Treatment of ADHD PDF

**[ATTENTION DEFICIT HYPERACTIVITY DISORDER]** **[Treatment of ADHD-areas of treatment-communication deficits, academic issues, memory deficits, behavioral, medical and social issues]** **[Intervention --]** Although the importance of an accurate diagnosis has been emphasized repeatedly, finding...

**[ATTENTION DEFICIT HYPERACTIVITY DISORDER]** **[Treatment of ADHD-areas of treatment-communication deficits, academic issues, memory deficits, behavioral, medical and social issues]** **[Intervention --]** Although the importance of an accurate diagnosis has been emphasized repeatedly, finding an effective treatment strategy is also vitally important. **[Medical:]** The Multimodal Treatment Study1999 of ADHD (MTA Study) is the largest study (involving approximately 570 children over 6 different sites in the United States and Canada) to date comparing the effectiveness of different treatments for ADHD. The results from the MTA study showed **that medication was the single most effective treatment.** However, the most effective treatment strategy overall was a combination of medication and psychosocial treatments (social skills training or anger management training). **The MTA results are groundbreaking in suggesting that medication is not the only option for people with ADHD, and that combination therapy will likely provide the most positive impact**. Medication is usually the first line of treatment for Attention-Deficit/Hyperactivity Disorder. In the last ten years, the number of prescriptions written for medications to treat ADHD has increased dramatically, particularly in the United States. The exact reasons behind such dramatic increases are not entirely clear. These **drugs are not a cure for ADHD**. Instead, they can help minimize the negative impact of ADHD symptoms on an individual\'s life. - Biophysical (Pharmacological /dietary modifications) - Behavioral - Cognitive-behavioral **[Pharmacological]** **Stimulants.**  The most common type of medication used for treating ADHD is called a "stimulant." Although it may seem unusual to treat ADHD with a medication that is considered a stimulant, it works because it increases the brain chemicals dopamine and norepinephrine, which play essential roles in thinking and attention. They can reduce the hyperactivity and impulsiveness of children with ADHD and can increase their ability to focus attention, work and learn. Drugs approved by the FDA for treating ADHD include stimulants (considered first-line agents), such as methylphenidate and amphetamines, and non-stimulants (considered alternative agents), such as atomoxetine and extended-release α-2 agonists (guanfacine and clonidine). Tricyclic antidepressants (TCAs), immediate-release α-2 agonists, and bupropion have been used off-label to treat ADHD. Although stimulants are considered first-line agents, they may not be suitable for nearly 30% of ADHD patients. Non-responsiveness or partial responsiveness to stimulants; intolerance to their side effects (eg, insomnia); presence of medical issues such as psychiatric, cardiovascular, or tic disorders; and family aversion to controlled substances may require alternative agents categorized as non-stimulants for either replacing stimulants or added as adjuncts to treat ADHD. Medications do not cure ADHD, they only control the symptoms temporarily. Although these medications help the child better attention and complete school task, they cannot increase knowledge or improve academic skills and class performance. They help the child to use those skills he or she already possesses. E.g.: - - - - **Non-stimulants.** ** **A few other ADHD medications are non-stimulants. These medications take longer to start working than stimulants, but can also improve focus, attention, and impulsivity in a person with ADHD. Doctors may prescribe a non-stimulant: when a person has bothersome side effects from stimulants; when a stimulant was not effective; or in combination with a stimulant to increase effectiveness. Non-stimulant drugs 1.  Atomoxetine (Strattera) 2.  guanfacine (Intuniv) 3. Clonidine(Kapvay). **[Dietary Interventions]** - Dietary and nutritional approaches to controlling hyperactivity offer another form of treatment for children with ADHD. - - - - **[Neurofeedback]** Neurofeedback is a computer-aided type of nonpharmacologic treatment for ADHD that is based on biofeedback principles. Treatment typically involves patients using a computer monitor that shows brainwave activity through EEG. In the neurofeedback process, patients are trained to adjust their attention and thereby their brainwave activity. **[Behavioral Intervention]** Also called behavior modification, Contingency management, behavior management. The purpose of behavioral interventions is to assist students in displaying the behaviors that are most conducive to their own learning and that of classmates. Behavioral intervention approach is based on the principles of operant conditioning. Well-managed classrooms prevent many disciplinary problems and provide an environment that is most favorable for learning. - ***Positive reinforcement*** - ***Response cost*** - ***Time out*** Alternatives to this can include cognitive behavior strategies such as self-monitoring, self-reinforcement and self-instruction, as well as other metalinguistic and meta cognitive activities, such as "think aloud" and "directed reading thinking activities" (Damico, Damico & Armstrong, 1999). For young children with ADHD - Parent training in behavior management gives parents the skills and strategies to help their child. - Parent training in behavior management has been shown to work as well as medication for ADHD in young children Young children have more side effects from ADHD medications