Dr. Lindsay Evans is a child and adolescent psychologist at the Austin Psychology & Assessment Center (ApaCenter). In her work with children and families, she is often asked about the best interventions for individuals with Attention-Deficit/Hyperactivity Disorder (ADHD) or similar concerns. In particular, many families want to know if there are any effective treatment options for managing ADHD without medication. We’re grateful to Dr. Evans for addressing these questions here as a guest contributor.

Many parents are surprised to hear that comprehensive ADHD treatment should always include a strong psychosocial (non-medication) component. Behavior therapy has been shown to be an effective behavioral treatment for child and adolescent ADHD. In fact, for preschool age children (under 5), the American Academy of Pediatrics recommends behavior therapy as the first line of treatment for children. For older children, research indicates that when medication is the only form of treatment, it generally does not lead to positive long-term outcomes. And, importantly, a substantial percentage of children and adolescents with ADHD may be able to avoid using medication if good behavioral treatments are employed. If behavioral interventions are not sufficient, the combination of medication and behavioral modifications strategies can be considered.

Behavior therapy involves using positive reinforcement and structure to help modify a child’s behavior and environment. The interventions can improve the parent-child relationship, and teach children concrete skills to help them function better at home and school. Because they work best when coordinated across settings (home, school, and community), behavior therapy typically involves three components:

Parent training
Teacher consultation/school interventions
Child-focused treatment

Behavior therapy often helps to reset the “magic ratio,” or the frequency of positive to negative interactions and feedback that a child receives. A more in-depth description of behavior interventions for ADHD can be found at the Center for Children and Families.

Parent Training

The first and most important aspect of behavior treatment for ADHD is parent training. As we often tell parents in our practice, although many parents know standard (good) parenting strategies, having a child with ADHD can require a “black belt in parenting,” which is where Behavior Parent Training comes in. Parent training programs (such as Parent Management Training/PMT and Parent-Child Interaction Training/PCIT) are typically provided in weekly individual or group sessions, lasting 12–18 weeks. Parents are taught specific strategies and are asked to practice those in the session with their child or to go home and practice for a week. At the next session, the family reviews their progress with the therapist, problem-solves, and learns new skills to assist their family. Here is a more detailed description of Behavior Parent Training and how to find a provider in your area.

Consultation/School Interventions

School interventions typically involve having a child’s teacher provide more structure and positive reinforcement (e.g., specific verbal praise and a sticker chart) in the classroom to help a child reach specific behavior goals. Teacher involvement is critical because behavior therapy is most effective when it is consistent across settings, times of day, and people. A “Daily Report Card” coordinated between teacher and parent can be a very effective method for helping a child reach specific goals at school (a parent guide for starting one can be found here: ADHD parent resources). Coordinating with teachers is an integral piece, and we have listed some tips about parent and teacher collaboration at our ApaCenter blog.

Child-focused Treatment

The third part of behavioral treatment involves teaching children how to improve their interactions with other children. Social skills interventions are typically most effective when they are implemented in school or recreational settings, and the training typically needs to take place frequently for the child to learn the skills (e.g., such as through daily practice at school or in Saturday or summer therapeutic recreational programs). Besides social skills training, a new intervention called Organizational Skills Training has also been shown to improve organization, time management, and planning skills in elementary school children with ADHD.

Finally, it is important to note that individual or small group counseling sessions with children in a therapist's office (such as “Play Therapy”) are not effective for treating child ADHD because they do not help a child practice new skills in other settings. Behavior therapy is effective because it teaches concrete skills to parents, teachers, and the children themselves.

And, a quick note: When I am providing guidance to families about how to help their child, I rely on recommendations that are backed by scientific evidence. Some great websites for finding unbiased information about interventions for children are www.Effectivechildtherapy.org and www.ChildMind.org. Treatment guidelines for ADHD in children can be found at the Center for Disease Control website (believe it or not, a great resource for parents!). Importantly, ADHD is a chronic condition and children with unmanaged ADHD are at risk for poor academic performance, greater problems (such as substance use) in adulthood, and difficulties in their relationships.

