Treating Children and Adolescents with ADHD: An Overview of Empirically Based Treatments by Russell A. Barkley, Ph.D. 2 Credit hours - $49 Last revised: 11/02/2007 Course content © copyright 2004-2007 by Russell A. Barkley, Ph.D. All rights reserved. ContinuingEdCourses.Net is approved by the American Psychological Association (APA) to sponsor continuing education for psychologists. ContinuingEdCourses.Net maintains responsibility for this program and its content. ContinuingEdCourses.Net is approved by the Association of Social Work Boards (ASWB) to offer continuing education for social workers, through the Approved Continuing Education (ACE) program. ContinuingEdCourses.Net maintains responsibility for its courses. ASWB provider #1107. ContinuingEdCourses.Net is approved by the National Board for Certified Counselors (NBCC) as an NBCC-Approved Continuing Education Provider (ACEP) and may offer NBCC-approved clock hours for events that meet NBCC requirements. ContinuingEdCourses.Net solely is responsible for all aspects of the program. NBCC provider #6323. ContinuingEdCourses.Net is approved by the California Board of Behavioral Sciences (CA-BBS) to offer continuing education for MFCCs (MFTs) and LCSWs. CA-BBS provider #3311. ContinuingEdCourses.Net is approved by the Ohio Counselor, Social Worker, & Marriage and Family Therapist Board (OH-CSWMFT) to offer continuing education for counselors, social workers, and MFTs. OH-CSWMFT provider #RST080501 & #RCX010801. Take the Course Take the Test Buy your Certificate

Learning Objectives

This is an intermediate to advanced level course. After completing this course, mental health professionals will be able to:

• Discuss the assumptions that affect treatment choices for ADHD
• Apply knowledge of developmental issues to the management of ADHD
• List the four classes of psychotropic medications useful in the treatment of ADHD, as well as their mode of action and side effects
• Train parents in contingency management using the author's 10-step program
• Provide treatment suggestions for classroom management of children/adolescents with ADHD

Introduction

Children and teens who are inattentive, impulsive, and restless and who possess these attributes to a degree that is markedly deviant for their age and sufficient to create impairments in major life activities are currently diagnosed as having attention-deficit/hyperactivity disorder (ADHD).¹ Their problematic behavior often arises early in childhood in most cases (< 12 years)² and is typically persistent over development.³ Some cases may arise secondary to brain injury at later stages of development but this is uncommon. The disorder is among the most well studied child psychiatric conditions yet the public struggles to accept the notion that it may be a largely biologically based developmental disability. This paper will briefly review treatments for teens with ADHD that have some empirical support for their efficacy in the scientific literature. But that review is grounded in a particular theory of ADHD discussed in the first course and described in detail elsewhere.⁴ For further discussion on gender, socioeconomic status, and cross cultural issues related to diagnosis and prevalence of ADHD, please see the first course in this series titled ADHD: Nature, Course, Outcomes, and Comorbidity.

The vast majority of research has been conducted on children with ADHD with strikingly less attention to the efficacy of treatments for teens with the disorder.⁵ For instance, less than 5 percent of the studies done on medication management of ADHD children have been done with teens having the disorder; and only a handful of family training studies have focused on this age group. There also have been a plethora of studies on educational management strategies with children but far fewer with teens with ADHD. None of this means that there are no recommendations to make in these areas for teens with ADHD. It does mean that many will be based largely if not entirely on extrapolating (with caution!) from the child research and what little research on teens exists. That is fine up to a point but one must always recognize that adolescents’ psychological and physical stages of maturity, their developing sense of autonomy, and their emergence into the larger community require that adjustments be made even to the most effective of the treatments for childhood ADHD. Worth noting as well is that teens are far less likely to receive mental health services of all forms than are children⁶ perhaps owing to their increased autonomy and capacity to counteract efforts by parents to get them treatment. But it may also arise from the greater costs likely to be associated with the more extensive treatment that teens with ADHD and their families are likely to require.⁵

This course briefly describes the major interventions likely to be of benefit to children and teens with the disorder and raises issues that are necessary to address in treatment with this age group. It must be said at the outset, however, that no intervention has been found to cure this disorder. Treatment is therefore focused on symptom management and the reduction of secondary harms that may ensue if the disorder is left unmanaged. In this sense, treating ADHD is comparable to treating diabetes. A combination of medication and psychosocial accommodations may work very well to contain the disorder and preclude the occurrence of both secondary harms and even some comorbid disorders but treatment only works when used and often does not produce any enduring benefits if removed.

Advances in the treatment of ADHD over the past 20 years have been relatively circumscribed and have mainly occurred in the area of psychopharmacology rather than psychosocial treatments. This is not to say that more information on the prevailing treatments has not been gained. Just that no significant breakthroughs in the psychosocial treatment of the disorder have been forthcoming. Most research has clarified the efficacy (or lack of it) of already extant treatment approaches, or their combinations. Findings concerning multi-modality treatments have been especially sobering^7,8 though all have been conducted with children, not teens. Before discussing the efficacy of specific treatments for ADHD, it will be helpful to re-examine some traditional assumptions about the treatment of this disorder. They are being called into question not only by newer theoretical models⁴ but the results of research on the etiologies of the disorder (behavioral genetics and neuro-imaging) and on the efficacy of particular treatments.⁹

Re-examining Treatment Assumptions

Advances in research on the etiologies of ADHD and in theoretical models about the disorder seem to suggest why few treatment breakthroughs, especially in the psychosocial arena, have occurred. The information yielded from these sources increasingly points to ADHD as being a development disorder of probable neuro-genetic origins in which some unique environmental factors play a role in expression of the disorder (including biological hazards affecting brain development), though far less than do genetic ones.⁹ Common family environment factors, once thought to have a major effect on the disorder, now appear to have a minor and often insignificant role in determining individual variation in the traits making up ADHD.¹⁰ Thus, new family-focused treatments are unlikely to be discovered at this time that would result in an amelioration of the disorder or even its practical containment since they are unlikely to correct the underlying neurological substrates or genetic mechanisms that are contributing so strongly to it.

Contrary to the social learning models on which family interventions for ADHD were originally founded, children with ADHD are not tabula rasas on which socialization makes the major contribution to psychological development. The disorder is not learned through imitation of poor role models, and it surely does not arise from exposure to faulty contingencies such as through parenting. As with the learning disabilities and mental retardation that appear to have relatively analogous etiologies, treatment is actually symptomatic management or containment. It is management of a chronic developmental condition and involves finding means to cope with, compensate for, and accommodate to the developmental deficiencies.

These means also include the provision of symptomatic relief such as that obtained by various medications. And given the greater relative contribution of genotype to environment in explaining individual differences in the symptoms of the disorder, it is highly likely that treatments for ADHD, while providing improvements in the symptoms, do little to change the rank ordering of such individuals relative to each other in their post-treatment levels of ADHD. It is also likely that such treatments, particularly in the psychosocial realm, will prove to be specific to the treatment setting, showing minimal generalization without actively arranging for its occurrence.

The theoretical model of ADHD proposed by Barkley⁴ provides other reasons why treatment effects may be so limited. This is largely because, according to this model, ADHD does not result from a lack of skill, knowledge, or information. It is, therefore, not going to respond well to interventions emphasizing the transfer of knowledge or of skills, as might occur in psychotherapy, social skills training, cognitive therapies, or academic tutoring. All of these contain a tacit assumption that the client with ADHD is naïve about or ignorant of these skills. Yet no research has actually examined that issue in detail. Instead, in this model, ADHD is viewed as being a disorder of performance -- of doing what one knows rather than knowing what to do. It is more a disorder of “when” behavior should be performed rather than “how” to perform it. Like patients with injuries to the frontal lobes, those with ADHD find that it has partially cleaved or dissociated intellect from action, or knowledge from performance. Thus, the individual with ADHD may know how to act but may not act that way when placed in social settings where such action would be beneficial to them. The timing and timeliness of behavior is being disrupted more in ADHD than is the basic knowledge or skill about that behavior.

From this vantage point, treatments for ADHD will be most helpful when they assist with the performance of a particular behavior at the point (place and time) of performance in the natural environments where and when such behavior should be performed. A corollary of this is that the further away in space and time a treatment is from this point of performance, the less effective it is likely to be in assisting with the management of ADHD. This includes assistance at the “point of performance” with the time, timing, and timeliness of behavior in those with ADHD, not just in the training of the behavior itself. Nor will there necessarily be any lasting value or maintenance of treatment effects from such assistance if it is summarily removed within a short period of time once the individual is performing the desired behavior. The value of such treatments lies not only in providing assistance with eliciting behavior that is likely to already be in the individual’s repertoire at the point of performance where its display is critical, but in maintaining the performance of that behavior over time in that natural setting.

