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Behavior intervention for adhd


ADHD Behavioral Treatment | Therapy for ADHD

There are two kinds of behavioral interventions that can help children with ADHD manage their symptoms of hyperactivity, impulsiveness, and inattention. These ADHD therapies don’t affect the core symptoms, but they teach children skills they can use to control them. Some focus on strategies for staying organized and focused. Others aim at cutting down on the disruptive behaviors that can get these children into trouble at school, make it difficult for them to make friends, and turn family life into a combat zone.

Some children, especially those with severe ADHD symptoms, benefit from behavioral therapy along with medication; for others, the training may make enough difference to enable them to succeed in school and function well at home without medication.

One important reason for kids to participate in behavioral therapy (whether or not they also take medication) is that ADHD medications stop working when you stop taking them, while behavioral therapy can teach children skills that will continue to benefit them as they grow up.

For behavior problems

For kids whose impulsive behavior is creating conflict at home and getting them into trouble at school, therapy can help them rein in the behavior that’s problematic and establish more positive relationships with the adults in their lives. It’s called, generally, parent training, because it involves working with parents and children together. It trains parents to interact differently with children, in order to elicit desirable behavior on the part of the child and discourage behavior that’s causing them trouble.

Parent training is not just for children with ADHD, but since kids with ADHD are often prone to tantrums, defiance, and tuning out parental instructions, it can substantially improve their lives, and the wellbeing of their whole families. Though it focuses on interaction with parents, it’s also been shown to reduce outbursts and other problem behaviors at school, as the skills kids learn in responding to very predictable parental interactions are transferrable to other settings. The training is generally done by clinical psychologists.

There are several kinds of parent training that have been shown to be effective, including Parent-Child Interaction Therapy (PCIT), Parent Management Training (PMT), Positive Parenting Program (Triple P). They all teach parents how to use praise, or positive reinforcement, more effectively, as well as consistent consequences when kids don’t comply with instructions. They result in better behavior on the part of children, decreased arguing and tantrums, better parent-child interactions, and reduced parental stress.

Young children with ADHD often find themselves scolded or punished much more than they are praised, so a clear way to earn positive attention from the most important people in their lives can be a big motivator. It’s not unusual for kids who’ve been negatively affected by their behavior problems—kicked out of preschool, black-listed from play dates—to make dramatic improvements through parent training.

School interventions

Young children with ADHD can benefit from systems that encourage positive behavior, like the “Daily Report Card. ” These approaches pinpoint specific goals for behavior in school, give kids feedback on how they’re doing, and reward them for meeting those goals successfully.

Parents and teachers work together on the Daily Report Card. Teachers choose goals for an individual child based on the behaviors that present the biggest challenges for them. Goals might involve academic work (finishing tasks), behavior towards peers (reducing teasing or fighting) and adherence to classroom rules (not interrupting, staying in their seat, following instructions). The teacher rates the child’s performance each day on each goal. They get a star or a check for each positive behavior, and if they get enough during the day, there is a prize for them when they get home—coveted screen time or some other small reward.

This kind of system can be very helpful for children from preschool to as old as 12.

For attention problems

The other broad area of behavioral help for kids with ADHD includes skills-based interventions to teach techniques they can use to stay on top of their schoolwork and manage their responsibilities at home. This kind of training, which is done by learning specialists, teaches kids skills to maximize their strengths and compensate for their weaknesses.

Children with ADHD tend to be weak in what we call “executive functioning.” Executive functions are the self-regulating skills that we all use to accomplish tasks, from getting dressed to doing homework. They include planning, organizing time and materials, making decisions, shifting from one situation to another, controlling our emotions and learning from past mistakes.

To bolster kids with weak skills in these areas, learning specialists teach a mix of specific strategies and alternative learning styles that complement or enhance a child’s particular abilities.

With elementary school children, the learning specialist usually works with parents and kids together, to establish routines and tools to use to get work done successfully and with minimal conflict. For instance:

  • Checklists can be useful for anything from getting out of the house on time in the morning to doing homework after school to the bedtime routine. Since the steps necessary for completing a task often aren’t obvious to kids with ADHD, defining them clearly ahead of time, and posting them prominently, makes a task less daunting and more achievable.
  • Educational therapists also recommend assigning a time limit for each step, particularly if it is a bigger, longer-term project. Deadlines can sneak up on all of us, but kids with ADHD are particularly susceptible to underestimating how long it will take to do something.
  • Using a Planner is essential for Kids with ADHD who have what’s called poor working memory, which means it is hard for them to remember things like homework assignments.
  • A rewards chart at home, as well as at school, can help motivate kids who are easily distracted and struggle to acquire new skills.

For middle and high school aged students, educational therapists work with kids to develop systems for tackling the work, both organizationally and academically. For kids with ADHD, managing their time and school materials can be a huge issue—not leaving enough time to study or complete projects, forgetting to use their planner, losing track of assignments. Materially, their backpacks may be a disaster, notes Michael Rosenthal, PhD, a neuropsychologist. Specific skills like studying, memorizing, note-taking, and doing assignments on time can all be addressed.

And executive functions apply to academics, as well as managing homework, explains Dr. Rosenthal. Reading, writing and math all involve skills kids may be weak in. A middle schooler might be a perfectly fluent reader, he explains, but at the same time have difficulty capturing the point of each paragraph or summarizing what they’ve read. Writing requires organizing thoughts into a narrative, imagining what the intended audience needs to know, staying on topic, and writing to a chosen length, among other skills. Math requires multi-step operations, and word problems require extracting the information important to solve the problem. These are all skills that educational therapists can focus on with children to strengthen their learning strategies.

Spelling out the rationale

While a child is learning new skills, they need to understand how they will help them. “Kids with attention problems, in particular, are very pragmatic in a way about how much effort to put into things,” explains Matthew Cruger, PhD, director of the Child Mind Institute’s Learning and Development Center. “We think of it as ‘neuroeconomics’ — they save their energy for things they are confident will pay off.” A good educational therapist will structure skill building so that kids score successes. “When kids put hard work into something, they expect a return, and if they don’t see the return, it’s doubly frustrating,” says Dr. Cruger. “They’ll think, ‘You see, it wasn’t a good idea to try.’”

The frustrating thing about behavioral interventions like parent training and Daily Report Card is that they are labor-intensive for parents and teachers, in addition to the kids themselves. “Parents may have the preconception that when they bring a child for therapy the child is going to be doing the work,” notes Jill Emanuele, PhD, Senior Director of the Mood Disorders Center at the Child Mind Institute. “But this takes a huge investment on the part of parents.” On the other hand, she adds, “the training can be a huge help to parents, too, who often come to us feeling burned out and ineffective in handling these kids. They develop a lot of confidence.”

