children with ADHD do better if they know that every day they can play at a certain time, do their daily chores at a certain time, do their homework at another time, and eat and sleep at a predictable time

Lack of sleep will make anyone less attentive,

Kids with ADHD are prone to not getting enough sleep. Some kids with ADHD are easily over stimulated and as a result do not get enough sleep. Regular bedtimes and calm activities before bed sometimes can be very helpful. If this problem is severe, this may be a reason to consider medications; as poor sleep makes for poor attention.

What Can Be Done to the Environment to Help Impulsivity?

Most impulsive acts occur during unstructured time in the home or at school. One environmental change to make is to decreased unstructured time. At home, this \ means that rather than letting a ADHD child play all afternoon, you provide supervised activities—groups like scouting, martial arts programs, church groups, or any structured activity that is interesting for the child. At school, come up with a plan for recess so the child is busy in structured activities such as sports, helping someone, fixing something or other ideas; the child needs to have a break however from seated learning.

Avoid idle time

Standing quietly in line for meals, standing in line to check out books \, is part of school life. Kids with ADHD find waiting time to be a great time to do stupid things that get them into trouble. Let the ADHD child do something else rather than wait in lines. Allow the child to be first to do an activity or to continue to browse for books and be at the end of the check out line is an example and applies to many other waiting time situations.

Supervision

Children with ADHD are often not as mature as other same age children therefore, the child may be ten and still have to be watched as if they were four. You need to supply the impulse controls that they are missing. Talking about events in advance, and describing what kind of behavior you expect, can be helpful and the child may need quiet reminders of expected behaviors during the activity as well.

What About Reducing "Hyperactivity"?

My child isn't so impulsive; she just cannot stop for a minute. Children with ADHD get restless very easily. This has to be kept in mind. An ADHD child may experience sitting still for 10 minutes in the same way a normal child will experience sitting still for 50 minutes. For these children to sit still, you need to make it for very short periods of time. When the sitting still time is over they need to be given time to get up and do something physical—walk around the room, go outside, whatever. Trying to get a restless child to sit beyond their ability rarely works.

Make sure they have plenty of time for recess.

Never use the restriction of recess as a consequence for bad behavior. Children with ADHD need to blow off steam.

Transition time

When a child is zooming around, make sure they are given the time to cool down. Kids with ADHD do not quickly go from running to sitting quietly. An in–between calming activity can be useful.

Physical activity

Find the right sport or physical activity for the ADHD child

One big plus of having ADHD is that you have a lot of energy. These kids often make great athletes—in the right sport. Not usually baseball or golf, but soccer, hockey, swimming, biking, running and other high activity sports are great ways to burn off some energy. Many of these children perform well in karate as well as benefiting from the structure.

Structured, calm enviroments

Children with ADHD do poorly in chaotic homes. They react more severely than normal children to the chaos. Abusive relatives, fighting or absent parents, custody battles, substance abuse, poverty, and bad housing will make ADHD in a child worse. If these situations are present in the home everything possible should be done to alleviate them.

Limit television

Television is a major force in all our lives. Study after study show that television is filled with violence, drug and alcohol use, and sexuality. The average child spends 2–3 hours a day watching television, and many children spend as much as 4–6 hours a day watching this kind of programming. It is no wonder that children who watch a lot of TV are more violent, are more likely to use drugs, and are preoccupied with sex. A child with a problem like ADHD or ODD, something clearly needs to be done. The American Academy of Pediatrics recommends the following: (16)

• Limit all media use to no more than 1 to 2 hours per day.
• Monitor a child's use of the media.
• Co–view television with their children.

It goes without saying that it is impossible to limit children's viewing if the parents are watching television all day and night. Turning off the TV is the most effective, solution to a host of child psychiatric problems. My advice is to do it!

Eliminate or reduce video and computer games

Anyone who has ever seen a child play Nintendo can see that there is a very potent force at work here. Unfortunately, the vast majority of computer and video games are violent, and they are becoming more graphic, not less, in their depiction of violence. Large amounts of television viewing can cause increased psychiatric problems for children and although there is a less research on games, the same trend is present.

