How to Treat ADHD Effectively? Pills, Skills & Love

Joseph, a five year old boy diagnosed with ADHD, was making good progress in yoga class at school. He was coming to friendship group once a week, and his mom and dad were working with me [Lynea] on parenting skills.

For Joseph, change came slowly but consistently. He had learned how to catch himself when excited and ask for help. His breathing practice was more rhythmic and controlled. His parents were learning how to help him regulate his emotions.

Then he was put on medication for ADHD. The results were quick and impressive. He was instantly calmer and more capable of focusing in class. Parenting and teaching him were both a lot easier. But it also seemed like he’d lost some of his fire and passion.

Soon after, Joseph stopped attending yoga and friendship group. His mom and dad stopped coming for parenting classes.

Deciding whether to medicate a child is a big decision. It can give a child the chance to experience life with less anxiety and social conflict. Sometimes, medication is absolutely necessary. But often, there’s an unfortunate side effect: parents drop the skills-training and other support they were providing their child. And their child gets the message loud and clear: When you’re struggling, use medicine. No need to keep practicing your friendship skills or learning tools for attention and how to self-regulate. Put all your faith in the pills.

Yet, as L. Alan Sroufe, professor emeritus of psychology at the University of Minnesota’s Institute of Child Development, noted in a recent op-ed in the New York Times, ADHD drugs offer a short-term solution at best.

Attention-deficit drugs increase concentration in the short term, which is why they work so well for college students cramming for exams. But when given to children over long periods of time, they neither improve school achievement nor reduce behavior problems. The drugs can also have serious side effects, including stunting growth.

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To date, no study has found any long-term benefit of attention-deficit medication on academic performance, peer relationships or behavior problems, the very things we would most want to improve.

But in 2009, findings were published from a well-controlled study that had been going on for more than a decade, and the results were very clear. The study randomly assigned almost 600 children with attention problems to four treatment conditions. Some received medication alone, some cognitive-behavior therapy alone, some medication plus therapy, and some were in a community-care control group that received no systematic treatment. At first this study suggested that medication, or medication plus therapy, produced the best results. However, after three years, these effects had faded, and by eight years there was no evidence that medication produced any academic or behavioral benefits.

Indeed, all of the treatment successes faded over time, although the study is continuing. Clearly, these children need a broader base of support than was offered in this medication study, support that begins earlier and lasts longer.

The skills and strategies we teach in Yoga Calm, of course, aim to provide just this kind of support. Over time, the desired effect of drugs like Ritalin, Adderall and Strattera fade, while undesired effects – i.e., side effects – remain. But when we provide opportunities for kids to develop self-awareness, focus and social skills; when we safely address underlying issues of stress and trauma; when we instill and support healthy habits, we provide them with a body of skills, knowledge and experience they can draw on for the rest of their lives.

And we see this especially with children who have weaknesses in attention and impulse control – like Joseph.

Concurring with this need for a broader treatment approach, ADHD specialist Dr. Edward Hallowell, writes in Ritalin Redux, his response to Sroufe’s article, that what’s most important is

a loving, safe, and richly connected childhood. The long-term study that Dr. Sroufe cited in his opinion piece does indeed show that over time, medication becomes a less important force in a child’s improvement and that human connections become ever more powerful. It is good and heartening to know that human connection — love — works wonders over time. Love is our most powerful and under-prescribed “ medication.” It’s free and infinite in supply, and doctors most definitely ought to prescribe it more!

This doesn’t mean that, as Dr. Sroufe say[s], Ritalin has “gone wrong.” We may go wrong in how we use it, when we over-prescribe it, or when we use it as a substitute for love, guidance, and the human connection.

Indeed, continuing on the current path of biasing treatment approaches toward pills while ignoring proven and complementary behavioral interventions carries some serious risks, says Sroufe:

First, there will never be a single solution for all children with learning and behavior problems. While some smaller number may benefit from short-term drug treatment, large-scale, long-term treatment for millions of children is not the answer.