There is evidence that these parent and teacher-based interventions do improve the outcome for children with ADHD, though they don’t directly affect symptoms. “Ideally, these environmental adjustments will alter the developmental trajectory of the child or adolescent with ADHD,” explains ADHD specialist Russell Barkley, PhD. “However, such interventions are not expected to produce fundamental changes in the underlying deficits of ADHD, rather they only prevent an accumulation of failures and problems secondary to ADHD. ”

The strongest gains, Dr. Barkley notes, are in children who are particularly defiant or oppositional. “Thus, researchers and clinicians should anticipate,” he notes, “that long-term studies are more likely to find treatment effects on problems secondary to ADHD than on deficits specific to ADHD.”

Teenagers with ADHD

Once children with ADHD reach adolescence, there is less evidence for the effectiveness of behavioral training. Several studies have failed to show results for cognitive behavioral therapy for teens with ADHD, Dr. Barkley explains, but CBT does have a role for kids with ADHD who develop secondary problems like conduct disorder and oppositional defiant disorder.

And Dr. Emanuele notes that since ADHD puts kids at risk for developing an anxiety or mood disorder, many of them are treated with CBT for those disorders. In some cases, she notes, kids have actually outgrown their ADHD symptoms but they’re still struggling.

Behavioral Interventions for ADHD - CHADD

Podcast Transcript

Behavioral Interventions for ADHD

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Summary:
Behavioral interventions are one of two evidence-based classes of treatment for ADHD. Behavioral parent training (BPT), classroom behavior management, and interventions that target executive function challenges are examples of behavioral interventions. Key principles of behavior management apply across the different types of behavior treatment, and the age of a child will determine what type of intervention to use. BPT and classroom interventions are typically used for younger children, while older children, including teens, are taught strategies to cope with executive function challenges.

Margaret Sibley, PhD, associate professor of psychiatry and behavioral health at Washington School of Medicine, discusses the ADHD symptoms that children and teens struggle with and the behavioral interventions supported by research that can help to improve these symptoms. She also discusses the best times to implement these behavior therapies and the synergy between these strategies and medication management.

Margaret H. Sibley, PhD
Dr. Sibley is an associate professor of psychiatry and behavioral sciences at the University of Washington School of Medicine and Seattle Children's Research Institute. Her work focuses on the diagnosis and treatment of ADHD in adolescents and young adults. She developed a parent-teen therapy for ADHD (Supporting Teens’ Autonomy Daily) that combines motivational interviewing and skills training for parents and teens. She has authored or coauthored more than 80 scientific papers on ADHD and published a book with Guilford Press on treating executive functioning and motivation deficits in teens. She is a member of CHADD’s professional advisory board.

Learning Objectives:
Listeners will be able to:

  1. Explain the importance of integrating behavioral and other interventions for people with ADHD.
  2. Describe the importance of interprofessional collaboration in treatment of ADHD.

 

Announcer:  You are listening to Pocket MD, training on ADHD in children and adults.

Dr. Eugene Arnold:  Hello, this is Dr. Eugene Arnold, professor emeritus of psychiatry and behavioral health at Ohio State University and CHADD's resident expert. Today we're talking about some of the non-pharmacological interventions for ADHD, and we have with us today, Dr. Maggie Sibley, who will introduce herself.

Dr. Margaret Sibley:  I'm Maggie Sibley, and I'm associate professor of psychiatry and behavioral health at the University of Washington School of Medicine. I'm a researcher at Seattle Children's Hospital, and I'm a clinical psychologist by training.

Dr. Eugene Arnold:  Before we begin, I might just say that there are two evidence-based classes of treatment for ADHD. One is the FDA-approved medications and the other is behavioral interventions. And we'll be focusing today on the behavioral and other non-pharmacological interventions for ADHD. Dr. Sibley, could you describe in general what those are?

Dr. Margaret Sibley:  I'll start with what interventions look like in childhood. One of the main forms of behavioral intervention for children with ADHD is behavioral parent training. And behavioral parent training is a treatment that focuses on teaching parents practical everyday strategies that they can use in order to increase good behaviors and minimize negative behaviors in the home setting. And another piece of behavior therapy for younger children is classroom behavior management. What that is, it's establishing clear rules and goals and expectations for a child in the classroom and then delivering rewards, whether it's through a token economy system or through some sort of reward system in the classroom, in order to motivate the child to meet those expectations.

In terms of social skills, there's actually not a lot of evidence for social skills treatments for ADHD. Social skills groups and social skills training has not been shown to be highly effective, and so that's an area that we're still trying to learn how to improve for kids with ADHD.

When kids with ADHD get older and they start reaching adolescence, the nature of those behavioral treatments changes a little bit. We start focusing more on teaching kids skills that they can apply in their daily life. And because their brains, as they get older are capable of more learning and capable of more independent application of those skills, we can start teaching them organization skills strategies, time management strategies, cognitive strategies, to overcome difficulties like procrastination. And then usually what we do is partner with parents or other adults in their lives, to create rewards and consequences for the application of those skills. So, for example, we can teach a teenager with ADHD how to write every day in a daily planner to keep track of their homework assignments and to keep their schedules straight, and then we can make a rule at home that is overseen by the parents, that all electronics time has to wait until after homework is done, in order to help kids learn to use those skills independently without a lot of help and reminding from their parents.

Dr. Eugene Arnold:  Just for completeness, I might mention that there's also another area of interventions there are called complementary and alternative, which includes things like nutritional interventions, diet, biofeedback, transcendental meditation, and so forth, which have varying levels of evidence and are under study by groups in various parts of the country. But are there other components of the behavioral interventions and educational interventions that you mentioned that should be brought up?

Dr. Margaret Sibley:  I think it's important for people to understand what some of the key principles of behavior management are, that essentially transcend all of these treatments and sort of unite them as behavior therapies. So, one of them is defining clear expectations for behavior, whether that is that a child needs to raise their hand before speaking, or that an adolescent needs to get all of their homework done by 6:00 PM. It's teaching strategies to give positive attention or contingent rewards to good behaviors and to minimize negative attention to negative behaviors. So, pieces of that could be ignoring small negative behaviors by children, like complaining or whining instead of arguing with kids and then escalating conflicts.

It's also applying strategies like point systems in the home or the school setting, where over time kids can accumulate points for good behaviors and then rewards for those behaviors. And using principles like what we would call the Premack principle, so that would be making all exciting, enjoyable activities wait until responsibilities for the day are done.

