Treatment for ADHD

Treatment for ADHD should include education about the characteristics (symptoms, if you prefer) associated with ADHD and how these impact the individual in just about every area of life. Demystification refers to helping a person understand how they may differ without feeling that they are wrong because of their wiring. First-line treatments include medication, various forms of talk therapy, coaching, and techniques for coping.

Individual Treatment Includes:

  • Discussion regarding medical and non-medical options

  • Managing Co-Occurring Problems (Anxiety/ Depression/Defiance)

  • Address Executive Skill Deficits

  • Cognitive Behavioral Therapy (CBT) or Mindfulness-Based Cognitive Therapy (MBCT) (education, behavioral goals, structure, incentives)

  • Self-Compassion Training

  • Examine the Impact ADHD Has on Self-concept

  • Organization, Structure, Consistent Schedule/ Time Block Planning

  • Help the Person Build a Support System / ADHD Coaching / CHADD? Therapeutic Stories.

  • Externalizing Structure (regular times for wake-up, meals, homework, outdoor play, and bedtime)

  • Occupational Therapy (sensory integration), Speech Language Therapy

  • Mind Body Exercises (Yoga and Meditation)

  • Omega-3 Fatty Acids, Neurofeedback, and Working-Memory Training,

  • Explore Natural Ways to Boost Dopamine

  • Manage Stress, Mood, and Threat

  • Calming Strategies

  • School/Work Support Strategies (IEP-504 plan)

  • Tutoring

  • Exercise/Nutrition/Sleep

  • Parenting Support (More Praise than Corrections)

Natural Ways to Boost Dopamine:

Completing a task (the more challenging, the better)

•Physical contact - A big hug

•Listening to music

•Good night’s sleep

•Take a cold shower

•Drink green tea

•Deeper breathing

•Physical activity

•Meditation

•Creative activities like art, drawing, painting, writing, photography, playing games, or cooking

•Eat fruit to increase tyrosine

•Doing something new

•Turn off phone/computer notifications and replace phone time with any of the above.

Breath Awareness

•Finger Trace Breathing and Hand Play Games (Five Finger Breathing), Counting (noticing) # of Breaths per minute

•STOP Procedure

•Putting on the Brakes (Dr. Hallowell)

•Self Time Out

•Practicing Mindful Walking/Talking/Thinking

•Writing/ Drawing

•Self Regulation Skills

•Understanding The Need To Slow Down/Reduce Arousal/ Manage Stress

•Developing Personal Strategies To Keep Calm and Carry On

•Meditation

•Breath Awareness (Counting Breaths)

•Body Scan

•Open Awareness

•Loving Kindness a task (the more challenging, the better)

•Physical contact - A big hug

•Listening to music

•Good night’s sleep

•Turn off phone/computer notifications

Daily Mind Body Integration Exercises (Yoga and Meditation)

•Daily Practices/Strategies to Manage Stress, Improve Mood, and Reduce Threat

•Practicing Slowing The Body Down, Mindful Walking/Talking/Thinking

•Practice Pausing, Stop Procedure/ RAIN Procedure

•Strengthen Understanding of The Brain-Body Connection

•Attention is a Series of Skills That can be Cultivated.  Build Executive Skills/Dedicated Time/Place. Practice Skills Every Day

•Focus on Small Daily Pleasurable Experiences, Building Tiny Habits/Prompts for Behaviors You Want to Strengthen

•Set Aside Quiet Time for Self, Practice Self-Compassion

•Strengthen “Attitudes of Mindfulness”

Treatment is extremely important because ADHD can lead to frequent emotional ups and downs. People driving slowly or waiting in line can make a person with ADHD quite irritable. Minor setbacks, such as a project not turning out quite right or a boss who changes deadlines, can be emotionally challenging. People with ADHD overreact to these minor annoyances or get distracted from the task they need to perform, and then feel bad about themselves,s thinking that they should somehow do better or have better control, because they know what they should do or not do. ADHD is a problem of doing what you know, not knowing what to do.

Psychological and Behavioral Interventions for ADHD

Overview of Behavioral Therapies in ADHD

There is strong evidence supporting the use of behavioral therapies in the treatment of ADHD. These therapies are recommended as the first-line treatment for individuals who have mild symptoms, as well as for preschool-aged children.

