Medications are often used as the primary treatment for attention deficit disorder (commonly abbreviated as just ADHD, with or without hyperactivity), reducing the severity of the inattention, hyperactivity and impulsiveness. However, medication may not always be the best option. Susan Young and J. Myanthi Amarasinghe, authors of The Journal of Child Psychology and Psychiatry article “Practitioner Review: Non-pharmacological treatments for ADHD: A lifespan approach,” state that “stimulant medication, as a ‘standalone’ treatment, is unlikely to adequately address the multiple mental health needs and pervasive impairments associated with ADHD.”
Stimulants are more effective on a short-term basis, and are not without their dangers. The Mayo Clinic notes that stimulants, like Ritalin, Adderall and Dexedrine, have been linked to heart problems and addiction. Nonstimulants, like Strattera, which are also approved for ADHD, can cause liver problems and suicidal thoughts in some patients.
Young and Amarasinghe note that non-pharmacological treatments of attention deficit disorder, such as parent training, classroom interventions, cognitive behavioral therapy (CBT) and social skills training, are effective on a long-term basis. While ADHD is commonly considered a “childhood disorder,” symptoms can persist into adulthood. Non-pharmacological treatment adapts to the patient’s needs and age, and also takes into consideration comorbid psychiatric conditions. These treatments are also implemented at both home and school, the two main environments for younger patients.
With this age group, the child has inattention, hyperactivity and impulsive behaviors, which can impair her social interactions with other people, especially her peers. Comorbid disorders can also begin to present themselves, which include anxiety disorders, depression, conduct disorder and oppositional defiant disorder. Young and Amarasinghe recommend parent training as the primary treatment option, stating that “parent training addresses the issue of parenting problems directly by working with parents to enable them to modify and enhance their parenting skills in order to improve parent-child relationships.” With parent training, the practitioner must be careful not to make the parents feel inadequate, but rather emphasize that the training will teach them techniques particular to ADHD. In addition, parent training also addresses issues that can arise in the parents dealing themselves, such as depression, low self-confidence, social isolation and marital difficulties.
Parent training starts by educating parents on the condition, then teaches them behavior strategies for the preschool age group. Parents are encouraged to document problematic behaviors, and monitor any changes. When the child performs an appropriate behavior, parents can reward her with praise, tangible rewards like a toy and positive attention. Parents respond to negative behaviors with time-outs and effective commands, but do not resort to physical discipline. By rewarding positive behaviors and showing consequences for negative behaviors, the child will be discouraged from acting out and start to learn how to manage her symptoms.
During this age group, new comorbid disorders appear, like disobedience and aggressive behaviors. The child can also deal with low self-esteem and anxiety after being introduced into a new social setting where her ADHD symptoms can pose a hindrance. Parent training should continue until the child is 12 or 13, according to the National Institute for Health and Clinical Excellence (NICE)’s 2009 Clinical Guidelines. Behavioral techniques used with school-age children are similar to those used with preschool children, but are adapted for that age group.
Classroom interventions and school accommodations are introduced during this age group. Some of the behavioral techniques used with parent training are also used with classroom interventions, such as using praise, planned ignoring and effective commands. One technique used in school for behavioral issues is the Daily Report Card: the teacher sets behavior goals for the child, based on age, developmental level and severity of the symptoms. For example, a younger patient will have fewer goals on her Daily Report Card and receive more reinforcement than an older student. When the child fulfills the goals on the Daily Report Card, she receives a tangible reward that the teacher and student agree upon. The teacher can also work on time management with the child by setting a schedule that allows for more time per task and breaks in between.
A child with behavioral problems or difficulty adjusting socially may also benefit from CBT. If the child has problems interacting with other people, social skills training may be implemented; it teaches the child what are socially acceptable manners, such as making eye contact, waiting her turn and not interrupting other people. However, social skills training should not be used as the only ADHD treatment, and may not be beneficial for a patient who also has oppositional defiant disorder, according to Young and Amarasinghe. The Mayo Clinic notes that cognitive problem solving training and parent-child interaction therapy (PCIT) are other treatment therapies for oppositional defiant disorder.
Young and Amarasinghe note that about 50 percent of children continue to have attention deficit disorder symptoms when they reach adolescence, though hyperactivity becomes less of a problem. Comorbid conditions during this age group include substance abuse, antisocial personality disorder, anxiety and depression. Classroom interventions and school accommodations continue, though the Daily Report Card is phased into a Weekly Report Card, where the patient works towards long-term rewards instead. The teacher should also work with the patient on study skills and test-taking strategies. There is also greater interaction between the parent and child for behavioral targets.
CBT and social skills training also become more prevalent as a treatment during adolescence. These therapies increase opportunities with the patient’s peers, and teaches her how to better interact with them. For example, the patient will be taught appropriate eye contact, voice volume and body positioning. CBT also teaches the patient problem-solving strategies and how to monitor her own behavior, which can be implemented in both social interactions and at school. CBT also treats depression and anxiety, but is not as effective with comorbid conduct disorder.
In adult ADHD, there is diminished impulsive behavior and hyperactivity, but persistent attention problems. Comorbid conditions during this age group include mood and anxiety disorder, substance abuse and sleep problems. CBT is continued into adulthood, but now the therapist works directly with the patient instead of coordinated through the parents. The patient works with her therapist to determine goals for behavior, plan, monitor and evaluate her progress. CBT focuses on cognitive restructuring strategies, such as changing negative thought patterns to healthy coping strategies. The therapist also works with the patient to improve attention, memory, time management, organization and planning skills. CBT can also treat other disorders that the patient has, such as depression.
Non-pharmacological treatment methods can be effective ways to deal with ADHD by teaching the patient how to cope with her symptoms. For these therapies to work, it is necessary to adapt the treatment programs to the patient’s age, current symptoms and needs. It also relies on monitoring the patient’s symptoms and changes in her behaviors and emotional state.
Journal of Child Psychology and Psychiatry; Practitioner Review: Non-pharmacological treatments for ADHD: A lifespan approach; Susan Young and J. Myanthi Amarasinghe; February 2010
Mayo Clinic: Attention-deficit/hyperactivity disorder (ADHD)–Treatment and Drugs
National Institute for Health and Clinical Excellence: Clinical Guidelines
Mayo Clinic: Oppositional Defiant Disorder (ODD)–Treatment and Drugs