This is a good time to reiterate that our Course Notes series is just that. Occupational therapists need to take a certain number of continuing ed classes each year. These classes are geared toward therapists, counselors, practitioners, etc. But from these classes, there is a ton of really great information that I think can be helpful for parents as well. I am in no way diagnosing, prescribing or treating a specific person. Now that that is covered, let’s get to ADHD, Part 3.

ADHD affects how information is taken in and processed due to its alterations in brain structure, neural connectivity, and neurotransmitter levels. These changes impair the executive functions, resulting in difficulties with attention, recall, and self-control. While there is no “cure”, it is considered one of the most treatable conditions out there. So, what are the most effective management treatments out there for child ADHD these days?

Believe in Medication

As it stands, medication is the most effective treatment in managing ADHD. Studies have shown improvement in 70-90% of clinical cases, as well as normalizing behavior in 50-60% of them. Additionally, new research suggests that long-term use of ADHD medication can result in brain growth in executive functioning structures. Despite the substantial evidence supporting their effectiveness, there is still some stigma surrounding it when it comes to kids. So, let’s clarify a few things:

• ADHD drugs are among the safest in all of psychiatry to prescribe
• They can be taken for years, starting at the age of 3 all the way to adulthood
• There is no evidence supporting the idea that they will stunt a child’s growth or brain development
• ADHD meds reduce the future risk of substance abuse

The main purpose of ADHD medications is to reduce symptoms by increasing neurotransmitter levels (dopamine and norepinephrine) as well as strengthening neural pathways to the prefrontal cortex. This allows for increased attention and concentration to presented tasks, improved inhibition and impulse control, and a reduction in hyperactivity. Unfortunately, the symptoms return if the medication stops.

The average medication duration is about 3 years. While factors such as expenses, the severity of side effects, or even the current stimulant drug shortage play a role in this, most times it is the perceived ineffectiveness of the drug. The truth is that many clinicians are nervous to up the dosage level to see any improvements in symptoms and parents are impatient to wait to see the effects (some meds may take up to a month to work). Dosage levels are dependent on how fast the drug metabolizes in the system. This means that not every kid is going to respond to the same dosage amount of a drug.

ADHD meds are constantly evolving, adjusting to ensure effective results while limiting the side effects. For instance, drugs like Ritalin and Adderall have been improved and/or replaced with new ones like Concerta, Vyvanse, or Strattera. The development of extended-release capsules has eliminated the need to take a pill every three to five hours to reduce symptoms. Oh, and if your child can’t tolerate swallowing a pill, medications can now be delivered via patches, liquids, and even chewable gummies.

The moral of the story: Medications help reduce the symptoms of ADHD and its effects on the child brain have been positive thus far.

Say No to Drugs…For Now

While prescriptions are a convenient go-to in managing symptoms, they are only one part of the solution. However once the meds stop, so do all the positives that go with it. Additionally, parent education and behavioral therapy are initially prescribed to address ADHD in children 6 years and younger before medication is even considered.

There are many methods to treat ADHD, but some may not be age appropriate. For instance, cognitive behavioral training (CBT) has been found to be effective for those with adult ADHD; however, its approach is not helpful for children since they may not fully understand many of the concepts. Even though meds take a back seat until the age of 7, research finds that a combo of medication and other forms of treatment is an effective way for managing ADHD.

Here are the current interventions that have proven helpful for kids.

Behavioral Therapy

Behavioral therapy helps children with ADHD develop necessary skills to control their symptoms and manage daily tasks/activities. The process involves the whole family, from acknowledging how the symptoms affect the household and other environments to goal setting and implementation of behavioral strategies (ex: external incentives, positive reinforcements, etc.) The goal is to replace the negative behaviors affecting performance with positive ones that will allow them to succeed in areas that were previously a challenge.

Modifications/Accommodations

While you may see some of these strategies at school, they can also be implemented at home.

• Time management – using a clock or timer; map out a schedule for the week
• Motivation – reward system; token economy
• Working memory – verbal single-step instruction; written multi-step directions; visual reminders
• Self-awareness/self-monitoring – self-rated report cards; daily/weekly check-ins
• Emotional-regulation – quiet/calming spaces; sensory tools
• Planning – creating a to-do list to complete tasks/activities
• Inhibition – fidget toys; wiggle chairs

It’s important to know that ADHD is not a skills or knowledge disorder; it is a performance disorder. This means that once these behavioral strategies are removed, the skills diminish. It’s not that they need more skills training, they know what is required. The difficulty is in doing what they know. To be successful, these interventions should be part of the daily flow of activity in the child’s natural environment (what neuropsychologist Dr. Russell Barkley calls the point of performance) and should remain there until their brain develops and executive functions mature. Definitely not a quick fix.

Other Methods of Management

Green Therapy (for kids, it’s outdoor play). Studies observed that children diagnosed with ADHD displayed fewer symptoms when they spent significant time outdoors.

Sensory Inputs. Engaging certain sensory systems, such as the vestibular (movement), proprioceptive (body awareness), and tactile (touch), have been shown to reduce the hyperactive/impulsivity traits of ADHD by boosting neurotransmitter levels. This explains why fidget tools have seen great success in children with ADHD.

Mindfulness training (MMT). This approach focuses on the awareness of thoughts, feelings, and sensations occurring in the present moment (also known as slowing down and checking in). Research has found not only a reduction of symptoms, but also significant improvements in executive function performance as well as increases in the concentration of gray matter in those with ADHD who practiced mindfulness techniques regularly.

Structured Movement Activities. Yoga, martial arts, and Tai Chi all have been found to reduce symptoms and improve executive functions in children with ADHD. Not only do these practices encourage movement, but their framework and expectations provide a clear path towards achievement. Additionally, instructors become positive role models and mentors, offering stability and consistency in times of disappointment and frustration to help them positively build resilience.

Getting Sufficient Sleep. Children with ADHD have a higher rate of sleep difficulties than the general population. While some reasons are due to disrupted sleep (like motor restlessness, sleepwalking, or sleep apnea), it may be due to a sleep disorder called delayed sleep phase syndrome. This is caused by their circadian rhythm being thrown off by two hours resulting in difficulties falling asleep at night and waking up in the morning due to persistent exhaustion. One way to curb this issue is with good sleep hygiene.

Limit Screen Time. The amount of TV viewing and video game playing has been associated with attention problems. People with ADHD take in more screen time than those without the diagnosis. This may be due to the ADHD brain being naturally stimulated by novelty of moving images on the screen, holding their attention for extended periods of time.

Eating Healthy. A diet rich in proteins, complex carbs, and omega-3 fatty acids have been known to reduce ADHD symptoms by increasing neurotransmitter levels.

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As more ADHD research and findings come in, we’ll get more treatments and ways to manage it. But none of that will matter unless we have a better understanding and compassion towards the diagnosis.

 In fact, many interventions are successful thanks to the cooperation and consistency of parents who gained insight into their child’s behavior and reframed their perceptions and expectations to help their kid succeed.

Next post: Diagnosis and Reframing ADHD

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