Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders of childhood, affecting approximately 5% to 10% of school-age children in the United States. Researchers have estimated that in a classroom of 25-30 children, at least 1 child will likely have ADHD. Children with ADHD experience significant problems at school, resulting in a higher risk for school failure and grade retention. Family interactions also suffer significantly, with ADHD children being less compliant with parents' instructions than same-age peers. Likewise, their parents are more controlling, more disapproving, and experience more stress than parents of children without ADHD.[5,6] Longitudinal research has suggested that ADHD is a relatively chronic condition, with at least 50% to 70% of diagnosed children continuing to manifest symptoms into adulthood. Taking into account the chronicity, prevalence, and level of impairment associated with ADHD, Pelham and colleagues noted that "effective treatment for childhood ADHD is a major public health agenda."
In a 2001 Clinical Practice Guideline, the American Academy of Pediatrics (AAP), suggested that when treating target ADHD symptoms, clinicians should recommend stimulant medication and/or behavior therapy, "as appropriate." Drawing upon the available research, the AAP noted that although "stimulant medication is highly effective in the management of the core symptoms of ADHD . . . behavioral interventions are valuable as primary treatment or as an adjunct . . . based on the nature of coexisting conditions, specific target outcomes and family circumstances." Unfortunately, specific referral guidelines are notably absent, leaving the clinician to consider whether a trial of behavior therapy is appropriate in a given case. This column reviews the current research on the effectiveness of behavior therapy with ADHD children and identifies patients who are likely to benefit from behavioral treatment.
Behavioral vs Other Nonpharmacologic Interventions
Behavioral interventions have received more attention in the research literature than other, nonpharmacologic approaches to treating ADHD. In their review of the literature, Pelham and colleagues found 25 studies demonstrating the effectiveness of behavior therapy with ADHD children. By contrast, they found no studies demonstrating effectiveness of individual or play therapy. According to Barkley, other treatments with little or no evidence of effectiveness in treating ADHD include long-term psychotherapy, psychoanalysis, and sensory-integration training. Cognitive behavioral (CB) interventions can be distinguished from behavioral approaches in that CB interventions are typically conducted with the child, and include training in self-instruction, problem solving, self-reinforcement, and error coping. Despite early promising results, CB interventions have been found to be largely ineffective for treating children diagnosed with ADHD. Thus, the current emphasis on behavioral treatments appears reasonable.
Defining Behavioral Treatments
Behavioral treatments for ADHD can be divided into 2 broad categories: clinical behavior therapy and direct contingency management. Clinical behavior therapy is usually conducted by a mental health professional (eg, psychologist or social worker) in an outpatient setting. Although meetings with the child will occur on occasion, the primary focus of treatment is the significant adult in the child's life. The treatment typically consists of parent training in child behavior management plus teacher consultation in behavior modification.
In parent training programs,[12,13] the initial sessions focus on psychoeducation. Parents are taught to consider their child's behavior as a function of the disease, rather than as noncompliance or evidence of failed parenting. This first step is essential; studies have shown that parents' beliefs about themselves, their ADHD children, and their parenting are associated with child treatment outcomes. Subsequent sessions focus on teaching parents to pay attention to appropriate behavior, ignore minor inappropriate behavior, give clear and concise directions, and establish effective incentive programs, such as token or point reward systems. Reward programs allow parents to deliver immediate, tangible rewards for appropriate behavior. In developing a reward program, parents and children must first agree on a set of desired and reasonable rewards (eg, computer time or playing a favorite game). Parents then construct a list of desired behaviors (remaining on task during homework completion, keeping room clean, etc), assigning point values for each. Behavior is monitored throughout the day and points are assessed accordingly. At the end of the day, a portion of the points may be redeemed for small rewards. Unredeemed points may be applied toward the purchase of larger weekly rewards. Contingency programs are adjusted regularly to account for changes in behavior and to prevent satiation of rewards. In parent training programs, parents are also taught the importance of anticipating misbehavior and providing immediate, specific, and consistent consequences in response. Strategies for managing noncompliant behavior in public are also offered. Parents are encouraged to monitor school behavior through review of a Daily School Behavior Report Card, completed by their child's teacher. Appropriate school behavior is rewarded with a privilege at home. Although most parent training programs (eg, Barkley) were originally designed to be delivered in a group setting, with modest adjustments, many can be implemented individually. Typical training programs take approximately 8-10 sessions to complete.
Through school consultation, mental health professionals directly assist teachers of ADHD children with implementing various behavior management strategies in the classroom. Examples of academic adjustments include reducing workload to fit the child's attention span, altering teaching style and curriculum, setting time limits for work completion, dividing longer assignments into smaller steps, and increasing the immediacy of consequences.[15,16] Specific interventions are selected on the basis of a constellation of attentional and behavioral difficulties displayed by the child. Progress is closely monitored throughout the academic year, either through routine phone contact between teachers and the mental health professional or through periodic meetings at the school. Depending on the level of impairment, a child with ADHD may also be eligible for special services through certain federal statutes, ranging from minor accommodations (eg, untimed testing) through a Section 504 plan to the development of a full Individual Education Plan (IEP) allowing for more extensive special education services. (For further discussion, see Latham and Latham).
With many of the same principles that are emphasized in clinical behavior psychotherapy, direct contingency management programs are conducted in highly controlled settings (ie, summer treatment programs, specialized schools) by paraprofessionals. In addition to implementing behavioral interventions (eg, point systems), contingency management programs tend to focus on enhancing social skills. This approach differs from a clinic-based social skills group because the training occurs in the setting where the child is experiencing the social difficulty (ie, at school), thereby improving its effectiveness.
