Pharmacotherapy, psychotherapy and other alernative interventions to help children with ADHD Foto: Jakub Majerský (2017)

Multiple studies have confirmed that attention deficit hyperactivity disorder is one of the most common mental disorders in children. It is a diagnosis that affects the child's functioning in all areas of life. In a large proportion of children, symptoms persist into adulthood and may lead to other serious mental disorders. Early initiation of therapy is therefore essential.

Regarding terminology, the International Classification of Diseases (ICD-10) uses the term Hyperkinetic Disorder. The diagnosis of Attention Deficit Hyperactivity Disorder (hereinafter ADHD) can only be established according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In both cases, the diagnosis is based on similar symptoms, with the main signs being: inattention, hyperactivity, and impulsivity. Despite this, there are several significant differences between the two classification systems. The first is that ICD-10 has stricter diagnostic criteria and also includes symptoms of conduct disorders. Another difference is that while according to DSM-5, excessive talking is a symptom of hyperactivity, ICD-10 assigns this symptom to impulsivity. Furthermore, according to DSM-5, six or more symptoms must persist for at least six months. We倾向 the term ADHD, as the DSM-5 diagnostic criteria are associated with several advantages. Diagnosis based on ICD-10 may result in children suffering from certain symptoms of the disorder being deprived of therapy because they do not meet the stricter criteria. Another advantage is that most international studies, research papers, and projects focus on patients diagnosed according to DSM-5 criteria (Čermáková, Papežová, and Uhlíková, 2013; Munden and Arcelus, 2008; Paclt, Ptáček, and Florián, 2006).

Based on both classification systems, we can define ADHD as a neurodevelopmental disorder characterized, as mentioned above, by inappropriate attention, impulsive behavior, and hyperactivity. These symptoms significantly interfere with various areas of the child's life. Attention problems manifest primarily in tasks that are too difficult, boring, or repetitive (homework). Another characteristic of children with ADHD is insufficient persistence, which is closely linked to significantly impaired behavioral regulation relative to the child's age. Impulsivity manifests as the child reacting very quickly in various situations without adequately assessing what is expected of them. The child fails to consider the negative or even life-threatening consequences associated with the activity. Research has also confirmed that poor self-control is a significant characteristic of ADHD (Paclt, Ptáček, and Florián, 2006). Inappropriate attention and impulsivity can result in children being unable to understand social norms, and therefore they may also have difficulties forming friendships (Munden and Arcelus, 2008). Another characteristic feature of ADHD is excessively increased activity. Psychomotor restlessness is often observed in these children (fidgeting in the chair, falling off the chair, playing with hands, grimacing, running around). Excessive vocal activity (shouting out, frequently interrupting) is also common (Jucovičová, 2014; Paclt, Ptáček, and Florián, 2006). According to DSM-5, the above symptoms may appear before the age of twelve, whereas previously the cutoff was six years.

Perceptual-motor disorders are common in children with ADHD. Motor disorders manifest significantly as problems in both gross motor skills (clumsiness, awkwardness, poorly coordinated movements) and fine motor skills (difficulties with self-care, problems with writing and reading). Impaired motor skills of the speech organs can lead to articulatory clumsiness. Furthermore, disorders of perceptual functions may occur, which can impair the perception of one's own body schema as well as left-right and spatial orientation. Regarding the cognitive domain, memory disorders and disorders of thinking and speech are frequent. Various comorbid disorders can also be observed in children with ADHD, which require increased attention during therapy. Comorbid difficulties include tics, stuttering, increased anxiety, and an increased incidence of multiple depressive symptoms. Sleep problems are more common in children with ADHD compared to healthy children (Jucovičová and Žáčková, 2015; Paclt et al., 2007). In practice, these children commonly exhibit truancy, theft, cheating, running away, destructive behavior, various forms of verbal and physical aggression toward peers and adults, and excessive use of alcohol and other addictive substances. All these manifestations are consequences of failure in social relationships, reduced capacity for empathy, and decreased tolerance to stress.