than older children. The long-term effects of ADHD medications on young children have not been well-studied. For children ages 6 years and older. behavior therapies, includes: Parent training in behavior management. Behavioral interventions in the classroom. Peer interventions that focus on behavior; and Organizational skills training. These approaches are often most effective if they are used together, depending on the needs of the individual child and the family. COGNITIVE-BEHAVIOURAL TREATMENT (CBT) **-ARON BECK ,1960** **[Aim]** : To teach children with ADHD to self-regulate own behavior according to rules, use strategies to behave properly, self-evaluate and self-correct their behaviors, develop a healthy self-esteem and satisfactory relations with others (Orjales, 2002). CBT has more positive effects when parents and/or teachers get involved to promote the generalization of the techniques at home and/or at school (Pfiffner, 2003). The basic techniques of the treatment are; self-instructions, contingent reinforcement response cost (Calderón, 2001) Students are trained to become aware of their maladaptive thoughts. The therapist models appropriate behaviors while verbalizing effective actions strategies. The students then perform the targeted behavior while verbalizing appropriate self-instructions and then trying them out. (Shilingford et al., 2007) The self-instructional training teaches children a sequence of useful thoughts for solving problems by replacing the wrong thoughts and to make appropriate behaviors. This model is often employed to aid students with impulsivity difficulties. Cognitive interventions are most effective when they are combined with behavioral contingencies in the natural environment at the time that the problem behavior occurs (in the classroom or home rather than at the clinic) (Purdie et al., 2002). **[Antecedents Consequences modification Program]** - **Effective treatment for students with ADHD is through behavior therapy that includes strategies based on antecedent-consequence (Barkley, 2006).He explained the concept of antecedent-consequences modification is basic models of operant conditioning, namely the concept of A-B-C (Antecedents-Behavior-Consequences).** - **Antecedents is a stimulus which was created to provoke a response (Behavior) which is then followed by a reinforcing stimulus (Consequences). Consequences is any stimulus, such as events or consequences that can increase the chances of a response that is expected to reappear (Schunk, 2012).** - **Rules become very important and weak response (no reinforcement) from environment caused the emergence of ADHD. If there are no rules, children won't understand what to do, and no reinforcement will make them do not recognize whether their behavior is acceptable or not in their environment.** - **An antecedent-based intervention has been widely used to prevent inattention and disruptive behavior.** - **Antecedent will give children cues what behavior they should do. First, the teacher can strategically place the class rules (DuPaul & Weyandt, 2006). Rules should be slight and expressed in the positive behavior (for example say to students what to do, not just the behavior that should be avoided), and puts the rules that can be viewed by all students.Teachers should regularly praise the students who follow the class rule. Children with ADHD need more intense rules and must be provided with more praise when they obey the rules (Pfiffner, Linda J; Barkley, R; DuPaul, 2006).** **Article: A study has reported an effectiveness of consequence-based strategies in ADHD children using contingent positive reinforcement and response cost (DuPaul & Weyandt, 2006). The use of contingent positive reinforcement example praise from teachers or token reinforcement is effective in forming the expected behavior (DuPaul, George; Stoner, 2003).** ** ** **[COMMUNICATION INTERVENTION WITH CHILDREN WITH AD/HD]** - **Structured Environment:** Create a structured and predictable environment to reduce distractions and help the individual focus. - **Visual Supports:** Use visual aids, such as schedules, charts, and graphic organisers, to help with understanding and organising information. - **Social Skills Training:** Teach social skills explicitly through role-playing, social stories, and direct instruction. Focus on skills such as turn-taking, eye contact, and understanding nonverbal cues - **Active Listening**: Encourage active listening skills, including maintaining eye contact, nodding, and summarising what has been said - **Self-Monitoring Techniques**: Help individuals develop self-monitoring skills to recognize when they are off-topic or not following social norms. - **Executive Function Support:** Work on improving executive function skills, such as planning, organising, and time management, which can impact communication. - **Behavioural Interventions**: Implement behavioural interventions to reinforce positive communication behaviours and reduce negative ones. - **Pragmatic Language Therapy**: Focus on the practical use of language in social contexts, teaching appropriate conversational skills and the understanding of social cues. - **Parent and Teacher Training:** Provide training for parents and teachers to support the individual\'s communication skills in different settings. - **Technology and Apps**: Utilise technology, such as speech and language apps, to engage and motivate the individual while practising communication skills - **Short, Clear Instructions:** Give short, clear, and concise instructions to avoid overwhelming the individual. - **Positive Reinforcement**: Use positive reinforcement to encourage desired behaviours and build confidence. - **Modelling**: Model appropriate communication behaviours