| | Using nonpharmacological treatments in conjunction with stimulant medications for children with ADHD☆
Attention deficit hyperactive disorder (ADHD) is a neurobiological disorder that arises in early childhood. This disorder interferes with the child's ability to sustain attention and focus on tasks. ADHD often co-exists with impulsive behaviors that are not socially acceptable (The Disorder Named AD/HD, 2001). It is more prevalent in boys than girls and affects eight percent to ten percent of school-age children in the United States (Kelly, 2003). Without proper treatment, ADHD can result in conditions such as: school failure, substance abuse, imprisonment or delinquency, depression, anxiety disorder, and failed relationships with peers and adults (Jensen, Hinshaw, Swanson, Greenhill, Conners, Arnold, et al., 2001). The American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP) recommendations include a treatment plan that consists of pharmacological treatment, behavioral management, and psychosocial and educational interventions (AAP, Committee on Quality Improvement, 2000).
The cause of ADHD remains controversial. Through research, scientists have discovered that stimulant medications and behavior treatments are more effective in treating ADHD than medication alone (Stein et al., 2002, AAP, 2001a). Stimulant medications are the most commonly prescribed and most effective medication for children with ADHD (Stein et al., 2002). There are many myths regarding use of stimulant medications. One of the most persistent is the fear that stimulant use will lead to future drug addiction. On the contrary, it may prevent addiction by providing the child with more positive experiences and outcomes as well as less negative experiences and emotional problems (Medication management of children and adults with AD/HD., 2001, Wilens et al., 2003). Approximately eighty percent of children with ADHD who require a stimulant will require one through their teenage years (Kelly, 2003). Seventy percent to eighty percent of children with ADHD respond to stimulants positively resulting in an overall decrease in ADHD symptomology (Medication Management of Children and Adults with AD/HD, 2001).
Stimulants reduce impulsivity, hyperactivity, poor self-control, and aggression, as well as improve academic performance. They do not, however, help academic skills or antisocial behaviors (Kelly, 2003). Psychosocial interventions provide tools for children with ADHD to develop meaningful social interactions and rewarding relationships with family and peers (Jensen et al., 2001, Silver, 1999). The consistent use of behavioral interventions, such as the token systems, can help to promote socially acceptable behavior in children with ADHD (Kelly, 2003, NIMH, (2003 rev)).
This article will discuss common strategies used in conjunction with stimulant medications. These strategies will include home management, school management, and individual and family counseling. Successful management of ADHD requires a multimodal treatment approach with behavioral management playing a vital role. Research has shown that children have better outcomes at home and at school when behavioral and pharmacological treatments are utilized together (Jensen et al., 2001, Olfson, 2003). Practitioners in pediatrics and primary care may encounter children with ADHD and their families regularly. Using the following approaches they can provide invaluable resources and instruction to promote functionality at home, school, and in the community.
