Assessment and management of ADHD

Non-medical treatment of ADHD

Diet and ADHD

Although there is no conclusive research evidence to support the idea that controlling a child’s diet can influence behaviour, dietary intervention is often cited in media articles as a cause of ADHD.
The lack of conclusive evidence may simply be because such research is almost impossible to carry out in western society where most parents and children are fortunate enough to be surrounded by food. Today, we live in a world where refrigerators are well stocked and unlocked, where shops and supermarkets are plentiful and practically always open, and where even the youngest member of the household can eat almost whatever he chooses at any time of the day – courtesy of the local home delivery or take-away service.
Stopping children eating particular foods or drinks is not easy. Therefore, the lack of any conclusive evidence linking diet and behaviour may simply suggest that such research is impossible.
However, some compelling anecdotal evidence for how diet can influence behaviour often comes from reports like this one, from Toby’s dad.
 

Case study: Toby

Toby is our youngest son. Ever since he was born he seemed to be in a state of perpetual motion, into everything and could not be left alone for a minute. He was diagnosed with ADHD at the age of seven. By the time he was nine, life in the house was becoming unbearable.
We badly needed a break, but simply couldn’t think what to do because on every previous holiday, hotel staff and other guests had complained about his behaviour. He was impossible to control in the dining rooms and was a positive danger to himself and others in crowded swimming pools.
So that year we decided to go on a walking holiday. Two weeks camping in the Yorkshire Dales, with no hotel staff or fellow guests to worry about.
The journey to Yorkshire was only 200 miles but it felt like 5,000: Toby was his usual irrepressible self – chaos in the car, needing to stop at every service station for a ‘run-around’ and then tearing round the tables and up and down the passageways. It’s a wonder they didn’t phone to warn the next service station he was on his way – or maybe they did?
On the first two days of the holiday he was as troublesome as ever but then, miraculously, he seemed to calm down, and the last ten days were ten of the best days we’d ever had with him.
Sadly, on the journey home, it seemed no sooner had we stopped for our first break at a service station, than Toby was back to his old self, shouting and racing about like a madman. When we eventually got home it was as if we’d never had a holiday at all.
A few days later I was talking about our holiday with my next door neighbour, a teacher, who suggested perhaps Toby’s excitability had something to do with diet.
I have to admit I was a bit sceptical at first but she suggested we wrote down what Toby had eaten on the holiday.
When making out the list I realised that once we’d left all the service stations behind us, there just weren’t any ‘junk foods’. Almost by accident, Toby had lived for nearly two weeks with no burgers, no pizzas, no fizzy drinks. For lunch, we’d always had homemade sandwiches, which I’d filled with cheese or ham. In the evening we’d eaten at a little restaurant up the road from the campsite. On the first night, Toby had chosen Yorkshire gammon and onion-mash and liked it so much he had the same thing every night.
I decided right there and then to stop Toby eating junk food and for a week there were no burgers, pizzas or anything that could be called ‘junk food’ in the house. I gave Toby a packed lunch to take to school with strict instructions that he wasn’t to eat anything else.
As you can imagine, all this caused a real pressure in the family because Toby’s brother and sister weren’t at all happy – they, of course, had grown to like their daily quota of burgers and pizzas. His sister said living with Toby was becoming ‘a life sentence’. In fact the whole diet thing nearly fell apart completely when, on the fourth day, Toby went to his cousin’s party where, as a surprise for the birthday boy, everybody was taken to a burger-bar! I was ready to give up at that point but at the start of the next week I decided banning burgers and pizzas was just too difficult so instead I banned every form of drink that had an additive: fizzy drinks, orange squash, milk-shakes, the lot. They could all have a burger, pizza, whatever – but no drinks with additives. By Tuesday, the effect on Toby was miraculous. He was back to being like he was on the holiday. By Wednesday, when I picked him up from school, even one of his teachers mentioned the change in his behaviour.
On Friday he came home with a note saying what a good week he’d had and he had such a smile on his face! From that day on, Toby himself decided to take charge of what he drank.
This is a heartening story and there are many instances where parents have found that avoiding certain foods reduces challenging behaviour.
 