and provide opportunities for the individual to practise in a safe and supportive environment.. - To enable the child with ADHD to gain maximally from classroom instructions and other teaching or learning situations in schools and /or home. - Factors to be considered on developing educational intervention plans - Behavioral profile - Child's cognitive profile - ADHD symptomatology - Child's strengths and weaknesses +-----------------+-----------------+-----------------+-----------------+ | | | - Allowing | - For tasks | | | | work with | to be done | | | | partners in | in the | | | | small | later | | | | groups. | periods of | | | | | school and | | | | - Make the | tasks that | | | | ADHD child | are | | | | sit closer | lengthy. | | | | to the | | | | | teacher. | - This can be | | | | | achieved by | | | | | changing | | | | | the setting | | | | | or by | | | | | employing | | | | | novel ways | | | | | to do a | | | | | task | +=================+=================+=================+=================+ | | | | | +-----------------+-----------------+-----------------+-----------------+ | | | | | +-----------------+-----------------+-----------------+-----------------+ - Useful strategy used in the school setting for children with ADHD. - Child with ADHD is taught by other classmates. - Effective with ADHD children in improving classroom behaviors and academic performances - A scope for inclusive education and chances of getting bullying is reduced. - Produce effective results in behavioral modification and tackling learning difficulties in Children with ADHD. - Both parents and teachers identify a few desirable behaviors that they want to encourage in the child and strive to instill those behaviors in children with ADHD. - This helps in maintaining a continuity in behaviors learned in school at home and other settings. - It increases the generalizability of learned behaviors. - Lack of parental involvement cause regression in the child's academic success (Nicholas,2000) - The home school collaborations is helpful to teachers because it reduces their labour (Kelly,1990) **Academic Intervention for Writing** COGNITIVE (FUNCTIONAL) PROCESSES ================================ 1. ***Intervention procedures using specific and full-strategy approach.*** 2. ***Intervention procedures using a more general approach.*** - Includes Explicit and systematic teaching of a series of task-specific strategies. - To accomplish an academic task or problem(eg; opinion essay writing) - Involves sustained, direct and systematic instructions to facilitate student mastery. - Explicit strategies for planning,revising and/or editing text. - Explicit strategies for writing include specific instructions for grammar sentence combining and generating essay elements.(Caeran &Cornoldi,2008) **[Self-Regulated Strategy Development(SRSD)] model (Harris & Graham,1996)** - In SRSD instruction students are enabled in **[self-regulation]** by teaching how to set goals, [monitor their own performance and how to use self-instructions,] [and/or self-reinforcement.] - Emphasis is laid on [independent use of the writing strategy by the students] and accompanying self-regulation procedures. Students learn when, where and how to apply these procedures. - Responsibility for self-regulation procedures gradually shifts from the instructor to the students. - Individualized instructional support and feedback are given so that they are responsive to every child's needs. Students proceed from one instructional stage to another at their own pace. - Instruction is not time-based but criterion-based.So students move to later stages of instruction only when they have met the criteria for doing so. - A general planning strategy used to frame the writing process. - Comprises 3 steps for planning and writing. - Teaches the students to use TREE for composing their opinion essays. +-----------------------------------+-----------------------------------+ | **1** | - **Background knowledge is | | | developed.** | | | | | | - **Students are introduced to | | | 2 strategies-POW and TREE.** | | | | | | - **POW is introduced first | | | followed by TREE strategy.** | | | | | | - **Students are given a | | | graphic organizer with | | | picture of tree to assist | | | them in remembering the parts | | | of TREE.** | +-----------------------------------+-----------------------------------+ 2. ** Discussion happens on the two strategies.** - **Students are asked to focus on these strategies and remember the steps too.** - **ADHD student practices to find essay elements and analyze their own opinion essays.** - **Also taught goal setting and self-monitoring the number of essa elements he includes in his opinion essays.** 3. ** POW and TREE strategies are explicitly modelled by the instructor.** - **Focus is on self-instruction and self-talk.** - **Instructor collaboratively with the student generates an opinion essay including all the essay elements.** - **Then the instructor records the responses on the planning sheet using self-statements.** - **Eg; 'what is my goal'?-goal setting/'what is my next step'?(planning)/ 'does that make sense'?(self-evaluation)/ 'Ilike that part'.(self-reinforcement) /'I am almost done'.(coping)** - **After the essay is written , the instructor and the student identify all elements in TREE and also count the number of words written.** 4. ** Support-stage.** - **Collaborative writing experience.** - **Instructor and student together write an essay using POW,TREE and a graphic organizer.** - **Student controlled stage.** - **Instructor gives support only when it is necessary.** - **Support fades as the student gets proficient in strategy.