ADHD Non-Pharmacologic Management

1. See Also
   1. Attention Deficit Disorder in Children
   2. School Problem Evaluation
   3. Attention Deficit Disorder in Adults
   4. ADHD Diagnosis
   5. ADHD Differential Diagnosis
   6. ADHD Comorbid Conditions
   7. ADHD Medications
   8. Dextroamphetamine (Dexedrine, Dextrostat, Adderall) or Lisdexamfetamine (Vyvanse)
   9. Methylphenidate (Ritalin, Methylin, Concerta)
   10. Atomoxetine (Strattera)
2. General
   1. Medications are only a part of treatment plan
   2. General measures are a cornerstone of ADHD therapy
      1. First-line in children under age 6 years old
      2. Important adjunctive role that potentiates medications in age over 6 years old
   3. Behavioral therapy is a first-line measure, despite which only 50% receive it
      1. Visser (2016) MMWR Morb Mortal Wkly Rep 65(17): 443-50 [PubMed]
3. Efficacy
   1. Behavioral, social, interpersonal and academic outcomes are similar for those on medication
      1. With or without behavioral intervention
      2. (1999) Arch Gen Psychiatry 56(12): 1073-86 [PubMed]
   2. Behavioral management has additional adjunctive benefits such as parent and teacher treatment satisfaction
      1. When behavioral management is used in combination with medications
      2. Molina (2009) J Am Acad Child Adolesc Psychiatry 48(5): 484-500 [PubMed]
4. Management: General Measures
   1. Overall Most Effective Psychosocial Measures
      1. Parent Training in Behavior Management
         1. Specialists work with parents on home strategies
         2. Reinforce desired behaviors
         3. Discourage unwanted behaviors
      2. Classroom Interventions
         1. Proactive behavior strategies (e.g. reminders of class rules, daily report cards)
      3. References
         1. Shrestha (2020) Transl Pediatr 9(suppl 1):S114-24 [PubMed]
   2. Other effective measures
      1. Ensure adequate sleep
         1. Hiscock (2015) BMJ 350:h68 [PubMed]
      2. Regular Physical Activity
         1. Zang (2019) Medicine 98(46): e17980 [PubMed]
5. Management: Establish Treatment Goals (Examples)
   1. Finish school written work in reasonable time period
   2. Recall recently read material
   3. Complete one project at a time
   4. Avoid procrastination and get organized
   5. Start needed but boring tasks without wasting time
6. Management: Educational Interventions
   1. Special education
      1. Parents in U.S. Can request an eligibility evaluation for an individualized education plan (IEP)
      2. Children with ADHD are covered for accommodations at school
         1. Rehabilitation Act (section 504)
         2. Individuals with Disabilities Education Act
   2. Learning adjuncts
      1. Books on tape
      2. Computers
      3. Dictaphone
      4. Spell check
      5. Oral and non-timed examinations
   3. Educate the family and the school about ADHD
      1. See below
      2. Provide daily behavioral report cards to be shared with parents
   4. Classroom modification
      1. Frequent reminders of classroom rules
      2. Short, brief assignments with time for feedback
      3. Preferential seating
      4. Reduction of written tasks
      5. Support in organization and study skills
      6. Non-timed written tests and assignments
      7. Colored cued materials and techniques
      8. Reward positive behaviors with tokens (and charge tokens for disruptive behaviors)
7. Management: Counseling for parents and adolescent patients
   1. Develop a sense of self esteem
   2. Behavior management (Cognitive training)
      1. Learning to "Stop and Think"
      2. Self monitoring skills
8. Management: Family understanding (Coping)
   1. Learn difference between inability and non-compliance
   2. Offer routine environment in which to succeed
      1. Brevity
      2. Variety
      3. Structure
   3. List making skills
   4. Prepare for changes in routine
   5. Redirection and ignoring of disruptive child behaviors
   6. Reward good behaviors and accomplishments (e.g. tokens or points as positive reward)
   7. Become an informed advocate for your child
9. Management: Treatments that show no specific benefit in ADD (Disproved, Avoid)
   1. Dietary intervention (no conclusive evidence)
   2. Mega-Vitamins and mineral supplements do not work (e.g. Fatty Acids, Vitamin B, Vitamin D, Ginkgo, St John's Wort)
   3. Anti-Motion Sickness medications do not work
   4. Chronic yeast infection treatments do not work
   5. EEG biofeedback does not work
   6. Applied kinesiology, chiropractic or manual manipulation show no specific benefit in ADD
   7. Optometric Vision training does not work
   8. Acupuncture, yoga, Mindfulness show no specific benefit in ADD
10. References
    1. Barbaresi (1996) Mayo Clin Proc 71:463-71 [PubMed]
    2. Baumgaertel (1999) Pediatr Clin North Am 46:977-92 [PubMed]
    3. Chang (2020) Am Fam Physician 102(10):592-602 [PubMed]
    4. Felt (2014) Am Fam Physician 90(7): 456-64 [PubMed]