About a third of children play computer or video games.(11) As anyone with a child who plays these games knows these games can be very addictive. One out of five children from grades 5–8 are addicted to computer games just as an alcoholic is addicted to alcohol.(10) The earlier children start playing these games, the more likely they are to get addicted. Children who play lots of video and computer games aren't as nice to others. Children who play violent games are more physically aggressive and are not as intelligent.(12) Unfortunately, the question remains whether or not children who are aggressive and have problems are attracted to these games or whether the games make them that way. Evidence suggests that violence on TV makes more violent kids. Given that video and computer games are a much more powerful medium than TV, I think it is quite safe to assume that they are having a detrimental effect on children.

Behavior Modification

The idea behind behavior modification is that even though there is something wrong with the brain in ADHD, if people are strongly motivated, they can, in part, make up for this deficit. In other words, if a person had a good reason, they would try very hard to sit still, listen, and think before acting. A good example of this type of program is "1–2–3 Magic" by Thomas Phelan, PhD.

Behavior modification must have certain properties to work:

• One important behavior needs to be targeted. Rather than targeting "being good", you are very specific such as, "no hitting" and "no swearing."
• The behavior desired must be clearly stated, not fuzzy. Wording like "Listen when I tell you something." won't work because it is too unclear. Clearer wording would be "Sit down and look at me when I ask you to listen."
• The behavior must be consistently expected. There is no bending of rules in this sort of thing. No difference in what is expected between the baby–sitter, mom, or dad.
• The rewards and punishments need to be geared to the individual.
• The rewards should not be money or purchased things, but privileges you can grant or activities the child can do.
• There need to be an even mix of negative and positive re–inforcers. A typical positive re–inforcer might be later bedtime on the weekend or a choice of dinner. A typical negative re–inforcer would be going to your room or no TV.
• It should be simple and straightforward so that your child easily understands it.
• The program should be discussed with the child in advance and if the child can read, written out and posted so the child can refer to it.

Almost every book on ADHD in children contains many good examples of behavior modification.

Behavior Modification doesn't work for everyone. It works best when you find the perfect positive or negative re–inforcers. Many children just don't have anything they are willing to try that hard for or the child is so severely impaired they just cannot benefit from this kind of program.

One–to–One Supervision

If you stay with a child with ADHD, you can sometimes do for them what their brains can not. Most children with ADHD cannot pay attention to boring things like work or schoolwork for long periods. If left to do their homework it takes them forever. Sometimes, by sitting with them, you can bring their attention back to what they are supposed to be doing and help keep their mind from wandering. This is probably the most frequently used intervention of all. Most children with ADHD will do amazingly better in school if they have one–on–one teaching all the time and their parents sit with them to keep them on task for their homework.

If one–to–one works so well, why do all these other things? There are few human beings who can stand to doing one–to–one for very long. Continuing to bring people's attention back to the task at hand is very hard work. It requires an enormous amount of patience, resolve, and determination.

The child with ADHD often interprets this as nagging and gets mad at the person who is trying to help them.

It does not exactly promote independence. Nevertheless, it is the backbone of all non–medical interventions for inattention in ADHD.

Does it help with the other symptoms of ADHD?

It certainly does. When children are doing things oneþto–one with a caring adult, they don't get into a lot of trouble. Their hyperactivity can be put to good use. It is hard to get too impulsive when someone is right there watching you. For example, a boy with ADHD might get into a lot of trouble in the village by himself or with peers. But if he spent the same amount of time out in the woods setting snares with his Dad, Grandpa, or Uncle, he would be putting all that energy to good use and would most likely not get into trouble.

Social Skills Interventions

Truly social skills are often poorly developed in children with ADHD. Poor attention, impulse control, and hyperactivity interfere with the acquisition and practice of social skills.

How do you teach social skills?

Social skills cannot be taught like you teach piano, reading, or math. People have tried to teach social skills in special groups, but, by and large, the social skills they learn in these special groups do not transfer outside the groups.

What does work?

Putting your child in a group where there is a need for social skills, but not extremely good social skills. The best social skills are required for the most unstructured settings, like recess. You have to find some one to play with who wants to play with you, compromise on what to do, share, take turns talking, and control your temper if something frustrates you so you don't spoil the relationship in the future.

