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Importance of Multi-modal Treatment
A great deal is known about treating childhood ADHD, and the research literature on adult treatment is growing. There have been numerous studies to investigate the efficacy and safety of a number of different treatments. Only three treatments have been proven to be effective for ADHD: behavior modification, medication, and the combination of the two. These treatments have been demonstrated to have short-term effects. No treatment has been shown to influence outcomes in adolescents or adults with ADHD over the long term.
Initial results of the National Institute of Mental Health (NIMH) funded Multimodal Treatment Study of Children with ADHD (MTA Study) were published in 1999. In this study, nearly 600 children ages seven to nine were assigned to four treatment conditions (medication, behavior treatment at home and school, combination of medication and behavior treatment, and community treatment). During the 14 months of treatment, children were evaluated on ADHD symptoms by parents and teachers. Medication accounted for the largest improvement in ADHD symptoms. The addition of behavior treatments resulted in additional gains that normalized behavior.
Other treatments, including individual counseling, play therapy, dietary interventions, treatment for inner ear problems, neurofeedback/biofeedback, perceptual-motor training, sensory integration training, chiropractic manipulation, pet therapy and others have no proven efficacy for ADHD.
Academic performance of children with ADHD can be improved by using known treatments in the classroom and by teachers making appropriate accommodations in school to assist the student.
American Academy of Pediatrics Guidelines for Treatment of ADHD
In 2001, the American Academy of Pediatrics (AAP) published clinical practice guidelines for the treatment of school-aged children with ADHD. The AAP recommended the following: (1) primary care clinicians should establish a treatment program that recognizes ADHD as a chronic condition; (2) appropriate target outcomes designed in collaboration with the clinician, parents, child and school personnel should guide management; (3) stimulant medication and/or behavior therapy as appropriate should be used in the treatment; (4) if a child has not met the targeted outcomes, clinicians should evaluate the original diagnosis, use all appropriate treatments and consider co-existing conditions; and (5) periodic, systematic follow-up for the child should be done with monitoring directed to target outcomes and adverse effects. Information for monitoring should be gathered from parents, teachers and the child.
Behavioral treatments have been used for more than three decades to treat children who exhibit disruptive or aggressive behavior (O’Leary & Becker, 1967). Behavioral treatments have been successfully applied to children with ADHD to facilitate in the management of disruptive behavior, inattention, social skills building, academic performance, etc.
Dr. William Pelham, an expert in behavioral treatments for children with ADHD, describes five categories of behavioral treatment:
Cognitive-Behavioral Interventions (CBI)
The goal of this form of behavioral treatment is to teach self-control through verbal self-instructions, problem-solving strategies, cognitive modeling, self-monitoring, self-evaluation, self-reinforcement and other strategies. Typically, a therapist meets with a client once or twice a week in an attempt to teach the client through modeling, role playing and practicing cognitive strategies, the person can use to control his or her inattention and impulsive behavior. As a simple example, a child may be taught to say “stop” to himself when he is about to call out in class. Children with ADHD seem to lack these internal cues and so it was thought that teaching them such cues would be helpful. While CBI was popular in the 1980’s and early 1990’s for treatment of ADHD, its popularity has waned in the absence of strong research to support its efficacy.
Clinical Behavior Therapy (CBT)
The goal of this form of behavioral treatment is typically to train parents, teachers or other caregivers to implement contingency management programs with children. Parents generally attend parent training programs where they are given assigned readings and instruction in standard behavioral techniques. Therapists using CBT often work with teachers in a consultation model to teach behavioral strategies for application in the classroom. The use of a daily report card system wherein the child receives tokens or points for certain target behaviors in the classroom is a popular example of an effective CBT program for children with ADHD.
Contingency Management (CM)
Contingency management is a behavioral treatment that involves a more intensive program of behavior modification. Typically this type of program is implemented in a specialized treatment facility or specialized classroom. The techniques used in such programs include token economies set up to encourage specific behavior through the use of rewards and consequences earned by the child, time out, response cost and precise teacher responses to behavior through attention, reprimands and gain or loss of privileges.
Intensive Behavioral Treatments
The focus of intensive behavioral treatments is to combine clinical behavior therapy and contingency management into an intensive program to improve self-control and socialization. Children who attend the Children’s Summer Treatment Program designed by William Pelham (1997), for example, attend an eight-week program for nine hours a day. Children have a “summer camp” experience and are placed in groups of twelve. Each group spends two hours daily in classrooms where behavioral interventions and other types of instruction are provided. The rest of the day consists of recreationally based group activities. The children’s progress is tracked and rewarded at home by parents who attend classes to learn how to apply behavior management at home.
Combined Pharmacological and Behavioral Interventions
This form of treatment focuses on the combined use of medication and behavioral treatment. This combination has been shown to be quite effective in treating children with ADHD and has several advantages over medication alone or behavioral treatment alone. With the addition of medication, the behavioral component of treatment may be able to be scaled down, thereby reducing the amount of time parents and teachers need to spend on shaping behavior. The dose of medication can be reduced for children using a combined approach. Parents knowledgeable about the use of behavioral treatments can apply such treatments during times when the child is not taking medication (i.e., in the evenings for those on stimulant medication).
Fortunately, we have made many advances in treating ADHD. Stimulants are the best studied medicines for ADHD. There are basically two classes of stimulants: methylphenidate and amphetamine products. With over 150 controlled double-blind studies of stimulant use in children with ADHD, the findings are well documented that these medicines improve attention span, self-control, behavior, fine motor control and social functioning. Stimulant preparations can be quick-acting (within 30 minutes) and short lasting (four to six hours) or longer lasting (eight to 12 hours). Preparations, such as Vyvanse, Daytrana, Concerta, Adderall XR, Focalin, Methylin, Metadate and Ritalin LA, offer once-a-day dosing lasting from 8 to12 hours.
Effects on Motor Activity and Coordination
Effects on Social Behavior
Educational Interventions—Programs and Accommodations
Educators understand the importance of providing assistance to students with ADHD. Under existing federal laws (IDEA, ADA, Rehabilitation Act of 1973 [Section 504]), public schools are required to provide special education and related services to students with ADHD who need such assistance (Davila et al., 1991). Schools must meet the needs of those with ADHD who require accommodations in regular education classes. Such accommodations may “even the playing field” for those disabled by ADHD who must compete with other students in school.
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be subjected to discrimination
under any program
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Under IDEA the qualifying
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an Individual Education
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The child may receive
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EEG biofeedback training for ADHD is still a controversial treatment. While many ADHD experts are not convinced that EEG biofeedback is efficacious in the treatment of ADHD, there is a growing body of evidenced-based information that provides substantial (but still not yet conclusive) empirical support for this treatment. This treatment may best be viewed as a promising alternative approach to addressing the core symptoms of ADHD so long as the consumer fully appreciates that the evidence surrounding the efficacy of this approach is still not fully accepted within the ADHD scientific community.
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Davila, R. R., Williams, M. L., & MacDonald, J. T. (1991), September 16). Clarification of policy to address the needs of children with attention deficit disorders within general and/or special education. Washington, DC: U.S. Department of Education, Office of Special Education and Rehabilitation.
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O’Leary, K.D., & Becker, W.C. (1967). Behavior modification of an adjustment class: A token reinforcement program. Exceptional Children, 33, 637-642.
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