Types of Psychological and Behavioral Therapies

Several psychological therapies are commonly utilized in the management of ADHD. These include psychoeducational interventions, traditional behavior therapy, and cognitive behavioral therapy (CBT). Other therapeutic approaches involve interpersonal psychotherapy and family therapy. In addition, interventions delivered in school settings, social skills training, behavioral peer interventions, organizational training, and parent management training are important components of psychological treatment for ADHD.

Cognitive Behavioral Therapy:

A widely used approach to ADHD is cognitive behavioral therapy (CBT). This type of therapy helps replace negative thought patterns with healthier, more positive ways of thinking. The idea is that if you change the way you think about a situation, your feelings and behaviors can change, too. For example, CBT may help change "all or nothing" thinking, in which many people with ADHD tend to think that their accomplishments must be either perfect or a failure.CBT is very focused on giving you tools to help deal with stress and challenges in life. Working on self-esteem is also an important aspect of ADHD treatment.

Neurofeedback:

Neurofeedback has demonstrated greater treatment effects than controls for up to 6 months and possibly longer following treatment. However, despite its efficacy in some research settings, regulation of neurofeedback practice remains insufficient. This lack of oversight can result in ineffective applications and the proliferation of false claims about innovations in the field.

Parent Training and Behavioral Interventions

Parent training programs have shown the potential to improve various behavioral problems in children with ADHD, including oppositional and non-compliant behaviors.

Family Therapy and Support Groups

While there is limited high-quality research on the effectiveness of family therapy for ADHD, the available evidence indicates that its outcomes are similar to those of community care and are better than placebo. ADHD-specific support groups can also play a valuable role by providing information and helping families cope with the challenges of ADHD.

Peer Relationships and Social Skills

Interventions such as social skills training, behavioral modification, and medication may offer limited benefits for peer relationships. Importantly, stable and high-quality friendships with non-deviant peers can protect against future psychological problems in children with ADHD.

Treatment for Co-Occurring Conditions:

It's common for adults with ADHD to have other mental health conditions. An estimated 50% of adults with ADHD, for example, also have an anxiety disorder, according to the Anxiety and Depression Association of America. Having ADHD along with another condition can severely interfere with daily functioning so these issues must also be managed.

Using Behavior Therapy to Promote Discipline and Focus

How to change your child’s behavior with a few adjustments to your parenting approach.

 

Behavior therapy is a structured discipline strategy based on rewards and consequences – such as increased or decreased TV privileges – that aims to incrementally teach children preferred ways of behaving.  The desired behavior – waking up on time or reducing interruptions – varies widely from child to child.  According to the American Psychological Association, behavior therapy, rather than medication, should be the first line of treatment for children with ADHD under the age of five.  William Pelham, Jr., Ph.D., director of the Center for Children and Families at the State University of New York at Buffalo, recommends starting with behavior therapy only for all children (Barkley and AAP disagree).

The benefit of using behavior therapy first is that, if a child also needs medication, he can often get by with a smaller dose,” says Pelham.  Also, parents who see that medication is working are less motivated to follow through with behavior therapy.  That would be fine if the data showed that medication alone helped the long-term trajectory of ADHD kids.  It doesn’t, according to most experts.

How do you implement a course of behavioral therapy at home?  Have you ever given your child a time-out for talking back – or a “heads-up” before taking him to the supermarket or another setting that is likely to challenge his self-control?  Then you already have a sense of how behavior therapy works. A lot of behavior modification is just common-sense parenting,” says Pelham.  “The problem is that none of us were trained how to be good parents, and none of us expected to have children who needed parents with great parenting skills and patience.”   

The basic idea is to set specific rules governing your child’s behavior with positive consequences for following them and negative consequences for infractions.  Try the following four-step plan:

Step One

Name a single goal for which you can easily measure progress.  If your goals are too diverse (going to bed at a certain time, being dressed by 8 am, doing homework immediately after school), you likely won’t be able to observe and keep track of your child’s accomplishments.  You may also overwhelm your child and set him up for disappointment if he slips on one or more goals.