And then there's also strategies that we can use for really disruptive, escalated behaviors, like timeout in younger children and in teenagers, it's things like taking away a really important privilege like driving, if something like marijuana use is discovered.

So all of these treatments, though they may look different for different ages, they have something in common. They're using basic behavioral principles to try to motivate children in adolescence to display appropriate behavior, which is hard for people with ADHD, because they often struggle with self-control.

Dr. Eugene Arnold:  Now you mentioned that the differences by age, and of course the executive function of the ability to plan your work and work your plan, tends to change with age; hopefully, with maturation improving. How does that fit in with the strategy at different ages?

Dr. Margaret Sibley:  So, around age maybe 10, 11, we start to see success with these interventions that teach skills that help people compensate for their executive function deficits. We haven't had a lot of success with treatments that directly target these executive function deficits and try to make them biologically better. But what we can do is teach people workarounds, so that they can let these executive functioning deficits have a less of a negative impact on their life.

As adolescents age and their cognition develops more and more, they start in a good way being able to control more of their behavior and apply these strategies a little bit more reliably. On the other hand, compared to their peers, they're still having a lot of dysfunction. And what happens is, the environment of adolescence is requiring teenagers to be more and more self-sufficient because that's what their peers can do. But when you have ADHD, being able to keep up with those demands is a lot harder, and so we see that treatments target executive functions a lot more as individuals age and the demands of their environment is that you need to be self-sufficient, you need to use your executive functions to be able to succeed in day-to-day life.

Dr. Eugene Arnold:  Could you speak a little bit to the issue of positive illusory bias and whether there's a development of more insight as they age, and how that would affect the treatment?

Dr. Margaret Sibley:  Sure. I like to call it self-perception bias because we're not exactly sure why children, adolescents, and adults do this. But one thing that seems to happen is that when you ask them to report on their own behavior, they tend to underestimate how severe their difficulties are, whether that's because they're doing something self-protective for their self-esteem, whether it's because they're just not paying attention to how they are because they don't pay attention well, or whether it's because every single human being tends to minimize their difficulties, is unclear. But what we do see is a trend of growing insight as people get older, although the biggest jump in that seems to be after age 25, if we look at the longitudinal studies like Russ Barkley's done, it's really not until they are approaching the 30s that we see a notable improvement of insight.

But all the same, there's still a group of kids who tend to have good insight, and the cognitive behavioral approaches, which is really kind of the family of compensatory skill-teaching interventions—teaching people to be more aware of what they're thinking right before they do something like decide to put off their homework towards later—are a lot easier to deliver and to have success, as people with ADHD tend to improve their insight.

In younger children, if the insight's particularly poor, it's really hard for things like talk therapy to be effective because it's just not landing with kids. They're not able to sort of see the deficit that they're having and then have the self-control to say, because I have this difficulty, I need to try harder or I just need to suck it up and do better. Those approaches have not been successful.

Dr. Eugene Arnold:  Is there a downside to developing more insight into the problems one is having?

Dr. Margaret Sibley:  Now that's a good philosophical question. One of the things that is important in people with ADHD is protecting their self-esteem and how they think about themselves. When you're a person with ADHD in childhood, there've been studies that just show that, exponentially, they receive more negative feedback from their environment—from their teachers, from their friends, from their parents, from the girl that somebody asks out on a first date in middle school—than the average child.

And so over time when you get a lot of those messages, unfortunately, we can see in research that people with ADHD by adulthood have pretty strong deficits in their self-esteem, their self-efficacy, which means, do I believe that there's any point in working hard towards a goal? Because if I don't think I'm going to be successful anyways, why try?

I think your question is well taken. On one hand, we want people to have insight because we want them to be able to make good choices about who they are in the world, and what they're good at, and what would be the best educational track for them, or the best vocational track for them. But at the same time, I think it's important to shine a light on the good things about the person and not just always have the light shining on the bad.

Dr. Eugene Arnold:  Well, what would be the focus of these non-pharmacological interventions? Who would they be addressed to and does age make a difference in how that's handled?

Dr. Margaret Sibley:  Usually people employ a family member, at least until a person's 18. And as you get older, you see the individual with ADHD's involvement becoming bigger, a bigger part of that. So, in the youngest children, behavioral parent training may not involve the child at all, other than sometimes bringing them in with the parent for something like parent-child interaction therapy, where the parent is being coached in real time about how they should interact towards their child, but not so much putting expectations on the child themselves to be practicing therapy skills. Parent training, parent behavior management, parent-child interaction therapy, this collection of parent based behavior therapies, is really the gold standard behavior therapy at least through elementary school.

When you get into classroom behavior management interventions, where you're working directly with the school, how it actually plays out in real life, is kids sometimes get an Individualized Education Plan or Section 504 plan, which gives them entitlement to services from the school. And then somebody like a school psychologist or a special educator will come in and they'll analyze what behaviors are causing problems in the classroom, and they'll figure out maybe some rewards that the school can administer to make those behaviors improve. But in a lot of situations, again, you end up engaging the parent, even in school-based interventions for something like a daily report card, where the school might be the one monitoring the behaviors, but ultimately it's the parent at home that's providing the rewards for the good behavior. So, really engagement of the family is probably the most important component.

As individuals move into the teenage years, you see more of what we would call parent/teen contracting. So, the parent isn't going to be imposing a behavior management system anymore. The parent and the teen will sit down together as equals and they'll negotiate rules for home that they both can agree are fair. They'll both have to compromise. The parent is going to have to be willing to allow more freedoms to the teenager if they've earned them, and the teenager's going to have to be willing to do some things that they may think are hard, boring, or unnecessary, in order to meet their parent’s wishes.

Dr. Eugene Arnold:  Okay. So, when should these interventions be implemented? How about the timing of them?

Dr. Margaret Sibley:  I think the most critical thing to think about with timing, is that there are certain points in an individual with ADHD life, where things get a little bit messier and a little bit harder. And we've seen in research, time and time again, that developmental transitions—like the transition to kindergarten, the transition to third grade, when all of a sudden there's a lot more seatwork and expectation to sit still, transition to middle school, high school, and even college or post-high school life—tend to really disrupt the functioning of people with ADHD. So, these might be the key times to deliver behavioral intervention.

