ADHD Treatment Options for Children

Behavioral Approaches

Behavioral approaches represent a broad set of specific interventions that have the common goal of modifying the physical and social environment to alter or change behavior (AAP, 2001). They are used in the treatment of ADHD to provide structure for the child and to reinforce appropriate behavior. Those who typically implement behavioral approaches include parents as well as a wide range of professionals, such as psychologists, school personnel, community mental health therapists, and primary care physicians. Types of behavioral approaches include behavioral training for parents and teachers (in which the parent and/or teacher is taught child management skills), a systematic program of contingency management (e.g. positive reinforcement, "time outs," response cost, and token economy), clinical behavioral therapy (training in problem-solving and social skills), and cognitive-behavioral treatment (e.g., self-monitoring, verbal self-instruction, development of problem-solving strategies, self-reinforcement) (AAP, 2001; Barkley, 1998b; Pelham, Wheeler, & Chronis, 1998). In general, these approaches are designed to use direct teaching and reinforcement strategies for positive behaviors and direct consequences for inappropriate behavior. Of these options, systematic programs of intensive contingency management conducted in specialized classrooms and summer camps with the setting controlled by highly trained individuals have been found to be highly effective (Abramowitz, et al., 1992; Carlson, et al., 1992; Pelham & Hoza, 1996). A later study conducted by Pelham, Wheeler, and Chronis (1998) indicates that two approaches-parent training in behavior therapy and classroom behavior interventions-also are successful in changing the behavior of children with ADHD. In addition, home-school interactions that support a consistent approach are important to the success of behavioral approaches.

The research results on the effectiveness of behavioral techniques are mixed. While studies that compare the behavior of children during periods on and off behavior therapy demonstrate the effectiveness of behavior therapy (Pelham & Fabiano, 2001), it is difficult to isolate its effectiveness. The multiplicity of interventions and outcome measures makes careful analysis of the effects of behavior therapy alone, or in association with medications, very difficult (AAP, 2001). A review conducted by McInerney, Reeve, and Kane (1995) confirms that the effective education of children with ADHD requires modifications to academic instruction, behavior management, and classroom environment. Although some research suggests that behavioral methods offer the opportunity for children to work on their strengths and learn self-management, other research indicates that behavioral interventions are effective but to a lower degree than treatment with psychostimulants (Jadad, Boyle, & Cunningham, 1999; Pelham, et al., 1998).

Behavior therapy has been found to be effective only when it is implemented and maintained (AAP, 2001). Indeed, behavioral strategies can be difficult to implement consistently across all of the settings necessary for it to be maximally effective. Although behavioral management programs have been shown to enhance the academic performance and behavior of children with ADHD, followup and maintenance of the treatment is often lacking (Rapport, Stoner, & Jones, 1986).

In fact, some research has shown that behavioral techniques may fail to reduce ADHD's core characteristics of hyperactivity, impulsivity, and inattention (AAP, 2001; U.S. Department of Health and Human Services [DHHS], 1999). Conversely, one must consider that the problems of children with ADHD are seldom limited to the core symptoms themselves (Barkley, 1990a). Children frequently demonstrate other types of psychosocial difficulties, such as aggression, oppositional defiant behavior, academic underachievement, and depression (Barkley, 1990a). Because many of these other difficulties cannot be managed through psychostimulants, behavioral interventions may be useful in addressing ADHD and other problems a child may be exhibiting.

Pharmacological Approaches

Pharmacological treatment remains one of the most common, yet most controversial, forms of ADHD treatment. It is important to note that the decision to prescribe any medicine is the responsibility of medical-not educational-professionals, after consultation with the family and agreement on the most appropriate treatment plan. Pharmacological treatment includes the use of psychostimulants, antidepressants, anti-anxiety medications, antipsychotics, and mood stabilizers (NIMH, 2000). Stimulants predominate in clinical use and have been found to be effective with 75 to 90 percent of children with ADHD (DHHS, 1999). Stimulants include Methylphenidate (Ritalin), Dextroamphetamine (Dexedrine), and Pemoline (Cylert). Other types of medication (antidepressants, anti-anxiety medications, antipsychotics, and mood stabilizers) are used primarily for those who do not respond to stimulants, or those who have coexisting disorders. The results of the Multimodal Treatment Study (MTA), which are discussed in further detail in the next section, confirm research findings on the use of pharmacological treatment for patients with ADHD. Specifically, the study found that the use of medication was almost as effective as the multimodal treatment of medication and behavioral interventions (Edwards, 2002).