Step Two

Create a chart or other visual reminder that outlines exactly what is expected of your child and how their behavior will be assessed.  Post the chart or checklist where your child will see it – this serves as a reminder and cuts down on dreaded parental nagging.

Step Three

Reward your child quickly and effusively each time she achieves the desired behavior.  Place stars on the child’s reminder chart and extend a special privilege, like 15 minutes of additional playtime after dinner.  The rewards need not be expensive, but they should be meaningful to your child – and worth working for.

Experts often advise parents to discourage negative behavior by ignoring it because children may act up to get attention.  If the negative behavior is too serious to ignore, take away a privilege – for example, 15 minutes of television time.  At the same time, parents should keep an eye out for the negative triggers that encourage this bad behavior and do their best to alleviate them.

Step Four

Speak to your child’s teacher about the behavior therapy tactics you’re using at home and work with her to devise a way for her to keep track of and reward desired behavior at school as well.  You might employ a daily report card or regular journal entries to keep track.

 

Steer Clear of These Common Mistakes:

Murky rules:  State your expectations clearly and post them around the house

Unclear commands:  Spell out your desires in detail, not generalities

Dwelling on the negative:  Praise your child for doing something well at least five times as often as you criticize bad behavior

Little patience:  Keep in mind that children with ADHD often struggle to transfer what they’ve learned from setting to setting, so be prepared to maintain a role as your child’s advocate for a long time.

ADHD Treatment Supplements 

Facts About Fish Oil

Can this common supplement sharpen your child’s focus?

By Karen Barrow

Found mainly in cold water and fatty fish, such as sardines, tuna, and salmon, omega-3 fatty acids are believed to be important in brain and nerve cell function.  The body cannot make omega-3 fatty acids by itself, and most people don’t consume enough of them in food to derive benefits, which is why fish oil supplements are so popular today.

While omega-3 fatty acids seem to improve mental focus, several small recent studies suggest that the compounds may be especially helpful to those with ADHD.

Edward Hallowell, M.D. founder of the Hallowell Center for ADHD In Massachusetts, recommends that all of his patients take an omega-3 supplement and notes that “it seems to help most with mental focus, not hyperactivity or impulsivity.”  It may take up to six weeks for patients to begin seeing benefits. 

Picking the Right Pill

There are two main types of omega-3 fatty acids in fish oil:  eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).

The most popular omega-3 supplements differ in the amounts of EPA and DHA they contain.  Based on the most recent research, Dr. John Rately recommends that you choose a supplement that has at least three times the amount of EPA to DHA.  “The data seem to show that those using supplements containing higher ratios of EPA get a better response in ADHD symptoms, including mood swings and aggression,” says Ratey.

Children may take up to 2.5 grams of fish oil each day; adults may take up to 6 grams.

Be aware that high doses of omega-3s may cause nausea, diarrhea, and other gastrointestinal discomfort.  Consult your doctor before adding this supplement to your routine.

“I tell my patients that there are two things they need to do for their health:  Exercise and consume omega-3s.”  John Ratey, M.D., associate clinical professor of psychiatry at Harvard Medical School and coauthor of Driven to Distraction (Touchstone)

 

ADHD NUTRITION:  Balanced Meals, Better Behavior

Strike the perfect balance between fruits and vegetables, protein, and complex carbs to ease some ADHD symptoms.

By Karen Barrow

Choosing the right foods – or cutting back on the wrong ones – may be a proactive way to prevent ADHD symptoms from swinging out of control.

Dr. Edward Hallowell advises all of his patients to think about their plates when preparing a meal.  Half of the plate, he recommends, should be filled with fruit and vegetables, one-fourth with carbohydrates, and one-fourth with protein.  This combination is a balanced diet, and it may control swings in behavior caused by hunger, surges in blood sugar, or a shortfall of a particular nutrient.

Protein is particularly important, in part because it prevents surges in blood sugar that may increase hyperactivity.  The brain makes a variety of chemical messengers, or neurotransmitters, to regulate wakefulness and sleep.  Certain neurotransmitters, including dopamine and norepinephrine, boost alertness.  Others, including serotonin, cause drowsiness.