There's also evidence out there that behavioral interventions do not necessarily have long-term effects. And, in fact, we see if we look at some of the contingency management literature, that a good contingency management program rewards-and-consequences point system, and a lot of parents will say, they've seen this with their own eyes, over time it will lose its potency. So, if we have the ability to use rewards as an important motivator, but we need to be smart about when we use them because they're not going to be able to work every single day, 365 days of a child's life, we want to be strategic about applying them during times when we really need them. So, I think those transitions, or if there's a certain time of year when a child is most vulnerable to doing poorly—for example, at the end of the school year a lot of times motivation wanes and kids really needed a boost to kind of get them back on track and make sure they pass their classes—those could be really good times as well to be implementing behavioral strategies like a reward system.

But there're some strategies like just catching kids being good and saying positive things to them, or ignoring those minor negative behaviors and not letting them escalate, that can be done every day, that there's really no downside to using. Making sure that every parent of a child with ADHD, when they get that diagnosis, just learns the nuts and bolts of those really basic things they can do to improve the child's functioning at home and at school, I think should be always administered right away. I think there's some evidence to support that when you do administer parent training when a diagnosis is first given, that it does have some benefits to family chaos and to just parents feeling more in control over the situation with their child.

Dr. Eugene Arnold:  Well, what I derived from what you just said, is that behavioral intervention should be used to pull people out of a rut and get them in the right track, but not try to continue everything the same after they're in the right track. Is that a fair statement?

Dr. Margaret Sibley:  I think so, because it's really not practical to think that somebody is going to be implementing a reward system every single day of a child's life. A, it's too hard to do; B, we know that kids gain tolerance to rewards after a while. The same thing that motivates them, if you give it every day, it stops to be motivating.

And we want those breaks from behavior management, just like we would want breaks from medication sometimes, so that kids can develop their own motivation for things. There's something to be said about learning from mistakes, especially as kids are getting older. We're not letting them have autonomy in their own choices and seeing the natural consequences of some of their actions, they're not going to be learning long-term about choices that are important and healthy to make. So, I do think that there's sort of a mix here that needs to be considered, and it's an individual choice for every family about what missteps you're willing to watch your child take and not rescue them from, so they can learn a lesson, versus what missteps are really important for you to avoid by doing something like a reward system.

In middle schoolers, for example, is it worth failing sixth grade, or do you want to implement a really strong contingency management system to avoid that, but at the same time, your child doesn't learn their own reasons for working hard. So, there is kind of a tradeoff that it gets, especially as kids get older, it gets really hard for parents to navigate, and there's no real perfect answer to the question what to do and when.

Dr. Eugene Arnold:  So, both strategy and tactics are important?

Dr. Margaret Sibley:  Yeah.

Dr. Eugene Arnold:  Strategy being the management over the long-term, the big picture, and the tactics being the technical details of how you implement the program. I liked your analogy with tolerance and your mention of pharmacotherapy, because there is an issue among pharmacologists about developing tolerance to the FDA-approved medications for ADHD. And that brings up the issue of the synergism between the two and how it should be important to take advantage of the improvement from medication to implement and get the most out of the behavioral treatments and vice versa. Could you comment about the data there are about the synergism between the two?

Dr. Margaret Sibley:  Yeah. So, I think one interesting piece of this is that, stimulant medication and behavioral therapies, they act through different mechanisms, right? So, what stimulant medication is really good at helping with is actually mitigating a chemical biological deficit in the brain and therefore, helping people self-control and better focus. But what behavioral treatments generally do is (a) they teach people skills that they can use to compensate, and hopefully long-term, having their arsenal toolkit of things they can do as they're growing older to manage their symptoms; and (b) it helps people identify the environments that they function best in, and what they need from the people around them, and from educational setting they're in, to succeed, so that detective work is really valuable. So, yes, if you just give somebody a symptom rating scale, a lot of times medication looks like it wins the horse race. But at the same time, the long-term effects of being able to gather some of these pieces of wisdom from behavior therapy shouldn't be forgotten.

There's not a lot of work on behavior therapy’s long-term effects or combined treatment effects in adolescents. My team is doing probably most of it right now. There's a couple of things that are convincing me that if you deliver psychosocial behavioral treatment in adolescence, it's probably having more bang for its buck in a lot of ways than in childhood. For one, we've found that there are four-year effects on organization skills and ADHD symptoms when you deliver behavioral treatment to high schoolers, and that's good to see because the MTA study wasn't able to show that in younger children.

And then, in addition, there's been no real, true combined treatment studies for adolescents as there have been for children, but we've seen a little bit of a blip on the radar that there are some effects of combined treatment, especially when dealing with family conflict, which is really big for teenagers with ADHD. So, you could imagine that the medication might help with something like verbal impulsivity, which leads to a lot of fights, but at the same time, the behavioral treatment might be helping with things like the organization, time management, planning problems, that are leading to the fights. And so they can kind of work in different ways to help the overall functioning go well.

Dr. Eugene Arnold:  Could you kind of summarize the key take-home points from this?

Dr. Margaret Sibley:  Sure. I think that behavior therapy is an important piece of the treatment toolkit for ADHD. I think that it could be applied at different times in one's life and it's going to look a little bit different, no matter how old you are. So, getting behavior therapy during key developmental transition points not only helps the child do their best, but it also equips the family with the strategies that they need to support the child, and those strategies should be applied in both the home and the school setting. Medication and behavior therapy are important complements for each other, though behavior therapy is more expensive and takes more time and energy to administer. It does have some benefits that are separate than the benefits of medication—for a lot of folks, it could be a really important piece of treatment, but ultimately I think family choice is a big part of this as well. Some families prefer medication, and some families prefer behavior therapy, and some people might want to do both, and I think that should be a part of the conversation as well.

Dr. Eugene Arnold:  Okay. Thank you, Dr. Sibley.

Dr. Margaret Sibley:  Thank you.

Announcer:  Pocket MD is brought to you by CHADD, with funding from the US Centers for Disease Control and Prevention, and in partnership with the Rainbow Center at Rainbow Babies and Children's Hospital.

Resources

  • American Academy of Pediatrics (AAP).  Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics, October 2019.
  • Society for Developmental and Behavioral Pediatrics (SDBP). Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder, Journal of Developmental & Behavioral Pediatrics, January 30, 2020.
  • US Centers for Disease Control and Prevention. Parent Training in Behavior Management for ADHD
  • Behavioral Therapy: What It Is and Finding a Therapist. CHADD NRC Ask the Expert webinar.

CDC, our planners, presenters, and their spouses/partners wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters with the exception of Dr. L. Eugene Arnold, MD, MEd, Dr. Craig Surman and Dr. Margaret Sibley and the wish to disclose research funding from commercial interests.

Planning committee discussed conflict of interest with Dr. Arnold, Dr. Surman and Dr. Sibley to ensure there is no bias.

Content will not include any discussion of the unlabeled use of a product or a product under investigational use.