Home management  Educating families about home management may be the most overlooked, yet important, area in the management of the child with ADHD. Guidance in this area can enable a parent to develop positive rather than negative parenting skills and help the family function better as a whole (Parenting a Child with AD/HD, 2001). Many parents will blame themselves for their child's behaviors (AAP, 2001b), but it is important for parents to have self-confidence and consider themselves to be good role models and mentors (Tanner, & Hanmer, 1998). The American Academy of Pediatrics (2000) recommends three basic principles for behavior therapy. First, specific clear rules must be set; second, rewards and consequences must be provided; and, finally, these rewards and consequences must be used on a regular and long-term basis (AAP, 2001b). Clear rules By practicing the three principles mentioned above parents will feel increasingly confident in guiding and directing the child's behaviors. First, rules need to be defined and consequences determined (Phelan, 1996). They need to be discussed with the child to assure a thorough understanding has been reached. For example, the child may not understand what it means to “be nice.” The parent should create a specific list of what it means to “be nice,” such as: no hitting your sister, no name calling, no fighting with the neighborhood kids, and no refusing to do what you are told. Clear consequences Children with ADHD should receive positive reinforcement and/or negative consequences immediately after their actions because they forget quickly (Parenting a Child with AD/HD, 2001). Consequences for violation of rules must be clear (Pfiffner & Barkley, 1998). An example is, “If you hit your sister you will receive five minutes in time-out.” It is considered standard by most developmental behavioralists to institute one minute of time-out for each year of age (Tanner & Hanmer, 1998). In addition, time-out need not mean isolation in the child's bedroom. It can mean sitting on a chair facing the wall. A variant strategy for time-out puts the length of time in time-out in the child's hands, directing the child to remain in the time-out location until he or she is ready to cease the annoying behavior or apologize. Many professionals who specialize in ADHD treatment programs recommend the resource 1-2-3 Magic (Phelan, 1996) to teach parents the correct usage of time-out. If a child commits an offense that is extreme or dangerous, the parent should not wait to count to three but place the child in time-out immediately and add at least an extra 5-15 minutes to the required time-out. Timers should be set and parents should remain near the area to ensure compliance. Parents and siblings should not interact with the child during time-out or institute further discussion about the inappropriate behavior unless the behavior would endanger the family or child in the future. An example of a dangerous and/or extreme behavior would be when a child runs across the street without looking or a child hits a parent. After establishing specific rules and consequences, it is imperative for parents to “stick to it” on a daily basis. Behavioral management only works when it is used consistently and over the long term (AAP, 2001b). The focus on appropriate negative consequences must be balanced with equal focus on positive consequences for appropriate behavior. Depending on the age and interests of the child, as well as the good behavior being reinforced, rewards may range from positive verbal acknowledgment to hugs or other physical demonstrations of appreciation. Other rewards may include additional video game time, extra special time with a parent, etc. Positive reinforcement is critical to rebuilding and sustaining a positive parent-child relationship that often is frazzled and frayed by the time treatment begins. Structuring for success Increased structure is essential in the home. Children with ADHD require a stable, daily routine and strict organization (NIMH, 2003). There are valuable free resources on the Internet to help parents learn organizational strategies. One of these Web sites is the Agency for Healthcare Research and Quality's (AHRQ) ADHD Living Guide located at www.health-center.com. Organization is increasingly important as the child with ADHD moves through the years of schooling. Creating designated places for backpacks, toys, and other items will save the parent and the child a great deal of frustration. Try to ensure that the home is run on the same routine daily (AHRQ, 2003). Some recommendations for providing structure are located in Box 1. BOX 1 Recommendations for providing structure Prepare a list of tasks you expect the child to complete; review and reinforce this frequently to assure compliance
Set a scheduled clean-up time daily or have the child return items immediately after use (for example, putting books back to the bookshelf)
Every evening, be sure baths and homework are completed before dinner
Have clothing and shoes in sight and accessible for morning preparation
Check backpacks to assure homework is completed and in the right place. Consistently place items needed for the next day in a designated area
Keep medication in a safe yet central place (e.g., next to car keys) so they will not be overlooked School management Children with ADHD are at increased risk for academic failure (Quinn, 1997). Consequently, they are at risk for developing low self-esteem and poor self-image that often lead to depression and anxiety (Thompson, Newton, & Primary Children's Center for Safe & Healthy Families, 2000). Appropriate school intervention programs must be provided for children with ADHD to help them attain optimal functioning and academic success. This process requires cooperation among parents, teachers, and providers. Teachers should be well-trained and willing to work with the parents and child to meet their special needs. To implement appropriate accommodations, parents should ensure that the teacher is educated about ADHD and is well informed on which strategies work best for their child (Tanner & Hanmer, 1998). The same basic principles used to manage the home environment must also be employed in the classroom: goals must be set and rewards and consequences identified and used on a consistent basis. Rules and schedules must be clearly defined and posted in a prominent place, such as posters on the walls or cards on the child's desk. Restating the rules and goals before an activity also helps to remind the child to stay on task (Pfiffner & Barkley, 1998). Rewards are critical for they are positive reinforcement. Teachers should seek every opportunity to give praise for desirable behaviors. The use of a home token economy system can be used to motivate the child to follow rules and complete tasks at school as well as at home. A daily note to the home allows the teacher to maintain effective communication with the parent. When the teacher reports good behavior, the child receives a reward at home as identified by the home token economy system. The classroom environment can be modified to accommodate the child with ADHD (Pfiffner & Barkley, 1998). The child who is easily distracted by sounds can benefit from seating in a quieter area in the classroom, away from the window, noisy heaters and air conditioners. Other helpful environmental strategies include the following:
•Seat the child close to the teacher's desk
•Surround the child with well-behaved and industrious students
•Use privacy boards, earphones, or earplugs to block distractions during test-taking and classroom work
•Provide adequate desktop space so work can be organized(Rief, 2001).
