Attention
Deficit Hyperactive Disorder (ADHD) is the most serious behavioural problems
not only among the children with special needs, but also among the normal
children. It requires timely and effective interventions. Most of the
professional especially clinical psychologists are less aware about different
modalities of effective treatment. This paper orients them about the different
modalities of treatment with details.
Comprehensive
Treatment for ADHD should always include a strong psychosocial component. Most
professionals believe that effective psychosocial treatment is the backbone of
good treatment for ADHD. Apart from pharmacotherapy, following psychosocial
modalities are found most effective in the treatment of ADHD.
(1) Behavioural
Intervention:
There are three parts of effective behavioural
interventions for ADHD children—
(i)
parent training,
(ii)
school interventions, and
(iii)
child-focused treatments.
Four points apply to all three parts:
(1) Always start
with goals that the child can achieve and improve in small steps (e.g., “baby
steps”);
(2)
Always be consistent—across different times of the day, different settings, and
different people;
(3)ADHD is a chronic problem for the
individual and treatments need to be implemented over the long duration—not
just for a few months; and
(4) Teaching and
learning new skills take time, and children’s improvement will be gradual with
behaviour modification.
(i)
Parent Training:
The first
session is often devoted to an overview of the diagnosis, causes, nature, and
prognosis of ADHD. Thereafter, in group or individual sessions, parents learn a
variety of techniques, some of which they may be already using at home but not
as consistently or correctly as needed. Parents go home and implement what they
learn in sessions during the week, and return to the parenting session the following
week to discuss progress, problem solve, and learn a new technique.
The topics covered in a typical series of parent training
sessions include the following topics in sequence.
1. Establishing house rules and structure
Ø Posted
chore lists
Ø Posted
morning and evening routines
Ø Posted
House Rules
Ø Review
until child has learned them
2. Learning to praise appropriate behaviours (praise
good behaviour at least five times as often as bad behaviour is criticized) and
ignore mild inappropriate behaviours.
3. Using appropriate commands
o
Obtain the child's attention: say the
child's name first
o
Use command not question language
(“Don’t you want to be good” is a bad command!)
o
Be specific, describing exactly what the
child is supposed to do (at the grocery checkout line “be good” is not a good
command! “Stand next to me and do not touch anything” is more specific!)
o
Be brief and appropriate to the child's
age
o
State consequences and always follow
through (praise compliance and provide consequences for noncompliance)
o
Have a firm but neutral (not angry) tone
of voice
4. Using when………..then contingencies
o
Give access to desired activities when the
child has completed a less desired activity (e.g., ride bike when finished
homework; watch TV when finished evening chores, going out with friends after
completed yard work)
o
For younger children, important to have
rewarding activity occur immediately
5. Planning ahead and working with children in
public places
o
Explain situation to child before activity
occurs
o
Establish ground rules, rewards, and
consequences
6. Time out from positive reinforcement
o
Assign short times away from preferred
activities when the child has violated expectations or rules
o
Give time off for appropriate behaviour
during time out and lengthen time for noncompliance with time out
o
Base times on children's ages—shorter
for younger children—e.g., one minute for each year of age
7. Daily Charts—Point/token systems with rewards and
consequences
o
Make charts with home rules/goals and
post prominently in house
o
Establish system for rewards for
following home rules and consequences for violations
o
Nickel jar for noncompliance or talking
back (e.g., put a nickel in for each compliance, remove two for noncompliance)
o
Home Daily Report Card (see target list
and creating a Daily Report Card for the home
8. School-home note system for rewarding behaviour
at school and tracking homework (see description below in School Interventions)
There are many other techniques that are part of a
good behavioural parenting program. Those listed above are included in almost
all of the good programs. Some families can learn these skills quickly in the
course of 8 or 10 meetings, while other families—often those with the most
severely impaired children—require more time and energy.
(ii) School Interventions
The following list includes typical classroom
behavioural management procedures. They are arranged in order from mildest and
least restrictive to more intensive and most restrictive procedures. Some of
these programs may be included in Individualized Educational Programs that may
apply to ADHD children
Typically an intervention is individualized and
consists of several components based on the child’s needs, the classroom
resources, and the teacher’s skills and preferences.
