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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.

Behavior Modification

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
  • clinical behavior therapy
  • direct contingency management
  • intensive, packaged behavioral treatments
  • combined behavioral and pharmacological treatments

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).

Medication Treatments

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.

Atomoxetine, brand name, Strattera, is a non-stimulant drug that was approved in November, 2002 and became available in US pharmacies in early 2003 for children and adults with ADHD. It is a selective norepinephrine reuptake inhibitor. While the stimulants primarily affect the dopaminergic system, atomoxetine has its primary effect on the noradrenergic system. It has been shown to improve core symptoms of ADHD, namely, inattention, impulsivity, and hyperactivity. It has some weak antidepressant properties as well and may help improve and regulate mood. While stimulants start working within a half hour to an hour after ingestion, atomoxetine has a more gradual onset and the maximal effect may not be seen for three weeks.

Certain anti-hypertensive medications known as adrenergic agonists (Clonidine and Tenex) are used in combination with other medications to help very hyperactive and impulsive children.

Documented Effects of Medication on Children with ADHD

Effects on Motor Activity and Coordination

  • reduced activity level to normal in classroom
  • improved handwriting and neatness of written work
  • improved fine motor control

Cognitive Effects

  • reduced distractibility
  • decreased impulsivity
  • increased work production
  • increased accuracy of work

Effects on Social Behavior

  • reduced off-task behavior in classroom
  • decreased anger, better self-control
  • improved participation in organized sports (i.e., baseball)
  • reduced bossy behavior with peers
  • reduced verbal and physical aggression with peers
  • reduced non-compliant, defiant and oppositional behavior

Adverse Effects of Stimulants and Atomoxetine

The stimulants have certain adverse effects. Among the common adverse effects are: headaches, stomachaches, insomnia, decreased appetite, weight loss and irritability. Some of the infrequent side effects that can be caused by stimulant use include rebound effects, difficulty falling asleep, irritable mood and tics. These side effects can be temporary and decrease with time or with change of medication or dosage. In cases where side effects interfere significantly with the person’s health or quality of life, other treatment approaches may need to be considered.

Common side effects of atomoxetine may include appetite suppression, sleep disturbance, jitteriness, and irritability. There may be a small increase in pulse and blood pressure. Nausea and sedation can occur. Atomoxetine can lead to urinary retention in some individuals. It can also cause problems with sexual functioning (about 7% of men experienced difficulty with erections and 3% experienced impotence). Atomoxetine is most commonly given in the morning, however, some individuals split the dose between morning and night or take it at night alone to counteract the sedation that can occur with the drug.

Monitor the Effects of Medication to Achieve the Best Result

Medication should never be given without an established system to monitor its effectiveness. The doctor prescribing the medication should obtain information from parents and teachers concerning their observation of any changes in behavior, attentiveness, mood or physical complaints the adolescent may have while taking medication. Typically, teachers are a good source of information about medication effects. Teachers may report information about the student’s reactions to medication informally to the physician or they may complete similar forms as the parents for more systematic data collection. Use of behavior rating scales such as these can be extremely helpful in determining changes in behavior. The ADHD Monitoring System developed by Dr. David Rabiner is a convenient program that parents can use to carefully monitor how their child is doing at school. By using this program, parents will be able to carefully track their child’s progress in school and will be alerted to when any adjustments or modifications to their child’s treatment needs to be discussed with their physician.

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.

Section 504 of the Rehabilitation Act of 1973 guarantees that no person “shall, solely by reason of her or his disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.”

To qualify for Section 504 services there must be evidence of the existence of an identified physical or mental impairment that substantially limits a major life activity. Having a diagnosis of ADHD alone is not enough to qualify for accommodations under Section 504 unless the person’s ADHD significantly impacts on learning or behavior.

Under Section 504, the definition of a disability is much broader than it is under the Individuals with Disabilities in Education Act (IDEA). While all IDEA students are covered by Section 504, not all Section 504 students would qualify for protection under IDEA. Under IDEA the qualifying student will receive an Individual Education Plan (IEP) tailored to the child’s unique needs. The child may receive special education and/or related services at public expense in accordance with the IEP.