Second, the large-scale medication of children feeds into a societal view that all of life’s problems can be solved with a pill and gives millions of children the impression that there is something inherently defective in them.

Finally, the illusion that children’s behavior problems can be cured with drugs prevents us as a society from seeking the more complex solutions that will be necessary. Drugs get everyone — politicians, scientists, teachers and parents — off the hook. Everyone except the children, that is.

Consider Joseph, 10 years after first being given medication. He’s now 15. His relationship with his parents is tense. He wants more freedom. They want him to focus on school and get a part time job. As he’s grown, doctors increased his dosage. Since his latest growth spurt, he’s noticed that he feels anxious and is having a hard time paying attention in class. After an argument with his girlfriend, a friend offers him some drugs to help him mellow out.

What have we, as a culture, taught Joseph to do?

Image by jlynn11235, via Flickr

9 Ways to Teach & Nurture Focus for Kids with ADHD

As we mentioned last time, the line between “normal” and behavior that signals ADHD can seem fuzzy at times.

ADHD is marked by a weakness in the ability to sustain, shift or divide attention, coupled with a biologically-based weakness in the ability to control impulses. One aspect or the other – hyperactivity or attention – may be more pronounced, but in any case, the behaviors must significantly affect learning and social relationships and must show up in several areas (e.g., home, school, sports). If it occurs only in the classroom, for instance, it may not be ADHD but a sign of teacher-student mismatch, learning disability or other issue.

Yet even signaling behaviors can be misread. Sleep deprivation, anxiety, stress, diet, neurological conditions or even inadvertently reinforced behavior can all contribute to ADHD-like behaviors. Consequently, they must be ruled out before a definite diagnosis can be made.

In fact, as Dr. Jeff Sosne discusses in our course ADHD: The Mind-Body Connection, our home and school environments can actually set the stage for behavior that looks like ADHD but isn’t.

For instance, consider the demands for attention made on children in overly structured lives. There’s increased academic pressure and heavy homework loads, even at the K-5 level. There may be afterschool obligations such as sports, music, tutoring, church and service groups, or lessons of some sort. While such activities may be pursued for personal pleasure or enrichment, they’re just as often used to sweeten a youth’s “resume” for later schooling.

The resulting stress easily leads to distracted or “wild” behavior, as children find it harder and harder to conform to such demands.

Much can be accomplished through making sure the child eats right, gets enough exercise and adequate sleep, and has opportunities for unstructured play. We see a big reduction of symptoms when these basic human needs are met – whether the child actually has ADHD or not. Children become more able to learn practices that can help them improve their ability to focus, pay attention and self-regulate. These, in turn, support ongoing healthy habits, for through them, kids are nurtured into mindfulness, including awareness of their bodies and what their bodies are telling them.

Courtesy of Dr. Sosne, here are 9 tips for nurturing those skills – useful for all children, but especially for those diagnosed with ADHD:

1. Attitude is everything! Emphasize a positive, “Can Do” attitude and internal motivators (e.g., “This is a good time to clean your room.”).
2. Make eye contact during activities. Practice not responding to a child until they make eye contact, too! Some good games for practicing this skill: Red Light/Green Light, Steal the Bacon, 20 Questions.
3. March toward a goal. Talk out loud about the process so the child can later internalize it. Announce a goal and timeframe for every activity.
4. Start with small goals – things the child can do in 15 minutes. Observe and reward small changes. Don’t give too much time for an “ADHD child” to complete a task.
5. To teach that things change, occasionally stop activities at random and reward the child for handling it well.
6. Focus on accomplishments. Have the child write a note on what he or she accomplished in school today.
7. Acknowledge their agenda and pair it with a request from you – e.g., “While I am getting you a sandwich, could you pick up that wet towel?” Getting something they want does not in itself promote a sense of entitlement.
8. Build habits and routine. Build skills, not consequences.
9. Don’t put too much emphasis on the label “ADHD.” It stereotypes and only points to weaknesses, not strengths. Redefine. Instead of saying, “Robert is ADHD,” say “Robert loves baseball and does better when in the middle of the action (i.e., infield),” or, “Jillian has a great sense of humor but has trouble listening, as well as telling jokes.”