Causes of ADHD

The etiology of ADHD involves several factors. Paclt et al. (2007) describe four models that focus on the possible causes of ADHD. The first is the genetic model. This model assumes the existence of potentially risk genes. Studies focusing on twins, adopted children, and their families provide evidence for the significant role of heritability (Geissler and Lesch, 2011). According to the latest studies, the risk of heritability of this disorder is much higher through the male line. The cognitive model points to problems with inhibition of activity. According to this model, the biggest problem in children with ADHD is not excessively fast reactions, but significantly slowed inhibitory mechanisms. The neurobiological model points to structural and functional brain abnormalities in individuals with ADHD. The latest research on structural brain changes has confirmed a smaller area of brain tissue in the right frontal lobe in children with ADHD. This part of the brain is responsible, among other things, for planning and impulse control and is connected to the limbic system, which manages emotions (Munden and Arcelus, 200). Hynd, Semrud-Clikeman, Lorys, Novey, Eliopulos, and Lyytinen (1991) pointed out in their research that children with ADHD have a smaller corpus callosum compared to the control group, which anatomically and functionally connects the right and left hemispheres. A reduced volume of the amygdala, which regulates negative emotions, was also confirmed. Research on brain function abnormalities describes a diminished response to stimuli in children with ADHD, metabolic changes in the frontal parts of the brain, as well as reduced glucose metabolism. The biochemical model emphasizes the connection between ADHD and certain neurotransmitters. Chemical substances such as dopamine and norepinephrine contribute to the symptoms of ADHD, although they are not the only neurotransmitters closely related to this disorder. Dopamine and norepinephrine have a significant impact on thinking and attention. This primarily concerns motivation, increasing concentration of attention, and maintaining alertness. Thus, ADHD involves reduced activity of these neurotransmitters (Geissler and Lesch, 2011; Hunt, 2006; Munden and Arcelus, 2008; Rief, 2016).

Environmental factors also contribute to the development of ADHD. Jucovičová and Žáčková (2015) believe that one of the most common causes of ADHD is mild brain damage sustained during pregnancy, childbirth, or early childhood. As examples, the authors cite adverse maternal health during pregnancy, complicated delivery, prematurity, or infectious disease after birth. Other authors cite lead contamination, low birth weight, and maternal smoking or alcohol consumption during pregnancy as possible risk factors related to environmental influences. Many experts believe that the family background and parenting style themselves can also have a significant impact on the child's behavior. Research on the influence of psychosocial factors confirmed that a murder in the family, maternal alcoholism or depression, discord or violence between parents, as well as parental separation, appear to be statistically significant psychosocial factors contributing to the development of ADHD. Infants raised in such conditions had up to eleven times more frequent occurrence of ADHD. Another risk factor is early deprivation and institutional care. An interesting perspective on the etiology of ADHD is provided by studies examining the relationship between a child's diet and ADHD symptoms. Food colorings are most frequently mentioned as potentially causing ADHD or worsening symptoms (Banjerjee, Middleton, and Faraone, 2007; Munden and Arcelus, 2008; Šuba, 2009; Vasconcelos, Malheiros, Werner, Brito, Barbosa, Santos, and Lima, 2005). Most experts emphasize the mutual interaction of genetic, neurological, and environmental factors as the cause of ADHD.

First Steps in the Treatment and Therapy of ADHD

The first step toward selecting an appropriate treatment method, whether with psychopharmaceuticals, psychotherapy, or other alternative approaches, is an accurate diagnosis. Despite the fact that understanding the symptoms alone can significantly facilitate an accurate diagnosis, it is very important to obtain information from various sources, as symptoms manifest to varying degrees in different children. Some symptoms may even go unnoticed for many years. The following sources of information are used in diagnosing ADHD:

  • history of symptoms and their consequences – when symptoms first appeared, when they worsen or improve, and what impact they have on the child and their family;
  • medical history – course of pregnancy and delivery, presence of risk factors, any mental health problems that occurred in the past;
  • school history – academic performance, presence of specific learning disorders, the child's relationship with teachers and classmates;
  • family history – mental and physical health of parents and other family members;
  • psychodiagnostic methods – observation, intellectual ability tests, attention tests, visual perception tests, visual and auditory analysis tests, memory tests, social skills tests, etc.;
  • information from other professionals – special education teacher, school psychologist, counseling psychologist, speech therapist, pediatrician, endocrinologist, neurologist, child psychiatrist.