** - SRSD model directly addresses the problem of establishing goals, holding goals in memory, persisting in efforts towards goal completion ,and shaping and directing behaviors in order to achieve goals. - It develops self-regulation through strategies that improve ability to maintain focus and effort in ADHD children.(Reid,Trout,2005) - The working memory deficits in ADHD children is also addressed by this model. Demand on working memory is reduced by the SRSD instruction by presenting instructions in small steps. - In addition, prompts, cues and organizers are provided initially to support efforts. **[Intervention procedures using a more *general approach*]** - Given by Re,Caeran &Cornoldi in 2008, provides procedural facilitation. - Involves providing some form of assistance that helps the child carry out one or more processes required in the writing task. - The assistance is in the form of a **guide scheme** which facilitates expressive writing. - A training is provided before using the guide scheme to help them use the facilitation - Training session involves a trainer(psychologist) and the student where both will do the writing task together. This training involves steps; ACADEMIC INSTRUCTIONS ===================== - Teachers can help prepare their students with ADHD to achieve by applying the principles of effective teaching when they *[introduce, conduct, and conclude] [each lesson.]* - Students with ADHD learn best with a carefully structured academic lesson---one where the teacher explains what he or she wants children to learn in the current lesson and places these skills and knowledge in the context of previous lessons. - Effective teachers preview their expectations about what students will learn and how they should behave during the lesson. ------------------------- -- **INTRODUCING LESSONS** ------------------------- -- **Provide an advance organizer-**Prepare students for the day's lesson by quickly summarizing the order of various activities planned. Explain, for example, that a review of the previous lesson will be followed by new information and that both group and independent work will be expected. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- **Review previous lessons-**Review information about previous lessons on this topic. For example, remind children that yesterday's lesson focused on learning how to regroup in subtraction. Review several problems before describing the current lesson. **Set learning expectations-**State what students are expected to learn during the lesson. For example, explain to students that a language arts lesson will involve reading a story about Paul Bunyan and identifying new vocabulary words in the story. **Set behavioral expectations-**Describe how students are expected to behave during the lesson. For example, tell children that they may talk quietly to their neighbors as they do their seatwork or they may raise their hands to get your attention. **State needed materials-**Identify all materials that the children will need during the lesson, rather than leaving them to figure out on their own the materials required.(Pencils, crayons, colours) **Explain additional resources-Tell students how to obtain help in mastering the lesson. For example, refer children to a particular page in the textbook for guidance on completing a worksheet.** **Simplify instructions, choices, and scheduling-The simpler the expectations communicated to an ADHD student, the more likely it is that he or she will comprehend and complete them in a timely and productive manner.** **CONDUCTING LESSONS Contd..** ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ **Lower noise level-** Monitor the noise level in the classroom, and provide corrective feedback, as needed. If the noise level exceeds the level appropriate for the type of lesson, remind all students---or individual students---about the behavioral rules stated at the beginning of the lesson. **Divide work into smaller units-** Break down assignments into smaller, less complex tasks. For example, allow students to complete five math problems before presenting them with the remaining five problems. **Highlight key points-** Highlight key words in the instructions on worksheets to help the child with ADHD focus on the directions. Prepare the worksheet before the lesson begins, or underline key words as you and the child read the directions together. When reading, show children how to identify and highlight a key sentence. **Use cooperative learning strategies-** Have students work together in small groups to maximize their own and each other's learning. Use strategies such as Think-Pair-Share where teachers ask students to think about a topic, pair with a partner to discuss it, and share ideas with the group. (Slavin, 2002). **Use assistive technology-** All students, and those with ADHD in particular, can benefit from the use of technology (such as computers and projector screens), which makes instruction more visual and allows students to participate actively. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Provide advance warnings-** Provide advance warning that a lesson is about to end. Announce 5 or 10 minutes before the end of the lesson (particularly for seatwork and group projects) how much time remains. **Preview the next lesson-** Instruct students on how to begin preparing for the next lesson. For example, inform children that they need to put away their textbooks and come to the front of the room for a large-group spelling lesson. CLASSROOM ACCOMODATIONS ======================= - Children with ADHD often have difficulty adjusting to the structured environment of a classroom, determining what is important, and focusing on their assigned work. - They are easily distracted by other children or by nearby activities in the classroom. - As a result, many children with ADHD benefit from accommodations that reduce distractions in the classroom environment and help them to stay on task and learn. - One of the most common accommodations that can be made to the physical environment of the classroom involves determining where a child with ADHD will sit. - Three special seating assignments may be especially useful: - Seat the child near the teacher. Assign the child a seat near the teacher's desk or the front of the room. This seating assignment provides opportunities for the teacher [to monitor and reinforce the child's on-task behavior.] - Seat the child near a student role model. Assign the child a seat near a student role model. This seat arrangement provides an opportunity for children [to work cooperatively and to learn from their peers in the class.] - Provide low-distraction work areas. As space permits, teachers should make available [a quiet, distraction-free room or area for quiet study time and test] [taking]. Students should be directed to this room or area privately and discreetly in order to avoid the appearance of punishment. SOCIAL SKILLS TRAINING ====================== The fifth area of management is the social aspect of dealing with ADHD. As stated previously, many children with ADHD are perceived as rude and uncaring, so these issues need to be addressed. They also need to be taught how to deal with their emotions appropriately. The psychologist is the most likely person to work with these particular aspects. In addition, the teacher might explain ADHD to the whole class in an effort to ease some of the confusion regarding the disorder. It is also critical to monitor the social status of the child with ADHD because of the inclination to poor self-esteem and depression, particularly among older children. Behavior therapy should be provided to help the child analyze the situations in which he or she finds himself or herself and to practice problem solving as it relates to personal and academic problems. The use of positive reinforcement is critical, and the timing is important. Remember that delayed gratification is difficult for children with ADHD, so frequent use of positive reinforcement is essential. The use of behavior management, particularly positive reinforcement, is admittedly difficult because children with ADHD tend to elicit primarily punitive responses from teachers, parents, and peers. This often results in inconsistent attempts at behavior management, with increases in depression. - In children with ADHD the social performance is disrupted due to problems in attention and problems in impulse control in several ways (DuPaul and Stoner, 2003). - Compared with other problems social skill issues are very difficult to treat (Pfiffner et al., 2000). - ADHD children often may enter into ongoing peer activities in an abrupt manner that ultimately may lead to their peer becoming dissatisfied with the activity. - And also children with ADHD may fail to follow the implicit rules of good conversation (Stroes et al., 2003). The children with ADHD may show more aggressive behaviors than their peers this will also disrupt their peer interaction. - Since children with ADHD suffer greater risk with social skills, there is a need to work on peer relationships. - Social skill training program focuses on the development and reinforcement of behaviors and skills that are socially accepted and appropriate, such as cooperation and communication. - These programs believed to have more direct effect on social interaction of children with ADHD (Pfiffner et al., 2000) - These programs are provided in a group setting and include both 1. One consistent factor is that in traditional social skills training is provided [directly to the child by a clinician]. 2. The topic of instruction may change every week but the topic typically focuses on providing knowledge about key social skills. 3. The social skills taught in this training include [sharing, making conversations,] [joining new groups of peers, following rules when playing games, taking turns,] [claiming down when upset and identifying emotions. ] 4. Usually the clinician introduces the social skills to the child in a didactic fashion, but also [includes discussions and role plays within the session for the purpose of] [allowing children to practice the skills.] **[Memory Deficits intervention]** **[6) STRATEGIES TO DEAL WITH MEMORY DEFICITS:]** [ ] Cognitive Strategies: 1\. Chunking: Break down information into smaller, manageable chunks to make it easier to remember. This can be applied to numbers, words, or tasks. 2\. Repetition and Practice: Encourage frequent repetition and practice of information to reinforce memory retention. Spaced repetition techniques can be particularly helpful. 3\. Visualisation: Use visual imagery or mental visualisation techniques to help encode and retrieve information. Creating mental images or diagrams can aid in recalling information. outlines 5. Organisation: Help individuals develop organisational strategies, such as creating, using calendars or planners, and categorising information, to improve memory recall. Environmental Support 6\. Minimise Distractions: Create a quiet, organised environment with minimal distractions to help individuals focus on tasks and information retrieval. 7\. Routine and Structure: Establish consistent routines and schedules to provide predictability and reduce the cognitive load associated with memory tasks. 8\. Visual Supports: Use visual cues, reminders, checklists, and sticky notes to prompt memory retrieval and reinforce learning. Technology and Tools 9\. Note-Taking Apps: Recommend apps or software that support note-taking, organisation, and task management. These tools can help individuals keep track of information and deadlines. 