Disorders of performance like ADHD pose great consternation for the mental health and educational arenas of service. This is because at the core of such problems is the vexing issue of just how to get people to behave in ways that they know are good for them yet which they seem unlikely, unable, or unwilling to perform. Conveying more knowledge does not prove as helpful as altering the motivational parameters associated with the performance of that behavior at its appropriate point of performance. Coupled with this is the realization that such changes in behavior are maintained only so long as those environmental adjustments or accommodations are as well. To expect otherwise would seem to approach the treatment of ADHD with outdated or misguided assumptions about its essential nature.

This conceptual model of ADHD as a disorder of performance (executive functioning) has other implications for the management of ADHD too numerous to discuss in detail here. Some of them are:

• If the process of regulating behavior by internally represented forms of information (the internalization of behavior) is delayed in those with ADHD, then they will be best assisted by “externalizing” those forms of information; the provision of more external, physical representations of that information will be needed in the setting at the point of performance. Since covert or private information is weak as a source of stimulus control, making that information overt and public may assist with strengthening control of behavior by that information.
  
  
• The organization of the individual’s behavior across time is one of the ultimate disabilities rendered by the disorder. ADHD is to time what nearsightedness is to spatial vision; it has created a temporal myopia in which the individual’s behavior is governed even more than normal by events close to or within the temporal now and immediate context rather than by internal information that pertains to longer term, future events. Those with ADHD could be expected to be assisted then by making time itself more externally represented, by reducing or eliminating gaps in time among the components of a behavioral contingency (event, response, outcome), and by serving to bridge such temporal gaps related to future events with the assistance of caregivers and others.
  
  
• Given that the model hypothesizes a deficit in internally generated and represented forms of motivation that are needed to support goal-directed behavior, those with ADHD will require the provision of externalized sources of motivation. For instance, the provision of artificial rewards, such as tokens, may be needed throughout the performance of a task or goal-directed behavior when there is otherwise little or no such immediate consequences associated with that performance. Such artificial reward programs become for the ADHD teen like prosthetic devices or mechanical limbs to the physically disabled, allowing them to perform more effectively in some tasks and settings with which they otherwise would have considerable difficulty. The motivational disability created by ADHD makes such motivational prostheses nearly essential for most of those with ADHD. Yet the greater autonomy of teens from their parents and teachers, the more numerous adults teens are likely to be interacting with, the increasing time spent with peers and in unsupervised community settings, all make for difficulties in the provision of such prosthetic motivational devices. For instance, when a teen is driving home late on a weekend night from a dance at the high school, no one else is in the car to provide externalized information and prosthetic motivation, such as tokens, for the use of safe driving behavior. Many other such scenarios exist in the lives of ADHD teens where the delivery of psychosocial interventions is difficult if not impossible. Often, medication may be needed for such activities to insure control of the symptoms of the disorder and their impact on functioning in that setting and activity.

The theoretical model of ADHD discussed in the first ADHD course may offer some explanation for such limited treatment effects. For one thing, it model implies that the acquisition of skills is not likely to prove particularly useful in the treatment of ADHD given that the children’s primary problem lies more in the realm of performance than of knowledge. Cognitive-behavioral treatment is predominantly a skill training program and does little to address the performance problems of those with the disorder. But the theoretical model also suggests that there is a developmental delay in self-speech and its internalization that makes teaching verbal self-instruction procedures questionable as a means of treatment. Such self-speech may have less stimulus control over motor behavior in these children than in normal children. Moreover, the problem with self-speech lies downstream from the problem with response inhibition and thus self-instruction training is focusing on a secondary consequence of ADHD rather than on its primary deficit. Such a theoretical position would tend to strongly question the utility of cognitive-behavioral therapies for children with ADHD, at least as the major modality of intervention. For all of these reasons, then, this form of treatment will not receive any further attention here.

Similarly, social skills training is not likely to benefit ADHD children or teens. The social interaction problems of children with ADHD are quite heterogeneous, and are not likely to respond to a treatment package that focuses only on social approach strategies and that treats all ADHD children as if they shared common problems in their peer relationship difficulties. Nor is it especially clear at this time what the actual source of these peer difficulties happens to be or the mechanism by which it operates, with the exception of aggressive behavior as noted above. For instance, do ADHD children actually lack the knowledge of proper social skills or is it that they know how to act with others but do not do so at the points of performance in social interactions where such skills would be useful to have performed? The theoretical model presented earlier would suggest that the latter is likely to be more of a problem than the former, at least for children having ADHD without significant aggression. Teaching them additional skills is not so much the issue as is assisting them with the performance of the skills they have when it would be useful to do so at the point of performance where such skills are most likely to prove useful to the long-term social acceptance of the individual.

Those ADHD children with comorbid aggression may well have additional problems with peer perceptions, particularly around the motives they attribute to others for their behavior, as well as in information processing about social interactions.¹¹ This combination of both perceptual/information processing deficits along with problems with the performance of social skills in social interactions with others may make ADHD children with aggression particularly resistant to social skills training.¹² And so until more evidence for the efficacy of social skills training for ADHD children is forthcoming, this form of treatment will receive no further coverage here.

Ineffective or Unproved Therapies

A variety of treatments have been attempted with ADHD children over the past century ‑‑ far too numerous to review here.¹³ Vestibular stimulation,¹⁴ running,¹⁵ EMG biofeedback and relaxation training,¹⁶ sensory integration training,¹⁷ EEG biofeedback or neuro-feedback,¹⁸ among others, have been described as potentially effective in either uncontrolled case reports, small series of case studies, or in some treatment vs. no-treatment comparisons, yet are lacking in well‑controlled experimental replications of their efficacy. Many dietary treatments, such as removal of additives, colorings, or sugar from the diet or addition of high doses of vitamins, minerals, or other “health food” supplements to the diet have proven very popular despite minimal or no scientific support.^13,19 Certainly traditional psychotherapy and play therapy have not proven especially effective for ADHD or other externalizing disorders.²⁰

The provision of cognitive-behavioral treatment, or cognitive therapy, was previously felt to hold some promise for children with ADHD. Indeed, a few small-scale studies suggested some benefits to this form of treatment when used with ADHD children.²¹ But this form of treatment has been challenged as being seriously flawed from a conceptual (Vygotskian) point of view on which the treatment was initially founded.²² And its efficacy for impulsive children or those with ADHD has been repeatedly questioned by the rather poor or limited results of empirical research.²³ In the most ambitious cognitive-behavioral program ever under taken and involving the training of parents, teachers, and children, researchers found no significant treatment-specific effects on any of a variety of dependent measures with the exception of class observations of off-task/disruptive behavior.²⁴ Even this treatment effect was not maintained at 6-week follow-up. Reviews of this literature using meta-analyses have typically found the effect sizes to be only about a third of a standard deviation and, in many studies, even less than this.^25,26 While such treatment effects may at times rise to the level of statistical significance, they are nonetheless of only modest clinical importance and usually are to be found mainly on relatively circumscribed lab measures rather than more clinically important measures of functioning in natural settings.

As noted above, social skills training will receive no further attention here. Again, this is largely due to the fact that reviews of this treatment as applied specifically to children with ADHD have been quite discouraging.^27,28 A recent study of social skills training (SST) in subtypes of ADHD children²⁹ found some benefit on parent and child-rated assertion skills but no benefits on other domains of social competence. Those with comorbid ODD appeared to benefit little from the program while those with the inattentive type of ADHD improved more than the Combined Type in assertion skills (but not in other domains of social competence). By follow-up, these few gains especially in the inattentive type were not sustained. Of some concern was the small subset of I-type children whose parents rated them as significantly worse following SST, perhaps owing to a social contagion effect of being in training with more aggressive peers.³⁰ The authors concluded that SST had little efficacy for addressing the social problems of ADHD children, consistent with other studies.^31,32

Those treatments with some proven efficacy for assisting ADHD teens and their families are:

1. medications;
2. parent training in contingency management methods;³³
3. parent-teen training in problem-solving and communication skills;³⁴
4. classroom applications of contingency management techniques;^31,32 and
5. assorted combinations of these approaches with psychopharmacology.

Medications for Managing ADHD

Four classes of psychotropic drugs have proven useful in the management of ADHD symptoms: the stimulants, noradrenergic reuptake inhibitors, tricyclic antidepressants, and the antihypertensives.

