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Friday, February 19, 2016

Beyond Medication: Evidence-Based ADHD Care

From Smart Kids with LD

By Mark Bertin, M.D., with Eve Kessler, Esq.
February 16, 2016

For children with ADHD who do not take medication, managing symptoms successfully includes the consistent application of proven behavioral and educational interventions at home and at school. There is scant evidence to suggest complementary and alternative therapies work.

ADHD is a condition that is often managed safely and effectively with prescription medications. But for a segment of the ADHD population, drugs are not the answer. Some people don’t respond to them at all; others suffer adverse side effects; and some parents refuse to have medication prescribed for their children.



In addition, even kids who respond positively to ADHD medications may find they’re still plagued by symptoms related to aspects of executive functioningfor which drugs are not available.

If medication isn’t the sole answer for your child, what then are the best alternatives to manage ADHD? The answer lies in a comprehensive approach that includes parenting, behavioral, and educational interventions.


As a parent, your job is to foster independence by giving your child skills and strategies to succeed as an adult, but that can be especially hard to achieve for a child with ADHD.

The Challenge

Your child has a challenging neurobiological condition that affects his attention management, self-regulation, organization skills, and planning. What you might interpret as defiance may be his inability to self-regulate or manage his attention.

For example, a child engaged in play or watching television might not even “hear” when you ask him to do something. Or, in spite of his best intentions, he may forget what you asked him to do, become distracted, or be unable to shift his attention away from playing.

The most successful parent is one who is able to put herself in her child’s shoes and try to understand executive function from his perspective. It is not his fault that he can’t monitor his behavior and emotions or organize his world, and placing blame is inappropriate and hurtful.


Family-Based Approach

Your child’s ADHD symptoms can either be made worse or improved by your parenting style. When faced with difficult challenges, parents may feel overwhelmed, becoming either too lax, too authoritarian, or exhibit an inconsistent mix of both approaches.

Family-based interventions help teach parents how to shift the dynamic away from negative and corrective parenting styles. The goal instead is to focus on creating positive and enduring relationships that emphasize success balanced by clear limits.

Kids with ADHD are used to getting negative feedback all day from every angle. Direct teaching in behavior management techniques and cognitive behavior therapy encourage less anxiety and more self-confidence in kids, and greater satisfaction for parents.


Examples include:
  • Building structure and routine into the day
  • Using appropriate reward systems
  • Managing expectations
  • Identifying triggers of challenging situations
  • Separating skill deficits from character flaws

Educational, Academic and Classroom Planning and Interventions

The learning profile of a child with ADHD usually encompasses more than his attentional/hyperactivity challenges: it also includes symptoms caused by his executive function disorder, and by any co-existing conditions he may have (e.g., difficulties with language processing, reading comprehension, a math learning disability, irritability, explosiveness, etc.).

After identifying your child’s unique challenges, work with his teachers and team to create a short-term plan to serve as a “safety net” and a long-term plan to build skills. If a challenge is recognized, a support system should be put in place to address it before it becomes more serious.


For example, if the class is reading a book and your child struggles with reading and vocabulary, in the short term pre-teaching words and content can be helpful to prepare for reading the book (e.g., listening to the book on audiotape, viewing a video version, etc.).

For a long-term plan, he should work with a reading specialist to develop reading skills and strategies.

Possible educational/academic interventions include:

  • Writing down assignments and rules and making sure they are understood
  • Maintaining communication with teachers regarding classroom behaviors as well as academics (e.g., creating a behavioral report card)
  • Making and reviewing calendars for long- and short-term projects
  • Breaking down tasks and assignments into smaller parts
  • Repeating and making sure he understands directions for tests, assignments, and homework
  • Highlighting important aspects of the material (without using the highlighter to the point of distraction)
  • Redirecting him if he appears inattentive or off-topic
  • Directly teaching and monitoring organizational strategies for lockers and backpacks as well as for narrative writing
  • Modifying homework to support learning
  • Setting up a structure for a nightly routine
  • Allowing for a note-taking partner or teacher’s notes
  • Reminding him to hand in assignments
  • Providing duplicate sets of books
  • Testing away from distractions, with or without extended time.

The overall plan and “look” of a classroom is also important for maximizing the performance of a child with ADHD and for keeping him involved and open to learning. Environmental distractions should be minimized, such as hanging artwork or large windows with views. Desk “clusters” are disruptive and may increase problem behavior.

If a punishment needs to be imposed, make sure never to take away recess, exercise or outdoor activity breaks.

In addition, children with ADHD can be accommodated under Section 504 of the Rehabilitation Act of 1973, if their impairment “limits one or more major life activity,” such as speaking, learning, reading, writing, performing math calculations or caring for oneself. They may also be eligible for services under the IDEA, if they have an identified disability, such as a specific learning disability, and, for that reason, need specialized instruction.


Complementary and Alternative Interventions?

Up to 60% of families of children with ADHD try “alternative” approaches to care. However, alternative therapies alone have not been shown to be effective for ADHD.


When thinking about whether or not to try an alternative intervention, ask yourself:
  • Is it safe?
  • Is there a rational theory behind it?
  • Why would this particular intervention help a deficit in frontal lobe function?
  • What are the monetary, emotional and relationship costs involved? (e.g., how disruptive would the intervention be for my family? Does it make sense for my family to cut a particular food out of our diets?).

Should You Limit Sugar?

While there is some evidence that adding fish oil/Omega 3s to the diet and avoiding food dyes may be helpful for ADHD symptoms, there is no evidence that a sugar- or gluten-free diet will have a positive impact.


Brain Training

Some families use techniques that aim to train attention. While attention training cannot cure ADHD, it may help alleviate symptoms by encouraging the participant to re-focus his attention over and over again. Specific types of meditation, computer programs, video games, and neurofeedback are some of the available tools that help in training attention.


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This article is based on a presentation by Mark Bertin and covered in more detail in his book, The Family ADHD Solution (Macmillan, 2011), www.developmentaldoctor.com. Dr. Bertin is a developmental pediatrician in New York.


Eve Kessler, Esq., a criminal appellate attorney with The Legal Aid Society in New York City, is co-founder and President of SPED*NET, Special Education Network of Wilton, Ltd., www.spednetwilton.org, and a Contributing Editor of Smart Kids.

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