Which foods are commonly involved?

Chocolate and drinks with high levels of colourings, such as orange squash and colas, are frequently mentioned so you might first try eliminating these from your child’s diet. If eliminating one or the other or both seems to improve your child’s behaviour, test it out by noting his behaviour after he has resumed drinking them.
 

Finding the best diet by keeping careful records

If you want to examine whether there is a relationship between your child’s diet and his behaviour, begin by keeping a fairly detailed record of your child’s normal diet over a period of a few weeks – including everything, from the extra sugar on the cornflakes, to the cup of hot chocolate before bed. At the same time, keep a record of your child’s behaviour from day to day, perhaps scored on a scale of 1 to 5: where 1 means excellent behaviour, 3 means satisfactory behaviour and 5 means completely unacceptable behaviour. If possible give a separate score for morning, afternoon and evening.
It will probably be more convenient for you, as a parent, to keep the diary during part of a school holiday because it is not easy to keep a check on what a child eats at school: he can often buy some foods for lunch; friends will sometimes share sweets with him; and he may even ‘swap’ parts of the packed lunch that you so carefully prepared!
In addition, if you do need to keep a record of your child’s diet and behaviour during term time, you will have to ask the school to help, for example, to keep a record of the child’s behaviour. If this can’t be done, then it’s best to postpone the trial until one of the lengthier school holidays.
The record is likely to require more paperwork than you might at first think, as it is probably best to have a separate page for each day. The diary below is a very simplified example for one day.
 

Sample diary

To help you find the best diet for your child you need to keep a careful record of what he or she eats and what his or her behaviour is like. To be useful it is probably best to have a page for each day as in this example.
Clearly, from the diary, behaviour was unacceptable both in the afternoon and in the evening. Before these episodes of unacceptable behaviour, the diary indicates that fizzy drinks and chocolate had been consumed.
 

Testing suspect foods

On subsequent days after the diary has been kept, you might try to arrange the diet so that neither of these items is present, and check consequent behaviour.
If behaviour seems improved when these two foods are eliminated, then you might reinsert fizzy drinks into the diet on one subsequent day and chocolate the next and note the result.
Using this method of systematic trial and careful record keeping, you can slowly attempt to find out which foods seem to be related to episodes of particularly unacceptable behaviour, and you can then try to eliminate these foods from the diet.
It should be noted that, for the purposes of this explanation, the diary has been deliberately simplified, and life is rarely this easy. It may take weeks of careful record keeping, together with systematic elimination and reintroduction of particular foods, before clearly identifiable patterns emerge.
It is easy to be convinced by articles in newspapers and magazines, which suggest that so-called ‘junk’ foods and drinks are the only culprits. Toby’s story (see earlier) is obviously a ‘success’ but there are many instances where eliminating ‘junk foods’ has not resulted in improvements in a child’s behaviour.
Indeed, many parents have found their child’s behaviour to be influenced by what are often thought to be ‘good’ foods, such as dairy or wheat products.

Finding the most appropriate diet for your child

• Keep a daily record of the food that your child eats
• Keep a daily record that ‘rates’ your child’s behaviour through the day
• Examine both records to see if there are recurring instances where consumption of a particular food or drink seems to be followed by challenging behaviour
• When trying to eliminate suspect foods or drinks from your child’s diet, make notes on what your child eats or drinks together with comments on his or her behaviour over the next few hours
• Before attempting to eliminate principal foods, such as wheat or dairy products, consult your family doctor

Getting expert advice

As a word of caution, if you are thinking of controlling your child’s diet to any substantive degree, maybe by trying to avoid dairy or wheat products, you should consult your family doctor who may recommend that you speak to a dietitian.
 

What will it be like?

In real life, in a real family, this approach requires a huge commitment in terms of organisation, patience and persistence. Furthermore, it is unlikely that you will find a particular diet that ‘cures all problems’.
It is more likely that avoiding certain foods may reduce challenging behaviour to a degree that makes family and school life more tolerable.
 

