Clinicians must always modify, in big and small ways, their approaches to evidence-based treatments that suit the strengths and needs of their patients. Children, for example, often require more time and personalized instruction than adults when learning to practice resonance frequency breathing. When treatments match an individual’s needs and preferences, patients are more engaged and likely to follow the plan, leading to better outcomes and a more positive experience (National Research Council, 2011). This personalization is particularly important for youth with ADHD (Hamburg & Collins, 2010), who experience unique challenges in traditional therapeutic settings where time constraints require patients to stay focused, engage intently, and sit still for periods of up to an hour. Nonetheless, given ADHD’s complexity and variability, clinicians should spend time getting to know their patients so they can appropriately modify treatment approaches.
Recognizing ADHD Symptoms
ADHD is characterized by a pattern of inattention with or without hyperactivity-impulsivity that significantly hampers functioning or development. To meet the diagnostic criteria, an individual must exhibit six or more of these symptoms for at least 6 months.
Inattentive Symptoms
Fails to give close attention to details or makes careless mistakes
Has difficulty sustaining attention in tasks or play activities
Does not seem to listen when spoken to directly
Does not follow through on instructions and fails to finish schoolwork or chores
Has difficulty organizing tasks and activities
Avoids or is reluctant to engage in tasks requiring sustained mental effort
Loses things necessary for tasks or activities
Is easily distracted by extraneous stimuli
Is forgetful in daily activities
Hyperactive-Impulsive Symptoms
Fidgets with or taps hands or feet or squirms in seat
Leaves seat in situations when remaining seated is expected
Runs about or climbs in situations where it is inappropriate
Unable to play or engage in leisure activities quietly
Is often "on the go," acting as if "driven by a motor"
Talks excessively
Blurts out answers before questions have been completed
Has difficulty waiting their turn
Interrupts or intrudes on others
When discussing ADHD, it's essential to recognize that each combination of symptoms can impact treatment differently. For example, a child with attention difficulties may struggle to stay focused, impacting their ability to listen and retain information. Hyperactive-impulsive behaviors, like fidgeting or interrupting, can also impede effective communication and impact the accuracy of physiological measurement. Moreover, no two people with ADHD are the same due to the numerous possible symptom combinations—there are 249,528 unique ways these symptoms can manifest. This variability means each person has unique challenges and strengths. Clinicians should mindfully adjust their approach, treatment pace, and other crucial elements to effectively address each individual's specific needs.
How ADHD feels from the inside from a former young adult client:
Looking back, I felt like I was thinking through mud. The teacher would explain an assignment and I would try to write down what she said but I’d get lost along the way and if I raised my hand to ask her to repeat, she would complain that I wasn’t paying attention. I would try to do homework and I couldn’t follow the structure. It was enormously frustrating and my head would hurt with the effort. I’d give up and go read a book. I was smart and was reading several grade levels above my own. I understood what I was reading and as time went on, I became a pretty good writer. That saved me, as I was able to express myself through written assignments as long as they were open ended and didn’t require organization or structure. After doing neurofeedback, I can now organize things and make my way through step-by-step processes. I’m still not at a typical level but I’m so much better that everyone notices and remarks on the changes. I still often feel like I’m trying to think through mud, it’s just that the mud is quite a bit thinner than it used to be.
Evidence-Based Recommendations for Personalizing Therapy
Patience and Understanding
Look for opportunities to practice patience and empathy with your patients. Children with ADHD often find it more difficult to focus on a single task, which can extend their time to complete tasks. Moreover, this slow progress can make it challenging for children to stay motivated. Although there are multiple means of addressing these challenges, some foundational strategies are maintaining a calm demeanor, avoiding frustration, and providing frequent reminders and prompts (e.g., 2 minutes until we switch tasks). Patience creates a supportive environment where children feel safe and accepted (Barkley, 2014). Show empathy by listening attentively and using reflective responses, among other means of demonstrating your understanding and care.
Set Realistic Expectations
Set realistic and achievable goals to keep motivation high and reduce frustration. Tailor goals to the child's abilities and progress. Break larger tasks into smaller, manageable steps to prevent the child from feeling overwhelmed. Achievable goals help maintain motivation and prevent feeling overwhelmed (DuPaul & Stoner, 2014). Be flexible and ready to adjust strategies, as each child with ADHD is unique, and what works for one may not work for another.
Build Supportive Relationships
Build a supportive and trusting relationship with the child for effective intervention. Create an environment where the child feels safe to express themselves without fear of judgment. Trust forms the foundation of a successful therapeutic relationship, enhancing treatment adherence and outcomes (Miller & Rollnick, 2013). Provide consistent support and encouragement by checking in regularly and praising the child's efforts and achievements, no matter how small.