Teachers should also try to shorten tasks by breaking each assignment into smaller units to accommodate the child's attention span (Rief, 2001). Shortening the number of homework assignments will help the child to complete tasks with more precision and learning (Silver, 1999). Creativity in teaching and the use of a wide spectrum of teaching techniques can help to capture and maintain the attention of the student with ADHD (Tanner & Hanmer, 1998). Some strategies that effectively stimulate learning are listed in Box 2. BOX 2 Learning strategies that can be employed for children with ADHD Hands-on activities
Videos
Computer and computer games
Verbal games
Role playing
Oral reading
Skits and demonstrations
Music (choice of music can range from rap to classical based on teaching need; e.g., rap for learning spelling) In many instances, parents find roadblocks when it comes to obtaining accommodations for their child in the classroom (Pfiffner & Barkley, 1998). Children with a disability (ADHD) qualify for free services within the school system (Stein et al., 2002, National Information Center for Children and Youth with Disabilities). When a child is diagnosed with ADHD, a stimulant should be started (if appropriate) and a meeting between the parents, teacher, counselor, and other team members should be initiated (Stein et al., 2002). The teacher may have a negative attitude and be unwilling to provide special interventions for the child or may claim that the large class size prohibits special treatment. For this reason, parents seeking an informal arrangement must be careful not to place too many demands on the teacher, but instead ask for the accommodations that would be most helpful for the child. In the case of a teacher who is resistant and unwilling to work with the family, the parent should speak with the school counselor or principal to explore other options. Parents must be aware of the rights of the child under Section 504 of the Federal Rehabilitation Act and the Individuals with Disabilities Education Act (IDEA) (Cohen, 1998). Both Acts stipulate that services must be provided for the child with ADHD, whether it is a simple accommodation or special education classes (Box 3). Formally, a student can have a “504 student accommodation plan” under Section 504 or an “individualized education plan (IEP)” under the Individuals with Disabilities Education Act (IDEA) (Stein et al., 2002, National Information Center for Children and Youth with Disabilities). If the teacher or school system is not helping the child, the parent may seek help from community resources. Local ADHD support groups, like CHADD, or a government education department can help parents achieve appropriate accommodations for their child (Tanner & Hanmer, 1998). BOX 3 Examples of common accommodations in IEP planning Using quiet areas of the classroom to help improve concentration
Interval visits from special education teachers
One-on-one assistance with tasks
Allowing child to move around if needed to decrease energy
Formal tutoring
Avoiding timed tests
Repeating verbal instructions and providing written instructions (especially in adolescents)
Seating child in front row of classroom to decrease distractions Individual and family counseling Children with ADHD are not the only ones affected by this debilitating diagnosis. Often family members and care providers are depressed, frustrated, feeling hopeless and alone (Kelly, 2003). Siblings are significantly affected and should be educated about ADHD. This will help them understand and cope with the behaviors of their brother or sister. It is important to assure younger siblings that ADHD is not a transmittable disease in order to prevent fear and avoidance of the affected sibling (NIMH, 2003). The treatment plan should include education for older siblings to help them understand the symptoms of ADHD and how to help their brother or sister control their behavior. This understanding will help them deal with unpleasant situations and avoid embarrassment, especially in front of their peers (ADHD and the Family, 2002). Between 30% and 40% of children with ADHD have a relative with a similar disease (Kelly, 2003). If a parent has ADHD, parenting a child with similar characteristics is extremely challenging (Harman, 2001). Parents deal with many difficult issues when faced with raising a child with ADHD, such as:
•Trouble at school
•Difficulty with communication due to distractibility
•Homework issues
•Problems on the playground
•Fighting with siblings.