Researchers believe that psychostimulants affect the portion of the brain that is responsible for producing neurotransmitters. Neurotransmitters are chemical agents at nerve endings that help electrical impulses travel among nerve cells. Neurotransmitters are responsible for helping people attend to important aspects of their environment. The appropriate medication stimulates these underfunctioning chemicals to produce extra neurotransmitters, thus increasing the child's capacity to pay attention, control impulses, and reduce hyperactivity. Medication necessary to achieve this typically requires multiple doses throughout the day, as an individual dose of the medication lasts for a short time (1 to 4 hours). However, slow- or timed-release forms of the medication (for example, Concerta) may allow a child with ADHD to continue to benefit from medication over a longer period of time. Doctors, teachers, and parents should communicate openly about the child's behavior and disposition in order to get the dosage and schedule to a point where the child can perform optimally in both academic and social settings, while keeping side effects to a minimum. If it is determined that the child should receive medication during the school day, it is important to develop a plan to ensure that medication is administered in accordance with the plan. Such a plan would be an appropriate component of the child's IEP. In addition, schools must ensure that the child's and parent's rights to medical confidentiality are maintained.

Although the positive effects of the stimulant medication are immediate, all medications have side effects. Adjusting the dosage of the medicine can diminish some of these side effects. Some of the more common side effects include insomnia, nervousness, headaches, and weight loss. In fewer cases, subjects have reported slowed growth, tic disorders, and problems with thinking or with social interaction (Gadow, Sverd, Sprafkin, Nolan, & Ezor, 1995). Medication also can be expensive, depending upon the medicine prescribed, the frequency of administration, and the subsequent frequency of refills. Stimulant medicines do not "normalize" the entire range of behavior problems, and children under treatment may still manifest higher levels of behavioral problems than their peers (DHHS, 1999). Nonetheless, the American Academy of Pediatrics (AAP) finds that at least 80 percent of children will respond to one of the stimulants if they are administered in a systematic way. Under medical care, children who fail to show positive effects or who experience intolerable side effects on one type of medication may find another medication helpful. The AAP reports that children who do not respond to one medication may have a positive response to an alternative medication, and concludes that stimulants may be a safe and effective way to treat ADHD in children (AAP, 2001).

In January 2003, a new type of nonstimulant medication for the treatment of children and adults with ADHD was approved by the FDA. Atomoxetine, also known as Straterra, may be prescribed by physicians in some cases.

Multimodal Approaches

Research indicates that for many children the best way to mitigate symptoms of ADHD is the use of a combined approach. A recent study by the NIMH-the Multimodal Treatment Study of Children with ADHD (MTA)-is the longest and most thorough study of the effects of ADHD interventions (MTA Cooperative Group, 1999a, 1999b). The study followed 579 children between the ages of 7 and 10 at six sites nationwide and in Canada. The researchers compared the effects of four interventions: medication provided by the researchers, behavioral intervention, a combination of medication and behavioral intervention, and no-intervention community care (i.e., typical medical care provided in the community).

Of the four interventions investigated, the researchers found that the combined medication/behavior treatment and the medication treatment work significantly better than behavioral therapy alone or community care alone at reducing the symptoms of ADHD. Multimodal treatments were especially effective in improving social skills for students coming from high-stress environments and children with ADHD in combination with symptoms of anxiety or depression. The study revealed that a lower medication dosage is effective in multimodal treatments, whereas higher doses were needed to achieve similar results in the medication-only treatment.

Researchers found improvement in the following areas after using a multimodal intervention: child anxiety, academic performance, oppositional behavior, and parent-child interaction. Positive results also were found in school-related behavior when multimodal treatment is coupled with improved parenting skills, including more effective disciplinary responses, and appropriate reinforcements (Hinshaw, et al., 2000). These findings were replicated across all six research sites, despite substantial differences among sites in their samples' sociodemographic characteristics. The study's overall results appear to apply to a wide range of children and families identified as in need of treatment services for ADHD (NIMH, 2000). Other studies demonstrate that multimodal treatments hold value for those children for whom treatment with medication alone is not sufficient (Klein, Abikoff, Klass, Ganeles, Seese, & Pollack, 1997).

In October 2001, the AAP released evidence-based recommendations for the treatment of children diagnosed with ADHD. Their guidelines state that:

• Primary care clinicians should establish a treatment program that recognizes ADHD as a chronic condition;

• The treating clinician, parents, and the child, in collaboration with school personnel, should specify appropriate target outcomes to guide management;

• The clinician should recommend stimulant mediation and/or behavioral therapy as appropriate to improve target outcomes in children with ADHD;

• When the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and the presence of coexisting conditions; and

• The clinician should periodically provide a systematic followup for the child with ADHD. Monitoring should be directed to target outcomes and adverse effects, with information gathered from parents, teachers, and the child.

The AAP report stressed that the treatment of ADHD (whether behavioral, pharmacological, or multimodal) requires the development of child-specific treatment plans that describe not only the methods and goals of treatment, but also include means of monitoring over time and specific plans for followup. The process of developing target outcomes requires careful input from parents, children, and teachers as well as other school personnel where available and appropriate. The AAP concluded that parents, children, and educators should agree on at least three to six key targets and desired changes as requisites for constructing the treatment plan. The goals should be realistic, attainable, and measurable. The AAP report found that, for most children, stimulant medication is highly effective in the management of the core symptoms of ADHD. For many children, behavioral interventions are valuable as primary treatment or as an adjunct in the management of ADHD, based on the nature of coexisting conditions, specific target outcomes, and family circumstances (AAP, 2001).