Structure the Environment
A structured environment is crucial for children and adolescents with ADHD. It reduces distractions and provides a predictable framework for daily activities. Consistent routines help children know what to expect, reducing anxiety and improving focus. Research shows that structured routines significantly manage ADHD symptoms by reducing inattention and hyperactivity (Evans et al., 2014). Visual aids like charts and checklists outline tasks and schedules, providing reminders that reinforce routines and keep children on track. Organizational tools such as planners, timers, and apps help with task and time management, aiding children in staying organized and focused.
Provide Regular Feedback and Reinforcement
These recommendations provide a much-needed framework for managing the training session when providing biofeedback training, including neurofeedback training. Provide regular feedback and positive reinforcement to manage ADHD symptoms and encourage desired behaviors. Children with ADHD benefit from immediate feedback on their behavior and performance, helping them understand the consequences and adjust accordingly. Studies show immediate and consistent feedback improves behavioral outcomes and academic performance (Pelham & Fabiano, 2008). Positive reinforcement, like reward systems, also works well. Rewards can be tangible (stickers, toys) or intangible (praise, extra playtime), promoting positive behaviors and reducing disruptive ones (Chronis et al., 2004). Additionally, behavioral contracts that outline expectations and rewards create a clear framework for behavior and accountability. Providing immediate reward-based feedback, pausing training frequently for brief periods – 10 seconds every 3 minutes is common – and setting measurable and achievable goals can help reduce frustration and facilitate rapid progress. One of the benefits of any type of biofeedback training is the ability to track progress in real-time, across individual sessions, and across multiple sessions. This helps give the client a real sense of accomplishment and success.
Involve the Parents
Engage parents in the treatment process to achieve consistent and lasting improvements. Parent training programs that teach effective behavioral management strategies and provide support at home are highly beneficial. Research shows these programs significantly improve behavior and reduce ADHD symptoms (Chronis et al., 2004). Look for opportunities to model behavioral strategies in the clinic (e.g., visual schedules, timers) that parents can use to reinforce positive behavior at home. Encourage parents to participate in therapy sessions when appropriate to enhance intervention effectiveness and give them hands-on experience in managing ADHD symptoms.
Conclusion
To support children and adolescents with ADHD, recognize their symptoms, use evidence-based accommodations, and adopt a patient, compassionate approach. Key strategies include creating structured environments, providing regular feedback, using positive reinforcement, and involving parents. These methods improve focus, behavior, and overall functioning. Patience, realistic goals, and supportive relationships foster a positive therapeutic environment, enhancing treatment outcomes and offering empathetic support.
References
Barkley, R. A. (2015). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). Cognitive Behaviour Therapy, 44(4), 526. https://doi.org/10.1080/16506073.2015.1073786
Chronis, A. M., Chacko, A., Fabiano, G. A., Wymbs, B. T., & Pelham, W. E. (2004). Enhancements to the behavioral parent training paradigm for families of children with ADHD: Review and future directions. Clinical Child and Family Psychology Review, 7(1), 1-27. https://doi.org/10.1023/B:CCFP.0000020190.60808.a4
Danielson, M. L., Claussen, A. H., Bitsko, R. H., Katz, S. M., Newsome, K., Blumberg, S. J., Koga, M., Ghandour, R. (2024). ADHD prevalence among U.S. children and adolescents in 2022: Diagnosis, severity, co-occurring disorders, and treatment. Journal of Clinical Child & Adolescent Psychology, 1–18. https://doi.org/10.1080/15374416.2024.2335625
DuPaul, G. J., & Stoner, G. (2014). ADHD in the schools: Assessment and intervention strategies (3rd ed.). The Guilford Press. Cognitive Behaviour Therapy, 44(4), 526. https://doi.org/10.1080/16506073.2015.1073786
Evans, S. W., Owens, J. S., & Bunford, N. (2014). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology, 43(4), 527-551. https://doi.org/10.1080/15374416.2013.850700
Hamburg, M. A., & Collins, F. S. (2010). The path to personalized medicine. The New England Journal of Medicine, 363(4), 301-304. https://doi.org/10.1056/NEJMp1006304
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York: The Guilford Press. Journal of Clinical Psychology, 43(4), 527-551. https://doi.org/10.1080/15374416.2013.850700
National Research Council. (2011). Toward precision medicine: Building a knowledge network for biomedical research and a new taxonomy of disease. The National Academies Press.
Pelham, W. E., & Fabiano, G. A. (2008). Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology, 37(1), 184-214. https://doi.org/10.1080/15374410701818681
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