Behavioural programmes and ADHD

It is sometimes suggested that children with ADHD will benefit from what are called behavioural programmes. This means that a programme is devised that attempts to ‘control’ the child’s behaviour by the systematic use of rewards.
The most successful behavioural programmes are those that involve both the parents and the school working together.
 

Case study: David

David is our second son; he’s now aged 12, and we always had trouble with his behaviour almost from the day he was born. There’ve been frequent rows at home, and at school, always caused by David getting out of control and overexcited.
There’re times when not me, his dad or his teachers can control him. Two or three times a term, the head teacher would telephone me to collect David from school because he’d become uncontrollable.
The school was patient with him for a long time but it all blew up into a big crisis when David was nine. He’d kicked his teacher when she tried to stop him running out of the classroom and we had a letter from the school saying David was suspended for five days and that if his behaviour didn’t improve he’d be expelled for good.
The head teacher suggested that David be referred to a local child assessment unit and, as we were so worried he’d be permanently expelled from school, we agreed. As the assessment unit was part of the health service we needed a referral letter from our family doctor who provided it once we’d explained the problem.
About a month later David went to the assessment unit every day for a full week and, because the staff at the unit wanted details of David’s behaviour almost from the time he was born, we also went for two afternoons.
In the week after the assessment, there was a case conference at David’s school, which included us as David’s parents, staff from the special unit, an educational psychologist and some of his teachers. The educational psychologist was there to help with what she called a ‘behavioural programme’, which would operate both at home and at school.
To be honest, the ‘behavioural programme’ all seemed a bit complicated at first and it took a few weeks for us and the school to work together, but once it got really started David gradually began to change for the better. Looking back, that meeting, and the help we had with the behavioural programme, was one of the best things that happened.
One of the conditions of the behavioural programme was that the school agreed to send a short report on David’s behaviour home each day and, at the beginning of every school day, we sent a report back on his behaviour the previous night. This in itself had a big effect on David because he quickly realised that whatever happened at school we knew about it at home, and vice versa.
What really surprised my husband and me was how chuffed David was when he brought home school reports that said he had been good in some lessons. If he’d been no trouble in mathematics that morning we knew about it at home that night, and the same was true for all the other lessons. Obviously, there were lots of hiccups, because David still sort of ‘lost it’ sometimes at school, but there was usually more good than bad in the school reports.
The educational psychologist said that both we and the school must be ‘diligent throughout the day’ in always letting him know immediately after he’d behaved well in a lesson, or after finishing a meal at home, or in getting ready for bed at the right time. (I admit I was so keen to do it properly, I even looked up ‘diligent’ in the dictionary to make sure we were doing it all just right!) The psychologist said it was important we didn’t just wait until the end of the day to tell him he’d been a good boy.
With the help of the educational psychologist we and the school also had to work out a system of rewards and sanctions. For example, in school, after each lesson, David would either be given points for good behaviour or have points removed for bad behaviour. These would then be totted up throughout the day and David knew that when he got home then, depending on the number of points he’d earned, he’d have some kind of reward.
All the rewards were agreed with David in advance so he knew exactly where he stood. He always started a day with ten points, because if he had trouble in the first lesson he had ‘minus’ points and this just messed him up for the rest of the day. For example, if he came home and had 12 points he’d get extra time to use his Game-Boy and if he had 14 points he’d get more pocket money which we ‘diligently’ gave him each day rather than waiting until the end of the week.
If on a particular day he’d earned a lot of points, say 15 or more, he’d be allowed to save up some points for a special treat at the weekend, like being taken to the go-karting track which he loved. If David had fewer than 10 points at the end of a school day then we would cut down on the time he was allowed to spend at home on his Game-Boy or watching television.
The educational psychologist said it was very important that we were ‘diligent’, that word again, in making sure that the rewards were something David really valued and wanted. The rewards were not to be something we thought he wanted or that we thought might be good for him. This was sometimes quite hard for his dad because he didn’t really like David watching too much television, which David loved.
In the beginning, one of the difficult parts of the programme was to convince David that the plan operated the same way both at school and at home in the sense that it wasn’t just the school that gave or took away points. We also did it at home, and at first David had difficulty accepting this because we’d never done anything like that before.
He’s quite clever and, in the beginning, tried to make us feel guilty when we took away points at home. He complained that home was getting like school. In the end, though, I’m glad we stuck to the ‘diligent’ bit.
There were also times when David did something really, really bad and when this happened the educational psychologist said we’d have to operate a sanction, which was called ‘time out’. This usually meant that David had to spend time alone in his room, without the television or his Game-Boy.
This was always for short periods and David always understood he could come out if he apologised in a way that showed he meant it, and was prepared to do as he was asked. His dad often used the phrase, ‘he must apologise with good grace’. It’s a bit of a strange way of putting it but David soon came to know what he meant.
The most difficult thing at home was stopping David arguing about how many points he should have if he did something good; he always wanted more. It was the same thing if he did something bad; he always argued that fewer points should be taken away.
The educational psychologist said it was very important we never argued or negotiated with David about how many points were to be given or taken away. This was always to be our decision, not David’s, and if he argued we were told to subtract points, making it clear to him the points were being taken away just for arguing.