Pharmacotherapy and Psychotherapy of ADHD

It is very important to know that ADHD cannot be completely cured, but one of the options that can lead to symptom reduction and significant improvement in the child's condition is psychopharmaceuticals. As Šuba (2009, p. 117) states, "pharmacotherapy is the most accepted treatment given the proven biological basis of the disorder." The most commonly used medications for treating ADHD in our country are psychostimulants and atomoxetine. Psychostimulants are the first-line treatment for ADHD without comorbidities. Although they stimulate and support the body, they have a calming effect in children with ADHD. According to research, they can lead to significant improvement in up to 80% of studied children (Munden and Arcelus, 2008). Positive changes are observed in all areas where children with ADHD differ from other children. They increase attention span, reduce impulsivity and hyperactivity, thereby improving the child's academic performance and adaptation. Another advantage is that their beneficial effect is observable within the first week of treatment. Atomoxetine is a non-stimulant substance that is a first-line treatment for:

  • patients with comorbid disorders,
  • patients with contraindications to stimulants,
  • patients who do not respond to stimulants (Šnircová, Kulhan, Ondrejka, and Nosáľová, 2012).

Tricyclic antidepressants represent another alternative form of treatment, particularly for children suffering from tics, depression, or anxiety, and for children who do not respond to stimulants. Although they have a sedative effect, they do not negatively impact the learning process. Another group of medications includes antipsychotics, which are used in patients with significant aggression (Munden and Arcelus, 2008; Šnircová, Kulhan, Ondrejka, and Nosáľová, 2012).

Many studies have pointed out that effective treatment for ADHD includes not only psychopharmaceuticals but also psychotherapy and various forms of psychosocial intervention. While medications have a significant effect on the primary symptoms of the disorder, psychotherapy and psychosocial interventions are effective for the comorbid disorders and problems mentioned above. The literature most frequently cites behavioral therapy as one of the most effective methods leading to significant improvement in children with ADHD. It is the first choice for preschool and early school-age children (Rief, 2016). The goal of behavioral therapy is to modify the environment in order to achieve a change in the child's behavior. Behavioral techniques therefore do not work directly with the child, but with parents and teachers. It primarily involves helping to improve the ability of parents and teachers to manage the child's undesirable behavior and to encourage displays of good behavior (Munden and Arcelus, 2008). Parent training programs include:

  • preventive strategies (recognizing the motives leading to undesirable behavior in the child),
  • instructive strategies (guiding the child to achieve their goals through appropriate means),
  • consequence-focused strategies (effective use of rewards and punishments) (Wolraich and DuPaul, 2010, in Rief, 2016).

The literature most commonly describes two behavioral techniques aimed at reducing manifestations of undesirable behavior. The ABC Analysis technique is based on the assumption that in most cases, behavior is influenced by antecedent events (what happened before the undesirable behavior) and consequent events (what happened after the undesirable behavior). The goal of this technique is to achieve a change in the frequency of undesirable behavior by altering either the antecedent or consequent events. Recording these events provides information about the circumstances under which the child behaves inappropriately, how the parent responds to the child's behavior, and what the child may gain as a result of their behavior. Often, what the parent considers a punishment is actually a reward for the child.

For example, a child who enjoys spending time in their room is punished by being sent to their room. Another technique is positive reinforcement. In this case, the role of parents is to:

  • describe to the child in as much detail as possible the behavior they expect,
  • explain to the child the consequences of desired behavior so they know what they will receive and under what conditions,
  • reward desired behavior so the child believes they can succeed,
  • not respond (within reason) to undesirable behavior,
  • help the child achieve correct behavior (do not expose the child to situations where they are likely to fail) (Munden & Arcelus, 2008).

While behavioral therapy works with parents and teachers to achieve change in the child, there are many different methods and interventions focused on working directly with the child. Their goal is for children to acquire new ways and strategies for coping with problems and to learn to appropriately manage stress, anger, and frustration. The psychodynamic approach is based on the assumption that some symptoms of ADHD are to some extent the result of early life experiences. Therapy allows the child to reveal their feelings, thoughts, and experiences without the risk of angering their parents (Munden & Arcelus, 2008). Frequently used and effective psychotherapeutic methods include music therapy and art therapy. Fast music helps a child with ADHD expend energy, and slow music calms them down. By alternating fast and slow music, we can regulate hastiness, impulsiveness, and also slowness, which is not at all easy for a child with ADHD (Jucovičová and Žáčková, 2015). Art therapy helps a child with ADHD increase self-confidence and improve social skills. Through art therapy techniques, children can acquire strategies and skills leading to success both at home and in the school environment (Malchiodi, 2011). Dramatherapy techniques can significantly modify a child's behavior. They are very effective in relieving tension and stress, releasing negative emotions, experiencing positive emotions, practicing positive forms of behavior, and eliminating inappropriate behavioral manifestations (Jucovičová and Žáčková, 2015). Various relaxation techniques have also proven effective in practice. Through muscle relaxation, they lead to physical and subsequently mental relaxation. Family therapy considers the problem of ADHD as a matter for the whole family. Therapists do not focus on the causes of the disorder but concentrate on improving communication and understanding within the entire family (Munden and Arcelus, 2008).