Stimulant Medication

Since Bradley first (accidentally) discovered their successful use with behavior problem children in 1937,³⁶ the stimulants have received an enormous amount of research; far more than any known treatment for any childhood psychiatric disorder. The results overwhelmingly indicate that these medications are quite effective for the management of ADHD symptoms in most children older than 5 years.^37,38 Between 4 and 5 years of age, the response rate is probably much less, and under 3 years of age, the drugs are not recommended for use. The effectiveness of these medications has led to their widespread use with ADHD children, with approximately 2.8 percent of the school‑age population possibly being treated with stimulants for ADHD symptoms.³⁹ These medications may be nearly as useful with ADHD adolescents,⁵ although fewer than 10 studies exist with this age group.

The most commonly prescribed stimulants are methlyphenidate (Ritalin, Concerta, Metadate CD, Focalin), d‑amphetamine (Dexedrine or Dextrostat), d- and l-amphetamine combination (Adderall, Adderall XR), and pemoline (Cylert). Methylphenidate (MPH) appears to work by slowing down dopamine reuptake from the extracellular space. The amphetamines appear to work by primarily increasing dopamine release but may also have some effect on reuptake. It is not known how pemoline achieves its therapeutic effect. Because of the potential for liver complications,³⁸ pemoline is no longer recommended for use with patients unless frequent monitoring of liver functioning is undertaken. It receives no further attention here given its near disuse in treating children. Adderall is a recently approved stimulant compound for use in the management of ADHD. It is a combination of different forms of amphetamine salts that is effective in the treatment of symptoms of ADHD in children^40,41 and adults.⁴²

MPH (in various forms) and amphetamine (AMP) are the most commonly prescribed medications for ADHD. In their original forms, they are rapidly acting stimulants, producing effects on behavior within 30 to 45 minutes after oral ingestion of their standard preparations and peaking in their behavioral effects within 2 to 4 hours.⁴³ Their utility in managing behavior quickly dissipates within 3 to 7 hours, although minuscule amounts of the medication may remain in the blood for up to 24 hours.^37,43 Because of their short half‑life, they were often prescribed 2-3 times per day, posing great inconvenience and the requirement for school administration of at least one (noon) dose. Although once used predominantly for school days, there is an increasing clinical trend toward usage throughout the week as well as school vacations. This is the result of more recent discoveries that the growth of ADHD children on stimulants is not as seriously affected as was once believed⁴⁴ and so the rationale for universal drug holidays is no longer justifiable. Focalin, or dex-methlyphenidate, was recently approved for use in ADHD. It is simply the right turning methylphenidate molecule. Some research suggests this may be the effective form of this medication as opposed to the left turning molecule (levo-methylphenidate). It is otherwise identical in effects and side effects to methylphenidate but requires only half the typical dose of MPH.

Both MPH and AMP later came in slow release preparations (Ritalin SR; Dexedrine spansules) that reduced the number of daily doses children require for management of their ADHD. But their control of behavior was less than ideal owing to sub-optimal blood levels during the sustained release of the medication. New and more effective delivery systems have been invented over the past 5 years that make these earlier slow release formulations nearly outdated. These include Concerta, Metadate CD, and Ritalin LA for methylphenidate delivery and Adderall XR for mixed amphetamine delivery. Concerta is a miniature osmotic pump resembling a capsule that oozes liquid methyphenidate while transversing the gut for an interval of 10-12 hours.⁴⁵ Metadate CD, Ritalin LA, and Focalin XR are tiny MPH pellets having various time-release coatings applied to them such that they dissolve at increasingly longer time intervals as they course through the gut and last for roughly 8-12 hours. Adderall XR uses the same pellet technology for delivery of a mixed amphetamine salts compoint. These pellet release systems have the advantage of being able to be opened and sprinkled on soft food for easier oral ingestion in patients having difficulties swallowing tablets or capsules without affecting its pharmacokinetic properties.⁴⁶ The latest delivery system is Vyvanse, a newly created pro-drug that combines the mixed amphetamine salt compound used in Adderall XR with another chemical that prevents the amphetamine from activating unless it is in the human gut (stomach or intestines). It has an advantage of having a longer-lasting effect on behavior than does Adderall or Adderall XR while not being potentially abusable.

The behavioral improvements produced by MPH and AMP occur in sustained attention, impulse control, and reduction of task‑ irrelevant activity, especially in settings demanding restraint of behavior.^37,38 Generally noisy and disruptive behavior also diminishes with medication. ADHD children may become more compliant with parental and teacher commands, are better able to sustain such compliance, and often increase their cooperative behavior toward others with whom they may have to accomplish a task as a consequence of stimulant treatment. ADHD children are able to perceive the medication as beneficial to the reduction of ADHD symptoms and even describe improvements in their self-esteem, though they may report somewhat more side effects than do their parents and teachers.

Drug-related improvements in other domains of behavior include: aggression; handwriting; academic productivity and accuracy, persistence of effort, working memory, peer relations, emotional control, and participation in sports, among others.^37,38,43 The effects of medication are idiosyncratic, with some children showing maximal improvement at lower doses while others are most improved at higher doses of medication. Stimulants appear to remain useful in the management of ADHD over extended periods of time^8,38 and can be used successfully into adulthood.

Side effects include mild insomnia and appetite reduction, particular at the noon meal.³⁷ Temporary suppression of weight gain may accompany stimulant treatment initially, but is not generally severe nor especially common, may rebound in the second year of treatment, and can be managed by insuring that adequate caloric and nutritional intake is maintained by shifting the distribution of food intake to other times of the day when the child is more amenable to eating. A small percentage of ADHD children may complain of stomachaches and headaches when treated with stimulants, but these tend to dissipate within a few weeks of beginning medication or can be managed by reducing the dose. In approximately 1 to 2 percent of ADHD children treated with stimulants, motor or vocal tics may occur.³⁸ In others where tics already exist, they can be mildly exacerbated by stimulant treatment in some cases, but may even be improved in others. It now appears to be relatively safe to use stimulant medications with children with ADHD and comorbid tic disorders but to be prepared to reduce the dose or discontinue medication should the child experience a drug-related exacerbation of their tic symptoms.

There is little doubt now that the stimulant medications are the most studied and most effective treatment for the symptomatic management of ADHD and its secondary consequences. Their side effects are relatively benign, particularly in comparison to other psychiatric drugs. For many children with moderate to severe levels of ADHD, this may be the first treatment employed in their clinical management. Other treatments may then be added adjuncts for domains of impairment unaffected by medication or when medication-free periods are required.

Norepinephrine Reuptake Inhibitors

Several medications are now available that have some therapeutic benefit for the management of ADHD and that function by slowing reuptake of norepinephrine. The noradrenergic reuptake inhibitors are bupropion (Wellbutrin) and most recently (January 2003), atomoxetine (Strattera). Bupropion appears to affect both noradrenergic and dopaminegergic systems. Several studies with ADHD children and one more recently with adults show that it results in significant improvement in ADHD symptoms relative to placebo.⁴⁷ The beneficial effects are not as substantial or dramatic as those achieved by the stimulants. Potential side effects include edema, rashes, irritability, loss of appetite, seizures (rare), and insomnia. No studies have examined this medication with teens with ADHD but there is no doubt it would prove of some effectiveness for them in view of its demonstrated efficacy with children and adults having the disorder.

Atomoxetine (Strattera) is the first new molecule for the treatment of ADHD approved by the FDA since 1975. Indications have been approved for children, teens, and adults with ADHD. Over the past 10 years, Eli Lilly has conducted various studies of atomoxetine relative to placebo and in some cases to MPH. Further research continues to be done examining the effect of the drug on specific domains of functioning in children (family functioning) and adults (occupational functioning, driving, etc.) with ADHD. Unlike bupropion, atomoxetine works selectively on noradrenergic reuptake thereby making more norepinephrine available in the extra neuronal space. Atomoxetine has been studied in at least 6 acute, large, randomized, double-blind, placebo-controlled studies (2 in children, 2 in children and adolescents, and 2 in adults).⁴⁸ One trial in children was conducted with once-daily dosing (6 weeks), while the others employed twice-daily dosing, all on weight-adjusted basis (8-9 weeks). Adults were dosed twice daily over 10 weeks in dose escalation within a fixed range. In all studies, atomoxetine was superior to placebo in reduction of mean symptom ratings for the primary outcome measure. The effect size for once-daily treatment was similar to that of twice-daily treatment. No serious safety concerns have been observed and tolerability has been good, evidenced by discontinuation rates for adverse events under 5% in the pediatric studies.