1. Classroom rules and structure
o
Typical classroom rules:
Ø Be
respectful of others
Ø Obey
adults
Ø Work
quietly
Ø Stay
in assigned seat/area
Ø Use
materials appropriately
Ø Raise
hand to speak or ask for help
Ø Stay
on task/complete assignments
o
Post rules and review before each class
until learned
o
Make rules objective and measurable
o
Number of rules depends on developmental
level
o
Establish a predictable environment
o
Enhance children’s organization
(folders/charts for work)
o Evaluate
rule-following and give feedback/consequences consistently
o
Tailor frequency of feedback to child’s
developmental level
2. Praise appropriate behaviours and ignore mild
inappropriate behaviours that are not reinforced by peer attention
o Use
at least five times as many praises as negative comments.
o Use
commands/reprimands to cue positive comments for children who are behaving
appropriately—that is, find children who can be praised each time a reprimand
or command is given to a child who is misbehaving.
3. Appropriate commands (clear, specific,
manageable) and private reprimands (at child’s desk as much as possible)—same characteristics
as for good commands for parents described above.
4. Accommodations and structure for individual child
(e.g., desk placement, task sheet)
o
Structure the classroom to maximize the
child’s success
o
Sit by teacher to facilitate monitoring
o
Pair with peer to help copy assignments
from board
o
Break assignments into small chunks
o
Give frequent and immediate feedback
o
Require corrections before new work
5. Increase academic performance
o
Focus on increasing completion and
accuracy on work
o
Provide task choices
o
Peer tutoring
o
Computer-assisted instruction
Such interventions have the advantage of being
proactive (i.e., could prevent problematic behaviour from occurring) and can be
implemented by individuals other than the classroom teachers (e.g., peers,
classroom aide). When disruptive behaviour is not the primary difficulty,
academic interventions sometimes lead to improvements in behaviour that are
equivalent to gains associated with more intensive classroom behavioural
strategies.
6. When…….then contingencies (e.g., recess time
contingent upon completing work, staying after school to complete work before
dismissal, assigning less desirable work prior to more desirable assignments,
require assignment completion in study hall before allowing free time) (same
guidelines as for parents described above)
7. Daily School-Home Report Card - Means of
identifying, monitoring, and changing classroom problems
o
Tool for parents and teacher to
communicate regularly
o
Individualized target behaviours
determined by teacher
o
Teachers evaluate targets at school and
send DRC home with the child
o
Parents provide home-based rewards; more
rewards for better performance and fewer for lesser performance
o
Continually monitor and make adjustments
to targets and criteria as behavior improves or new problems develop
o
Always used in the context of other
behavioral components (commands, praise, rules, academic programs)
o
Cost little and take minimal teacher
time
8. Behaviour chart/reward and consequence program
(point or token system) for the target child
o Establish
target behaviours and ensure child knows behaviours and goals (e.g., list on
index card taped to desk)
o Establish
rewards for meeting target behaviours
o Monitor
child and give feedback
o Reward
immediately for young children
o Use
points, tokens, stars that can later be exchanged for rewards
9. Class wide interventions and group contingencies
o
Establish goals for the class as well as
the individual
o
Establish rewards for appropriate
behaviour that anyone in class can earn (e.g., class lottery, jelly bean jar,
wacky bucks)
o
Establish reward system in which whole
class (or subset of class) earns rewards based on entire class functioning
(e.g., Good Behaviour Game) or ADHD child’s functioning (e.g., class earns
reward if ADHD child makes goals)
o
Encourages children to help one another
because everyone can be rewarded
o
Easier for teacher than individual
programs because improves whole class
o
Tailor frequency of rewards/consequences
to children’s developmental level
10. Time out (classroom, office); a program in which
a child is removed from the ongoing activity for a few minutes (less for
younger children and more for older) when he or she misbehaves (same guidelines
as for parents described above)
11. School-wide programs—e.g., discipline plans that
are school-wide can be structured to minimize the problems experienced by ADHD
children at the same time as they help manage the behaviour of all children in
a school.
(iii) Child Interventions
Nonspecific talk or play therapy in a therapist’s
office is not a form of treatment with scientific support for children with ADHD.
