Pediatric ADHD: Harnessing the Superpower
TERESA NEFF, ND, CLE
You may have heard people speak of attention-deficit/hyperactivity disorder (ADHD) as a superpower. Its many positive aspects, such as creativity, curiosity, hyper-focus, perseverance, and energy, can and should outweigh the negatives. These powers, however, are only successfully harnessed with knowledge and effort. All children with ADHD (and their families) need education and coordination. You can be the one to provide this, whether or not pediatrics is your specialty. While you may not know the ins and outs of lab testing or naturopathic modalities for ADHD, you can make a powerful contribution to the well-being of a child with ADHD and that of his or her family.
I have experience treating ADHD; however, this article leans heavily on my personal experience with my 9-year-old superhero. I knew he was special from around 18 months of age, but I did not arrive at a diagnosis of ADHD until he was 6 years old. Even then, I was motivated to seek the diagnosis not by my knowledge of pediatric health, but rather by the urging of people outside my family. Parents, whether medical specialists or not, have blurred vision when it comes to their own kids.
Once I became convinced that my child had a neuropsychiatric condition, (although not necessarily ADHD), I needed to know where to start. Working with my insurance and still seeking a complete neuropsychiatric evaluation, we landed in the care of a provider who diagnosed ADHD in the span of a single office visit, and without needing the official diagnostic surveys to be convinced. He was concerned there might be further issues, however, and requested we complete our surveys and return to clinic for a more complete evaluation. As parents sometimes do, we dropped the ball and never returned to his office. Continuing on my circuitous route to help, I eventually consulted a different provider, completed the requisite surveys, and we received the diagnosis of ADHD and a recommendation to start our son on medication.
The process of arriving at the diagnosis took too long, as I did not know how to pursue it. We received inadequate guidance after the diagnosis; medication was the only remedy mentioned. For reasons that escape me now, we never consulted my son’s pediatrician. If we had, he would have likely facilitated the diagnosis and coordinated our treatment approaches. Patients, and parents of patients, do not always approach care via direct routes, nor do they excel at coordinating care for their own children. If patients with ADHD are in your care, take advantage of the opportunity to be their point person and advocate.
Three important lessons from my personal experience have enhanced my practice management:
- Lesson 1: Communicate vital information to the family in the first visit, and emphasize it at each subsequent visit. Offer hope as well as concrete action-items. For example: “I’ll need surveys back from you to make this official, but I’d like to make sure you understand that I can help with medications, and I will direct you to ADHD coaches who will train you and your child to excel with this diagnosis.”
- Lesson 2: Making suggestions once or twice is not the same as coaching. Choose vital points to emphasize periodically, to ensure they are absorbed and incorporated by the family. Use worksheets and other visual aids to help parents and child set reasonable goals, and outline the steps needed to achieve them. Review common problems, brainstorm solutions, and role-play effective responses. For example, if a bored child seeks attention by whining, the best response might be to intentionally ignore him rather than to express frustration at the whining.1 If a child is so upset that he starts breaking family rules, the best response might be a time-out or privilege removal rather than angry yelling.1
- Lesson 3: Office visits without the child can allow the parents to speak freely about their concerns. They also help facilitate more effective communication between the practitioner and parents.
A quick Internet search will show you there is consensus among healthcare providers that ADHD treatment must include behavior (modification) therapy (BT). In my own experience, BT has been a life-changer. BT trains the person with ADHD and the person’s parents, teachers, and other caregivers to excel with the brain as it is. For more information on BT, peruse the websites of Seattle Children’s Hospital, CHADD (Children and Adults with ADHD), and the Centers for Disease Control and Prevention (CDC). Given the importance of BT in empowering kids for success with ADHD, it is imperative that all providers interacting with kids with ADHD prescribe and advocate for BT.
Coaching and Acting as Care Coordinator
Whether or not you are the primary-care provider, you can assume a huge role: that of care coordinator and primary advocate, head coach, and cheerleader. The list of tasks that can be centralized under your care is long and important:
- Ensure the family receives appropriate care. From diagnosis to treatment, make sure you follow up on visits and action items, answer questions, advocate, and remind as needed. Provide a list of ADHD centers, programs, and coaches in your area, thereby ensuring the patient has access to behavior therapy. At subsequent visits, make sure the family has found a good fit, preferably one that’s covered by their insurance.
- Coordinate the multiple practitioners that may become involved. Ensure the various approaches feel cohesive to the family and that the family’s goals are understood and addressed.
- If concomitant conditions are present, such as Sensory Processing Disorder, Autism Spectrum Disorder, anxiety, etc, make sure these are being effectively treated as well.
- Interview the parents. Determine if they also have, or might have, ADHD or another condition. If so, is it being treated effectively? Parenting a child with ADHD is even more challenging when a parent’s poorly managed health condition causes additional stress and difficulty. Note that Dr Mark Stein of Seattle Children’s Hospital is currently running a study (called “Mother’s First”) that examines the question, “Can you improve how kids at risk for ADHD function by treating their mothers first, with either medicine or parent training?”2
- Counsel the family. The ADHD diagnosis can feel overwhelming and carries a stigma. How is your family dealing with the diagnosis? Is anyone reluctant to accept it? Make sure they know there are treatment options other than medication. Let them know how extremely common this diagnosis is. Educate them on the aspects of this diagnosis that make it a superpower.