The long-term safety of atomoxetine was assessed using data from clinical trials in children and adolescents treated for at least 3years. Tolerability and safety were assessed by evaluating discontinuations, adverse events, weight, and height. More than 4.5 million patients have been treated with atomoxetine as of this writing. Over 6000 patients have been exposed to atomoxetine in these and other clinical trials, with over 400 treated for at least 1 year. Discontinuations due to adverse events were uncommon (<5%). The most common side effects are sedation and nausea. Reports of decreased appetite and weight loss, which were reported statistically significantly more often than with placebo in acute trials, continued to decline during long-term treatment, as did other adverse events. After at least 1 year of treatment, atomoxetine increased mean heart rate 6.4 BPM and increased mean diastolic blood pressure 2.8 mmHg. For patients who lost weight, it tended to occur early in treatment (mean 0.5 kg in acute studies). Over longer treatment periods, weight increased (mean 4.0 kg after 1 year). Because 1 year is a relatively short period in the growth of many children, analyses of height increases are inconclusive, and require data over longer treatment periods. Atomoxetine appears to be safe and efficacious for the treatment of ADHD in children, adolescents, and adults and of equal efficacy for the reduction of ADHD symptoms in comparison to MPH.

Antidepressant Medication

Clinicians have used the tricyclic antidepressants, such as imipramine and desipramine, for the management of ADHD symptoms.⁴⁷ In part this has been due to the occasional negative (and often undeserving) publicity in the popular media focusing on the stimulants, and especially Ritalin. But the rise in antidepressant use may also have resulted from cases where stimulants have been contraindicated or have not been especially effective or where significant comorbid mood disturbance may exist. Less is known about the pharmacokinetics and behavioral effects of the antidepressants in children with ADHD as compared to the stimulants. However, research on these compounds, particularly desipramine, increased in the early 1990s and generally supports their efficacy in the management of ADHD. Often given twice daily (morning and evening), these medications are longer acting than the stimulants. As a result, it takes longer to evaluate the therapeutic value of any given dose. Some research suggests that low doses of the tricyclics may mimic stimulants in producing increased vigilance and sustained attention and decreased impulsivity. As a result, disruptive and aggressive behavior may also be reduced. Elevation in mood may also occur, particularly in those children in whom significant pre‑treatment levels of depression and anxiety exist. Treatment effects may diminish over time, however, such that the tricyclics cannot be used as long‑term therapy for ADHD, unlike the stimulants.

The most common side effects of the tricyclics are drowsiness during the first few days of treatment, dry mouth and constipation, and flushing. Less likely yet more important are the cardio-toxic effects, such as possible tachycardia or arrhythmia, and in cases of overdose, coma or death. Some children may develop sluggish reactions in focusing of the optic lens that may mimic nearsightedness. The reaction is not permanent, dissipating when treatment is withdrawn. Skin rash is occasionally reported and usually warrants ceasing drug treatment.

In general, clinicians would find it preferable to use atomoxetine first as an alternative to the tricylcic antidepressants owing largely to the greater safety and information available on the former medication. The tricyclic antidepressants may be useful in the short‑term treatment of ADHD children when the stimulants or atomoxetine are not effective. However, care must be taken to properly evaluate the cardiac functioning of children before initiating treatment and then periodically monitor such functioning throughout the course of treatment given the apparent risks of the tricyclic antidepressants for impairing cardiac functioning (see Wilens et al.,⁴⁹ for a review and guidelines for monitoring children on tricyclic antidepressants).

Antihypertensive Medication

In the late 1980s, a small number of research papers appeared suggesting that the antihypertensive drug, clonidine (Catapres), may be beneficial in the management of ADHD symptoms, particularly in the reduction of hyperactivity and over-arousal.⁵⁰ Another antihypertensive drug, guanfacine (Tenex) may also have some utility in managing ADHD.⁵⁰ These drugs are believed to act as alpha-2 adrenergic agonist that ultimately leads to the inhibition of the release of norepinephrine, increasing dopamine turnover, and reducing blood serotonin levels.⁵⁰ Some changes in behavior may be the result of the general sedation produced by the medication but others appear to be specific to improvements in activity regulation and attention. The limited research to date suggests that the drug is much less effective than the stimulants at improving inattention and school productivity but may be equally as efficacious in the reduction of hyperactivity and moodiness. The drug may also be useful in managing the sleep disturbances that some ADHD children may experience. Side effects include drowsiness, dizziness, weakness, and occasional sleep disturbance. Rarer side effects include nausea, vomiting, cardiac arrhythmia, irritability, and orthostatic hypotension. Werry and Aman⁵¹ have recommended that clonidine be employed in the treatment of ADHD only as a last line of medical management where stimulants have proven ineffective or are contraindicated. Given the recent availability and greater safety of atomoxetine, it would certainly be used ahead of the antihypertensives in the management of ADHD.

Direct Applications of Contingency Management

The initial rationale for the use of behavior modification techniques with ADHD children was often founded on their success in the management of behavior problems among mentally retarded children and on purported limitations and potential side effects of stimulant drug therapy rather than on its own merits for the management of ADHD. By themselves, such arguments provide a rather nonspecific rationale for undertaking such treatment. Moreover, at least one of these reasons can now be seen to have been based on outdated information concerning the side effects of stimulants, which are clearly more benign than were previously thought to be the case.³⁸

Stimulant medications typically result in as much or greater improvements in behavior in comparison to behavior modification as well as result in frequently greater improvements in academic productivity. Given this state of affairs, such medications may be viewed by some as the preferred first-line treatment for ADHD in place of behavior modification or at least necessary to combine with behavior modification methods to achieve maximal treatment effects. More convincing for the justification of using behavior modification techniques for ADHD is the argument that since referral of children for ADHD, in part, rests on the social distress they have created for their caregivers, an intervention which attempts to change the interaction between children and their caregivers should be quite useful.

A variation on this theme once provided an even more direct rationale for using behavioral interventions with ADHD children. Willis and Lovaas⁵² proposed that ADHD reflects poor stimulus control of behavior by parental commands resulting from the inconsistent or inadequate use of child management methods by the parents. Training parents in more consistent and effective child management should reduce, or even eliminate, the ADHD symptoms. However, such a theory of ADHD can now be dismissed on the grounds that the inconsistent, negative, or punitive management techniques of some parents of ADHD children have been shown to be more often associated with oppositional defiant disorder frequently seen in conjunction with ADHD than with ADHD itself.⁵³ Moreover, research suggests that the negative and controlling behavior of parents toward their ADHD children is more a reaction to than a cause of their children's inappropriate behavior. ⁵⁴Also, some parents of ADHD children do not show such poor management skills. And parent training does not normalize the ADHD symptoms of children nor do its effects generalize to other, no‑treatment settings such as school where ADHD symptoms may be equally problematic. The evidence seems to be against the concept of "bad parenting" as a primary etiology of ADHD and so this rationale can not be considered a reasonable justification for undertaking parent training with ADHD children.

But with the recent trend toward viewing ADHD as a potential problem in response inhibition and self-regulation in children and the secondary consequences this may create for their poor self-motivation to persist at assigned tasks, a persuasive theoretically-based rationale for employing behavioral interventions with ADHD may now exist. If ADHD is in fact a developmental delay in the self-regulation of behavior by internal means of representing information and motivating goal-directed behavior, then interventions which directly alter the nature of the stimuli controlling behavior as well as the pattern, timing, or salience of such consequences by socially arranged means would be useful, at least for symptomatic reduction in some settings and tasks. Such procedures for the manipulation of antecedent and consequent events are precisely those provided by the behavior therapies. A logical extension of this argument holds, however, that such socially arranged means of addressing this neurologically-based dysregulation would not alter the underlying neurophysiological basis for it. These techniques must be employed across situations over extended time intervals (months to years) much as prosthetic devices (e.g., hearing aides, mechanical limbs, etc.) are employed to compensate for physically handicapping conditions. Premature removal of the socially arranged motivational programs would predictably result in an eventual return to pre‑treatment levels of the behavioral symptoms. Also, use of the behavioral techniques in only one environment would be unlikely to affect rates of ADHD symptoms in other, untreated settings unless generalization had been intentionally programmed to occur across such settings. The research reviewed below for the various behavioral techniques seems to support this interpretation.

A number of early studies evaluated the effects of reinforcement and punishment, usually response cost, on the behavior and cognitive performance of ADHD children. These studies usually indicated that the performance of ADHD children on tasks measuring vigilance or impulse control or on academic-like tasks can be immediately and significantly improved by the use of stimulus control techniques or by the contingent application of consequences. In some cases, the behavior of ADHD children approximates that of normal control children. However, none of these studies examined the degree to which such changes endured after treatment withdrawal or, more importantly, generalized to the natural environments of the children, calling into question the clinical efficacy of such an approach. Given the findings of highly limited generalization and maintenance of treatment effects for the classroom interventions described below, it is unlikely that behavioral techniques implemented only in the clinic or laboratory would carry over into the home or school settings of these children without formal programming for such generalization and maintenance. Consequently, they receive no further attention here.