Unproven and Controversial Treatments for ADHD

With the increased interest paid to ADHD in the past two decades, there has also been an increase in claims made by vendors of products or services that purport to effectively treat symptoms of the disorder. Consumers need to know how to evaluate these claims so they can determine the efficacy of such treatments. ADHD experts (Ingersoll and Goldstein, 1993) warn consumers about unproven and controversial treatments. Typically they advise consumers to be wary of any company boasting "miracle" cures that work for everyone with ADHD, claims based on the results of just one study, or studies that lack a control group, claims that the product is a harmless, "natural" remedy with few or no adverse effects, and product ads that attack established, mainstream medical treatments.

ADHD experts often list the following treatments as either unproven or disproven as effective in treating ADHD: interactive mentronome training, dietary interventions, nutritional supplements, sensory integration training, anti-motion sickness medication, optometric visual training, applied kinesiology, treatment for lead toxicity, thyroid dysfunction, and candidas yeast therapy.

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.


American Academy of Pediatrics. (2001). Clinical practice guidelines: Treatment of the school-aged child with attention-deficit/hyperactivity disorder. J. of the Amer. Acad. of Pediatrics, 108 (4), 1033-1044.

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.

Ingersoll, B., & Goldstein, S. (1993). Attention Deficit Disorder and Learning Disabilities: Realities, Myths, and Controversial Treatments. New York: Doubleday Publishing Group.

Kratochvil, C.J., Heiligenstein, J.H., Dittmann, R., et al. Atomoxetine and methyphenidate treatment in children wtih ADHD. A prospective, randomized, open-label trial. J. Am. Acad Child Adolesc Psychiatry 2002, 41, 776-84.

MTA Cooperative Group. (1999). A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder: Multimodal Treatment Study of Children with ADHD. Archives of General Psychiatry, 56 (12), 1073-1086.

O’Leary, K.D., & Becker, W.C. (1967). Behavior modification of an adjustment class: A token reinforcement program. Exceptional Children, 33, 637-642.

Pelham, W.E., Greiner, A.R., & Gnagy, E.M. (1997). Children’s summer treatment program manual. Buffalo, NY: Comprehensive Treatment for Attention Deficit Disorder.

Pelham, W. E. (2002) Psychosocial Interventions for ADHD. In P.S. Jensen & J.R. Cooper (Ed.), Attention Deficit Hyperactivity Disorder: State of the science • best practices (pp 12-1-12-24) New Jersey: Civic Research Institute, Inc.

Rabiner, D. (1999). ADHD Monitoring System: A systematic guide to monitoring school progress for children with ADHD. Florida: Specialty Press, Inc.

Recommended Reading

Barkley, R. A. (2000) Taking charge of ADHD: The complete authoritative guide for parents. New York: Guilford Press.

Barkley, R. A. (1998). Your defiant child. New York: Guilford Press.

Dendy, C.A. (1995). Teenagers with ADD: A parents' guide. Maryland: Woodbine House.

Goldstein, S. & Goldstein, M. (1998). Managing attention deficit hyperactivity disorder in children: a guide for practitioners (2nd ed.). New York, NY: John Wiley.

Parker, H. (1992). Put yourself in their shoes. Understanding teenagers with attention deficit hyperactivity disorder. Plantation, FL: Specialty Press, Inc.

Phelan, T. (1995). 1-2-3 Magic. Illinois: Child Management.

Wilens, T. E. (1999). Straight talk about psychiatric medications for kids. New York: Guilford Press.

Ingersoll, B., & Goldstein, M. (1993). Attention deficit disorder and learning disabilities: Realities, myths, and controversial treatments. New York: Doubleday.

Mather, N. & Goldstein, S. (2001). Learning disabilities and challenging behaviors: A guide to intervention and classroom management. Baltimore, MD: Brookes Publishing Co.

Parker, H. C. (2002). Problem solver guide for students with ADHD: ready-to-use interventions for elementary and secondary students. Plantation, Florida: Specialty Press, Inc.

Rief, S. F. (1996). How to reach and teacher ADD/ADHD children. New York: John Wiley.

For more information about ADHD go to Library Tools.

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