Groups should be:

• Structured. There should be a definite beginning, and ending, and a fairly predictable course.
• Thematic. Only certain interests are pursued by the group. If you go one week for bible study, the next week won't be hunting safety.
• Geared to your child's interest. Children will be much more motivated to participate socially in something they are interested in.
• Fun. Even if it is up their line, if it is boring to the child or too hard, they will not socialize more, and they won't learn social skills.
• Not a burden to you. Not too far away, not too much money, not on all the wrong nights or at the wrong times.
• Flexible. A completely rigid group may not work.

What should we avoid?

Doing nothing. The easiest thing to do with kids who have bad social skills is to let them be. It is hard to get them involved with other kids because there can be problems and complaints. It is easy to let them just be by themselves.

The result is that the child will find a bunch of other people with very bad social skills who you would rather not have as your child's friends. Your child remains socially retarded, frustrated, and depressed

Will medications improve social skills?

Yes, they will, but, the dose has to be enough and given daily. The saddest thing I see is when I child is placed on just enough medicine to get them through school, but not enough to help them with their social skills.

Getting Someone to Help You Parent:

A parent says she has tried everything from groups to medicines and that she seriously can not imagine going on like this for ten more years. What should she do, give up my son?

No! Some children with ADHD and more children who have ADHD in addition to other psychiatric problems can require an incredible amount of patience, energy, and determination. Often this is more than any one or two human beings can provide. There is no natural law that states that all children can be managed by one or two reasonable parents. Many children are born who require three to five full time parents. You may have one!

What you should do is everything you can to share the parenting. First, think who in your family can take care of this child reasonably well for an hour? a day? a weekend? a week? Often there are cousins, aunts, uncles, good friends, fathers, mothers, or grandparents who can take a disturbed child for awhile, but not a long while. By putting a few of these together, you can get a little breathing space.

A mother states, "My family lives in another state and my husband's family don't see us.

The next step is to try what is available publicly.

• Daycare for little kids
• After–school programs for older kids
• Big Brother and Big Sisters
• A skilled babysitter
• The last step is respite foster care on a regular basis. In some cases, this is the best way to go, as it will give you a chance to catch your breath and not go crazy.

The most common mistake people make is to think they should be able to do it all. They then either end up giving up the child or getting so mad at the child that it would have been better if they had given it up. So don't be proud, get some help.

Dietary Interventions:

What about diet?

Many people have claimed that different diets control ADHD. In the last few years some good research has helped clear up this issue. Sugar and Aspartame (an artificial sweetener) do not make children with ADHD worse, even in large doses however, a couple of studies have shown that food coloring, preservatives, and additives may cause a worsening of ADHD symptoms in some children. This means that it might be reasonable to eliminate junk food and other items that show these things on the label. Is there good research to show that diet will work on controlling ADHD? No. There is only a little bit of evidence.

That means making things from scratch, plus more fresh vegetables and fruits. Try making homemade cookies for treats instead of store bought goodies. I would use pure juice, milk or water for drinks. Many people forget about Kool–aid and popsicles. These are full of colorings. I would try to make my own meals from scratch rather than buy pre–packaged and already prepared meals. I would try it for a week or so. All the studies have shown that if it works, it will work in that amount of time or never. We hardly eat anything that is pre–prepared. Should I eliminate these things completely? No, if your child's diet is low in foods containing the above things, you can assume that this is not the problem. Try some of the other suggestions below.

Breakfast and ADHD

There is good data to support the importance of breakfast for children. Children who eat breakfast do better in school, pay attention better, and get better grades. (18) The importance of this "dietary intervention" is much more important than additives or colorings. This may mean breakfast is a sandwich, soup, leftover pizza slices or a glass of instant breakfast for an ADHD child, but it is worth doing.

Family Interactions and ADHD:

How does the family affect the symptoms and signs of ADHD?

Many studies clearly show that family dynamics can worsen ADHD or improve it. The relationship between the ADHD child and the parent can affect his symptoms. If the parent is absent much of the time, is inconsistent, is drinking, or preoccupied with other problems the symptoms of ADHD in the child will be worse. If the parent sees the child with ADHD as her best friend and gives into everything the child wants, eventually the symptoms will be worse. On the other hand, hard, cruel and abusive parenting will also worsen ADHD. Parents who have ADHD themselves, bad tempers, or difficult personalities can sometimes cause a worsening of ADHD.