Important to note here is that virtually no research has focused on the effectiveness of the aforementioned behavioral treatments using teens with ADHD. Given the limited success and particularly limited generalization and maintenance of such approaches they are unlikely to receive such attention in the future. The overall treatment limiting features of these approaches, and the psychosocial ones discussed below, are telling of why they would be of limited utility with teens:

1. their reliance on the compassion and willingness of others to employ them with teenagers with ADHD when those others may have little time or inclination to do so;
2. the progressively greater time teens spend away from caregivers, often with peers, who are frequently not part of the treatment team;
3. the greater number of educators that teens are likely to take classes with than are children and the greater likelihood they will not comply with recommendations or do so only half-heartedly;
4. the increasing opportunity for teens to spend time with others and in places largely out of reach of psychosocial treatments (employment settings, driving, shopping at the mall, playing sports, etc.); and
5. the increasing capacity and desire for self-determination and freedom from coercion by others.

Moreover, in view of the latter, teens can exert effective counter-control against attempts by others to alter their behavior. In this case, intervening with teens becomes more akin to treating adults with mental disorders, placing far greater reliance on the willingness of the teen to cooperate with treatment recommendations. As in all other areas of adolescent medicine and clinical psychology, compliance with treatment becomes a, if not the, paramount issue in the management of ADHD in teens. And it is fair to say that most of these teens do not necessarily want the help or fully invest themselves in the treatments their parents may seek for them.

Training Parents in Behavior Management Methods

Despite the plethora of research on parent training in child behavior modification,³³ only a small number of studies have examined the efficacy of this approach with children specifically selected for hyperactive or ADHD symptoms and only two have studied its efficacy specifically with ADHD teens.^55,56 What limited research exists can be interpreted with cautious optimism as supporting the use of behavioral parent training with ADHD children.³⁵ Far fewer studies have been done with teens with ADHD. The results for teens are less impressive but still suggest some benefits to a minority of families.

Those treatment techniques used to date with ADHD children have primarily consisted of training parents in general contingency management tactics, such as contingent application of reinforcement or punishment following appropriate/inappropriate behaviors. Reinforcement procedures have typically relied on praise or tokens while punishment methods have usually been loss of tokens or time out from reinforcement. Why these particular methods were chosen or what specific target behaviors they were used with have often gone unreported. I have developed a parent-training program for ADHD children, the methods of which have been borrowed from research indicating their efficacy in managing defiant and oppositional children.⁶³

The program has been modified somewhat for families of ADHD teens³⁴ and even tested in combination with training of both parents and teens in problem-solving and communication skills.^55,56 Such treatments are viewed as being more relevant to the oppositional/defiant behaviors associated with ADHD in such cases rather than being likely to change the symptoms of ADHD or their underlying causes. The contingency management portion of the program consists of 10 steps, with 1 to 2 hour weekly training sessions provided either in groups or to individual families. Each step is briefly noted below and described in detail elsewhere. The program focuses on teaching parents about ADHD and ODD, how to implement greater use of positive attention, praise, and tangible reinforcers, improving commands and instructions, setting up a home point system, home punishment tactics, managing children in public places, implementing a daily school behavior report card, and several booster sessions.

The author’s program consists of 10 steps briefly presented below:

1. Review of Information on ADHD: In the first session, the therapist provides a succinct overview of the nature, developmental course, prognosis, and etiologies of ADHD. Providing the parents with additional reading materials can be a useful addition to this session. Professional videotapes are also available that present such an overview and can be loaned to parents for review at home and sharing with relatives or teachers, as needed. Such a session is essential in parent training to dispel a number of misconceptions parents often have about ADHD in children. A recent study suggests that just this provision of information can result not only in improved knowledge of parents about ADHD but also in improved parental perceptions of the degree of deviance of their child’s behavioral difficulties.

2. The Causes of Oppositional/Defiant Behavior: Next, parents are provided with an in‑depth discussion of those factors identified in past research as contributing to the development of defiant behavior in children. Essentially, four major contributors are discussed, these being: (a) Child characteristics, such as health, developmental disabilities, and temperament; (b) Parent characteristics similar to those described for the child; (c) Situational consequences for oppositional and coercive behavior; and (d) Stressful family events. Parents are taught that where problems exist in (a), (b), and (d), they increase the probability of children displaying bouts of coercive, defiant behavior. However, the consequences for such defiance, (c) above, seem to determine whether that behavior will be maintained or even increased in subsequent situations where commands and rules are given. Such behavior appears to primarily function as escape/avoidance learning in which oppositional behavior succeeds in the child escaping from aversive parent interactions and task demands, negatively reinforcing the child's coercion. As in the first session, this content is covered so as to correct potential misconceptions which parents have about defiance (i.e., it is primarily attention‑getting in nature). This session can be augmented by the use of two professional videotapes on the nature of oppositional defiant behavior.

3. Developing and Enhancing Parental Attention: The value of verbal praise and social reinforcement to oppositional or hyperactive children may be greatly reduced, making it weak as a reinforcer for compliance. In this session, parents are trained in more effective ways of attending to child behavior so as to enhance the value of their attention to their children. The technique consists of verbal narration and occasional positive statements to the child with attention being strategically deployed only when appropriate behaviors are displayed by the child. Parents are taught to ignore inappropriate behaviors but to greatly increase their attention to ongoing prosocial and compliant child behaviors.

4. Attending to Child Compliance and Independent Play: This session extends the techniques developed in Session 3 to instances when parents issue direct commands to children. Parents are trained in methods of giving effective commands, such as reducing question‑like commands (e.g., Why don't you pick‑up your toys now?), increasing imperatives, eliminating setting activities which compete with task performance (e.g., television), reducing task complexity, etc. They are then encouraged to begin using a more effective commanding style and to pay immediate positive attention when compliance is initiated by the child. As part of this assignment, parents are asked to increase the frequency with which they give brief commands to their child this week and to reinforce each command obeyed. Research suggests that these brief commands are more likely to be obeyed thereby providing excellent training opportunities for attending to compliance. In this session, parents are also trained to provide more positive attention frequently and systematically when their children are engaged in nondisruptive activities while parents must be occupied with some other work or activity. Essentially, the method taught here amounts to a shaping procedure in which parents provide frequent praise and attention for progressively longer periods of child nondisruptive activities.

5. Establishing a Home Token Economy: As noted above in discussing the theoretical model of ADHD, children with the disorder may require more frequent, immediate, and salient consequences for appropriate behavior and compliance in order to maintain it. If this is correct, then instituting a home token economy is critical to addressing these difficulties with intrinsically generated and represented motivation by bringing more salient external consequences, more immediately, and more frequently to bear on child compliance than is typically the case. In establishing this program, the parents list most of the children's home responsibilities and privileges and then assign values of points or chips to each. The parents are encouraged to have at least 12 to 15 reinforcers on the menu so as to maintain the motivating properties of the program. Generally, plastic chips are used with children 8 or younger as they seem to value the tangible features of the token. For 9 year olds or older, points recorded in a notebook seem sufficient.

During the first week of this program, the parents are not to fine the child or remove points for misconduct. The program is for rewarding good behavior only. Parents are also asked to be liberal in awarding chips to children for even minor instances of appropriate conduct. However, chips are given only for obeying first requests. If a command must be repeated, it must still be obeyed but the opportunity to earn chips has been forfeited. Parents are also encouraged to give bonus chips for good attitude or emotional regulation in their children. For instance, if a command is obeyed quickly, without complaint, and with a positive attitude, parents may give the child additional chips beyond those typically given for that job. Where this is used, parents are to expressly note that the awarding of the additional chips is for a positive attitude. Families are encouraged to establish and maintain such programs for at least 6 to 8 weeks to allow for the newly developed interaction patterns spawned by such programs to become habit patterns in dealing with child compliance.

6. Implementing Time Out for Noncompliance: Parents are now trained to use response cost (removal of points or chips) contingent on noncompliance. In addition, they are trained in an effective time‑out‑from‑reinforcement technique for use with two serious forms of defiance which may continue to be problematic despite the use of the home token economy. These two misbehaviors are selected in consultation with the parents and typically involve a type of command or household rule which the child continues to defy despite parental use of previous treatment strategies. Time out is limited to these two forms of misconduct so as to keep it from being used excessively during the next week.