Instead, child-based treatments for ADHD with a scientific basis are those that
focus on peer relationships and that typically occur in group settings outside
of the therapist’s office. Very often, children with ADHD have serious disturbances
in peer relationships, and those problems are very strong predictors of
long-term outcomes. Children whose difficulties with peers are overcome will
have considerably better long-term outcomes than those whose peer relationships
remain problematic. Thus, intervention for peer relationships is a critical
component of treatment for children with ADHD and it is the focus of
child-based treatments.
There are five forms of intervention for peer
relationships, listed below.
1. Systematic teaching of social skills
o Cooperation
o Communication
o Being
positive and friendly
o Participation
o Helping/sharing
o Giving
compliments
o Coping
with teasing
2. Social problem solving
o Identifying
problem
o Brainstorming
solutions
o Choosing
best solution
o Planning
implementation
o Evaluating
outcome
3. Teaching other behavioural competencies that
other children consider important
o Sports
skills
o Rules
of sports
o Board
game rules
o Good
sportsmanship and good team membership
4. Decreasing undesirable and antisocial behaviours
o Target
bossy, intrusive, aggressive, and other disruptive behaviours that children
with ADHD exhibit with peers
o Establish
reward/consequence program to reduce these behaviours and to replace with
prosocial behaviours taught in social skills training
5. Developing a close friendship
o Develop
program to help child with ADHD develop a close friendship with another child
o Work
with family and teacher to facilitate the relationship
o May
serve an important role in improving long-term outcomes
(2) Working memory training
Many of the problems shown by children with ADHD
are linked with deficits in working
memory (or short-term memory). Training this memory may diminish some of
symptoms of ADHD. In a study by Klingberg et al., children with ADHD who
completed a computerized training program for working memory reported a
decrease in ADHD symptoms and performed better on working memory tests than the
control group. Some researchers attribute this to an improvement in working
memory generally, while others believe it is merely the natural effect of
practice.
(3) Timers
Timers have been found to be effective for
allowing people with ADHD to concentrate more effectively on the task at hand.
When a target is set, one method is to only turn the timer on whilst
working on the given task. A physical stopwatch or an online timer may be used.
(4) Neurofeedback
Neurofeedback
(NF) or EEG biofeedback is a treatment strategy used for children,
adolescents and adults with ADHD. The human brain emits electrical energy which
is measured with electrodes. Neurofeedback alerts the patient when beta waves
are present. This theory believes that those with ADHD can train themselves to
decrease ADHD symptoms.
No serious adverse side effects from neurofeedback
have been reported. Research into neurofeedback has been limited and
of low quality. While there is some indication on the effectiveness of
biofeedback it is not conclusive: several studies have yielded positive
results, however the best designed ones have either shown reduced effects or
non-existing ones.
(5) Aerobic fitness
Aerobic fitness may improve cognitive functioning
and neural organization related to executive control during pre-adolescent
development, though more studies are needed in this area. One study suggests
that athletic performance in boys with ADHD may increase peer acceptance when
accompanied by fewer negative behaviors.
(6) Massage Therapy
For children and adolescents with ADHD, pediatric
massage therapy has been found to improve mood and increase on-task behaviors,
while reducing anxiety and hyperactivity.
(7) Art Therapy
Art is thought by some to be an effective therapy
for some of the symptoms of ADHD.
(8) Media
Preliminary studies have supported the idea that
playing video games is a form of neurofeedback, which helps those with ADHD
self-regulate and improve learning. On the other hand ADHD may experience great
difficulty disengaging from the game, which may in turn negate any benefits
gained from these activities, and time management skills may be negatively
impacted as well.
(9) Nature:
Children who spend time outdoors in natural
settings, such as parks, seem to display fewer symptoms of ADHD, which has been
dubbed "Green Therapy".
(10)
Dietary supplements:
Omega-3
supplementation (seal, fish or krill oil) may reduce ADHD symptoms.
Magnesium
and vitamin B6 (pyridoxine) - In 2006, a study demonstrated that
children with autism/ADHD had significantly lower magnesium than controls, and
that the correction of this deficit was therapeutic. Mousain-Bosc et al.
showed that children with ADHD (n =46) had significantly lower red blood cell
magnesium levels than controls (n =30). Intervention with magnesium and vitamin
B6 reduced hyperactivity, /aggressiveness and improved school
attention.