It took David a few weeks to learn not to argue and, to be honest, it was also very hard for us not to join in when he did argue. We had to learn to be consistent, fair and always firm. Once David learned that arguing was pointless, and often even lost him more points, he stopped arguing. I have a sneaky feeling this was one of the best parts of the programme because, for the first time, David came to know that we, as parents, meant what we said.
We’ve been working this programme now for about 18 months. The details of the programme have to change periodically because the rewards have to change as David gets older: what is a reward one month may not be as effective as a reward next month. I can’t say everything’s now perfect but life at home is certainly much easier and the reports from school indicate that his behaviour there has shown a huge improvement. The behaviour modification programme certainly hasn’t been easy, not for David, and not for us his parents or the school, but things are much better now and in that sense it’s worked and been worthwhile.
 

Medical treatment of ADHD

What drugs are given?

Guidelines issued in 2006 by the National Institute for Health and Clinical Excellence (NICE) recommend three alternative medications as appropriate treatments for children and adolescents with ADHD. The brand or proprietary and generic names for these medications are given in the box.
 

Who prescribes them?

The guidelines issued by the NICE require that treatment with any of these medications be started only after a specialist who is an expert in ADHD has thoroughly assessed the child or adolescent and confirmed the diagnosis. Once treatment has been started it can be continued and monitored by a family doctor.
 

Ritalin

Of these three recommended medications Ritalin is the most commonly precribed and the brief explanation that follows gives the basic rationale for the use of Ritalin in the treatment of ADHD.
Exactly how Ritalin works is not known but it is thought to activate those areas of the brain that enable us to focus on a task. So Ritalin acts as a stimulant.
It does not, as the more alarmist sections of the media sometimes claim, turn children into non-thinking automatons. Medical research indicates that about 70 to 80 per cent of children with ADHD gain benefit from taking Ritalin.
Ritalin has the same effect on all people, not just an ADHD child. To understand its effects, it is perhaps worth noting that it is one of the most misused drugs among the college student population in the USA.
If a college student wishes to keep awake and study all night to prepare for an examination, Ritalin will help the student remain alert and focused, although, clearly, such misuse of Ritalin is both unwise and illegal.
Ritalin is not a cure for ADHD but, during the time that it is active, it allows the child to focus and control behaviour more effectively. Its effect lasts for about four hours, building up at the beginning and tailing off at the end, so it is generally at its most effective for the second and third hours of a four-hour period.
There is a long history of Ritalin being prescribed in tablet form, two or three times a day, which typically means that a child with ADHD would take one tablet between 8 and 9am to help with the morning session at school and then another at lunch time to help during the afternoon. In some cases he may need to take another tablet for the evening.
 

Are there any problems with medication?