The time out procedure taught to parents often differs from that commonly used by them. First, the time out is to be implemented shortly after noncompliance by a child begins. Parents often wait until they are very upset with a child before instituting punishment, often repeating their commands frequently to a child in the interim. In this program, parents issue a command, wait 5 seconds, issue a warning, wait another 5 seconds, and then take the child to time out immediately should compliance not have begun to these commands or warnings. Second, children are not given control over the time out interval as they often are in many households. For instance, parents often place a child in time out then say the child can leave time out when they are quiet, ready to do as the parent asked, or when a timer signals the end of the interval. In each of these cases, determination as to when the time out interval ends is no longer under the parents’ control. This program teaches parents to simply tell the child to not leave the time out chair until the parent tells them to. Three conditions must be met by the child before time out ends and these are in a hierarchy:

1. The child must serve a minimum sentence in time out, usually 1 to 2 minutes for each year of their age;
2. the child must then become quiet for a brief period of time so as not to have disruption associated with the parents approaching the time out chair and talking to the child; and
3. the child must then agree to obey the command.
   
   

Failure of the child to remain in time out until all three conditions are met is dealt with by additional punishment. The consequence is tailored to meet parental wishes but may consist of a fine within the home token system, extension of the time out interval an additional 5 or 10 minutes, or placement of the child in his or her bedroom. In the latter case, toys or other entertaining activities are previously removed from the bedroom and the door to the room may be closed and locked to preclude further escape from the punishment.

7. Extending Time Out to Additional Noncompliant Behaviors: In this session, no new material is taught to parents. Instead, any problems with previously implementing time out are reviewed and corrected. Parents may then extend their use of time out to one or two additional noncompliant behaviors with which the child may still have trouble.

8. Managing Noncompliance in Public Places: Parents are now taught to extrapolate their home management methods to troublesome public places, such as stores, church, restaurants, etc. Using a "think aloud‑think ahead" paradigm, parents are taught to stop just before entering a public place, review two or three rules with the child which the child may previously have defied, explain to the child what reinforcers are available for obedience in the place, then explain what punishment may occur for disobedience, and finally assign the child an activity to perform during the outing. Parents then enter the public place and immediately begin attending to and reinforcing ongoing child compliance with the previously stated rules. Time out or response cost are used immediately for disobedience.

Time out in a public place may require slight modification from its use at home. For instance, parents may be taught to stand the child against the farthest wall from the central aisle of a store to serve as the time out location. If inconvenient, then taking the child to a restroom or having him face the side of a display cabinet may be adequate substitutes. If unavailable, then taking the child outside the building to face the front wall or returning to the car can be used for time out. When none of these locations seem appropriate, parents can be trained to use a delayed punishment contingency. In this case, the parent carries a small spiral notebook to the public place and, before entering the building, indicates that rule violations will be recorded in the book and the child will serve time out for them upon return home from this trip. I encourage parents to keep a picture of the child sitting in time out at home with this notebook and to show it to the child before entering the public building. This serves as a reminder to the child of what may be in store should a rule be violated. Whenever time out is used in a public place, it need not be for as long an interval as at home. I have found that half of the usual time out interval may be sufficient for public misbehavior given the richly reinforcing activities in public places from which the child has just been removed.

9. Improving Child School Behavior From Home: The Daily School Behavior Report Card: This session is a recent addition³³ to the original parent training program and was designed to help parents assist their child’s teacher with the management of classroom behavior problems. The session focuses on training parents in the use of a home-based reward program in which children are evaluated on a daily school behavior report card by their teachers and this card serves as the means by which consequences later in the day will be dispensed at home for classroom conduct. The card can be designed to address class behavior, recess or free time behavior, or more specific behavioral targets for any given child. The consequences provided at home typically consist of the rewarding or removal of tokens or points within the home token system as a function of the ratings the child has received from their teachers on this daily behavioral report card.

10. Managing Future Misconduct: By now, parents should have acquired an effective repertoire of child management techniques. The goal of this session is to get parents to think about how they might be implemented in the future if some other forms of noncompliance developed. The therapist challenges the parents with misbehaviors they have not seen yet and asks them to explain how they might use their recently acquired skills to manage these problems.

One Month Review/Booster Session: In what is typically the final session, the concepts taught in earlier sessions are briefly reviewed, problems which have arisen in the last month are discussed, and plans made for their correction. Other sessions may be needed to deal with additional issues that persist but for most families, the previous 10 sessions appear adequate for improving rates of compliant behavior in ADHD children.

The program is intended for children ages 2 to 11 years where oppositional or defiant behavior is an issue.

Research suggests that up to 64 percent of families experience clinically significant change or recovery (normalization) of their child’s disruptive behavior as a consequence of this program.⁵⁷ However, improvements in behavior may be more concentrated in the realm of aggressive and defiant child behavior than in inattentive-hyperactive symptoms. All of these studies have relied on clinic-referred families most of whom sought ought the assistance of mental health professionals for their children. Both studies my colleagues and I conducted with this program slightly modified for teens found significant improvement at the group level of analysis. That is, all treatment groups improved from pre- to post-treatment. But at the individual level of analysis, a mixed picture emerged. While 31-70% of families were brought to within the normal range (75th percentile or lower), only 23-30 percent of treated families actually showed what could be considered reliable changes (unlikely to be due to unreliability of measurement alone) on measures of parent-teen conflict – results that did not differ from the problem-solving approach discussed next.^55,56

We have also examined a family training program that includes Problem Solving Communication Training Program (PSCT) procedures developed by Robin and Foster.⁶⁰ This treatment program contains three major components for changing parent‑adolescent conflict:

1. problem‑solving: training parents and teens in a 5 step problem solving approach (i.e., problem definition, brainstorming of possible solutions, negotiation, decision making about a solution, implementation of the solution).
2. Communication training: helping parents and teens to develop more effective communication skills while discussing family conflicts, such as speaking in an even tone of voice, paraphrasing others’ concerns before speaking ones’ own, providing approval to others for positive communication, and avoiding insults, put-downs, ultimatums, and other poor communication skills.
3. Cognitive restructuring: helping families detect, confront, and restructure irrational, extreme, or rigid belief systems held by parents or teens about their own or the other's conduct.

These skills are practiced with the therapist during each session using direct instruction, modeling, behavior rehearsal, role‑playing, and feedback. Homework assignments are also given that involved the family using PSCT skills during a conflict discussion at home and audio taping these for later review by the therapist.

This procedure has been studied both separately and in combination with the above behavioral parent training procedure. The combination of the two approaches was superior to PSCT alone in just one respect, though it is an important one. Significantly more families in the combined group (receiving BMT first) stayed in treatment than did those receiving just PSCT.⁵⁶ Otherwise, the groups did not differ, either in their group level improvements or in rates of normalization and reliable change. At most, 23 percent showed reliable change while 31-70 percent showed normalization. We believe the former is a better indicator of true change occurring as a function of treatment over and above the expected unreliability of the measures used to assess treatment effects. Of some concern was that up to 17 percent of families showed significant worsening of family conflicts as a function of treatment, especially with PSCT, perhaps because treatment forces them to confront issues of conflict that at home they may otherwise have avoided directly discussing.

In sum, family treatments do not appear to be useful for the management of symptoms of ADHD. Their utility may be in addressing the parent-teen conflicts that often arise in such families, especially where ODD may be a comorbid disorder. Family training may be maximally effective for elementary-aged ADHD children. Its utility may decline for adolescents, where only a minority of families (<30%) derive clinically reliable change due to treatment. The combination of BMT with PSCT seems to be the most useful, if only in reducing rates of dropouts from treatment. Yet some families may actually show a worsening of conflicts as a function of treatment, apparently more so with PSCT.

Training Teachers in Classroom Management

More research has occurred on the application of behavior management methods in the classroom with ADHD children than with parent training. Moreover, there is a voluminous literature on the application of classroom management methods to disruptive child behaviors, many of which include the typical symptoms of ADHD. This research clearly indicates the effectiveness of behavioral techniques in the short‑term treatment of academic performance problems in ADHD children. I am aware of no studies that have tested these procedures directly with ADHD teens in school settings.

A meta-analysis of the research literature on school interventions for children with ADHD was conducted that comprised 70 separate experiments of various within- and between-subjects designs as well as single-case designs.^31,35 This review found an overall mean effect size for contingency management procedures of 0.60 for between-subject designs, nearly 1.00 for within-subject designs, and approximately 1.40 for single-case experimental designs. Interventions aimed at improving academic performance through the manipulation of the curriculum, antecedent conditions, or peer-tutoring produced approximately equal or greater effects sizes. In contrast, cognitive-behavioral treatments when used in the school setting were significantly less effective than these other two forms of interventions. Thus, the totality of the extant literature suggests that behavioral and academic interventions in the classroom can be effective in improving behavioral problems and academic performance in children with ADHD. The behavior of these children, however, may not be fully normalized by these interventions.