Alternative Methods

In addition to pharmacotherapeutic and psychotherapeutic care for children with ADHD, there are other alternative methods that can alleviate symptoms.

EEG biofeedback is among the neurofeedback methods and is considered an effective technique that can lead to significant symptom reduction. Through this method, the child learns to regulate the electrical activity of their brain. The session involves the child sitting and watching a video game that they play using only their concentration. In trying to play the game correctly, the child unconsciously induces the desired brain activity, for which they receive a reward (points, pleasant sounds). EEG biofeedback is based on the theory of operant conditioning, according to which reward increases the likelihood of desired behavior (a specific pattern of cortical activity). It has been found that the short-term effects of EEG biofeedback are comparable to the effects of stimulants at the behavioral and neuropsychological level. EEG biofeedback represents an effective alternative for children whose treatment is limited by poor response to medication, significant side effects, or negative parental attitudes toward pharmacological treatment. In addition, it can serve as a complementary method to pharmacotherapy and psychotherapy (Holtman and Stadler, 2006; Leung, 2011).

Another option is cognitive training, which according to several authors has a positive effect on both attention and working memory. Cognitive training is most often performed using a computer, with task difficulty gradually increasing. This method is based on the assumption that task repetition and feedback lead to improvement in certain neurocognitive functions. Various studies have confirmed the direct effect of training on specific brain regions and certain neurotransmitter systems (Chacko, Kofler, and Jarrett, 2014; Rutledge, van den Bos, McClure, and Schweitzer, 2012). Leung (2011) focused on the long-term effects of neurofeedback combined with cognitive training. His research confirmed the gradual alleviation of hyperactivity symptoms and improvement of attention even more than four years after the completion of training. Chacko, Kofler, and Jarrett (2014) highlighted the positive effect of cognitive training combined with social skills training. According to the authors, a supportive approach from parents and teachers is equally necessary to achieve positive change in children with ADHD.

As mentioned above, several authors have pointed to a connection between diet composition and ADHD. Various diets have been proposed that eliminate foods that may cause ADHD symptoms. Studies examining the significance of iron levels in relation to ADHD have indicated that iron deficiency has a significant impact on the CNS and can lead to behavioral disorders. Other research observed a better response to treatment in children with ADHD after administration of pyridoxine or zinc. A positive effect of omega-3 fatty acids on ADHD symptoms has also been noted (Šnircová, Kulhan, Ondrejka, and Nosáľová, 2012). Konikowska, Regulska-Ilow, and Rozanska (2012) reached the same conclusion and emphasize that chronic deficiency of certain minerals such as zinc, iron, magnesium, iodine, as well as insufficient intake of omega-3 fatty acids, may have a significant impact on the development and exacerbation of ADHD symptoms. On the other hand, no causal relationship between sugar consumption and ADHD has been demonstrated (Šnircová, Kulhan, Ondrejka, and Nosáľová, 2012). Numerous studies have focused on the relationship between ADHD symptoms and physical activity. Silva et al. (2015) confirmed the positive effect of increased physical activity on attention. Wilcox (2017) pointed out that yoga and meditation can reduce hyperactivity and improve the child's functioning in social relationships.

Recommendations for Parents and Teachers

Since children with ADHD have difficulty with self-regulation, they need firmly established boundaries and limits. A regular daily routine is also very important. Habits and rituals give them a sense of security. Regularity also applies to sleep, as children with ADHD may have problems falling asleep and with sleep quality. In the evening, the child should engage in calmer activities. Watching action movies and horror films or playing similar types of computer games before falling asleep is not recommended. Most parents try to suppress the child's excessive activity, but this can be very harmful. In such a case, the increased activity manifests itself in another situation, often to a greater degree, and usually in a negative way. Various leisure activities that allow the child to unwind can also be helpful. On the other hand, parents must be careful not to place too many activities on the child's shoulders. This can overburden them and achieve the opposite effect. Their ability to concentrate decreases and hyperactivity increases. An excessive amount of stimuli can also deepen ADHD symptoms. This also applies to the environment where the child studies and does homework. It should be a place where the child's attention is as little distracted as possible by interfering stimuli. The child should have only essential supplies within reach. The presence of a parent is essential during homework preparation, and it is important to work with the child every day at approximately the same time. The parent should observe when the child can concentrate the longest (Jucovičová, 2010; Jucovičová and Žáčková, 2015). Prekopová and Schweizerová (2008) list several activities that can help a child with ADHD:

  • gross motor skills – longer walks, trips, hikes, cycling, trampoline jumping, jump rope, gymnastics, dancing, swimming, household chores (shoveling snow, sweeping, etc.),
  • fine motor skills – handiwork (modeling, knitting, crocheting, etc.), peeling fruits and vegetables, kneading dough,
  • attention, behavioral control, empathy, adapting to others – horseback riding, partner dancing, juggling, pouring without spilling, etc.,
  • ability to endure disappointment from failure – all games where there is a winner and a loser.

Most of the recommendations given to parents also apply to teachers. On the other hand, when working with children with ADHD at school, several other principles must be observed. The child should sit near the teacher so the teacher can monitor the child and intervene if problems arise. It is recommended to seat the child next to a calm classmate and as far away from windows and doors as possible to minimize potential distractions. Teacher instructions must be clear and concise, and it is recommended to repeat them several times and verify that the child has understood. The most difficult subjects should be scheduled at the beginning of the timetable. More challenging tasks should always be followed by easier and more interesting ones. During the lesson, it is important to allow the child with ADHD to briefly change their activity. We can ask them to wash the board, collect or distribute notebooks and other supplies. The tasks themselves should also be divided into smaller units. This has a positive effect on attention, as we know that a child with ADHD cannot concentrate on one activity for long periods. The teacher should tolerate and ignore manifestations of hyperactivity as long as they do not disturb other children in the class, as they significantly contribute to releasing tension and excess energy. A child with ADHD can concentrate more easily on an activity if they can manipulate a small object at the same time. The teacher should evaluate not only performance but also the child's effort. This increases the child's motivation for further tasks and activities. The vocabulary the teacher uses is also important. They should avoid negative labeling and should not describe a child with ADHD as lazy, bad, or incapable. The teacher should regularly and systematically acknowledge any manifestations of desired behavior (attempts at self-control, helping classmates, not shouting out). Teachers should motivate children with ADHD to set realistic goals. Unattainable goals can lead to a vicious cycle of failure and subsequently to a decrease in the child's self-esteem. The teacher should pay attention to the child's feelings, fears, and anger, and provide space for the child to share them (Barkley, 2008; Jucovičová and Žáčková, 2015; Lavoie, 2007; Procházka, Šmahaj, Kolařík, and Lečbych, 2014; Rief, 2016).

An essential condition for success when working with children with ADHD is a comprehensive approach based on effective communication and close cooperation between parents, teachers, doctors, and other professionals. Each of these individuals plays a very significant role in the treatment process. Regular consultations between parents and a child psychiatrist, neurologist, and psychologist can be very helpful in assessing the need for and effectiveness of pharmacological treatment and psychotherapeutic care for children with ADHD. The presence of a special education teacher and a school psychologist in schools has proven effective in practice. Children with ADHD suffer from difficulties that manifest most prominently in the school environment. These are professionals who can provide teachers with valuable advice on how to work with a child with ADHD. The academic performance and behavior of a child with ADHD at school are significantly influenced by the quality of cooperation between teachers and parents. Teachers very often complain about insufficient cooperation from parents. On the other hand, it is important to point out that constantly emphasizing the child's problems and failures has a demotivating effect on both parents and the child. Like other children, these children also have their strengths. They are spontaneous, intelligent, perceptive, and creative. Therefore, we believe that work with children with ADHD should focus not only on alleviating symptoms but also on supporting their strengths. In this way, we can help children build healthy and positive self-esteem, which can be significantly reflected in their behavior.

Conclusion

Thanks to the above facts, we can conclude that attention deficit hyperactivity disorder is a typical example of a bio-psycho-social disorder. In addition to psychopharmaceuticals and psychotherapy, there are other alternative methods that can help a child with ADHD. However, the most effective approach is considered to be a comprehensive one that takes into account the individual characteristics of each child.

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