10\. Digital Voice Recorders: Use voice recorders or speech-to-text technology to capture and review verbal instructions, lectures, or ideas. Metacognitive Strategies 11\. Metacognitive Awareness: Teach individuals to monitor their own memory performance and use strategies like self-testing, summarising, and reviewing to enhance memory retention. 12\. Goal Setting: Help individuals set specific goals related to memory improvement and track progress over time. Celebrate successes and adjust strategies as needed. - It is also important to focus on memory deficits when working with children with ADHD. - Focused attention requires that the child complete an activity, usually under a time constraint (Heyer, n.d.). - This is important because the child may have difficulty accessing his or her memory bank to \"call up\" the information needed to complete a task. For example, a child who is taking a test on a story that has been read to the class may have trouble remembering the important information in the story in time to complete the test. - Teachers often report that a child with ADHD seems to daydream at times when attention should be focused on a specific classroom task. - Sustained attention is somewhat similar to focused attention, but in this case the child does not complete the test because he or she cannot stay focused on the test, rather than having difficulty recalling the important information. - Divided attention is a problem for the child with ADHD because he or she cannot decide how much attention to give to each activity (Heyer, n.d.). Problems with divided attention interfere with the ability to multitask **[.]** TABLE 10-3 Memory deficits in children with ADHD Selective attention Focusing on what is important amid myriad stimuli --------------------- ----------------------------------------------------------------------------------- Focused attention Having a specific activity that must be done, usually under a time constraint Sustained attention Similar to focused attention but less time restricted Divided attention Determining how much attention should be given to each activity Vigilance Completing the whole task without falling behind; needed to develop a memory bank For example, most children in third grade have homework in two or three subject areas per night. The child with ADHD has difficulty determining how much time to allot to each subject so that all of the assignments are completed. Vigilance is important because it underlies the development of a memory bank. The child with ADHD has a poor memory bank because he or she cannot stay focused enough on the information at hand in order to store it (Heyer, n.d.). For example, the young man who had difficulty with written spelling tests had trouble with vigilance. In fact, being unable to complete written spelling tests is a classic example of difficulty with vigilance. The child is busy writing word number three (for example) when the teacher calls out word number four. By the time the teacher gets to word number five, the child has fallen behind and cannot remember the words that have been called out. Consequently, these children fail to complete the spelling test because they have trouble refocusing and recalling the words that have been called out by the teacher. As a rule, vigilance, divided attention, and sustained attention are the forms of attention that create the biggest memory deficits in children with ADHD (Heyer, n.d.). Therefore, many children with these disorders do better on self-paced tasks cut into small units than they do on timed tasks. Other treatment strategies are suggested in following Table. TABLE - Treatment strategies to use with children who have ADHD - Provide a consistent routine across all environments - Break assignments down into smaller groups (e.g., five mathematic problems at one time instead of 20) - Give simple, single instructions or directions - Prepare for changes - Reinforce the strengths as much as addressing the weaknesses - Maximize function and circumvent or minimize the weaknesses **[Sensory strategies]:** Research has indicated that when learning tasks are inherently more stimulating, children with ADHD have their sensory needs satisfied, are more motivated to learn, and their academic performance subsequently improves. The stimulation from the assigned tasks must be stronger and more accessible than the competing stimulation in the environment (Lee &Zentall, 2006). If the learning activities are stimulating, novel, active, meaningful, and interesting, and are appropriate for particular sensory requirements, the child with ADHD will be more likely to benefit from them. Intervention should include strategies that address these diverse needs. Sensory strategies for optimal learning: [Tactile] Add novelty, texture, weight, colour, temperature, taste, and movement within tasks. Structure sessions as a string of short activities separated by short breaks (Greathead, 2008). Incorporate active learning into lessons. Allow for opportunities for computer based instruction (Zentall, 2002). Have the children hold objects that are relevant to the story while they are reading or being read to (Godwin Emmons & McKendry Anderson, 2005). Choose activities that involve creating, acting, and playing. Target verb vocabulary and grammar in the gym or playground. [Visual] Keep teaching tools simple, with sparse text or images to limit competing stimuli. Highlight important information and check off information once it has been covered. Add visual stimuli to add novelty to a repetitive task. Use a series of pictures to guide a spoken response for children with difficulty restraining impulses. (Babyak, Koorland, &Mathes, 2000). Give nonverbal visual cues such as thumbs up, a wink or exaggerated