Common problems with this form of treatment are, for example, that the child and/or carer might ‘forget’ to take the tablet, and some schools have proved to be wary of the legal situation in terms of non-medical staff (teachers) being responsible for the child taking the midday tablet.
However, medication is now more easily managed when the child is prescribed a ‘slow-release’ tablet, where he simply takes one tablet in the morning, rather than a tablet at intervals throughout the day. A recent survey has indicated that just over 50 per cent of Ritalin prescriptions are now for ‘slow-release’ tablets.
 

How long does treatment continue?

Treatment with methylphenidate (Ritalin) is normally considered a relatively long-term method of assisting the child with ADHD. It has already been mentioned that Ritalin does not ‘cure’ ADHD; it simply assists the child to control the symptoms.
It would not be possible to give a general rule on how long a child may be prescribed Ritalin, other than to say that it is taken for as long as the child needs it to control behaviour. As a result, treatment with Ritalin is often expected to operate over a period of years, as opposed to a few weeks or even months.
 

Regular review of medication

As with almost all medications some individuals may experience unwanted negative side effects, so ‘good practice’ demands that the effectiveness of the treatment be thoroughly monitored and reviewed regularly on the advice of the prescribing physician (most often a paediatrician).
A part of this review might, for example, require the child periodically to cease taking the medication
for a short period to check that there remains a sufficiently marked increase in the behavioural
symptoms associated with ADHD to justify continuing treatment with Ritalin.
 

Is Ritalin addictive?

Despite occasional statements reported in the media, Ritalin is not addictive, and there is little convincing evidence to indicate that it leads to any forms of addiction in later life.
 

Additional help with behaviour

Although Ritalin may help a child control unwanted behaviour, he may not know ‘how’ to behave because he has ‘missed out’ on the normal socialising experiences of childhood – such as how to behave with friends, how to join in conversations effectively, how to behave in the classroom and so on. Once started on a course of Ritalin it is almost as if the child needs a course in ‘how to grow up quickly’.
The use of Ritalin should therefore be accompanied by a behavioural programme to help establish good strategies on how to behave. As shown in David’s case study, ideally an educational psychologist (or other appropriately qualified medical/educational professional) will provide advice on the design of an appropriate behavioural programme.
 

Individual assessment

There is a great deal of controversy about the use of such medications and it is not possible to predict the length of time that a child may need to take them.
Each case must be carefully monitored by an appropriately qualified professional, usually a paediatrician or a child/adolescent psychiatrist.
 

Supporting a child with ADHD in school

As schools have access to advice from educational psychologists on how to manage a child with ADHD, the most sensible strategy is for the parents and the school to work together in supporting the child.
In addition to the points mentioned in the discussion of David’s case study (see page 30), most schools try to ensure that the strategies in the box on page 42 are implemented and it is considered good practice that, where possible, the parents do likewise.
It can also help to pair the child with a good role model. However, it’s important to remember that even the role model can’t be perfect all the time!
 

Supporting a child with ADHD at home

Whether or not your child is treated with medication, you will be offered advice by a member of the specialist paediatric assessment team on strategies for managing your child’s behaviour and helping him to control it. The following can help.
 

Rewards

The advice is likely to include some ideas on short-term reward systems, which are intended to offer your child an immediate reward for good behaviour. This is based on the theory that, for most human beings, behaviour that is rewarded is likely to be repeated, whereas behaviour that is ignored is less likely to be repeated.
 

Ten tips for effective child management in school

Schools tend to have the advice of educational psychologists on how to help a child with ADHD. The most sensible strategy is for the parents and the school to work together:
1 Ensure that every adult in the school understands the difficulties faced by a child with ADHD
2 In school, try to position the child close to an adult who can supervise his behaviour
3 Insist on eye contact when talking to the child and get him to repeat instructions
4 Give simple clear instructions; if necessary, break longer instructions into manageable chunks
5 Position the child away from obvious distractions (doors, windows, etc.)
6 Ensure that rewards are meaningful to the child and are given as often as is practicable
7 Remind the child that it is the behaviour (not the child) that is unwanted
8 Give firm reminders of what is needed and, when necessary, deal with correction in private
9 Ensure that there is no bargaining or prolonged discussion on what is or is not acceptable behaviour
10 Provide the child with a place of safety where he can retreat to calm down
 

Sanctions

You cannot always ignore challenging behaviour, however. There may be occasions when you have to operate some form of sanction. The most sensible is some ‘time out’ – which often means that the child has to spend some time alone in an allocated place of safety.
 