CDC did not accept commercial support for this continuing education activity.

 

Hyperactivity and inattention (ADHD) | Encyclopedia of Early Childhood Development

To distinguish between restlessness and attention deficit hyperactivity disorder (ADHD), we need to understand the root causes of ADHD, its development, the myths and prejudices associated with it, how to recognize it, and what are the most effective remedial measures.

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Generalization

Theme Editor: Russell Shakhar, MD, University of Toronto, Canada nine0004

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How important is this?

Attention-deficit/hyperactivity disorder (ADHD) is a neuropsychiatric disorder characterized by age-related, persistent and debilitating anxiety, impulsivity, and inattention from an early age. ADHD can be divided into three subtypes based on the type of behavior that is most noticeable: 1) the attention-impaired type; 2) hyperactive-impulsive type; and 3) combined type, depending on the nature of the symptoms. This syndrome is diagnosed when the symptoms appear and cause difficulty for the child in more than one life setting, such as school, home, or away from home. By some estimates, ADHD affects between 3 and 7% of school-age children worldwide, with boys showing higher rates of ADHD than girls. ADHD typically co-occurs with other psychiatric or developmental disorders (eg, anxiety, mood disorder, learning or speech disorders, conduct disorder, and sleep disorders) in 50-66% of cases. ADHD persists into adulthood in more than half of affected children. The symptoms of ADHD and its accompanying disorders interfere with learning and appropriate behavior in school, so the percentage of children with ADHD who graduate from school is lower. As they get older, they are also more likely to experience difficulty finding employment. Other negative consequences associated with ADHD include interpersonal difficulties and an increased incidence of accidental injuries, car accidents, and teenage pregnancies. In general, ADHD is one of the major health problems and can lead to significant losses both in the lives of individuals and society. nine0004

What do we know?

ADHD is believed to be caused by an interaction of genetic and environmental factors. Symptoms of ADHD are highly heritable (76%), but the nature of the genetic influence is still undiscovered. According to the results of published studies, genetic factors leading to ADHD are also associated with other disorders. Thus, common genetic influences were found in the case of dyslexia and symptoms of inattention, symptoms of hyperactivity-impulsivity and oppositional conduct disorders, ADHD and symptoms of autism. Moreover, genes responsible for cell division, cell adhesion, and neuronal migration have been suggested to be related to the onset of ADHD. In terms of environmental risk factors, here the researchers noted the negative impact of smoking and drinking by the mother during the prenatal period, maternal depression, low birth weight of the newborn, poor parenting practices, and living in disadvantaged areas. nine0004

Children with ADHD experience more learning difficulties than their classmates due to neurocognitive impairment and behaviour. ADHD is often associated with deficits in executive functions (eg, planning, organization, attention to important details, and impulse inhibition). Accordingly, children diagnosed with this disorder are more likely to experience learning and/or speech difficulties. The results of neurophysiological studies suggest that ADHD is associated with atypical activity in the frontal cortex, the area of ​​the brain responsible for cognitive processes. However, it is important to note that only a certain proportion of school-age children with ADHD (30%) have weak executive functions, which makes it possible to consider them neither as a necessary nor as a sufficient cause of the disorder. nine0004

What can be done?

Diagnosis

ADHD is usually first detected and treated in school-aged children. However, the presence of symptoms of hyperactivity, impulsivity, and inattention during preschool years is considered a major factor in the diagnosis. Direct observation of the child suggests a diagnosis, but a child with even the most severe symptoms may be calm and attentive in an unusual setting such as a doctor's office. Therefore, the survey should focus on obtaining the entire history of the child's behavior at home, during play and at school from early childhood to the time of the survey. A routine clinical conversation (interview) provides an opportunity to discuss how parents and educators have responded to the child's difficulties and to identify strategies that have worked and those that have not worked. Examination should not be limited to symptoms of ADHD, but should also be asked about associated symptoms that may be present, such as anxiety, mood and behavioral problems, for example. Parents are not always fully aware of how stressful environments can upset a child; this is why talking directly to the child can be an important part of the examination. Comorbid disorders are an important area of ​​treatment, and their presence can affect the effectiveness of therapy. nine0004

Many clinicians recognize that the parent-teacher rating scale is useful in the diagnostic process as a way of obtaining a description of a child's behavior that can be easily compared to age norms. Some children with high levels of restlessness (restlessness), inattention and impulsivity have medical problems or developmental delays that should be identified during the examination. Children with learning difficulties may show symptoms at school and during homework because they have difficulty learning the material. Other children may show symptoms at home, which only indicates some problems in the environment of the child, social difficulties or parenting problems. In the doctor's office, it can be very difficult to determine which children have specific learning problems. Therefore, consultation with an educational psychologist can be very helpful in getting a complete picture of a child's strengths and weaknesses. nine0004

Corrective intervention

Stimulant medications (such as methylphenidate, Ritalin TM ) in various short-acting and long-acting forms play an important role in the treatment of ADHD. Some time ago, non-stimulant medications such as Atomoxetine became available and play an important role in the treatment. These medications can help a large number of sick people improve their attention, control impulses and reduce their level of activity. Also effective are intensive behavioral interventions that combine teaching the child self-control with teaching parenting strategies. Positive parental attention, rewards for appropriate behavior, and the negative consequences of inappropriate behavior (such as forbidding a child to play with a favorite toy) are recommended methods of behavioral intervention. Educators can also apply similar methods in their classrooms. Available evidence suggests that the best corrective intervention is a combination of medication, behavioral intervention, and school-based behavioral and learning interventions. For optimal effect, these treatments must be intensive and long-term. Direct training of cognitive functions such as working memory (the ability to retain and process information in short-term memory) seems promising as a potentially effective intervention. Some children may have improved behavior when certain foods are removed from their diet, although the universality of this effect has not been proven. Brain electrical activity training can improve alertness and behavior in some children. In this regard, the main problem of such treatment is the generalization of positive dynamics and its transfer to another environment. Further research is needed to explore treatment factors (individual and context-specific) in order to increase the beneficial effects of treating children over time and in different settings. nine0004 Read more

Additional materials

Understanding ADHD: When does normal become abnormal?

Many people claim that genuine ADHD appears in the preschool years and that the symptoms associated with it are objective, implying that any observer would come to the same conclusion. This view is often, but not always, correct.

Although in preschool children the right to diagnose this disorder is left to specialists, in everyday settings, parents are experts on their children. If they notice that their child is restless, inattentive, or impulsive, that he has difficulty controlling his reactions, that he needs to move, or that he has difficulty waiting his turn, then caregivers should listen. nine0004

Ideally, the specialist will work with parents to observe the child's behavior in different settings and to assess whether the problem lies elsewhere (for example, parental expectations, coping strategies, stress levels, or socio-economic situation).