facial expression as important feedback for pragmatic language (Godwin Emmons & McKendry Anderson, 2005). [Auditory] Attention and language skills can be enhanced if auditory deficits are addressed. Pair auditory cues with visual cues and give short and specific instructions. Repeat auditory instructions, give extra processing time and emphasize key words. Use repetition and description to increase understanding. Ask the child repeat directions for comprehension checking. Use role-playing, gestures, physical tasks, or creating something to aid comprehension. Require active responses from students during listening tasks, such as writing answers to questions, using novel materials, or pressing buttons (Zentall& Meyer, 1987). Engage the child with questions during oral reading and point out the illustrations to match the text [Peer Interaction] Create natural situations where communication breakdown has natural consequences. Structure opportunities to practice pragmatic skills to provide children with opportunity to monitor amounts of verbal output and improve conversation skills. Set up peer tutoring situations (DuPaul&Henningson, 1993). Play games related to names and characteristics of classmates to improve working memory for salient characteristics of others while increasing positive interactions. Meaningful Intervention Employ strategies that have natural consequence for communication breakdown. Focus on real life situations in lessons and experiences meaningful to the child. Structure activities so the language goal is obvious. Provide natural contexts with informative language, high motivation to communicate within the task, cohesive texts or dialogue, and the use of decontextualized language. Expand on the child's language during natural experiences, tempt the child to use modelled forms, use communication temptations, and employ scripts (Paul, 2007). Consider the child\'s interests; incorporate characters from favorite video games, movies, and television shows into language activities. Make language goals relevant by embedding activities in classroom activities (justice &Kaderavek, 2004). [Sample Activities:] The following activities were designed using a sensory motor approach to address common language problems of children with ADHD. They serve as examples to illustrate how intervention activities can be designed with sensitivity to a child\'s sensory needs. These activities emphasize increased novelty, tactile stimulation, auditory stimulation, effective use of visuals and clear instruction, peer involvement, and meaningful intervention. Some activities are appropriate for explicit individual or small group instruction, while others are designed for use in the classroom. [Pragmatics: Assertiveness Responsiveness ] Visuals may be effective in encouraging children with ADHD to increase or decrease their amount of verbal output. Make a Cardboard \"Talk-o-meter\" with a moveable arrow pointing to \"Not Enough\", \"Just Right\" and \"Too much\" to provide visual feedback on verbal output. The saliency of visual information can be enhanced by using coloured backgrounds such as green for "just right" and red for "not enough" and "too much". Practice with the Talk-o-meter across variety of speaking tasks. To address too much verbal output, start with less interesting topics of conversation and work up to exciting topics of conversation. Eventually pair \"Talk-o-meter\" with facial expressions and gradually fade out "Talk-o-meter" to teach child to attend to facial expressions. [Pragmatics: Turn Taking ] Turn taking can also be taught explicitly by breaking down good conversation skills into several aspects. Use stuffed socks to make Turn Taking Characters, each illustrating a different component of turn taking. Pointy can wear a pointed hat and children can provide one sock character per turn. Shorty can wear a short hat and be used to remind students to take short turns. Turny, the sock that represents taking turns, can be adorned with a beanie on his head that spins or "turns". Finally, the topic sock, Toppy, can be dressed with a top hat and be used to remind students to stay on topic. Children can practice conversational turns by using walkie-talkies or by rolling an interesting ball to each other after speaking. The students can use newly acquired turn taking skills during question time at show-and-share or small group discussion in classroom activities. Create checklists based on the four aspects of turn taking to teach the children to self-monitor their own conversations. [Working Memory: ] Routines Consistent routines will help children with ADHD compensate for difficulties with working memory. Not only is it important for children to learn routines, they need to understand their rationale. Take a walk through the school and brainstorm about various routines that take place at different times in the day such as lunch or reading time and in different places in the school such as the coatroom or the gym. Students can also interview different staff members to discover how their routines help them remember and do their jobs. For example, they can learn from the secretary that she routinely takes the attendance every morning after announcements or from the custodian that he after school he starts cleaning rooms from one end of the school to the other. Make a visual to remind children about routines. Make a mother and baby kangaroo out of paper; call them \"Roo\" and \"Tina\" the routine mascots. Connect discussion of routines to personal experiences; brainstorm with the students about their own routines Have the children play charades, acting out various routines while reinforcing how they remembered all the steps and did them in a specific order. Explain that routines allow