Studies by Massachusetts Institute of Technology neuroscientist Richard Wurtman, Ph.D., and others have shown that dietary protein triggers the synthesis of alertness-inducing neurotransmitters, while dietary carbohydrates trigger the synthesis of neurotransmitters that cause drowsiness.

These findings add credence to the popular belief that people with ADD fare better on a protein-rich breakfast and lunch.  However, Hallowell also advocates eating several servings of whole grains each day to prevent blood sugar levels from spiking and then plummeting and cutting back on foods that contain dyes and excess sugar.

 

How Diet and Meds May Interact

Eating a high-fat breakfast can cause the body to absorb a stimulant medication more slowly and so delay the drug’s effectiveness.  Feed your child a low-fat morning meal to maximize the benefits of meds.

Appetite suppression is one of the most common side effects of ADHD medications.  For many parents, the solution is simply to keep mealtimes flexible and to serve their child a large meal that’s high in calories and nutrients late in the evening after the medication has worn off for the day.

Helpful Titles on Amazon.com…

The Kid-Friendly ADHD and Autism Cookbook, by Pamela Compart and Dana Laake

The A.D.D. and A.D.H.D. Diet!, by Rachel Bell and Howard Peiper

EXERCISE:  A MED WITHOUT SIDE EFFECTS

How physical activity can improve focus in children with ADHD.

When you walk, run, or do a set of jumping jacks or pushups, your brain releases several important chemicals, including endorphins – hormone-like compounds that regulate mood, pleasure, and pain.  That same burst of activity also elevates the brain’s dopamine, norepinephrine, and serotonin levels.  These brain chemicals affect focus and attention, which are in short supply in those with ADHD.

“Exercise turns on the attention system, the so-called executive functions – sequencing, working memory, prioritizing, inhibiting, and sustaining attention,” says John Ratey, M.D., an associate clinical professor of psychiatry at Harvard Medical School.  “On a practical level, it causes kids to be less impulsive, which makes them more primed to learn.”

Walking for 30 minutes four times a week will do the trick.  But studies have shown that any of the martial arts, ballet, ice skating, gymnastics, rock climbing, mountain hiking, whitewater paddling, and – sorry to tell you, Mom – skateboarding is especially good for adults and children with ADHD.  Why, exactly?”  The technical movement inherent in these types of sports activates a vast array of brain areas that control balance, timing, sequencing, evaluating consequences, switching, error correction, fine motor adjustments, inhibition, and, of course, intense focus and concentration.

Finally, exercise helps kids push through past failures and attack things they didn’t succeed at before.  “The refrain of many ADHD kids is, “No matter what I do, I’m going to fail,” says Ratey, author of Spark:  The Revolutionary New Science of Exercise and the Brain (Little, Brown).  “Rat studies show that exercise reduces learned helplessness.  In fact, if you’re aerobically fit, the less likely you are to learn helplessness.”

“Think of exercise as medication,” he says.  “For a very small handful of people with ADHD, it may actually be a replacement for stimulants, but, for most, it’s complementary – something they should absolutely do, along with taking meds, to help increase attention and improve mood.”

“Physical activities that involve coordination and complex movements – such as martial arts, dance, and basketball – cause connections to form between neurons in the cerebellum.  That’s the region of the brain that controls, among other things, our social interactions.”  - Dr. Edward Hallowell.

 

WORKING-MEMORY TRAINING

It may look like a video game, but this software is a serious business – reducing attention and hyperactivity in children with ADHD.

ADD talks with Bradley Gibson, Ph.D., lead author of a recent Notre Dame study underscoring the benefits of working-memory therapy, and Barbara Ingersoll, Ph.D., a trainer for Cogmed, the company that created the training module used in the research.

What is working memory?

It is the ability to hold onto information long enough to accomplish a specific goal – like holding a phone number in your mind as you dial it.

How does improving working memory help kids focus?

When you improve working memory, you improve fluid IQ – the ability to solve problems or adapt to situations as they occur.  Most kids who complete memory training become more alert to their surroundings.  They remember to bring books and materials to and from school and are more aware of social cues.

How does Cogmed working memory training work?

