Treatments for Children and Adolescents with Adhd

Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is the primary reason for referral to mental health services among school-aged children. Effective treatments for ADHD consist of stimulant medication and behavior modification. Although the efficacy of stimulant medication in the treatment of ADHD is well established, purely pharmacological approaches to treatment fall short of optimal outcomes for a number of reasons, highlighting the need for effective psychosocial treatments to be identified.

Many of the behaviors that characterize ADHD (e.g., difficulty sustaining attention, high activity level) are normative at certain stages of development, and may or may not be viewed as impairing depending on the environmental expectations at a particular developmental stage.

Treatments must also be developmentally sensitive, meaning that they must involve careful consideration of the child’s level of cognitive development and his/her developmental needs and challenges. In this regard, behavioral treatments for younger children must include consequences that are tangible, offered frequently, and presented immediately following the behavior so that children comprehend the connection between their behavior and the consequence. Likewise, treatments for adolescents must consider their desire for autonomy, for example, by involving them more fully in the treatment process.

The widespread use and evidence for the efficacy of stimulant medication are overwhelming. In fact, treatment effects of stimulants surpass evidence for pharmacological treatment of any other child psychiatric disorder. In the classroom, stimulants have been found to reduce classroom disruption and increase on-task behavior, compliance, and academic productivity. Additionally, stimulants have been shown to decrease negative social behaviors, including aggression, inappropriate peer interactions, and negative parent-child interactions.

The inattentive, hyperactive, and impulsive behaviors that characterize ADHD often contribute to impairment in the parent-child relationship and increased stress among parents of children with the disorder. Over time, parents may develop maladaptive and counterproductive parenting strategies to deal with these problems that may serve to maintain or exacerbate existing behavioral difficulties. Effectively modifying poor parenting practices is of utmost importance, as poor parenting is one of the more robust predictors of negative long-term outcomes in children with behavior problems. Behavioral parent training, then, is one of the most effective ways to change parenting and therefore treat ADHD.

Behaviorally based classroom interventions constitute an empirically supported treatment for children with ADHD. Teachers are then instructed regarding the use of specific behavioral techniques, including praise, planned ignoring, effective commands, and time out, as well as the daily report card (DRC) and/or more extensive individualized or classroom-wide contingency management programs. While behaviorally-based classroom interventions typically target task engagement and disruptive behavior, academic interventions for ADHD focus primarily on manipulating antecedent conditions such as academic instruction or materials in order to improve both behavioral and academic outcomes. Direct targeting of academic impairment is an important component of comprehensive treatment of children with ADHD due to the strong association between ADHD and academic underachievement.

Children with high levels of hyperactivity, noncompliance, or aggression are rated more negatively by peers on sociometric measures and are more likely to be rejected by peers. Thus, peer relationships are an important target of comprehensive treatment for ADHD. Social skills interventions focus on developing and reinforcing the use of appropriate social skills.

The Summer Treatment Program for children with ADHD (STP) is an intensive, 8-week outpatient program that combines evidence-based ADHD treatment components, including weekly, group-based parent training, a token or point system, positive reinforcement (i.e., praise), effective commands, time out, a DRC, social skills training, sports skills training, and problem solving skills training. Results of pre-post evaluations of the STP indicated statistically significant reductions in parent ratings of symptoms and impairment, as well as functional improvement ratings across multiple domains (e.g., rule-following, classroom productivity, sports skills, and self-esteem) completed by STP teachers and counselors at the end of each summer.

As reviewed herein, family-based interventions typically involve training parents to implement contingency management programs with their ADHD children and have consistently revealed improvement in the home setting. The treatments tested in these family-based intervention studies may be more useful in their ability to prepare parents to understand, cope with, and raise their ADHD adolescents while decreasing parental and family distress in the process. Unfortunately, no studies to date have examined the effect of combined behavioral and pharmacological treatment for adolescents with ADHD.

The remaining adolescent treatment studies examine interventions implemented within the school setting. Due to the increasing school demands adolescents face as they transition