While it is well established that medications can be an important aspect of treatment for youth who meet the criteria for attention-deficit/hyperactivity disorder (ADHD), too often clinicians neglect to address important nonpharmacologic interventions that have increasingly been shown to be effective. This column is devoted to reviewing some of the many components of a treatment plan other than medications that could be utilized to provide a more comprehensive and wellness-informed approach to children who struggle with ADHD symptoms.
Case summary
Ethan is a 7-year-old boy who presents with his parents for an ADHD evaluation. The pediatrician conducts the evaluation according to American Academy of Pediatrics guidelines, which include the use of rating scales from multiple sources. The outcome of the assessment is that Ethan does indeed meet criteria for ADHD and his symptoms are causing impairment in his school work, home environment, and interactions with his peers. Treatment is recommended.
Discussion
Dr. David C. Rettew
It is easy to rely exclusively on medications when the focus of the evaluation is solely about symptoms. When clinicians expand their view to assess various domains of wellness and health promotion, however, several other potential avenues for intervention often become apparent. Asking about sleep routines, nutrition, participation in the arts and music, physical activity, reading, and screen time – among other things – can reveal the following specific areas that require guidance and support:
• Exercise. Children today are increasingly sedentary, and there is increasing evidence that physical activity is inversely related to several ADHD behaviors (J Am Acad Child Adolesc Psychiatry. 2015 Jul;54:565-70). Counsel families about the importance of exercise and try to help the family develop a plan that includes the provision for regular physical activity. Joining sports teams may be particularly useful as it ensures that regular exercise takes place and offers some additional benefits inherent in playing with a team.
• Screen time. Although there has been active discussion lately about what constitutes “too much” screen time, it is clear that many children well exceed even the most liberal thresholds. Furthermore, there is increasing evidence that excessive screen time can lead to worsening attention problems over time (Pediatrics. 2004;113:708-13). One technique that can be effective, especially for younger children, is to have them “earn” their screen time by engaging in other activities such as reading or exercise.
• Nutrition. Apart from any specific deficiency states, research shows that a healthier diet in general is associated with lower levels of behavioral problems. With regard to ADHD, one aspect that is often worth investigating specifically is whether the child gets a nutritious breakfast each morning that can help keep attentional skills optimal.
• Musical training. Some intriguing new research is showing links between brain maturation and musical training, and in some of the very regions of the brain that have been implicated in ADHD (J Am Acad Child Adolesc Psychiatry. 2014;53:1153-61).
• Omega-3s. A meta-analysis demonstrated that omega-3 supplementation can improve ADHD symptoms (J Am Acad Child Adolesc Psychiatry. 2011 Oct;50:991-1000). While the optimal dose remains under investigation, there is some evidence that improved response was related to higher eicosapentaenoic acid doses.
• Skills training. To some degree, many skills associated with ADHD (disorganization, forgetfulness, distractibility) can be specifically taught with techniques such as mindfulness (J Atten Disord. 2015 Feb;19[2]:147-57). Having families work with counselors who have specific training in ADHD can be a very useful part of treatment and can help teach important lifelong skills. Parent behavioral therapy also can be effective around many behaviors such as defiance and aggression that accompany ADHD.
Case follow-up
The pediatrician decides to enhance her assessment by inquiring about many domains of wellness, and she discovers that Ethan has chronic problems getting to sleep, and he spends many hours each day playing video games to the exclusion of physical activity. She offers some strategies to improve these areas while the family investigates working with a counselor who has specific expertise in enhancing cognitive skills. Initial improvements are encouraging, and the family decides to pursue these avenues further while delaying medication treatment, at least for now.
By keeping in mind these important other treatment domains, pediatricians can avoid the trap of overrelying on medications as the sole method of treatment while encouraging techniques that will provide long-term benefits in overall health and wellness.
Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Rettew said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at pdnews@frontlinemedcom.com.