What can help children and teenagers who have ADHD?
A number of different treatment options are available for ADHD. They include parent education, support at school, behavioral therapy and medication. The choice of treatment will mainly depend on the type of ADHD and how severe it is.
Children and teenagers who have ADHD are much more inattentive, hyperactive or impulsive than other children of their age. Their behavior can cause conflicts at home and at school. It’s not always easy to differentiate between minor behavioral problems and ADHD.
Some children who have ADHD are mainly inattentive. Others may be more hyperactive or impulsive. The treatment options will largely depend on whether the child tends to be more inattentive or more hyperactive, how old they are, and whether their behavior is more of an issue at home or at school. And, last but not least, how much of a problem it is for everyone involved.
Diagnosis and consultation
A clear diagnosis is needed before treatment can start. It is important that ADHD be diagnosed using the official criteria.
If ADHD has been diagnosed, the first step is usually a consultation with a doctor, psychiatrist or psychotherapist who specializes in treating children and teenagers. This gives parents and their child the opportunity to describe how they feel the ADHD is affecting their family life and school activities, and what problems it is causing in everyday life. It is sometimes helpful to involve the child’s teacher too.
The therapist will then suggest suitable treatments based on what the main problems are. They often recommend professional advice and education programs for parents to start off with. If the child is having problems at school, interventions affecting his or her lessons may be recommended too. Medication or psychotherapy can be helpful if a child or teenager is very hyperactive or impulsive, can hardly concentrate, displays very antisocial behavior, or has other mental health issues such as depression or an anxiety disorder.
Medication is mainly considered for children with severe ADHD. It is usually only available on prescription, from pediatric doctors or pediatric psychiatrists. In Germany, these kinds of medicine are approved for children ages six and up, but exceptions are sometimes made for younger children.
Medication for ADHD should always only be used as one part of a comprehensive treatment approach that also includes extra support from teachers, social skills training and psychological therapy. This is because, although medication can lessen the symptoms of ADHD, it cannot necessarily solve other problems that are related to ADHD. What’s more, it only works for as long as it is taken, and it doesn't work in all children.
How urgently medication is needed, and what time of day it should be taken, will depend on the type of ADHD. For example, children whose main problem is inattentiveness may only need to take medication on school days.
What medications are used to treat ADHD?
Five medications have been approved for the treatment of ADHD in Germany:
- Methylphenidate (trade names: Concerta, Medikinet, Metadate, Ritalin and generic versions)
- Atomoxetine (trade name: Strattera)
- Dexamfetamine (trade names: Attentin, Dexedrine)
- Lisdexamfetamine (trade names: Elvanse, Vyvanse)
- Guanfacine (Intuniv)
Methylphenidate is almost always used first because it is the drug that has undergone the most extensive testing. There are short-acting and long-acting forms of this drug. The short-acting drugs start working after about 30 minutes and their effect lasts for 3 to 4 hours. The effect of long-acting drugs lasts for 8 to 12 hours. Long-acting drugs are also known as sustained-release or modified-release drugs. A low dose is used at first, and the dose can be increased gradually if necessary. But children and teenagers shouldn’t take more than the maximum daily dose of 60 mg.
Children and teenagers who have heart problems may not be able to take methylphenidate because it can slightly increase your blood pressure or heart rate.
The other drugs mentioned above are considered to be second-choice drugs. This means they are only used if methylphenidate doesn't help or can't be used for some reason. Unlike atomoxetine, the drugs dexamfetamine and lisdexamfetamine have only been approved for use in children and teenagers who have already tried out methylphenidate. Guanfacine may only be tried out if other medications weren’t well tolerated or didn’t help.
How effective is medication for ADHD?
Several studies have looked into whether methylphenidate is effective in the treatment of ADHD. They found that methylphenidate can reduce hyperactivity and help children concentrate better. Expressed in numbers, the studies found the following:
- With a placebo: Symptoms improved in about 23 out of 100 children who took a placebo.
- With methylphenidate: Symptoms improved in about 60 out of 100 children who used methylphenidate.
In other words, methylphenidate was found to help in about 37 out of 100 children with ADHD.
But hardly any of the studies lasted much longer than a year, so little is known about the long-term effects of the drug. Some children and parents say that the effect wears off after a while or that they have to increase the dose.
Methylphenidate, dexamfetamine and lisdexamfetamine are more effective than other medications.