us to keep organized and remember things. Ask children to draw a map of the school and, using fun plastic figurines, have the children walk through certain routines. Use visual schedules to remind children of routines on a daily basis. [Working Memory: Story retell] Make a The Story Grammar Marker to remind children of different aspects of a story. Choose materials with a variety of colours and textures to take advantage of the benefits of added visual and tactile sensation. Glue the following, in order, to the bookmark: Eyes: Represents the main character in the story. Star: Represents the setting in the story. Shoe: Represents the \"kick-off\" event that starts the story. Heart: Represents how the main character feels about the kick-off event. Hand: Represents what the main character does as a result of the kick-off event. Circles: A circle can be placed each time the character attempts to achieve the plan he/she made. Bow: Represents the consequence of the character's attempt to achieve the plan. Heart: Represents the way the character feels about the consequences of the plan (Moreau &Fidrych, 2008). Teach children to use the story grammar marker to assist in identifying the story elements in books as well as retelling a remote event that is meaningful to them. A large poster-sized version in the classroom will serve as a constant visual reminder. [Working Memory: Following Directions ] Utilize naturalistic experiences to teach children the importance of following directions by making a simple food item with the children such as pudding or a jelly sandwich. Discuss how important it is to follow directions and demonstrate what happens when you do not follow them. Children can make up a sport and instruct others how to play it. Do this activity in the gym and have others try out the sport based on the instructions emphasizing active learning, peer interaction and natural communication consequences. [Reading Comprehension: Predicting from Story Titles ] In order to encourage pre-literacy skills, teach children to predict story plots from titles and covers. Photocopy the covers of several books, giving each child their own set. Make a game of prediction by reading excerpts from each book and having the students guess which book cover goes with which story. Children can draw pictures of possible story events based on story titles. [Reading Comprehension: Concepts and Vocabulary ] Curricular objectives may require children to search the internet for information. This may be difficult for children with limited attention or who are distracted by visually irrelevant information. Modify Internet documents to simplify them both visually and in terms of language. First copy and paste the internet document into a Word document. Delete distracting visuals but keep relevant visuals, such as pictures and diagrams as these may facilitate comprehension. Ensure there is white space and enlarge the font so the child is not overwhelmed visually. Replace vocabulary words that are too difficult with simpler terms, or give definitions in brackets or in a glossary following the piece. Add the glossary on a separate page with words listed in the order of occurrence in the article so that the child can refer to it more easily while reading. Children should choose their own topic; if they are interested, the topic will be more intrinsically motivating and meaningful for the child. Select an article that has plenty of visuals and will suit the specific child\'s reading level with only minor modifications. Children with ADHD may require additional support to understand vocabulary. Make picture dictionaries for complex vocabulary words. Children can act out complex concepts to reinforce their meanings. For example, to teach the words carnivore, omnivore, decomposer, scavenger and herbivore, dress the children up as each type of animal. Distribute their food sources throughout the room and have them hunt for the appropriate one. ### ### ### **[Article 1:]** Interventions in ADHD: A comparative review of stimulant medications and behavioral therapies Adnan Rajeh, MDa,b, \*, Shabbir Amanullah, MD, FRCPsych, CCT, FRCPC, Adjunct Professorc , K. Shivakumar, MD, MPH, MRCPsych, FRCPC Consultant Psychiatrist, Associate Professord , Julie Cole, BA, MLISe Abstract- ADHD has a prevalence of approximately 10% in children with evidence supporting it's continuance into adulthood. This has a significant impact on how we address treatment at substance abuse facilities and also has implications for personal and occupational functioning. A lack of evidence to support the superiority of any one intervention over the other has created difficulties for both clinicians and parents. A recent review highlights long-term and short-term outcome (Craig et al., 2015). This article reviews the benefits and pitfalls of both pharmacological interventions and behavioral therapies in the treatment of ADHD. Key articles were reviewed on the benefits and side effects of stimulants, the methods and benefits of behavioral interventions, and the effects of combination therapy. Google Scholar, PsychINFO, Medline, Cochrane, and CINAHL were searched with the following search words: Attention Deficit Hyperactivity Disorder, ADHD, Stimulant Medication, Behavioral Interventions, Combination Therapy, Cognitive Therapy, Functioning and Growth. It was found that stimulants are very effective during the period in which they are taken. While short term benefits are clear, longer term ones are not. Behavioral interventions play a key role for long-term improvement of executive functioning and organizational skills. There is a paucity of long-term randomized placebo-controlled studies and current literature is inconclusive on what is the preferred intervention.