Some parents at this point may be thinking, “Gosh, that seems like a ton of work!” And they’re right that behavior therapy does require time and commitment from parents on the front end. But, once learned, the skills quickly become a more natural part of a family’s routine, and they set up a child for more success both in academics in their relationships. The extra effort on the front end can help a child overcome challenges in daily life functioning, which can be valuable in managing ADHD throughout a lifetime.

Dr. Lindsay Evans

For part 2 of our series for Mental Health Awareness Month, Shelley Sperry interviewed local psychologist Dr. Mike Brooks, who shared his insights and practical advice for reducing or preventing the stresses and anxieties so many teens are experiencing today.

Dr. Mike Brooks, a licensed psychologist and director of the Austin Psychology & Assessment Center (ApaCenter), says that there is some alarmism around the issue of rising anxiety disorders among teens. “We haven’t dropped off a cliff,” he says, but in many schools in Austin and across the nation the academic and social pressure is intense. “A lot of pressures come to a head in high school, and kids feel the weight and react in a variety of ways.”

Teachers, school administrators, coaches, parents, and peers all have high expectations in terms of grades and extracurricular activities. “I work a lot with stressed teens who think if you have one bad semester you won’t be able to get into your top school, or if you don’t take at least 5 AP classes, you’re falling behind,” explains Dr. Brooks. “These stresses can lead to anxiety and depression.”

But, Brooks says, most kids can find new ways to deal with stress and significant relief through some common-sense behavioral changes. Others will need counseling, often in the form of more formal cognitive behavorial therapy, and a few will need the assistance of drugs along with therapy to balance brain chemistry.

Dr. Brooks believes that the most basic solutions often work well, if kids are really motivated to make some changes. Exercise, sleep, and putting some limits on technology can work wonders to destress teens’ everyday lives.

Exercise. “We are meant to be active,” Brooks explains, “so if we don’t move enough, stress sets in.” Exercise breaks are essential for teens who study long hours, because exercise improves alertness and focus. “We get all that exercise time back later in higher productivity.”

Sleep. The same thing goes for sleep. Here, the science is clear: According to the UCLA Sleep Center, teens need more sleep than adults—an average of nine hours per night. But as a result of busy schedules at home and school, social expectations, or difficulty falling and staying asleep as their bodies adjust to puberty, most teenagers don’t get enough. Lack of sleep can be both a contributor to and a symptom of mental health problems. According to Harvard Medical School’s Mental Health Letter:

The brain basis of a mutual relationship between sleep and mental health is not yet completely understood. But neuroimaging and neurochemistry studies suggest that a good night’s sleep helps foster both mental and emotional resilience, while chronic sleep disruptions set the stage for negative thinking and emotional vulnerability.

Unplugging and single-tasking. Dr. Brooks specializes in helping parents and kids navigate technology, which often increases stress levels in teens. He has one word for those who spend their study time multitasking: Don’t. Most high school students today are instant-messaging, snapchatting, texting, checking Instagram, and watching YouTube—or some combination of these distractions—while doing homework or reading. The science is still in early stages, but multiple studies show that multitasking decreases the quality of work, can actually inhibit one’s ability to filter out irrelevant information, and can diminish working memory.

As a result of the time and attention lost to multitasking, stress levels and anxiety can increase. So encourage unplugging for part of every day—taking technology breaks—so students can focus on one important task at a time.

When asked what role schools have in lowering students’ anxiety, Dr. Brooks said, “I’d like to see schools be more aware of students’ emotional state. Allow them to step back and observe, and practice mindfulness. Encourage them to check in with themselves to figure out what they want and need.”

Many schools in the Austin area are developing programs that focus on mindfulness and allow students to monitor their own anxieties and feelings of stress. We’ll take a look at some of those solutions in the next installment.

Many thanks to Dr. Mike Brooks for taking the time to discuss his work for this post. Dr. Brooks is a licensed psychologist and the director of the Austin Psychology & Assessment Center. The ApaCenter is a group of psychologists and other practitioners who provide psychological and neuropsychological assessments, therapy, consultation, and coaching to individuals, couples, and families of all ages. Dr. Brooks works with a variety of patients but specializes in helping parents raise balanced kids in a technological world. He is writing a book on this topic and can be found online at DrMikeBrooks.com.