Want to learn even more? Join Dr. Sosne and us for our next session of ADHD: The Mind-Body Connection, October 22 – 23 here in Portland, OR. Registration is required and spots fill fast, so enroll today! CEUs are available.

Image by woodleywonderworks, via Flickr

Electronic Media and the Battle for Our Minds

When was the last time you had an hour – an hour without distractions – just to think about things? Or even a half hour? Fifteen minutes?

As I write this blog, instant messages flash up on my second monitor while my printer churns out workshop handouts and my cell phone beeps a voice mail alert. Yes, today’s communication and computer tools make us more productive than ever, but we’ve got to ask: At what cost?

News reports attest that our electronic addictions are starting earlier than ever – and involve more potential distractions than ever. Today’s kids have access to computers, iPods, smart phones, video games, TV and all sorts of gadgets. The power of electronic media’s grip on kids was pounded home last month in a New York Times article:

The average young American now spends practically every waking minute — except for the time in school — using a smart phone, computer, television or other electronic device, according to a new study from the Kaiser Family Foundation.

Those ages 8 to 18 spend more than seven and a half hours a day with such devices, compared with less than six and a half hours five years ago, when the study was last conducted. And that does not count the hour and a half that youths spend texting, or the half-hour they talk on their cellphones.

And because so many of them are multitasking — say, surfing the Internet while listening to music — they pack on average nearly 11 hours of media content into that seven and a half hours.

 

beret claire/Flickr

“Multitasking” indeed seems to be the norm for the youngest generations. But while we usually think of it as doing several tasks at once, it’s actually nothing of the sort. As psychiatrist Edward M. Hallowell defined it in an earlier Times article on the phenomenon and its effects, “Multitasking is shifting focus from one task to another in rapid succession. It gives the illusion that we’re simultaneously tasking, but we’re really not. It’s like playing tennis with three balls.”

This has, as the article notes, a severe impact on efficiency and the ability to focus. As Walter Kirn put it in his Atlantic essay on the culture of multitasking we find ourselves in:

Multitasking messes with the brain in several ways. At the most basic level, the mental balancing acts that it requires—the constant switching and pivoting—energize regions of the brain that specialize in visual processing and physical coordination and simultaneously appear to shortchange some of the higher areas related to memory and learning. We concentrate on the act of concentration at the expense of whatever it is that we’re supposed to be concentrating on.

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Even worse, certain studies find that multitasking boosts the level of stress-related hormones such as cortisol and adrenaline and wears down our systems through biochemical friction, prematurely aging us. In the short term, the confusion, fatigue, and chaos merely hamper our ability to focus and analyze, but in the long term, they may cause it to atrophy.

Thus, the effects of electronic media use in the Kaiser study mentioned above should be no surprise:

While most of the young people in the study got good grades, 47 percent of the heaviest media users — those who consumed at least 16 hours a day — had mostly C’s or lower, compared with 23 percent of those who typically consumed media three hours a day or less. The heaviest media users were also more likely than the lightest users to report that they were bored or sad, or that they got into trouble, did not get along well with their parents and were not happy at school.

The teachers in our Yoga Calm workshops report the same. They describe how increasing numbers of children have trouble focusing in class and seem to need to be more entertained than taught. They observe that extended reading (vs. quick screen “bites” of text) and time-on-task skills have diminished significantly.

Now, it’s neither practical nor desirable to cut off children’s access to electronic media altogether, but we would recommend providing more opportunities for children to “unplug,” move their bodies, develop face-to-face communication skills and practice focusing on just one thing for some length of time. Kids need uninterrupted time to be still, in their bodies and with their own thoughts and imaginations – a respite from multitasking. This is time for them to relax, as well as to integrate their experiences.