In some cases, ADHD symptoms may appear much later in development, after school entry or even later in the school years.

In all cases, the decisive factor in the diagnosis will be the deterioration of the condition - whether on a social, educational or emotional level.

Publications

Children with Attention Deficit Hyperactivity Disorder: Epidemiology, Comorbidity and Diagnosis

How to help a hyperactive child?

ADHD can affect all areas of a person's life. Children with ADHD who participate in early intervention programs tend to need less help in school, the court system, and the health care system later in life. Children with ADHD can also be improved by adding medication to educational and other interventions. The use of medications can help reduce the severity of symptoms and thus facilitate the implementation of corrective intervention. nine0004

Early intervention can help children improve:

  • Self-control - how they control their emotions and behavior
  • Executive functions - structuring and planning, decision making, judgment
    • be self-confident
  • School performance - the ability to sit still, listen, understand and progress well in school in accordance with one's stage of development. nine0081

Getting help at an early age can have a short and long-term positive effect on children, reducing the severity of problems associated with ADHD, such as learning disabilities, anxiety, depression and conduct problems.

Publications

ADHD and treatment

How to help a child with ADHD?

Attention deficit hyperactivity disorder (ADHD) is a behavioral developmental disorder. As as a rule, it is diagnosed in children. Child with ADHD has difficulty concentrating, he becomes hyperactive, poorly controlled and impulsive. Unfortunately, many parents and educators in schools do not take this disorder seriously and associate child's behavior with pampering and bad manners. Children with ADHD are often subjected to pressure from both parents and from other children. All this is fertile ground for further mental illness and the formation of criminogenic behavior in adulthood. How to determine in time Does your child need professional help? What are the reasons for the appearance syndrome? And what if your child is diagnosed with ADHD? Says the leading researcher of the Ural Federal University Sergey Kiselev. nine0041

Sergey Yurievich Kiselev – Candidate in Psychology, Leading Researcher at the Ural Federal University, Head of the Laboratory of the Brain and neurocognitive development.

— I remember how 13 years ago my cousin brother was diagnosed with Attention Deficit Disorder and hyperactivity. Then in Russia, almost no one knew about it. diagnosis. Tell us what is known today? nine0041

In fact, we still don't fully know what it is. disorder. There is a definition in the International classification of diseases, where deficiency syndrome is separately distinguished attention and separately - hyperactivity syndrome. However, often we We are faced with two sets of symptoms. Such a manifestation commonly referred to as Attention Deficit Hyperactivity Disorder or ADHD.

However, there is still no generally accepted concept of causes of ADHD, about the mechanisms that cause syndrome symptoms. We have at our disposal only a number of different models that attempt to explain externally observed symptoms. I view this disorder from a neuropsychological point of view in within the framework of the Lurie approach. Russian psychologist and neuropathologist Alexander Romanovich Luria created a national neuropsychology, which is known throughout the world precisely as Luriev neuropsychology. His followers and students developed their own concept of the nature of behavioral disorders and mental health in children with ADHD. nine0004

It's not just about attention problems or hyperactivity. These children have a range of symptoms associated with a disorder. different mental functions, for example, they often have specific memory impairment, increased exhaustion, difficulties of inclusion in tasks, activity fluctuation, etc. Before modern specialists are faced with the task of explaining the causes and mechanisms of this set of symptoms.

Why is it important? If we know the mechanism of disorder, then we can more effectively help children deal with them. it will allow us to correctly build a correction for the development of children with ADHD diagnosis, which will work with the mechanism of the disorder, not outward symptoms. Suppression or withdrawal of symptoms often does not mean that we act on the mechanism of disorder, Therefore, such a correction has a short-term effect. For example, if a person has a cough that is associated with tuberculosis, then cough pills, of course, will not cure this disease. AT In this case, it is necessary to treat tuberculosis, then cough, as one of the symptoms of this disease will disappear. Also with behavioral disorders. It is necessary to influence the mechanism of the disorder, and not "remove symptoms". nine0004

Unfortunately, there is still no generally accepted understanding what the variants of ADHD might be. Probably, There are different kinds and types of this syndrome. For example, modern research shows that under such a disorder How does ASD (Autism Spectrum Disorder) fall under the plethora of different variants of this disorder, including Asperger's syndrome, Kanner syndrome, RDA (early childhood autism), etc. It is obvious that ADHD also includes different varieties. nine0004

It is also important to understand that there are individual differences course of this disease.

Professionals should not just diagnose ADHD, thereby putting a label on the child. They must clearly understand which variant of ADHD you need to work with in a particular situation. It is necessary to understand the individual characteristics of the course of ADHD every child.

One of the serious tasks of modern child neuropsychology and neurology — development of an algorithm for helping children with ADHD, taking into account type of disorder, age, gender, individual and typological features of the child. nine0004

- Describe key symptoms that may indicate ADHD in its early stages?

- If we talk about the most rude version of ADHD, then there is a number of basic sets of symptoms.

The first set of symptoms is associated with behavioral characteristics. One of the key symptoms is increased exhaustion. Such children as a rule, they cannot engage in any one activity long time. At school, for example, children with ADHD cannot sit still 40 minutes of the lesson, listen to the teacher, complete assignments. They are fast exhausted and switched to other activities. Exhaustibility this kind of thing greatly interferes with successful learning, and in a broader sense, effectively adapt to the world. nine0004

The second key symptom is related to the inability to turn on quickly. into a certain activity. A simple example: the beginning of the lesson after change. The typical child quickly enters the appropriate learning activity pace of activity, begins to listen to the teacher, complete study assignments. A child with ADHD cannot change quickly level of brain activity. At recess, when he ran, jumped, played with other children, he had increased activity, but for it is not suitable for learning activities. Enhanced Level brain activity can not decrease to a suitable level for educational activity. Hence the serious problems with success learning, frequent comments from the teacher, etc. nine0004

The third symptom manifests itself in the form of peculiar waves of activity. At in such children, there is an effect of either increased activity, or its sharp decline. Similar undulating activity also manifests itself in school during the lesson. Against the backdrop of these fluctuations in activity, a specific effect occurs - at the peaks hyper- and hypoactivity children with ADHD are not successful in performing educational tasks. At such moments, their brain activity is not corresponds to learning activities. But when for a short period of time, their brain activity stabilizes and enters agreement with learning activities, they easily respond to teacher's questions, can solve a difficult problem, etc. nine0004

That is why many teachers notice that children with ADHD often disobedient, chaotic, but at the same time they have a normal intelligence. Indeed, the cognitive resources of such children are often good enough. And against the background of an optimal level of activity brain they realize them to the maximum. When the activity level does not correspond to educational activities, they, of course, show poor results.