What are the possible side effects of medications for ADHD?
Medications used to treat ADHD may result in sleep problems, loss of appetite and weight loss. Studies found that methylphenidate caused these kinds of side effects in about 12 out of 100 children. But many children who only used a placebo (fake medication) also had these kinds of problems. If you have sleep problems or notice other changes after taking medicine, it might be a coincidence. Just because two events occur at about the same time, it doesn't automatically mean that there is a link. So if you think that something might be a side effect, it's a good idea to wait and see first rather than jumping to the conclusion that the medication isn’t well tolerated.
ADHD medications may at least temporarily have a slight effect on growth. There is weak evidence that atomoxetine could lead to suicidal thoughts in rare cases. So if the parents of children or teenagers who are on this medication notice any such signs, they should take them seriously.
There is some disagreement as to whether methylphenidate can trigger tic disorders. This is because people with ADHD often have tic disorders anyway.
Also, when people stop taking ADHD medication or when the effect starts to wear off, the symptoms sometimes seem to be worse than before. Contrary to popular belief, there is no evidence that people can become dependent on ADHD medication.
What can you do about the side effects?
You don't necessarily have to stop taking medication if side effects occur. There are different ways to deal with them.
- Loss of appetite: If the medication is reducing the child’s appetite, they could try taking it with a meal or after a meal.
- Problems sleeping: If the child has trouble sleeping, lowering the evening dose or not taking the medication at all in the evening may help. Long-acting drugs can be taken early in the day so that the effect wears off before you go to sleep.
- Growth problems: If the medication is thought to be affecting a child’s growth, it may be possible to take breaks from it – for instance, at weekends or during school holidays.
- Tic disorders: To try to find out whether a tic disorder is being caused by medication, you can adjust the dose or stop using it for a while. If the tics go away then, there is good reason to believe that they are a side effect of the medication.
Having regular check-ups to monitor your blood pressure, height and other things can help avoid serious side effects. If side effects arise, it is important for parents to talk to the doctor rather than simply stop giving their child the medication. Adjusting the dose or using the medication at a different time of day may already be enough to reduce or stop the side effects.
Parent education programs
In parent education programs, mothers and fathers first learn more about ADHD. They may find out which behaviors can be influenced, which behaviors the child can change, and which he or she can't. This can help them with parenting issues and behavioral problems. They also learn a bit about the physical effects of ADHD. For example, some children who have ADHD react more sensitively to lack of sleep than others.
Another important part of parent education programs is learning how to structure daily family life so that it is easier for the child to carry out everyday tasks. Parents are given advice on what to do when their child misbehaves and how to encourage age-appropriate behavior using praise and other rewards. For example, they could use a star chart with which their child can “earn” certain rights, such as time on the computer, if he or she follows certain rules.
Different parent education programs vary in terms of how many sessions there are and how regularly they take place. The programs usually involve several weekly sessions that take one to two hours each. They are generally held in small groups, which also gives parents the opportunity to talk and share experiences.
So far, only few studies have looked into how effective parent education programs are. Some of those studies suggest that they have a positive effect on children’s behavior. Parents sometimes say that the program was helpful and increased their confidence in their ability to be a good parent.
In Germany, parent education programs are offered by some social-pediatric centers (“Sozialpädiatrische Zentrum”, or SPZ), clinics for psychosomatic medicine and psychotherapy, special education centers (“heilpädagogische Praxis”) and psychotherapy practices.
Psychological treatments and psychotherapy
Children with ADHD who have psychological treatment will usually have a type of therapy known as cognitive behavioral therapy. “Cognitive” approaches focus on things related to your memory, thoughts and mental abilities. Parents can learn behavioral therapy techniques in parent education programs. They will first use them under the supervision of their child’s therapist. Behavioral therapy typically combines several interventions that focus on changing various aspects of the child’s behavior.
One approach aims to encourage children using reward systems or negative consequences. Here it is important to clearly describe the desired behavior, and it should also be possible to check whether the child behaves in the desired way. In order to give the “behavior plan” a chance to work, you have to stick to it consistently for several weeks. You should therefore make sure it isn’t too much for your child to handle, and avoid trying to change too many types of behavior at the same time.
Another approach involves the use of “time-outs” when children misbehave. In time-outs, children spend a short amount of time in a different room.