In fact, we all need to do this. And what better way to teach the children in our lives than to model it ourselves? We can make a point of turning off our phones at dinner and when we are speaking with our children. We can have family “media fasts,” where we might actually sit and read together or play some “old fashioned games” like cards. Or how about a walk and talk?

I think I will start right now, by going for a walk without my phone!

- Jim Gillen

 

Post-walk postscript:

The good news: I walked for 20 minutes. My back felt better. I heard flickers and other birds, discovered my neighbors had chickens, remembered something important I had to do today…

The bad news: I also discovered that our roses, hydrangea and raspberries need pruning. Dang. Guess I’ll have to go back outside later today.

5 Tips to Teach Kids with ADHD Better Focus & Self-Control

Recently, Good Morning America ran a segment on how – and why – more doctors are recommending yoga for young patients. One situation in which yoga is increasingly recommended is for children diagnosed with ADHD, as it is well recognized that yoga-based activities of all kinds can be extremely effective in helping kids learn how to focus and self-regulate.

 

 

We see this efficacy regularly in our work with children – Lynea’s at the school where she is a counselor, and our work together in conducting children’s classes at a clinic. And because so many other teachers, counselors, occupational therapists and other adults who work with children are regularly faced with the special challenges of working with kids diagnosed with ADD/ADHD, we found it beneficial to create special Yoga Calm trainings focused on ways of meeting those challenges. (Parents, of course, find these workshops invaluable, as well!)

We teach the ADHD workshops with Jeffrey Sosne, PhD, a clinical Psychologist and Director of The Children’s Program. Widely recognized as one of Portland, Oregon’s leading authorities on ADHD, Jeff is the author of two practical guides for parents and school personnel: The ADHD Notebook and The Anger Notebook. Together, we cover Dr. Sosne’s strategies and games for working with ADHD and show how Yoga Calm activities – both the physical yoga and the social/emotional games – can be used to help nurture self-control and focus in kids for whom such things have been difficult.

Here are five of the tips we teach for doing so:

Practice Making Eye Contact

Eye contact helps children show that they are interested and paying attention. A lack of eye contact leads to “divided attention,” which makes it harder to focus and follow directions.

To practice “shifting” attention, introduce activities in which the children must switch between two (or more) adults giving signals or eye contact for directions (e.g., Steal the Bacon). Also, parents can get closer to their children when they are talking or giving directions, and stop speaking if their kids aren’t maintaining eye contact. If necessary, parents can schedule time to practice eye contact by having their child watch them as they move about the room while reading a story to their youngster. As the child improves, he or she can practice while learning to look away from distractions strategically placed in the room.

Model and Instill a Can-Do Attitude

In workshops, we use different games (e.g., Jenga) and positive self talk (e.g., “I am in control,” “I can do it,” “I can be responsible.”) to illustrate how a positive attitude improves performance and how helpful it is to decide what you can do instead of what can’t be done.

At home, parents can encourage their children to decide what they can do to help before dinner or what they can clean up before going to a movie. We will not respect tasks that are accomplished with a negative attitude, and we value accomplishment of reasonable goals that have been set by the child more than tasks that we have defined and the children have reluctantly completed. Positive self-talk should also be encouraged, leading children to focus on their strengths and accomplishments, nurturing a sense of self-mastery.

Practice Listening and Giving Feedback

There are lots of games you can play with children that require them to listen and to give feedback in a calm, clear manner. For instance, in workshops, we may play Hot and Cold, in which players give each other feedback about finding a hidden object. To find the object, of course, the child who is searching for it must listen, evaluate and respond to the feedback given, while those giving the feedback must do so clearly.