In fact, each of us has waves of activity. During We go through periods of growth and decline every day. This characterizes normal feature of our nervous system. She demands period of rest, rest and activity. But in children with ADHD, this feature manifests itself in a hypertrophied form. Waves activities change more often and more noticeably. nine0004

The fourth symptom is hyperactivity, which manifests itself in the form increased motor activity, restlessness, the number of unnecessary movements, speech incontinence, etc. There is such a thing as synkinesis - involuntary extra movements during the performance of some activity or motor activity. For example, a child writes something in notebooks, and at this time his tongue moves, his shoulders move or legs move.

According to such key symptoms in the behavior of the child, specialists identify the presence of attention deficit disorder and hyperactivity. nine0004

Although there are situations when the diagnosis is made when the presence of only one of these symptoms. And this is wrong. For example, increased exhaustion may not be in the context of ADHD, and manifest as a result of dystonia or another disease. Therefore, it must be clearly understood that ADHD is always set of symptoms.

In addition to the group of behavioral symptoms, there are a number of secondary manifestations. Children with ADHD often have cognitive Problems. For example, they do not solve problems well against the background of fluctuations. activity. An experienced diagnostician will immediately understand that the reason lies not in the cognitive abilities of the child, and in the presence of increased exhaustion during the task. Therefore, often such children, to Unfortunately, many unnecessary symptoms are attributed. In this case, you need clearly distinguish between primary and secondary symptoms. nine0004

Another interesting phenomenon has to do with memory. Often in children with ADHD there is an increased erasure of traces of memory in conditions interference, that is, interfering activity. Like this shows up? Imagine that you have to remember two text. First you read and, as you think, remember the first text. Then you are given a second text. Memorizing the second material, you forget the first one. This is a natural feature of our memory. But children with ADHD this manifests itself in an abnormal form. For example, we ask the child to remember first the first 3 words, and then the second 3 words. He repeats the second group of words clearly, but the first 3 do not can remember. Similar memory problems also interfere with children's educational activity. nine0004

In addition, these children have problems with voluntary control. Within the framework of the Luriev model for arbitrary control answers the so-called "third functional block in operation brain."

— Tell us more about this model.

— According to Luriev's model, there are three blocks of the brain. The first functional block is responsible for the level of brain activity. Second the block is cognitive. It is associated with processing, perception and remembering information coming from the outside world. The third the block is called the “programming, regulation and control block for the course of mental activity. nine0004

Children with ADHD often have secondary developmental delays. frontal cortex. This leads to derivative control problems and derived attention. For example, these children cannot focus on the task, can't control their behavior. This symptomatology of ADHD is especially pronounced in preschool children. It is clear that due to age the level of derivative control in these children is very immature. AT older age, closer to 9 years, in children with ADHD due to improvement of voluntary control over one's behavior occurs a decrease in the symptoms of this disorder, that is, it begins have a compensatory effect. However, ADHD does not go away, but only goes into a latent (hidden) form. nine0004

And, finally, another secondary symptom is connected precisely with involuntary attention disorder. It's a symptom for the most part. refers to biology and the so-called orienting reflex for new incentives. When we hear an unexpected loud sound, we involuntarily pay attention to the source of the sound. This one is pure biological response allows us to respond effectively to potentially dangerous external influences.

Children with ADHD have a peculiar heightened sensitivity to all external influences, for example, to various soft sounds. A child with ADHD has an effect orienting reflex to both strong stimuli and weak. Outwardly, this manifests itself as increased distractibility. child. It is important to note that the child is not in the least is to blame - it is the indicative reflexes. nine0004

Imagine that you are walking through a forest at night. Your nervous system is this situation will become very sensitive. You will pay attention to any rustles and sounds. However, under normal conditions, when there is no danger, we react only to strong incentives. A child with ADHD constantly feels like he or she is is, figuratively speaking, in such a "dark and terrible forest." it leads to big problems at school, in communication with teachers and classmates.

So the symptoms of ADHD are quite complex and complex. To understand how a child with ADHD feels, imagine this situation. You are at the railway station, around various events are unfolding, many sounds, people flash before you, you are pushed, etc. And in these conditions you are offered to solve some problem. It is clear that you everything will be distracting and you will not be able to quickly and efficiently to solve a problem. Of course, if you were asked to solve the same task at home in a calm environment, then you would have coped with it much faster. So, a child with ADHD seems to be all the time is in the situation of a railway station where its all distracts. nine0004

In addition, orienting reflexes are accompanied by an increase child's anxiety.

The situation is aggravated by the fact that others react to the behavior of these children is inappropriate. Teachers shout at them parents, peers. Children with ADHD are under severe pressure from the outside world. And that just makes them bigger. anxiety.

These kids are really hard. In life they are constantly face adaptation problems, even when they become adults. With age, the syndrome does not disappear anywhere. He only passes into a latent form, in which external symptoms do not appear clearly, but at the same time it is difficult for such a person concentrate on some work, he is overcome by a swarm of thoughts, he constantly distracted by various external and internal events. nine0004

— Are the causes of the syndrome known in children?

Almost all behavioral disorders in children are related to genetics. However, we cannot say for sure whether a child with genetic predisposition will form ADHD. The fact, that any phenotypic trait, including behavior, develops under the influence of two factors - genotype and environment. AT certain environmental conditions, a genetic predisposition to ADHD can lead to the development of this disorder, and in others conditions are not. nine0004

As risk factors that may lead to the development Attention Deficit Hyperactivity Disorder (ADHD) is traditionally referred to as birth trauma, hypoxia during childbirth, prematurity. However not always these factors lead to the development of ADHD. Especially if you have the child is not genetically predisposed to it disorder.

ADHD is always associated with a combination of genetic factors. predisposition and external adverse influences, especially in the first year of life. At this time, actively formed mechanism of neurodynamics in the brain, and external risk factors may lead to the development of this disorder. For example, emotional negative experiences of the child associated with the absence of the mother, may be such a risk factor. nine0004

In addition, children in the first year of life should develop in conditions of adequate sensory load. Level violation sensory information leads to adverse effects on reticular formation of the brain, which can lead to impaired neurodynamics and formation of ADHD.

- If you do not pay due attention to the disorder, to what could this lead to in the future?