The working-memory program is downloaded onto a home computer.  A child logs on and completes eight exercises, each consisting of 15 trials.  The exercises, which look and sound like a video game, become increasingly harder.  A trainer calls once a week to talk with the parents.  The training is rigorous, so few children under age seven can stick with it.  Children who have recently been diagnosed with AHD should have their medication titrated before beginning training.

How long is the training, and how much does it cost?

The training runs five weeks, five days a week, an hour a day.  It ranges from $1,500 to $2,000, and it is not covered by most insurance plans.

What percentage of kids show improvement after?

About 75 to 80 percent of kids show improvement – that is, inattention and hyperactivity are reduced.  MRIs of children who completed training showed physical changes in the brain’s pre-frontal and parietal regions.  At six-month and one-year follow-ups, about 80 percent of subjects maintained or improved their working memory gains.

Is working memory training a substitute for medication?

The program does not claim to replace medication.

Low-tech Ways to Help Your Child Improve His Working Memory

Let your child know when he’s about to hear information he needs to retain.  You can say, “I want you to remember this,” or “Put on your thinking cap.”

Teach your child to engage several senses.  If she’s learning to read, for example, have her trace letters with her finger while saying the sounds and looking at the symbols.

Provide a count of the details to be remembered.  You might say, “There are ten new vocabulary words.  Five are verbs related to transportation, and five are adjectives that describe speed.”

Help your child create charts, rhymes, and raps to remember spelling rules, multiplication tables, and history facts.  Rhythm makes information memorable.

Encourage your child to highlight or underline important facts as he reads and to re-read the underlined material.

Management of ADHD

Treatment Approaches

The management of ADHD often involves counseling or medications, which may be used independently or together. Medication therapies are particularly effective in improving long-term outcomes and can reduce certain elevated risks, such as obesity, although they may carry some risk of adverse events. Commonly used medications include stimulants, atomoxetine, alpha-2 adrenergic receptor agonists, and, in some cases, antidepressants. For individuals who struggle to focus on long-term rewards, substantial positive reinforcement can enhance task performance. While medication is generally the most effective treatment, with side effects usually mild and manageable, discontinuing medication typically reverses improvements. Stimulants also enhance persistence and task performance in children with ADHD. According to a systematic review, pharmacological treatment for ADHD is associated with increased academic achievement, reduced absenteeism, lower risks of trauma-related emergency hospital visits, decreased suicide risk and substance abuse, and reduced criminality. Combining medication with cognitive behavioral therapy (CBT) may yield further improvements, as CBT can address residual problems after medication optimization. The desired outcomes of ADHD treatment vary across diagnostic criteria, and treatment efficacy is commonly assessed by symptom reduction, with some studies also considering subjective ratings from teachers and parents.

Medication

ADHD medications alleviate symptoms primarily by modulating activity in the prefrontal executive, striatal, and related brain regions and networks, typically by increasing the neurotransmission of norepinephrine and dopamine.

Stimulants

Methylphenidate (Ritalin) and amphetamine (Adderall) or their derivatives are frequently the first-line treatments for ADHD. There are many different delivery systems for these two medications, but they have been the primary medications used to treat ADHD for over 50 years. Ritalin blocks dopamine reuptake, whereas Adderall increases dopamine release into synaptic clefts. They both increase dopamine signaling, but through different mechanisms. Approximately 70% of patients respond to the initial stimulant tried, while only about 10% do not respond to either amphetamines or methylphenidate. Magnetic resonance imaging studies indicate that long-term use of amphetamine or methylphenidate lessens brain structure and function abnormalities associated with ADHD. A 2018 review found that methylphenidate offers the greatest short-term benefits in children, while amphetamines are more effective in adults. Amphetamines are slightly more effective than methylphenidate in reducing symptoms and are more effective than α2-agonists (Clonidine and Guanfacine), although methylphenidate is comparably effective to non-stimulants such as atomoxetine (Strattera). Other systematic reviews confirm the safety and high efficacy of methylphenidate for symptom reduction, improvement of executive functioning, and mitigation of adverse consequences of untreated ADHD. Stimulants may also lower the risk of unintentional injuries in children with ADHD. Clinical guidelines consistently endorse methylphenidate as a safe and effective first-line treatment for ADHD.

