Comprehensive Treatment of Childhood ADHD

By John M. Grohol, Psy.D.

While learning of the diagnosis of attention deficit disorder (ADHD) makes many parents feel relief, the real work begins in finding the right treatment approach for a child or teen diagnosed with ADHD.

If the diagnosis was made by a pediatrician or family physician, the first thing you should ask for is a referral to a mental health professional trained in the treatment of attention deficit disorder. This should happen before any treatment is prescribed, because, as you’ll learn, the order and focus of treatment is important. Although the inclination may be to start medication treatment immediately (with drugs such as Ritalin or Adderall), you should not give in to this feeling that you need “do something.”

Since the diagnosis of ADHD requires the child to have inattentive behavior in at least two settings — the home and school most often — the obvious interventions to change the child’s behavior involve those two settings. Comprehensive, effective treatment of childhood ADHD involves four different treatment strategies, used individually or combination:

  • Behavioral Parent Training
  • Behavioral School Intervention
  • Child Interventions
  • Medication

Parents shouldn’t expect instant changes in their child’s ADHD or behavior. Improvement and learning is a gradual process that takes time, especially with the behavioral interventions and training. However, research has shown that such interventions are longer-lasting, while the effects of medications will fade over time.

Behavioral Parent Training

Parental training benefits the child with attention deficit disorder because most parents simply don’t know what to do when dealing with an ADHD child. Even if a parent has raised other, non-ADHD children, learning how to best help a child or teenager with ADHD is a unique situation most simply have never had experience with.

Parents of ADHD children also usually have significant stress, and sometimes they may simply lack basic parenting skills. Some parents are often grappling with their own mental health issues, such as depression, anxiety, or bipolar disorder. ADHD children unintentionally contribute greatly to parental
stress and disturbed parent-child relationships. Learning good parenting skills can actually mediate most negative outcomes and therefore it makes sense to make it one of the main focuses of treatment.

Parent training usually takes on a focused, behavioral psychotherapy approach. The focus is on parenting skills, the child’s behavior, and family relationships. In parent training, parents learn skills and implement treatment with child, modifying interventions as necessary based upon how the child is doing. One of the key components of parent training is creating ADHD behavioral interventions for the home. These are easy to learn and implement and are a must for virtually any parent. Parents should also consider implementing the home daily report card (PDF).

Parent training is often done in a group-based, weekly session with therapist initially that lasts from 8 to 16 sessions. Most therapists will continue being in contact with the parents once the group sessions are done, as the parents need it (often for years). If a parent needs additional help throughout that time, most therapists will be glad to see the parents to help them through difficult childhood transitions (such as becoming a teenager).

Training can also involve discussion about maintenance of the program and relapse prevention, especially when the parent is under increased stress from relationship issues, work, etc.

Parent training is most often offered through a private psychotherapist trained in such interventions, but can also sometimes be found in schools, churches, primary care physicians and other common community outlets.

Behavioral School Intervention

Why are school interventions important in the treatment of a child or teen with ADHD? 33 percent of children with ADHD have academic problems every year and 48 percent have at least one year of special education. 12 percent of children with attention deficit disorder get held back a grade and nearly 10 percent of teens with ADHD will drop out of school if left untreated. Teenagers with ADHD will often score a full letter grade lower than other teens, even when controlling for academic skills.

School interventions are a behavioral approach where teachers are trained and implement treatment with the child, modifying interventions as necessary based upon the progress of the ADHD child. School interventions focus on classroom behavior, academic performance, and the relationships the child with his or her friends.

School interventions are typically available in most schools. Such intervention programs are administered most often by teachers, who’ve received specialized training in how to work with ADHD children. A core part of the school intervention is the school daily report card (PDF). The daily report card servers as a means of identifying, monitoring and changing the child’s classroom problems. It also acts as an avenue of regular communication between the parents and the teacher. It costs nothing, takes only a little bit of the teacher’s time, and is very motivating to the child (as long as the parent has selected the right rewards at the home for positive report card reports).

As with parental training, school intervention programs allow for maintenance and relapse prevention and will provide treatment for the child as long as necessary.

Child Interventions

Children can be their own best keepers, especially when it comes to how older children and teens learn most from — their peers (friends). The measure of the severity of a child’s ADHD can be seen in how impaired their relationships are with their friends. ADHD children with no close friends are a sign of severe ADHD that, if left untreated, predicts negative adult relationships. Friends can help an ADHD child immensely.

Child interventions take a behavioral and developmental treatment approach. They tend to focus on teaching academic, recreational, and social/behavioral competencies, decreasing aggression, increasing compliance, developing close friendships, improving relationships with adults, and building self-efficacy in the ADHD child.

Child ADHD interventions can include intensive treatments such as summer treatment programs (9
hours daily for 8 weeks), and/or school-year, after-school, and Saturday (6 hours) sessions. Such programs can also help with relapse prevention (e.g., through integration with school and parent treatments, which can all be linked together through a home/school report card system).

Medication for Childhood ADHD

Since not all children will respond to behavioral interventions, medications may also be considered in the treatment of childhood attention deficit disorder (ADHD). Behavioral interventions, like those listed previously, may not always be sufficient for some children. Parents and teachers can also sometimes not implement the program correctly, or keep it up over the long-term (after the therapist’s contact has ended).

At such times, the prescription of an appropriate psychostimulant medication may be appropriate as medications often offer more immediate short-term benefits (allowing the child to be able to better focus on the behavioral interventions). Such short-term benefits include decreased classroom disruptions, improvement in teacher ratings of the child’s ADHD behavior, improvement in compliance with adult requests, improvement in peer interactions, and increase in on-task behavior and academic productivity.

However, medications rarely should be used as the first treatment implemented. Twice as many parents will refuse any additional type of treatment for their ADHD child when a medication is prescribed first (and is ineffective), than when a parent first tries their child on a behavioral approach. Research has also shown that most parents prefer a behavioral approach (or a combined behavior and medication approach) over medications alone. A combined treatment approach also has shown that children can gain as much value from medications at significantly lower doses. Since ADHD medications have been linked to stunted childhood growth (height and weight), lower doses are generally preferred.

The need for a medication prescription should be determined following initiation of behavioral treatments, and its timing will generally depend on severity of the ADHD and responsiveness of the child to the behavioral interventions.

An individualized, school-based medication trial should be conducted with your child to determine need and minimal dose needed to complement the behavioral intervention. The physician or psychiatrist should cycle through methylphenidate and amphetamine-based medications (such as Adderall, Ritalin or Concerta) before trying other drug classes with your child. Your doctor should begin by prescribing the minimal dose needed, and only increase if symptoms don’t decrease over time (1 to 2 weeks). Consider the long-acting versions of a medication if dosing schedule doesn’t allow for multiple doses administered throughout the day.

Keep in mind that ADHD medications generally only work for as long as they are taken, hence the reason a combined approach that involves both behavioral interventions and medications is nearly always preferred. Medications are not effective for all children, and there is uniform lack of research evidence for their long-term use (more than 2 years). Medication compliance has generally been shown to be poor the longer a child is on a medication, and medication alone will likely have little effect on academic achievement, family problems or problems with relationships with their friends.

This article based upon a presentation by Dr. William E. Pelham Jr., October 2008.

 

APA Reference
Grohol, J. (2009). Comprehensive Treatment of Childhood ADHD. Psych Central. Retrieved on October 24, 2014, from http://psychcentral.com/lib/comprehensive-treatment-of-childhood-adhd/0001747
Scientifically Reviewed
    Last reviewed: By John M. Grohol, Psy.D. on 30 Jan 2013
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