The relationship between the parents/caregivers can worsen ADHD. Fighting between partners, multiple significant others, and custody battles can often cause ADHD to worsen. A family should function with the parents in charge and the children under their authority. If, in reality, one parent is in charge and the other parent is below that parent there will be worse problems with an ADHD child. Sometimes a family will be set up so that certain children have greater authority than a parent. Obviously this will make ADHD a lot worse.

Siblings of a child with ADHD will be affected. They have more behavior problems themselves, have more trouble in school, and won't get along as well in general.

If these family problems are present to any degree, they need to be sorted out as part of the treatment package. Family therapy is not fun, it is time consuming, however, if the family is quite dysfunctional all interventions are likely to fail or be only partially effective until family life improves.

When my daughter is around, our family is quite dysfunctional. When she leaves we get along fine. Does this mean we need family therapy?

No, it does not. One of the hardest things to figure out in child psychiatry is whether or not family problems are causing the disturbance or whether the psychiatrically disturbed child is causing the family to have problems. It can be either or both. Studies have found that it is just as stressful to be the parent of an aggressive ADHD child as it is to be the parent of an autistic child. While it is impossible to say what is causing what, it is better to err on the side of assuming that the family dysfunction is caused by the psychiatrically disturbed child. It would be better to treat the child first and see what happens to the family. It is far easier to treat children with ADHD than it is to do family therapy. There is not a lot of evidence to support using family therapy as a primary intervention in ADHD. If you are living with an aggressive child with ADHD, it will destroy your family to a certain degree. Sometimes, even a child with ADHD who is not aggressive will cause turmoil in the family.

Many family members, neighbors, and some professionals, assume that if a child is disturbed, then the family must be the problem. They rarely consider that it could be the other way around-that the disturbed child is causing the family problems. If some of the children I see with ADHD were placed in my family without any treatments, I am sure that our family would look very chaotic and dysfunctional, too.

Enhancing the Child's Strengths

All of the interventions discussed above are directed at the disabling signs and symptoms of ADHD. While working on reducing these signs and symptoms is important, it is just as important to find out what your child is naturally good at and make him even better at it. ADHD can easily destroy a child's self esteem. Most children with ADHD will be spending a lot of time doing what is not naturally easy for them—going to school, staying out of trouble, and getting along with others, etc. They need to also spend time doing what they like to do and can do well.

As a physician I see a lot of children whose self–esteem remains intact even though they have ADHD because they are naturally good at something and their caregivers have encouraged this.

Almost everyone is at something. The trick is to find that. When children with ADHD are severely impaired, this is hardly the most important thing to be focused on. But as they improve, start thinking about it. Sometimes it takes a little creativity or someone outside the immediate family to identify the child's strengths. It is sometimes difficult to think of sending a child to art classes when they are in danger of failing school and in a lot of trouble however, if that is what they are good at and can stick with, it will help their self–esteem.

What are the strengths in your child?

• naturally good at sports?
• martial arts?
• collecting things?
• music? dancing? acting?
• computers?
• sewing?
• cooking?
• gardening?
• building or fixing things?( balsa wood is great for ADHD kids),
• art or drawing? drawing monsters?
• working with little kids?
• finding their way around?
• writing stories?
• working in the woods?
• working on the water?

In the end, you will have the best luck helping your child with ADHD if you:

• Look at all these possible interventions. Don't just rely on one thing.
• Realize that you may have to consider doing some things that you never thought you would ever do.
• Realize you may have to move mountains to get things to happen
• Talk with other people who have similar problems. Find support groups either in person or on–line at www.addresources.org, www.groups.yahoo.com or www.groups.msn.com .
• Read books, watch videos or listen to audiotapes about ADHD. Check listings at your local library or get a catalog from the ADD Warehouse.

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Dr. Jim Chandler is originally from Minneapolis, Minnesota. He graduated from the University of Minnesota Medical School in 1983 then moved to Iowa City, Iowa for a residency in psychiatry. He now lives and works in Yarmouth, Nova Scotia where he practices both pediatric and adult psychiatry. This information on ADHD is from a series of pamphlets Dr. Chandler wrote to provide accurate, unbiased information on common pediatric psychiatric disorders.

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