ADHD is a very common disorder with several medication treatment options. There also are wellness and parenting strategies that can address aspects of the challenges of ADHD that are not perfectly covered by medication, such as excess symptoms, times of day that are not covered, or oppositional behavior that often develops secondarily.

Case summary

James is a 6-year-old boy who has been an active, high-energy child since preschool. He has had difficulty with wiggling around in kindergarten and preschool, talking excessively, and being unable to follow directions and pay attention. He is impulsive, disruptive, and frequently doesn’t listen to what his parents tell him to do. Parents and teachers rank him in the clinical range for hyperactivity, impulsivity, and attention problems on standardized rating scales.

Discussion

When we first discuss a new diagnosis with a family, we have the opportunity to shape the family’s expectations about that diagnosis and how it should be addressed. When I discuss ADHD with a new family, I want them to understand the symptoms of inattention, hyperactivity, and impulsiveness, and that these symptoms are not the child’s fault, but rather related to the way his brain is connected. At the same time, I also emphasize that these connections are not entirely fixed, that they mature over time, and that they are affected by experiences in life. In particular, I stress that positive experiences and wellness activities can influence the brain in a positive way. While, of course, I discuss the range of medications that can address these issues, I also deal with wellness in the treatment plan.

In our clinic, we talk with every family not only about treating the emotional and behavioral challenges a family faces, but also about the importance of promoting positive aspects of life that are known to affect the brain. Our domains of wellness include exercise, mindfulness, reading, music, healthy sleep, healthy eating, positive parenting, and community involvement. I would like to focus on three of these – exercise, healthy sleep, and positive parenting – for which there is at least preliminary evidence of beneficial effects on either the core symptoms of ADHD or a common comorbidity, oppositional behavior.

Exercise

Studies in humans and animals have provided background evidence that exercise increases the release of neurotransmitters such as dopamine and norepinephrine that are important in the pathophysiology of ADHD. Cerillo-Urbina et al. did a meta-analysis in 2015 of randomized controlled trials and found medium to large effect sizes for a variety of physical activity programs with respect to attention, hyperactivity, and impulsivity, although the study quality was generally low.1 Clearly we need additional more rigorous studies, but given the positive direction of outcomes, the lack of side effects, and the many other positive effects of exercise, it does not seem too soon to add exercise as a prescription for our patients with ADHD. I review this evidence with families, ask them about physical activity they like, and ask if they are willing to work toward an hour of exercise a day.

Sleep

Many children with ADHD have problems with sleep even before they start on stimulant medications, which can further affect sleep. Addressing sleep early on can improve ADHD symptoms, as well as help parents change or avoid patterns like having children fall asleep to the sound of a television. Brief sleep hygiene and cognitive-behavioral therapy interventions over three visits were demonstrated in a randomized controlled trial by Hisock et al. to improve ADHD symptoms and behavioral function.2 These psychosocial interventions clearly are the first line in addressing sleep problems in ADHD, and can benefit even sleep problems connected to medication.

Parent training

Finally, behavioral parent training repeatedly has been demonstrated to be effective for the oppositional behavior so common with ADHD. Specific skills also can be used to help motivate children with things like homework. I emphasize that children with ADHD are quite challenging to parents, and we all can use extra skills to support them. CHADD, the national ADHD organization, offers a program called Parent to Parent that offers peer support, education about ADHD, and training in the specific behavioral skills. This is offered locally in many areas, and also can be accessed online at www.chadd.org by searching for Parent to Parent.

Treatment plan

1. Have the child exercise 1 hour every day. Have fun!

2. Establish a nightly bedtime routine, with a bath at 7:30 p.m., brushing of teeth, a story, and lights out at 8 with no TV in the room.

3. Check out the CHADD website for Parent to Parent.

4. Start a trial of stimulant medication.

5. Return in 2 weeks to monitor these interventions, adjust goals, and adjust medications.

When to refer

Many parents will be able to put such a plan in motion with your support and that of other parents. If they are struggling, therapists, psychologists, and psychiatrists trained in motivational and behavioral methods can provide more individualized parent training. Also consider whether the parents themselves may have ADHD and could use referral and treatment.

Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.

References

1. Child Care Health Dev. 2015 Nov;41(6):779-88.

2. BMJ. 2015. doi: 10.1136/bmj.h68.

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