Time out

‘Time out’ should only be a short period, appropriate to the age of the child: a good ‘rule of thumb’ is one minute for each year of the child’s age, so a five year old would have five minutes, an eight year old eight minutes, and so on. At the end of a ‘time out’, the child should be welcomed back with a smile, not with threats of further ‘time outs’.
 

Be fair and consistent

The links between behaviour and reward must be made clear to the child and rewards and sanctions must be seen to be fair, just and consistent.

Points for parents to note about helping a child with ADHD

Behavioural management of a child with ADHD can give great benefit. Ritalin medication may also help. The following list summarises the main points:

• Adults must give instructions one at a time and clearly to the child
• Ideally, the child should be asked to repeat the instruction
• The child must be involved in identifying appropriate rewards
• The links between rewards and appropriate behaviour must be made clear to the child
• Equally, the links between sanctions and inappropriate behaviour must be made clear to the child
• Adults make decisions on the distribution of rewards and sanctions (there should be no bargaining)
• Rewards and sanctions are best handled within a structured routine that remains consistent – the child should know what to expect
• Adults must ensure that they are consistent and fair, but also firm
• Ideally schools and parents should work together on behaviour management
• A behavioural programme should involve both the home and the school
• An expert, such as an educational psychologist, should assist in developing the programme
• Any rewards must be ‘valued’ by the child (these are not always those preferred by parents and/or teachers)
• The programme must be operated in ways that are always consistent, fair and firm
• There should be no negotiation with the child concerning the issuing of rewards and/or sanctions; these are decisions made by the adults involved
• It’s important to remember that overactive or impulsive behaviour is shown at some time by most young children
• Ritalin is a stimulant that enables a child to focus and sustain attention
• When Ritalin is properly prescribed and used, 70 to 80 per cent of ADHD children show improvements in behaviour
• Ritalin does not cure ADHD – it helps a child control behaviour
• Treatment with Ritalin is normally a relatively ‘long-term’ strategy with periodic reviews
• While on treatment with Ritalin the child will probably need help in learning how to behave appropriately
• Always remember that a child with ADHD is not showing challenging behaviour deliberately – it’s no-one’s fault

Developing an effective reward system

Nowadays, these behavioural management strategies, sometimes called ‘behaviour modification’, do not always involve the giving of material rewards such as sweets or more pocket money.
You will be encouraged to build up a repertoire of useful ways to indicate how pleased you are each time your child behaves well. This can be by giving verbal praise, or giving a hug, a thumbs-up sign or even in a less conspicuous style, such as a wink.
It is better to offer rewards and encouragement regularly and at short intervals rather than at longer intervals. For example, in a very young child, ten minutes of good behaviour might be an appropriate interval to merit a reward whereas, in an older child, a reward every half-hour or hour may be more appropriate.
You may be given advice on using token systems, where your child is rewarded with tokens for good behaviour which he can swap for privileges such as watching some extra television or inviting a friend for a sleep-over.
Although it can be hard, it is important at all times to remind yourself that, although the behaviour is neither your fault nor your child’s, he does need a consistent approach to help control it. So choose an approach that can be used by everyone: parents, grandparents, neighbours and teachers in school.
Any family with a child with ADHD is likely to be under great emotional pressure and will require skilled and sensitive support.

KEY POINTS 

• Non-medical, dietary control may improve your child’s behaviour

• Research evidence suggests that medication improves behaviour in 70 to 80 per cent of children with ADHD

• Parents and teachers should work together on strategies to modify behaviour in ADHD

• With appropriate support most ADHD children can and do grow up to be healthy, well-adjusted adults