- Frame the experience. Ensure the parents know how to recognize their child as a superhero that needs scaffolding. For example, coach the parents on how to explain the diagnosis to the child: “Your brain works a little differently than some kids’ brains, and we’re going to train ourselves and you to support and encourage that brain.”
- Parents should discuss the diagnosis and treatment strategies with the child openly and honestly: “Sometimes you and your brain struggle to make the right/safe/kind choice, and these strategies will help you make better choices and help us to encourage you in that.”
- Educate yourself about medications used in ADHD. Know their effects, side effects, and limitations. Understand drug holidays and typical recommended usage. Support the family that chooses to use medications, and ensure they understand the importance of concomitant BT. If your family chooses not to use medications, make sure they are receiving naturopathic support and that they too are receiving BT.
- Advocate for your patient when communicating with the school. The family and patient should have an open relationship with teachers, staff, counselor, and principal. If it’s a public school, encourage them to pursue an Individualized Educational Plan (IEP) or 504 Plan. Offer documentation as needed for the school. Most teachers and staff do not receive special training in ADHD. The family and ADHD coach should work together to determine the best interventions, and should request that the school provide them, rather than assuming the school knows best.
- Emphasize and review key points that will likely be covered by the behavioral therapist:
- Boundaries: Parents are in charge. These kids are resilient and determined, and if the ADHD has gone untreated for years, the parents may have been worn down. Ideally, boundaries are set at an early age. Kids excel with boundaries and they flounder without them, especially kids with ADHD.
- Screen time: Make sure the parents have set reasonable limits and are sticking to them.
- Behavior: Rules, rewards, consequences, and punishments should all be on board.1 (Remember, these are not neurotypical kids, so the approach is different. This can be hard to swallow.)
- Reasonable goal-setting: The child’s behavior, and the family’s responses to it, will not change all at once. Goals should be small, tangible, and crystal-clear. For example, avoid commanding the child to complete all homework on time, which is a vague and overwhelming goal. Instead, start by having the child complete a schedule of due dates for homework. Then work together to break down each assignment into smaller projects with corresponding due dates.
- Exercise: All that fidgeting does not count. They need big movement for prolonged amounts of time, and preferably outside. Make sure the family has a plan and a means to implement it.
- Food: Remember 2 important points about diet:
- Blood sugar may play a role.
- Before starting any elimination diet, assess whether the family currently has the bandwidth to take this on. It may have to wait until the stress of diagnosis and initial treatment subsides.
- Sleep: This is so important, and sleep is hard to come by for many of these kids. Ensure the child has a bedtime routine and consistent sleep and wake times. If sleep is still a challenge, implement your favorite pediatric sleep aids, and advocate for mindfulness exercises, meditation apps, etc. Make sure they’re also getting lots of physical activity.
- Props: Timers and schedules, written charts, and picture charts are extremely helpful and should be used whenever possible. They’re usually doing things right if their walls are plastered with reminders and instructions.
One quick note on working with parents who provide health care or education: Do not assume they have it covered just because they work in the field. Parenting is hard, but parenting a non-neurotypical kid is really hard. These parents need you just as much as any other parent. When it comes to our own kids, our vision is usually impaired.
Sum it up; make sure your family has a road map. Lay out possible treatment plans, with expected outcomes. Discuss medication openly and without bias. Discuss and document how the family will evaluate their efforts. How do they know when it’s time to move up the treatment hierarchy? Discuss the frustrations and hopes of the parents and the child. Remind the parents that the child wants to choose well and often cannot. If the parents are mired in frustration over their kid “being bad,” and the kid is sad and angry for the same reason, no one is moving forward. Treatment plans must be tiered and timed so that relief is ensured. Their lives must improve in tangible ways, and in a reasonable timeline.
Now, 3 years in, my whole family is on board with the diagnosis and the treatment plan. Yes, I said 3 years. ADHD (like other neuropsychiatric diagnoses) is not an easy term to hear. Make sure neither stigma nor overload is preventing the family from making progress.
Even if you’re not the one providing medical management to kids with ADHD, you can be the one making certain the family receives the help they deserve. You can be the one who allows the child with ADHD to be a superpower.
- Pfiffner LJ, Haack LM. Behavior management for school-aged children with ADHD. Child Adolesc Psychiatr Clin N Am. 2014;23(4):731-746.
- Seattle Children’s Hospital. Improving Treatment for ADHD. www.seattlechildrens.org/about/stories/improving-treatment-for-adhd/. Accessed June 10, 2021.
Children and Adults with ADHD (CHADD.org)
ADDitude – Inside the ADHD mind (ADDitudemag.org)
Seattle Children’s Hospital offers several programs for kids and families with ADHD
Hallowell Todaro Center also offers various programs for kids and families with ADHD
Teresa Neff, ND, CLE specializes in pediatric and adolescent primary–care medicine at Roots for Health, in Seattle, WA. Dr Teresa employs a wide range of tools, including craniosacral therapy, visceral manipulation, and constitutional homeopathy. She holds a certificate from Simkin Center as a Certified Lactation Educator (CLE). Dr Teresa graduated from Bastyr University in 2008 and trained for 2 years at The Kids Clinic before entering private practice. She lives with her husband and two sons, where she enjoys learning life lessons that she can apply to her practice.