Safety and efficacy have been extensively reviewed by regulatory agencies and guideline developers, including the US Food and Drug Administration, the European Medicines Agency, the UK National Institute for Health and Care Excellence, the American Academy of Pediatrics, and the Australian National Health and Medical Research Council. These organizations universally conclude that methylphenidate should be considered a first-line treatment for ADHD. Insomnia affects between 11% and 45% of patients taking stimulants and may prompt discontinuation. Other side effects, such as tics, decreased appetite, weight loss, and emotional lability, can also lead to discontinuation. Stimulant psychosis and mania are rare at therapeutic doses, occurring in approximately 0.1% of individuals, typically within the first weeks of amphetamine therapy. The safety of stimulant medications during pregnancy is unclear. Symptom improvement is not sustained when medication is discontinued.

The long-term effects of ADHD medications remain uncertain, although stimulants are generally beneficial and safe for up to two years in children and adolescents. A 2022 meta-analysis found no significant association between ADHD medications and cardiovascular disease risk across age groups, but further investigation is recommended for patients with preexisting cardiovascular disease and those on long-term treatment. Regular monitoring is advised for individuals receiving long-term therapy. Periodic discontinuation of stimulant therapy in children and adolescents may be considered to reassess the need for medication, minimize potential growth delay, and reduce tolerance. Although stimulants can be addictive at high doses, those used for ADHD have a low potential for abuse, and treatment is either protective against substance abuse or has no effect.

Studies of nicotine and other nicotinic agonists as ADHD treatments have generally shown positive results, but no nicotinic drug is approved for ADHD. Caffeine was previously a second-line treatment but is not effective in reducing ADHD symptoms, though it may aid alertness and reaction time. Pseudoephedrine and ephedrine do not impact ADHD symptoms.

Modafinil has demonstrated efficacy in reducing ADHD severity in children and adolescents, with increased appetite loss as the only reported side effect. It may be prescribed off-label for ADHD.

Non-stimulants

Atomoxetine and viloxazine are two non-stimulant medications approved for ADHD treatment in the United States and other countries. Atomoxetine, which lacks addiction liability, may be preferred for individuals at risk of recreational or compulsive stimulant use, though evidence does not support its superiority over stimulants for this reason. Atomoxetine alleviates symptoms by inhibiting norepinephrine reuptake and indirectly increasing dopamine in the prefrontal cortex, an effect that overlaps with that of stimulants in 70–80% of affected brain regions. Atomoxetine has demonstrated significant improvements in academic performance, and meta-analyses indicate that its efficacy, tolerability, and response rate are comparable to those of methylphenidate in children and adolescents. In adults, atomoxetine’s efficacy and discontinuation rates are similar to those of methylphenidate.

Clinical trial data suggest that viloxazine is approximately as effective as atomoxetine and methylphenidate, but with fewer adverse effects. Amantadine (used to treat Parkinson’s) has produced improvements comparable to methylphenidate in children, with fewer side effects, and may serve as an effective adjunct to stimulants for ADHD symptoms, representing a safer alternative to certain antipsychotics. Bupropion is also used off-label and is effective, though modestly less so than atomoxetine and methylphenidate. There is limited evidence on the effects of medication on social behaviors. Antipsychotics may be used to manage aggression in ADHD.

Alpha-2a Agonists

Extended-release formulations of guanfacine and clonidine are alpha-2a agonists approved for ADHD treatment in children and adolescents, though their effectiveness in adults has not been demonstrated. These medications are modestly less effective than stimulants and non-stimulants but can be useful alternatives or adjuncts to stimulant therapy. They work by modulating alpha-2a receptors on noradrenergic neurons in prefrontal executive networks, thereby improving signal clarity.

Guidelines

Guidelines for medication use in ADHD vary by country. The United Kingdom's National Institute for Health and Care Excellence recommends medication for children only in severe cases, but considers it a first-line treatment for adults. Most United States guidelines recommend medications for most age groups. Medication is generally not recommended for preschool children. Underdosing of stimulants can result in a lack of response or loss of effectiveness, especially in adolescents and adults, as dosing is typically based on school-aged children; some practitioners use weight-based or benefit-based off-label dosing to address this issue.