Children with ADHD become easily frustrated and often “act out” by destroying property or with physical violence. This cycle not only causes stress for family members but also decreases the child's self-esteem and self-image (NIMH, 2003). Providers must educate parents in effective behavior management strategies (Jensen, et al., 2001). Counseling can provide behavior management strategies tailored to the needs of the child and family with ADHD. Counseling sessions educate parents about ADHD, assist in strengthening the child's self-esteem, improve daily coping skills, and provide tips for discipline. In addition, support groups can help parents to feel less alone and allow them to share their mistakes and successes with others in similar situations (Silver, 1999). With the help of stimulants and behavioral/psychological training, families begin to realize that their child is talented and special just like other children (Silver, 1999). Caregivers need to focus on the child's strengths and encourage them to “be the best they can be” (Thompson et al., 2000). Encourage parents to spend 15 to 20 minutes each day with the child on a one-on-one basis. This time should be used to play, listen, and love. Make it special by letting the child dictate to the parent activities they wish to participate in—“Let them be the boss” (Thompson et al., 2000). This creates a sense of importance, makes the child feel special, and can decrease power struggles throughout the day. Parents must strive to let the child feel supportive, unconditional love. This will improve the mental health of all involved and promote success in all aspects of life. Conclusion Untreated ADHD can result in extremely negative outcomes. It is imperative that children with ADHD receive treatment that includes the multimodal approaches recommended by the AAP and the AACAP. Because behavioral therapy may be financially difficult to obtain due to lack of insurance coverage and the strain on personal financial circumstances, parents should be provided with alternative teaching and literature. Health care providers should guide parents to become involved in ongoing ADHD support and educational groups. Providers should give parents a list of reliable, high-quality community, national, and Internet resources (Box 4) and tips on home and school management of their child with ADHD (Box 5). Providers must reiterate that the combination of stimulants, home management, school management, and individual and family counseling are essential for positive outcomes in children with ADHD. BOX 4 Resources for parents, teachers, and providers National ADHD Organization: www.chadd.org
Legal Advice and Answers to Special Education Questions: http://www.reedmartin.com
Learning Disabilities Association, LDA National Office, 4156 Library Road, Pittsburgh, PA 15234
The ADHD Report, Guilford Press, 72 Spring Street, New York, NY 10012
ADHD Handbook for Families—A Guide to Communicating with Professionals: P. Weingarter, editor; Child and Family Press; Washington, DC; 1999
ADHD Magazine: www.additudemag.com
Attention Deficit Disorder Association: 4300 West Park Boulevard, Plane, TX 76093 BOX 5 Parent Handout: Tips to help your child with ADHD succeed at home and school
1.Make rules clear and brief
2.Make a list of tasks for the child to do and post it in an accessible place (refrigerator, bulletin board)
3.Establish and maintain a set routine for the morning and evening so child knows what to expect (hygiene, sleep, meals, homework, play and TV, bedtime)
4.Organize your home so child has a set place for everyday things (clothes, backpack, shoes, homework supplies)
5.Limit distractions in the home during homework time or other events that require concentration
6.Offer incentives for completed tasks (tokens, money, special events)
7.Frequently reward and praise child for successes (good behavior, grades, following the rules)
8.Use positives and praise more than negatives and punishment (for every negative follow up with 3 positives)
9.Communicate with teacher on a regular basis (daily report cards, phone calls, parent teacher conferences)
10.Remind your child of your love and support
11.Be consistent and patient
12.Give unconditional love and support
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☆ SECTION EDITOR Mary Margaret Gottesman, PhD, RN, CPNP Ohio State University College of Nursing Columbus, Ohio PII: S0891-5245(04)00182-8 doi:10.1016/j.pedhc.2004.07.002 © 2004 The National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. | |
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