Though very encouraging, such results need to be directly tested with teens having ADHD in their school environments. Given the large number of teachers teenagers must typically deal with each week (up to 6-8), the more limited time they spend with each, the greater periods of unsupervised time at school, and the larger school buildings teens are likely to be housed within, it is not clear that similar levels of success would be achieved by these approaches when used with ADHD teens as would be the case for children with ADHD. Only two studies have directly tested behavioral treatments with teens, mainly note-taking training in combination with an intensive summer treatment program, with some success.⁵

A serious limitation to these results has been the lack of follow‑up on the maintenance of these treatment gains over time. In addition, none of these studies examined whether generalization of behavioral control occurred in other school settings where no treatment procedures were in effect. Other studies employing a mixture of cognitive‑behavioral and contingency management techniques have failed to find such generalization with ADHD children, suggesting that improvements derived from classroom management methods are quite situation specific and may not generalize or be maintained once treatment has been terminated.

The range of accommodations that can be suggested for assisting individuals with ADHD in the classroom can be rather substantial. To illustrate the point, consider the list provided in Table 1 of various treatment recommendations that might be conveyed to school staff dealing with children or adolescents having ADHD. Such recommendations range from altering the productivity requirements, classroom seating arrangements, and even teaching style to instituting classroom token systems and daily school report cards linked to home-based token reward programs to suggestions concerning classroom punishment methods. Some of the recommendations are based mainly on common sense and clinical wisdom while others are derived from the scientific literature on treatments used in classrooms with ADHD children. Not all will prove appropriate or effective in all cases as any school intervention plan must be tailored to the issues involved in any particular case of ADHD.

Two additional classroom management techniques may prove of value in treating ADHD children, but their effectiveness remains to be more rigorously studied. One involves the use of a transmitter and receiver/counter for implementing an in‑class token system. The device, known as the Attention Trainer,⁶¹ consists of a small transmitter clipped to the belt of a teacher and a second counting device/receiver placed on the child's desk. The counter is turned on when the child is given an assignment to do at his desk. Every minute, the counter adds a point on the face of the device and the cumulative points can be exchanged later for other rewards. Whenever the teacher witnesses the child off‑task or disrupting the class, she presses a button on the transmitter which activates a red light on top of the receiver and deducts a point from the face of the counter.

This method of utilizing a combined token reinforcement/response cost procedure eliminates one of the major difficulties in implementing class token systems ‑‑ the need for proximity of the teacher to the child to administer the contingencies. After initially demonstrating its efficacy with ADHD children, Rapport et al.⁶² compared this procedure to stimulant medication for improving attention and academic productivity of two ADHD children in a classroom setting. The response cost procedure was superior to methylphenidate alone in increasing both attention and productivity during academic tasks. Others have reported successful results for this approach with ADHD children using a series of single case designs suggesting that it may be worthwhile to explore its efficacy in larger-scale group treatment studies.⁶³

Another promising method deserving of further evaluation is the use of home‑based contingencies for in‑class behavior and performance. Atkinson and Forehand⁶⁴ have reviewed this literature and find that the method offers some usefulness for managing disruptive classroom behavior but that much more rigorous research is required to evaluate its promise. As discussed above under the author’s parent training program, the method involves having a teacher rate a child's daily school performance, either one or more times throughout a school day. These ratings are then sent home with the child for review by the parents. The parents then dispense rewards and punishments (usually response cost) at home contingent upon the content of these daily ratings. Others have similarly found such home‑school behavioral report cards to be useful, either alone or in combination with parent and teacher training in behavior management, in the treatment of ADHD children.³²

Although little research has been done on the subject, it is likely that certain aspects of the teacher’s personality, presence of psychological difficulties, compatibility of teacher and student characteristics, and the teacher’s philosophy of child behavior management contribute to the success or failure of any contingency management methods to be used in the classroom and the success of the ADHD child in that classroom more generally. In my experience, I have found that the two greatest hindrances to implementing these methods are the time available to the teacher for doing so and his/her attitude toward behavioral techniques in general. Many regular education classes have 22 to 35 children making it difficult for a teacher to rigorously implement these procedures in what little time he/she may have for any individual child.

This problem can be partly remedied by keeping the methods relatively simple or by having an aide assigned to the class temporarily to assist with the initial implementation of the program. Should this prove unfeasible or ineffective and the severity of the child's ADHD symptoms warrants, placement of the child in a smaller, special educational classroom for part or all of the school day may help. Special education teachers often have much more training and experience in contingency management methods and typically have the time as well as a teacher assistant to implement them.

Overcoming an antagonistic philosophy held by a teacher is more difficult. Some teachers have had negative experiences with poorly designed behavioral techniques or simply feel that they are dehumanizing and mechanistic to children, failing to address the child's true, inner emotional disturbance. In such cases, I have often sought a change of classrooms for the ADHD child. In extreme circumstances, I recommend that the parents place the child in another school where teachers may be more amenable to providing the additional time and special techniques ADHD children require for improved classroom adjustment.

Combined Interventions

Optimal treatment is likely to be comprised of a combination of psychosocial and medication approaches for maximal effectiveness.⁵⁹ Some research studies have examined the utility of such treatment packages with interesting results. None were done with teens having ADHD, however. It appears that in many studies, the combination of contingency management training of parents or teachers with stimulant drug therapies are generally little better than either treatment alone for the management of ADHD symptoms. Classroom behavioral interventions may mildly improve the deviant behavior of ADHD children but may not bring such levels of behavior within the normal range. Medication, in contrast, renders most children normal in classroom behavior. Others have found more impressive results for classroom behavior management methods³¹ but also found that the addition of medication provides added improvements beyond that achieved by behavior management alone.⁵⁹ Moreover, the combination may result in the need for less intense behavioral interventions or lower doses of medication than might be the case if either intervention were used alone.

Where there is an advantage to behavioral interventions, it appears to be in reliably increasing rates of academic productivity and accuracy. Yet, here too stimulant medication has shown positive effects. Despite some failures to obtain additive effects for these two treatments, their combination may still be advantageous given that the stimulants are not usually used in the late afternoons or evenings when parents may need effective behavior management tactics to deal with the ADHD symptoms. Moreover, between 8 and 25 percent of ADHD children do not respond positively to the stimulant medications,³⁷ making behavioral interventions one of the few scientifically proven alternatives for these cases.

An historic collaboration across 5 sites spearheaded by the National Institute of Mental Health systematically evaluated the effects of intensive, multi-method behavioral intervention alone (for 1 year), rigorous psychopharmacological testing, titration, and monitoring (1-3 years), and their combination against a community treatment group (treatment as available in the children’s normal community setting.⁸ The study involved 579 elementary aged ADHD children (ages 7-9) having combined type ADHD.

Results indicated that, for the management of ADHD, the medication only and combination therapy were equally effective and superior to the intensive behavioral and community control groups, which did not differ between them. Combined management may have been slightly superior to medication only for certain subgroups of children or for other outcome domains. Over the two years the children have been followed since intensive treatment ended, only the medication management group has continued to benefit from ongoing treatment. The results of this study continue to reinforce the notion that medication continues to provide benefit for the management of ADHD symptoms so long as it is sustained. Gains from behavioral interventions do occur, in some instances enhancing medication treatment, but typically those gains can be sustained only if the interventions are continued.

Developmental Considerations

Not all of the treatments reviewed above are appropriate for all ages of individuals having ADHD. Some consideration in the selection of appropriate therapies for ADHD needs to consider this important characteristic of the child, not to mention the psychological adjustment of the parents, their willingness to carry out or cooperate with the treatments recommended, the degree of family intactness, the extent to which their insurance or managed health care plan may cover (or not cover) the recommended services, and even the availability of particular resources for such treatments within a geographic region. Given the strong hereditary nature to the disorder, clinicians are likely to find that at least one parent is similarly affected. While no research is available to suggest how ADHD in a parent may affect the daily management of and psychological risks for the ADHD child, it is unlikely to be an effect that is particularly beneficial. Hence, treatment may be needed for any parental psychological or psychiatric difficulties along with those proposed for the ADHD child.