- Imagine the world in which a child with deficiency syndrome lives attention and hyperactivity. At school, he most often does not succeed, on he is pressured by teachers, parents. This kid is trying to defend himself. often due to aggressive reactions. This, after all, may escalate into criminal behavior. And increased anxiety further may provoke the development of serious mental diseases, such as pathological depression. That is, at such children are at risk of developing adverse scenarios in life. nine0004

Therefore, it is necessary to treat them correctly already in the early childhood, to build the right atmosphere around such children, adequately respond to the manifestation of certain features, be more tolerant of them. This will reduce the risk development of deviant behavior.

— What practices are used to help such children? Are there any medications?

- If we talk about attention deficit disorder and hyperactivity in its gross form, it is necessary here comprehensive support. It includes three elements intervention. nine0004

First, medical support is needed, especially when severe form of ADHD.

The second element is behavioral modification. There are many different techniques. But one of the most effective has to do with learning the so-called deep diaphragmatic breathing. Case is that the reticular formation, which is responsible for the general the level of activity of our brain, is sensitive to the lack of oxygen. Each of us has experienced severe exhaustion and inefficient work when in a stuffy room. If we improve the supply of oxygen to the reticular formation, the brain will work better. In a child with ADHD, breathing is often irregular and shallow. This impairs the supply of oxygen to the brain. situation can be improved if the child is taught the technique of correct diaphragmatic breathing. nine0004

By the way, children with ADHD are well helped by sports where deep breathing is practiced, for example, swimming. Michael Phelps, a 23-time Olympic swimming champion, is also in actually suffered from ADHD. Phelps dealt with this disorder thanks in large part to swimming.

Stories like these inspire parents who reach out to me. for advice on ADHD. Such children are helped not only swimming, and any other sport where breathing plays an important role - kayaking, canoeing, skiing, running and other rhythmic and aerobic sports. Proper breathing brought to automatism is one of the most important helpers for children with ADHD. nine0004

The third direction is aimed at working with the family. This is about family therapy and creating the right atmosphere in which he lives child. As a rule, children with ADHD show inadequate forms of behavior from the point of view of the parents themselves. Moms, dads, grandmothers, brothers and sisters can be aggressive, punish child for inappropriate behavior. And this, as I said above, only exacerbates the already problematic anxiety in these children. Therefore, it is important that within the family, a child with ADHD develops harmonious and tolerant relationships. Under these conditions, higher the probability that he will form a mechanism of arbitrary regulation and control, and he will gradually get rid of bright manifestations of ADHD symptoms. nine0004

The most unfavorable parenting strategy that leads to aggravation of ADHD symptoms - this is an authoritarian upbringing. At preschool age, it gives rise to a child increased infantilism, shifting responsibility to adult. A mature parenting strategy is to mother gradually transferred responsibility to the child in conditions joint activities.

Tell us what you are working on today? nine0041

— Our laboratory of brain and neurocognitive development operates in several directions. One of the important areas of research employees of our laboratory is associated with the influence parent-child interaction on the development of young children and preschool age. We're trying to figure out what strategies and styles upbringing has the most beneficial effect on the development of the child, and which ones can increase the risk of developing various disorders, for example, ADHD.

Another important area is devoted to the study of digitalization, influence of virtual space and computer addiction on children development. In the international classification of diseases has already been introduced diagnosis called digital addiction or digital addiction. Unfortunately, this is how the modern environment works - it provokes a situation in which the child is immersed early in the virtual space and becomes dependent on it. Some studies show that the child's early interaction with digital environment negatively affects the development of many basic brain mechanisms. It is clear that digitalization is a reality, from which is now nowhere to go. However, it is very important to correctly to introduce the child to the digital environment in a timely manner, to adapt him to this new reality. nine0004

The third aspect of research is devoted to the formation of a unified system diagnosis of preschool children, which in Russia so far no. Unfortunately, we do not have a generally accepted standard for which we can assess the development of children at preschool age, in order to timely detect atypical manifestations and the risk of deviant behavior. The fact is that preschool age is a period in which during which most of the basic brain cells are formed mechanisms. Therefore, any mistakes are fraught with serious consequences. in future. We must learn to quickly identify the causes deviant behavior and deviant development of children, which will basis for the development of effective methods of correction. Necessary time to change the environment of a child with the risk of developing deviant behavior, adjust the parameters of its development in order to mitigate the risks of various disorders. therefore we need a unified system of sensitive diagnostics that will allow to identify not only gross violations in development, but also minimal deviations in order to help the child in time. nine0004

Preschool age is a very important period in development, because the child's brain is sensitive both to adverse external influences as well as favorable ones. Quickly noticing the deviation the specialist can change the child's environment, which will lead to to the rapid restoration of development mechanisms.

Therefore, at this age it is so important to create for the child the most favorable environment for the development of basic brain mechanisms.

Today, unfortunately, many parents focus on the formation of school skills in preschool age - reading, letters, bills. It is not right. So the parents ahead of events. Figuratively speaking, they build the roof of the house, not completing the foundation and walls. We must strictly follow a certain sequence of brain development, take into account individual characteristics of the child, including psychological. nine0004

The basic mechanisms of the brain must be formed in preschool age with the help of a variety of motor activities: gymnastics, dancing, sports, drawing, classes music and so on. And only then, when the foundation has been created, can it is easy to switch to the formation of a variety of school skills - letters, readings, bills, etc.

Today, together with Tomsk State University, we we are working on creating a unified diagnostic system that is easy to fit into the system of preschool education. It is necessary that she allowed to effectively identify risks at an early stage and gave the ability to quickly correct the development of the child. nine0004

— What advice would you give to parents whose children Have you been diagnosed with ADHD?

- Unfortunately, sometimes it happens that a child is diagnosed ADHD, but he doesn't really have that syndrome. I often I am facing this kind of overdiagnosis.

Therefore, it is important not to rely on the opinion of only one specialist. It is necessary to re-diagnose with another doctor, to make sure if the child really has a syndrome attention deficit and hyperactivity. nine0004

If the syndrome is confirmed by at least two specialists, then the child comprehensive support is required. Unfortunately, parents often rely on drugs. Of course, the effect of drugs is, but it short-term. If the child stops using them, then symptoms will return, and in some cases even worsen. Therefore, it is important to solve the problem comprehensively. Together with right built medical support must be carried out behavioral therapy, in particular, using the technique diaphragmatic breathing. nine0004

And, of course, parents should not forget that often their own misbehavior exacerbates the situation. AT In some cases, parents need to work even harder on yourself and your own behavior. Sometimes shown and personal therapy, which involves a change of position in relation to to kid. Sometimes, such changes give a stronger effect, than other influences or interventions.