Is Behavior Therapy as Effective as Pharmacologic Treatment?
Although research studies had extensively explored the short-term efficacy and limitations of psychosocial and pharmacologic treatment of ADHD by the early 1990s, these studies did not produce comprehensive data on the differential treatment effects and comparative long-term efficacy of these approaches. To address this need, researchers launched 2 landmark multisite clinical trials. In 1992, the National Institute of Mental Health (NIMH) launched the Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (MTA), in which 579 children with a primary Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnosis of ADHD-combined type were randomly assigned to 1 of 4 experimental arms: expert titrated stimulant medication vs behavioral treatment vs combination of medication and behavioral treatment vs community-based treatment. Behavioral treatment consisted of both clinical behavior therapy (parent training and school consultation) and direct contingency management. Approximately one third of the sample had a comorbid anxiety disorder.
The primary finding of this study was that behavioral treatment was not as effective at reducing ADHD symptoms as medication. Secondary findings included (1) patients in all treatment conditions experienced significant improvement over time, including those who did not receive medication, and (2) combined treatment (medication and behavior therapy) outcomes were achieved with significantly lower medication doses than used in medication management. Finally, combined treatment (medication and behavior therapy) was particularly effective for treating disruptive behaviors and internalizing symptoms in ADHD children with comorbid anxiety.
In 2004, in an attempt to improve upon the MTA study, researchers conducted a second multisite study comparing multimodal psychosocial treatment with stimulant medication. The sample consisted of 103 children who met the DSM-IV diagnostic and severity criteria for ADHD and had previously demonstrated a response to stimulants. This second study differed from MTA in that an attention control condition was included to allow researchers to explore the incremental value of psychosocial treatment. Unfortunately, psychosocial treatment for this study included a number of interventions of questionable efficacy with this population, such as clinic-based social skills groups, organizational skills instruction, and individual therapy. Moreover, parent training appeared to have been less than optimal. Although participants in the parenting program demonstrated better knowledge of parenting practices than those who did not participate, this knowledge did not actually enhance their parenting practices, demonstrating the prevalent disconnect between knowledge and implementation of the knowledge. Finally, school consultation and direct contingency management programs were notably absent.
Results from this study suggested that psychosocial treatments did not significantly improve functioning of stimulant-responsive children on any outcome measures. In their conclusion, the researchers noted that "in stimulant responsive children with ADHD there is no support for adding ambitious long-term psychosocial interventions to improve ADHD and oppositional defiant symptoms."
Reactions to the results of both studies have been vigorous. Researchers have debated the design of the studies[22,23]; clinicians have questioned the cost-effectiveness of psychosocial treatments compared with stimulant medication for the general population of ADHD children. In a recent editorial, Diller and Goldstein even expressed concern that "These 2 studies appear(ed) to drive the final nail into the psychosocial treatment coffin."
Although interesting, many of these discussions seem misdirected. It is undeniable that stimulant medication is highly effective for treating ADHD symptoms. With appropriate medication management, most children may not need multimodal treatment. However, several subpopulations will require treatment with behavior therapy.
Who Benefits From Behavior Therapy?
In 2001, Conners and colleagues developed expert consensus guidelines for the diagnosis and treatment of ADHD. These guidelines indicated that behavioral treatment was an appropriate first-level treatment in several scenarios: for milder ADHD, when the family prefers psychosocial treatment; for preschool-age children with ADHD; and in the presence of comorbid anxiety disorders. Although these guidelines were influenced by the MTA study, they are reconsidered here in light of newer research.
Behavior Therapy Can Be Beneficial in Treating Mild ADHD Symptoms
As noted, considerable evidence supports the short-term efficacy of behavior therapy for treating ADHD symptoms compared with other nonpharmacologic interventions, or wait-list controls. In the MTA study, patients who received behavioral treatment alone displayed fewer or less prominent ADHD symptoms following treatment. For mild ADHD symptoms that do not warrant a trial of stimulant medication, behavior therapy is strongly recommended.
Psychosocial Treatments Can Be Beneficial When the Family Prefers It
In their recent study, Krain and colleagues found that parent ratings of medication acceptability significantly predicted pursuit of medication treatment 3-4 months later. Thus, for those families who are unwilling to try medication, an initial referral for behavior therapy is appropriate.
Parents of Preschoolers With ADHD Should Participate in Behavior Therapy Before Considering a Medication Trial
As noted by Kratochvil and colleagues, given that information concerning the efficacy, safety, and administration of psychotropic medication in preschool-age children is still limited (neither of the aforementioned large landmark studies included preschool-age children), treatment of ADHD in this group should start with behavior therapy. The recently completed multisite Preschool ADHD Treatment Study (PATS) may provide new information about the safety of medications with this population. It is of note that all subjects in the PATS study initially completed a trial of behavior therapy. Only those preschoolers who failed to show significant improvements in symptoms following a trial of parent training participated in the medication trial.
Behavior Therapy Combined With Medication Management Is Recommended for ADHD Children With Comorbid Anxiety Disorders
Results of the MTA study suggested that patients with comorbid anxiety disorders benefited from combined medication management and behavior therapy. This finding was particularly robust for children with a comorbid anxiety disorder and comorbid disruptive behavior.
The effectiveness of stimulant medication for treating most ADHD symptoms is undeniable. With appropriate medication management, most children may not need multimodal treatment. The practitioner is encouraged to remember that some children will need a more comprehensive treatment plan, including both medication and therapy. Behavior therapy continues to be strongly recommended for certain subgroups.