Non pharmacological interventions for ADHD,
Non pharmacological interventions for ADHD- key learning points
- Training in and subsequent use of basic behaviour management techniques for parents and teachers should generally occur before a trial of medication is instigated
- Behaviour management interventions are recommended for treatment of co-morbid disorders such as oppositional defiant disorder and conduct disorder but usually need to be offered alongside a trial of stimulant medication
- There is insufficient evidence to routinely offer individual psychosocial interventions
- All children with ADHD should have a school-based behaviour intervention plan in place
- Psycho-education about ADHD for parents/carers and teachers is paramount
- On current evidence, it is not possible to recommend restriction or elimination diets for children with ADHD
- There is currently insufficient evidence to support the routine use of essential fatty acid or mineral supplementation
Behavioural Interventions
Evidence based behavioural interventions include behavioural parent training and behavioural interventions in the classroom. Evidence to support the use of individual therapies including cognitive behavioural therapy and play therapy is lacking (Pelham et al, 1998; National Institutes of Health, 2000). Parent training programmes utilizing contingency management as well as standard behavioural techniques are increasingly being offered in community as well as clinic settings. Benefits may include a reduction in the child's disruptive behaviour across settings and in the level of family stress as well as an increase in parents' own self-confidence in their parenting ability (Cantwell, 1996). Such programmes are also a valuable tool for managing preschool ADHD (Sonuga-Barke et al. 2001).
The first line of treatment for children and young people with moderately severe ADHD is usually a group based parent training/education programme (NICE, 2008, www.nice.org.uk/CG072).
The National Institute for Health and Clinical Excellence guidelines on diagnosis and management of ADHD in children, young people and adults (2008, p.24 www.nice.org.uk/CG072) recommend “that all parent-training/education programmes whether group- or individual based, should:
- Be structured and have a curriculum informed by principles of social- learning theory
- Include relationship-enhancing strategies
- Offer a sufficient number of sessions with an optimum of 8-12 to maximize the possible benefits for participants
- Enable parents to identify their own parenting objectives
- Incorporate role-play during sessions as well as homework to be undertaken between sessions, to achieve generalization of newly rehearsed behaviours to the home situation
- Be delivered by appropriately trained and skilled facilitators who are supervised, have access to necessary ongoing professional development and are able to engage in a productive therapeutic alliance with parents
- Adhere to the programme developer’s manual and employ all of the necessary materials to ensure constant implementation of the programme"
In addition, individual counselling or group work based on CBT and/ or social skills training may be offered to the child or young person to address issues of low self-esteem as well as to promote social skills and peer relationships and offer skills in the area of problem solving, self control, listening skills and dealing with and expressing feelings.
School based interventions using similar techniques (DuPaul and Eckert, 1997) as well as social skills training for children and their carers have also been found to be of benefit (Frankel et al., 1996). Despite the evidence for the benefits of behavioural approaches, the improvements that are made in the short term are typically not as large as those obtained with medication (Pelham et al.1998) and where response is sub-optimal, pharmacological interventions should also be considered.
Children with ADHD and co-morbid disorders such as oppositional defiant disorder and conduct disorder may benefit from a combination of parent behaviour management and pharmacological interventions being offered. Stimulant medication alone is only effective for the core symptoms of ADHD and does not address the wider range of problems experienced by effected children and young people.
In pre-school children, psychosocial interventions are potentially of greater value than for older children. Parent training seems to be particularly helpful in reducing core ADHD symptoms as well as associated oppositional behaviour. Psychostimulants are not a necessary component of effective treatment for many pre-school children with ADHD (Sonuga-Barke et al, 2001).
Dietary interventions
Kaplan and colleagues in Canada suggest that amelioration of some of the mood symptoms often associated with ADHD is possible with broad-spectrum mineral and vitamin supplementation (Kaplan et al, 2002), but the use of such an intervention for the core symptoms of ADHD has yet to be tested. A recent study showed that adding in a daily zinc supplement to methylphenidate when treating children with ADHD could dramatically improve the improvements in behaviour seen over and above that found in children treated with stimulants alone. It is unclear what dose of zinc is required to give this additional benefit as the dose used in the study (55mg/day) was far higher than the recommended daily dose of zinc for children (Akhondzadeh et al, 2004)