You can build opportunities for reflection into any game or activity, and, of course, give compliments after activities done well. In group situations, Yoga Calm’s Compliment Game can be an especially fun and effective way of learning how to give and receive praise. And it provides another opportunity to reinforce the importance of eye contact!

Practice Stillness

There are many activities in life that require staying in control and not going too fast. To teach this, you can have children participate in several activities that create a bit of excitement and then challenge the kids to stay calm and go slowly to be successful.

The Yoga Calm Mat Tag activity can provide just such a challenge. When any of the children get too excited or out of control, simply ask them to sit down. Once they have shown they can calm down, they may re-join the activity. During any activity, if a high level of chaos or excitement is reached, just stop until everyone is calm, or remind the children to say something to themselves like, “Go slow, easy, easy,” to help them think about staying calm.

Encourage Setting Goals and Making Plans

A goal is something we want to work toward, while a plan is the strategy used to get to the goal. For this concept, we will do some activities several times to work on adding parts to a plan to lead to a more accomplished goal. For example, we may ask students to do a number of increasingly difficult tasks involving tapping a balloon in the air: using just one finger, using only the feet, behind the back and so on. Because the tasks become more difficult, we stop after a child cannot complete the challenge and come up with plans that could help make reaching that goal easier. The children realize that sometimes they needed several points in their plan to be able to reach their goal.

Parents can work with their children at home on the idea of setting a goal and coming up with a plan to reach it. We suggest making a chart with a diagram of a sun with many rays coming off it. Inside the sun, write the goal; in the rays, parts of the plan that will be followed in reaching that goal.

 

To learn more about helping children with ADHD:

• Buy and watch Dr. Sosne’s ADHD DVD
• Attend a Yoga Calm ADHD workshop (next scheduled for Portland, OR; Feb. 6-7, 2010)
• Find an ADHD class at The Children’s Program

Adaptations & Applications: Starting the School Day with Hoberman Breathing

Kathy Flaminio is one of our trainers and a social worker at a Minneapolis K-8 elementary school. Along with Julie Hurtubise, she has helped bring Yoga Calm to the Minneapolis Public Schools district-wide. (To learn more about their pilot program, click here. To see news coverage about it, click here.)

Recently, Kathy told us about how they’ve been taking time at her school each morning to bring the school community together through a simple Yoga Calm breathing activity that she first taught in classrooms and to school staff. Daily, over the intercom, she – or sometimes a student – says something like this:

Good Morning, Jefferson Staff and Students. We want to welcome everyone back to school this morning.

Every day at 9:40, we will bring our entire school community together by joining our breath with the breathing ball [Hoberman sphere, which is now “standard equipment” in many classrooms].

 

 

If you are in the hallway or in a meeting, please take a moment to pause so we can all breathe together. If you are in a classroom, please get your sphere out.

Begin to come into stillness, letting go of the morning and all that has taken place before coming to Jefferson. If you in a chair or on the floor, sit up nice and tall. If you are standing, press your feet into the earth and lengthen through the spine.

Let’s begin with shoulder circles…taking our shoulders up to the ears …back and down. Do this two more times. Breathe in and lift the shoulders up to the ears…and breathe out as you bring your shoulders down. One more time. Now begin to watch the breathing ball, or close your eyes and begin. Breathing in…let the belly puff up, and breathing out…let the belly move back toward the spine. Again, breathing in…and out. Six more times. Inhaling and exhaling…. Five more….

Take a moment to notice how your body and mind feel after taking eight deep breaths. Know that at anytime today when you feel frustrated, angry or nervous, you can come back to your breath and find center.

Have a great day! We are so glad you are here.

 

In telling us about the success they’ve had with this activity, Kathy commented on how those unfamiliar with Yoga Calm initially may see such activity as a distraction, taking away valuable classroom time. “But of course,” she said, “the breathing helps students and faculty alike quickly get calm and focused, and so better prepared to do good work. It prevents even greater distraction. And this is exactly why it’s time well spent.”