Exercises like rock climbing, structured play sessions and even clapping along to musical beats are being used to help kids with attention deficit hyperactivity disorder, or ADHD, augmenting medication with these structured sessions.
About 11 percent of children have been diagnosed with ADHD, according to the Centers for Disease Control and Prevention. There are three main types: inattentive, hyperactive/impulsive and a combination of the two.
Kids with ADHD typically have trouble with executive function: things like paying attention to something that doesn’t interest them, making priorities, sticking with things until the end and imagining consequences, said Dr. Jeffrey Brosco, professor of clinical pediatrics and associate director of the Mailman Center for Child Development at the University of Miami School of Medicine.
“It’s not a problem when you’re not asking them to sit still and follow the rules and do a lot of boring stuff. But when you do require it, and they can’t do it, it’s a big problem,” he said.
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The best way to diagnose ADHD is with a comprehensive psychological evaluation that includes intelligence testing, processing speed, auditory and visual processing, said Gary Lancelotta, a psychologist at Baptist Children’s Hospital in Miami. “You want to get a sense of how attentional issues are impacting the child overall,” he said. An evaluation should include formal parent and teacher reports, and rule out other potential problems, like hearing issues, Brosco said.
Though it is one of the most common childhood disorders, it can be frustrating for a parent trying to determine the best way to treat a child with ADHD.
Stimulant medications like Ritalin and Adderall are the most widely used treatments. Between 70 and 80 percent of children with ADHD respond positively to these medications, according to the CDC. The American Academy of Pediatrics recommends a combination of medication and behavioral therapy.
“There is a lot of evidence that stimulant medications are excellent for the core symptoms of ADHD: not being able to pay attention to something that is boring, like math class, and for some kids, impulsivity and hyperactivity,” Brosco said. “For those symptoms, medication is very effective. It doesn’t fix the problem, it just provides a bridge until the child matures enough to handle the situation on his own.”
Stimulant side effects can include reduced appetite, stunted growth and interference with sleep.
“We have 30 years of research on stimulant medications, so we have a pretty good idea of what the risks are. You have to balance the risk and the benefit,” Brosco said.
When the medicines work well, children tend to eat less, and they don’t grow as fast, he said. “In the worst case scenario, a child might end up being an inch shorter than they would have otherwise been. So the question for a parent is, ‘If your child was destined to be 5-11, and he is going to be 5-10, but this allowed him to stay in school, graduate and get a job. Is that worthwhile?’ And for most parents, it is.”
Stories of college kids who use stimulant medications to pull all-nighters and middle schoolers selling the drugs at school do not accurately reflect the patient pool, Brosco said. In 20 years of practice, he has not seen patients take more of the medicine than they need of their own accord. “Sometimes families will push for a higher dose than I’m comfortable with, but it’s really not an issue for most children who have this condition and benefit from the medicine.”
If a child hasn’t responded to trials of two or three different stimulants, some try a nonstimulant like Strattera, “though we don’t often see a big difference,” Brosco said. “Instead, we’re moving toward long-acting Guanfacine, or Intuniv.”
Medicine is only one component of ADHD treatment. “Most of us in the field would say that it’s all the other stuff that matters, at least as much, if not more,” Brosco said. “It’s like a three-legged stool. Medicine is one leg, the other is what you’re doing to help a child with his behavior, and the third is what the child is doing himself.”
Appropriate behavioral interventions also will help with executive function, he said. “If a child is running around and the teacher says get back to your seat, that’s reinforcing a bad behavior,” Brosco said. “Instead, you want to catch that child sitting in their seat and being good, and you provide the reinforcement. But it’s hard when a teacher has 20 or more students in a classroom.”
Classroom interventions like a daily report card are an effective tool, he said. “Each day, a child gets a report from the teacher on key things, such as did he stay in his seat, finish his assignment, raise his hand before speaking?” Brosco said. “The idea is that the child gets rewarded for doing those things, and doesn’t get rewarded if he’s not doing those things. But it’s not punishment.”
Exercises like rock climbing, skateboarding and martial arts that require concentration can improve function in kids with ADHD.
“I don’t think anyone knows exactly how exercise helps. If you look at correlation studies, kids who exercise more have fewer symptoms,” Brosco said. “But it also falls into the realm of if you exercise, eat right and sleep more, you tend to do better, whether you have ADHD or not.”
Lancelotta leads a weekly rock-climbing session in Miami for kids with ADHD and autism, among others.
“It’s not an evidenced-based treatment for ADHD, but it requires team attention and concentration to the activity, or else they fall, so there is an immediate response if they’re not paying close attention,” he said. “It helps with motor planning, hand and foot placement. It helps with individual goal planning. It increases frustration tolerance.”
Kids with ADHD have a tougher time reading social cues, so it can help with socialization.
“Rock climbing presents a series of calculated goals. There are a lot of metaphors in rock climbing. Each rock represents an obstacle,” Lancelotta said. “In our group, kids come in with individual goals, ADHD, issues surrounding impulse control, behavioral self-control and anger management. Those are all aspects that we try to incorporate in the activity.”
Activities like skateboarding and martial arts focus on attention to detail, so if kids like that, and if their competency is increasing, it can build on itself, he said.
Tina Chilampath, an occupational therapist with Memorial Hospital West in Pembroke Pines, uses an Interactive Metronome as a tool to improve cognitive and motor skills in kids with ADHD. The computer program gets the child to clap their hands or tap their feet in time to a beat, essentially practicing their concentration skills, she said. The program tracks accuracy, and as a child progresses, it introduces distraction and the task becomes more difficult.
“Kids with ADHD have a very hard time focusing on one thing while other things are going on at the same time,” Chilampath said. “This works to improve attention and coordination. There’s been evidence that it improves language processing and reading skills.”
If you give a child with ADHD a multi-step task, they have a hard time figuring out how to motor plan, sequence, use their time and keep to a rhythm. All of these things are related to being able to pay attention, Chilampath said.
The Interactive Metronome is a tool that can be incorporated into physical, occupational or speech therapy. “It’s something to add to the mix,” she said.
The minimum frequency is twice a week for 15 to 60 minutes. There is also a home-based program that requires parent training.
Chilampath also helps conduct a Social Sensory Group, which meets in eight weekly one-hour sessions and is targeted to kids with ADHD and those who have trouble with social issues. Kids are grouped by cognitive level. “It helps teach them peer interaction and lets them practice what they’re learning in a group, rather than one-on-one,” she said. Crafts, games, obstacle courses and outings are incorporated into sessions.
Another therapy is neurofeedback, which uses sensors to monitor brain activity as a child plays a special video game, Brosco said. Brain waves are recorded, so the child can see when he is most efficient. The idea is, with practice, to retrain the brain to work in the most efficient mode. The therapy is typically done over multiple sessions. “There is some evidence that using it reduces the amount of medicine that you will need,” Brosco said, “but it is not as effective as medication.” In fact, the U.S. Department of Health and Human Services says that neurofeedback cannot be recommended as an alternative to medication use in ADHD.
Activities like yoga, meditation and self-calming exercises also can help. “There is some evidence that they can be helpful, but it’s not as strong,” Brosco said.
“There are also isolated studies on nutrient deficiencies and dietary supplements, but the research on those is not as strong as for behavioral interventions like daily report cards, or stimulant medications.”