Cognitive approaches help children and teenagers to plan and complete tasks more effectively. One example is the use of “when-then sentences.” These are instructions that children come up with themselves in order to practice completing certain tasks. For instance, “When I finish my homework I will look at my timetable and pack my backpack for the next day.” This is an example of a kind of technique known as self-instructional training.
A different technique is known as self-management training. Here children learn how to be better organized. For instance, they may learn to break tasks down into smaller steps, and check how successful they have been by asking themselves questions such as: What do I have to do? What do I need in order to do it? How can I do it? Did I succeed?
Studies have shown behavioral therapy to be effective, but it's not always enough. Sometimes it needs to be combined with medication in order to manage ADHD effectively. Children and teenagers with ADHD who also have other mental health problems, such as anxiety disorders and depression, may benefit from other psychological treatments too.
Families who would like to have psychological treatment often have to be patient. It can take several weeks or months to start therapy at a psychotherapy practice.
Support at school
ADHD usually affects the child's school life, too. For treatment to be successful, parents and therapists should therefore also involve the child’s school or kindergarten. If a child has learned self-management skills, for instance, it would be helpful if their teachers were aware of this.
Dealing with ADHD isn't easy for teachers either: They are expected to pay special attention to the child with ADHD while keeping the wellbeing and interests of the other children in mind at the same time. This can become a difficult balancing act if the ADHD is severe, or if several children in one class have it. So it's important for teachers and parents to be understanding towards each other and to try to find solutions together.
It's also possible for teachers to adjust the learning environment so that it's easier for children with ADHD to follow in class. This could include rearranging the classroom. For example, the child could sit at a desk that allows the teacher to keep an eye on them and react if they stop paying attention. They should also sit somewhere where they are exposed to as few distractions as possible. It can therefore be better to put desks in rows rather than group them. Objects that aren’t needed can be hidden from view in cupboards. When the class writes a test, the child with ADHD might be able to take their test in a separate room, away from distractions.
There are various other things that teachers can do at school, such as
- introduce short “physical exercise breaks” during lessons, or
- attend a training course to find out more about ADHD and how to better deal with children who have ADHD, as well as learn education techniques that aim to encourage children to behave well.
Different interventions will be suitable for different classes and different children. This will depend on a lot of factors, such as the options available to the school, the relationships between the students and the type of problems. So it's not really possible to give general recommendations.
What role does movement play?
In public discussions about ADHD, people often claim that the children are “fidgety” because they don't get enough movement nowadays. But it’s not that simple. There have only been few high-quality studies on whether sports can help improve ADHD. They suggest that regularly doing endurance sports could relieve ADHD symptoms – but more research is needed to say for sure.
Many parents and children find sports helpful, though. Regular exercise is generally very important for your physical development and health, so it's a good idea for many reasons – for both children and adults.
Another treatment option for ADHD is known as neurofeedback. This is a special kind of biofeedback. It involves measuring electrical activity in the brain (brain waves) using electrodes placed on your scalp, and then displaying the readings on a screen. By observing their own brain waves, children can learn to consciously control their thoughts and concentrate better as a result. Nowadays there are also devices with which you can learn to complete certain tasks, such as moving an object on the screen, using your brain waves.
There hasn't been much good research on neurofeedback in the treatment of ADHD. So it's not clear what parents and children can expect from it.
This is also true for many of the advertised treatment options for ADHD. These include certain diets or diet changes, herbal medicinal products and dietary supplements containing things like amino acids, special fatty acids or minerals.
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Cerrillo-Urbina AJ, Garcia-Hermoso A, Sanchez-Lopez M, Pardo-Guijarro MJ, Santos Gomez JL, Martinez-Vizcaino V. The effects of physical exercise in children with attention deficit hyperactivity disorder: a systematic review and meta-analysis of randomized control trials. Child Care Health Dev 2015; 41(6): 779-788.
Richardson M, Moore DA, Gwernan-Jones R, Thompson-Coon J, Ukoumunne O, Rogers M et al. Non-pharmacological interventions for attention-deficit/hyperactivity disorder (ADHD) delivered in school settings: systematic reviews of quantitative and qualitative research. Health Technol Assess 2015; 19(45): 1-470.
Zwi M, Jones H, Thorgaard C, York A, Dennis JA. Parent training interventions for Attention Deficit Hyperactivity Disorder (ADHD) in children aged 5 to 18 years. Cochrane Database Syst Rev 2011; (12): CD003018.
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