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Nonmedical Treatments for ADHD
By Thomas McCormack, M.D.

Attention Deficit Hyperactivity Disorder (ADHD) is a very common psychiatric disorder, affecting between 3-7% of school-aged children. Over the years, there has been opposition to the use of medications for the treatment of ADHD. The controversy is basically media-driven, often fueled by individuals and groups with a hidden agenda. Despite recent concerns, the 1998 Surgeon General's report stated there is "little evidence of overdiagnosis of ADHD or overprescription of stimulant medications. Indeed, fewer children (2-3 % of school-aged children) are being treated for ADHD than suffer from it." Increased use of stimulant medications today likely reflects better diagnosis and more effective treatment. Medical and public awareness of ADHD has grown considerably, leading to longer treatment with fewer interruptions. Clearly some of the increase in use may reflect inappropriate diagnosis and treatment. The American Academy of Pediatrics' recent treatment guidelines stated that use of medication should not be considered the complete treatment program for children with ADHD and should be prescribed only after a careful evaluation. The AAP also recommended a teamwork approach: healthcare professionals, parents, children, school authorities, and community groups should work together to identify goals that will help guide treatment.

Medication treatment of ADHD has been widely used since 1937, and clinical studies suggest that medication is the most effective treatment for ADHD, significantly helping up to 90% of affected children. However, some combination of medication with education about ADHD, school-related interventions, and behavioral psychotherapy is considered to be the most appropriate treatment for most children.

Teachers are a vital part of a treatment team, so if your child's teacher suggests that your child is having significant behavioral, emotional, or academic problems, then parents should consider seeking a thorough evaluation with a healthcare professional adept at identifying and treating such problems. Proper evaluation should include a medical exam, blood tests to exclude certain medical conditions, a thorough history from parents, an interview with the child, review of school behavior and academic records, and objective rating scales completed by both parents and teachers. There is no "test" for ADHD, but often intellectual and academic achievement tests are useful to screen for learning problems. A thorough psychiatric exam can screen for other disorders that may mimic ADHD symptoms and can identify psychiatric conditions that often co-occur with ADHD. However, parents should not feel compelled by educators to initiate a form of treatment with which they are not comfortable. Despite the evidence suggesting long-term safety and efficacy of medical treatments of ADHD, some children do develop side-effects and some parents simply feel more comfortable trying non-medical treatments first. I will briefly outline common alternative or adjunctive therapies to medication used to treat ADHD:

1) Education about ADHD

Information is power, and education regarding the nature of ADHD and its management are key. In addition to your healthcare provider, education may be attained in parent groups, support groups such as CHADD, newsletters, books, and the internet.

2) School-related interventions

Certain children may legally qualify for special education services under Section 504 of the Rehabilitation Act of 1973 and be granted an Individual Educational Plan (IEP) outlining specific accommodations. Even if a child with ADHD does not qualify under 504, she may qualify for certain accommodations by teachers regarding her physical placement in the classroom or how she is instructed, tested, graded, and communicated with. Because children with ADHD tend to respond better to one-on-one instruction, tutoring in specific areas in which the child is struggling academically can be helpful. Resources may be available at school or through private agencies.

3) Behavior modification therapy

The first step in implementing a behavior modification plan is to do away with negative and biased thinking. Concentrate on attaining desirable behaviors, not on eliminating negative ones. Set realistic goals and stick to them, and break down the goals into manageable steps. Praise your child's efforts even if he or she does not succeed, and be specific about the particular behavior with which you are pleased. A cost and rewards system will reinforce the consequences of both good and bad behaviors. Delineate a set of good and bad behaviors and corresponding consequences and allow your child to take part in defining rewards and costs. Stars and tokens are commonly employed rewards. Response cost strategies may involve withdrawal (a method by which parents withhold their attention from a child when he or she is misbehaving), time-outs for misbehavior after the child has had a chance to amend the behavior by offering "three strikes" prior to calling time-out, and taking away privileges (tends to work best with older children-12 to 18 years of age). All behavioral techniques must be consistently employed across various settings for the desired behaviors to become generalized.

ADHD coaching
A relatively new addition to the ADHD team is an "ADHD coach," who has the ability to observe from a distance, nurture, and enhance performance. The concept is that people with ADHD have unique abilities and are out-of-the-box thinkers, but that they often work ineffectively because they do not know how to channel their talents in a world structured by people without ADHD. Coaches help explore a child's strengths, accentuate them, and develop systems that facilitate daily utilization of these positive attributes.

5) Sports and Hobbies
Look into one-on-one sports, such as tennis, swimming, or track and field. Martial arts are particularly good because they emphasize personal control and discipline.

Help your child find a hobby, such as model building or raising animals for the 4-H show, that will make him or her feel special and will gain recognition from peers.

6) Diet and Vitamin therapy
Despite anecdotal reports, there is no scientific evidence of behavioral effects of sugar, food allergies, trace minerals, or megavitamins. Double-blind studies have shown no benefit from eliminating certain food dyes, for example. However, irritability or fatigue due to sensitivity to specific foods may affect behavior in some children, and physicians often suggest employing these methods in a conservative manner.

Be wary of "all-natural" supplements, such as "Focus-Factor." These are still drugs, yet their safety and efficacy has not been tested in a scientific manner in a large number of subjects.

An exciting new treatment with a growing evidence base is neurofeedback (EEG biofeedback). Children with ADHD have very specific physiological problems, which can be seen in their brain wave patterns on an electro-encephalogram (EEG). The parts of the brain generating the abnormal proportions of brainwaves can be taught to function normally by teaching the brain to produce normal proportions of brainwaves. This is accomplished by attaching scalp sensors over the parts of the child's brain that are to be trained. The sensors are connected to a computer, which runs a special training program that usually appears in the guise of a videogame. The videogame's progress is dependent upon the child producing the desired proportion of brain waves. The treatment may take 30 to 50 or more sessions for effects to be apparent and lasting. Two small studies have shown EEG biofeedback to be as effective as Ritalin on numerous measures, and another study found that 2/3 of patients taking medication were able to lower their doses or discontinue medication totally after successful training.

ADHD that is not properly treated can result in deleterious consequences to a child's development, education, and physical health. Always consult a professional to help you decide the risks and potential benefits of any treatment for ADHD.

Dr. McCormack is a board certified Child and Adolescent Psychiatrist and Clinical Professor of Psychiatry at the Emory University School of Medicine. He is founder of Athens Behavioral Medicine and is in private practice in Athens, Georgia.

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