Regardless of the child’s age, the single most important first step in treatment apart from diagnosis is the education of the parents and family as regards the nature of ADHD and related issues. Clinical wisdom dictates this as the necessary first step in treatment, and there is some small-scale research to suggest that such re-education of parents does alter their perceptions of their children’s deviance and their own stress in the care of such children. A similar re-education process may be needed for some teachers and preschool staff as well prior to under-taking formal behavior management or medication treatment programs so as to facilitate a better understanding by the educator concerning the likely etiologies of the child’s difficulties and the most effective ways to approach their management.

Preschool Age

Considering the issue of age alone, it is clear that stimulant medication is not FDA approved nor is it typically recommended for children below 4 years of age and may be of only modest benefit to those in the 4-5 year age range. Side effects in the preschool age group may also be more common. And so at the preschool age group, treatment for mild to moderate cases of ADHD may consist entirely of providing training to the parents in child behavior management methods. As part of this consultation, advising parents on the importance of child-proofing their home against the possibility of accidental injuries or poisonings is critical given the greater proneness of ADHD children to such accidents. Some consultation with the child’s preschool teaching staff may also be needed for those ADHD children participating in preschool programs and where there behavior is problematic in such settings. These consultations would also focus mainly upon contingency management methods that may prove useful for managing the particular problems in the preschool setting.

Elementary Age

For the elementary-age child, the increased importance of school in the life of the child brings with it an increased likelihood of behavioral and performance problems in this setting beyond those settings that may have proven problematic for the ADHD child in his preschool years. The broader or more numerous social settings in which the ADHD child may now be participating bring with them additional responsibilities for the child to behave well, follow established rules, interact cooperatively with peers, and generally display greater powers of self-regulation than was the case in earlier years. Associated with this expanded opportunity for difficulties outside of the home comes the increased likelihood of difficulties with peer relationships, both at school and in the larger community in which the ADHD child may now be more frequently interacting with others (i.e., scouts, sports, clubs, church functions, etc.). Interventions must now not only focus on addressing the parent-child conflicts that may have arisen earlier in the preschool years, but teacher-child and peer-child conflicts that may arise in the child’s participation in school and community activities.

The classroom contingency management procedures discussed earlier are well-suited to this age group of children as are some of the social skills training programs, though the latter remain to have their efficacy reasonably well-established for children with ADHD. The greater occurrence of comorbid disorders with ADHD, such as the learning disabilities, may make their presence more obvious during this developmental period and may necessitate additional interventions beyond those specifically targeted to the child’s ADHD-related problems. The increased probability of positive responding to stimulant medication at this age now makes this treatment approach a more viable option for the elementary-aged ADHD child. Here, again, the presence of other comorbid conditions, such as anxiety or tic disorders, may alter this treatment regimen by making it necessary to consider other medications in addition to or in lieu of the stimulants.

Adolescence

Adolescence brings with it additional considerations in the selection of possible treatments for the teenager’s ADHD and associated problems. The increased desire for autonomy from parents, for involvement in decision-making that pertains to oneself, for approval of one’s peer group introduce new issues into treatment planning. The cooperation of the teen with any treatments recommended for ADHD may now become the most salient or even singular issue in treatment efficacy forcing greater attention from professionals to the feelings, desires, and involvement of the teen in treatment planning and greater care in the negotiation with the teen for his/her cooperation with those plans. Simply training the parents in the same behavior management methods as would have sufficed in earlier years will not be sufficient as this approach has shown steep declines in its efficacy with the adolescent age group, as discussed earlier.

Family therapy with the teen actively involved now becomes necessary so as to negotiate the treatment plan with the teen and seek their cooperation with it. Programs that emphasize problem-solving, communication training, and the altering of unreasonable interpersonal beliefs on the parts of parents and teens become of equal or greater import to the success of treatment than simply working with parents exclusively on the management of behavioral consequences in the home. Certainly the wider geographic range in the community over which the adolescent is now likely to be roaming, often without parental supervision, the larger number of activities in which they may participate, the increased number of peers and adults with whom the teen may now interact, and the increased privileges and responsibilities that may be given to the ADHD teen by virtue of their age all conspire to broaden the possible opportunities for problems with which the teen and their parents must now deal. For instance, teen conduct at shopping malls, libraries, convenience stores, recreational parks, and even school facilities after hours may now become potential problems and sources of conflict with parents, not to mention local authorities.

The combination of the ADHD teen’s bursting sexuality at this age coupled with their immature self-regulatory powers makes this domain of adolescent adaptive functioning an increasingly important one for parents, if not for the teen, given the demonstrably greater risks of ADHD teens for adolescent pregnancies and sexually transmitted diseases as have been recently documented in my own longitudinal study. While advice about birth control may seem to be a simple solution to this issue, teen cooperation with such advice once more becomes the key ingredient to success or failure in the efforts to assist the teen with more effective and adaptive conduct at critical points of performance in their daily life. And the opportunities for the adolescent to obtain driving privileges after 16 years of age in most states brings with it a whole host of new potential problems for ADHD adolescents and their parents. As noted earlier, adolescents and young adults with ADHD have significantly and substantially increased risks for negative driving outcomes such as speeding and vehicular crashes over those normally associated with teenage drivers, who are already the highest risk driving age group.

Along with this broadening of treatment participants to include the teenager’s active involvement comes a broadening of the number of participants in any school-based interventions as well. By adolescence, if not earlier, teens will have a far larger number of teachers, coaches, and other school staff with whom to contend, none of whom exercises sole responsibility for the success of the teen’s school day. Enlisting the assistance of 7 or more teachers, several coaches, guidance counselors, school office staff, and others in the contemporary middle school or high school environment of the ADHD teen is a daunting and usually unsuccessful task. Finding anyone in the school environment willing to monitor and assist with the teen’s activities, organization, and responsibilities across an entire school day often becomes the first order of business in a school intervention plan for a teenager with ADHD. Such a person can serve as the conduit through which recommendations from the professional are infused into the teen’s school day by communication of the “case manager” or organizational “coach” who agrees to fulfill this capacity with the other teachers and school staff working with the teen.

Conversely, this pivotal person provides the means by which information about the teen’s conduct and performance and the success of any earlier treatment ventures is communicated to those mental health or medical professionals advising school personnel on the teen’s treatment plan. And this “coach” can further serve the important role of periodically meeting with the teen briefly across the school day to monitor the teen’s behavior, see to the teen’s success at obtaining necessary information on school assignments, and to provide both a public accounting of the teen’s performance of their prior agreements about school performance as well as motivational support to the teen for persisting with the plan and meeting their obligations at school. The use of stimulant medications with this age group is likely to be equally as efficacious as with younger children having ADHD. Yet the more salient issue now is enlisting the adolescent’s cooperation with the medication regimen, especially in view of the adolescent’s desire not to be different from their immediate peers in any way that might invite criticism from the chosen peer group.

Young Adult

Culminating this stage of adolescent development will be the myriad conflicts that may arise in the normal course of launching the ADHD older teen or young adult into gainful employment and eventually completely independent living or at least into college and the semi-independent living arrangements often associated with it. While medication treatment, family therapy, and comparable school-based interventions may be needed in this transition of the adolescent on to post-secondary education, the lion’s share of the responsibility for getting help now rests squarely with the older teen or young adult whose investment in and cooperation with treatment programs becomes the most important treatment issue. For those teens now going on for such education, the need to find appropriate employment and to see that such employment succeeds becomes an issue for both teen and parents. Vocational assessments and counseling may now be required as part of the intervention plan for the older adolescent. So may be some assistance from parents or others with the young adult’s bids for semi-independent or totally independent living arrangements, for the responsible management of their increased income and opportunities to obtain easy-credit, and the moderation of their use of now legal substances, such as tobacco and alcohol, all of which appear to be more problematic areas of adaptive functioning for ADHD teens and young adults than for their normal peers.

Conclusion

The treatment of ADHD requires expertise in many different treatment modalities, no single one of which can address all of the difficulties likely to be experienced by such individuals. Among the available treatments, education of parents, family members, and teachers about the disorder, psychopharmacology (chiefly stimulant medications), parent training in effective behavior management methods, classroom behavior modification methods and academic interventions, and special educational placement appear to have the greatest efficacy or promise of such for dealing with children having ADHD. To these must often be added family therapy around problem-solving and communication skills, the coordination of multiple teachers and school-staff across the high school day, assisting the ADHD teen with his/her expanded responsibilities, opportunities, and privileges, and the preparation of the teen for eventual independent living and self-support. To be effective in altering eventual prognosis, treatments must be maintained over extended time periods (months to years) with periodic re‑intervention as needed across the life course of the child as well as the need to increasingly enlist the ADHD individual’s cooperation with and investment in the long-term intervention program.

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