(dailyRx News) Perhaps one of the biggest controversies surrounding attention deficit hyperactivity disorder (ADHD) focuses on one of its treatment options: Ritalin, the stimulant prescription drug with effects similar to cocaine. Unfortunately, the many other treatment options for this disorder frequently get lost in the uproar surrounding this medication.
In fact, a number of ADHD treatment options have proven to be effective for some children. Effective strategies include behavioral, pharmacological and multimodal methods.
Behavioral approaches represent a broad set of specific interventions that share a common goal: modifying the physical and social environment to alter or change behavior. They're used to provide structure for a child diagnosed with ADHD and to reinforce appropriate behavior. Behavioral approaches are typically implemented by parents as well as psychologists, mental health therapists, school personnel and primary care physicians.
Types of behavioral approaches include behavioral training for parents and teachers, in which the adult learns child management skills; a systematic program of contingency management, such as positive reinforcement, time-outs, response cost and token economy; clinical behavioral therapy, including training in problem-solving and social skills; and cognitive-behavioral treatment, such as self-monitoring, verbal self-instruction, development of problem-solving strategies and self-reinforcement. In general, these approaches are designed to use direct teaching and reinforcement strategies for positive behaviors and direct consequences for inappropriate behavior.
Behavioral strategies hold promise for children and their families dealing with ADHD. They may appeal to parents and professionals for these reasons:
- Behavioral strategies are used most commonly when parents don't want to give their child medication therapy
- Behavioral strategies can be used with medication therapy
- Behavioral techniques can be applied in a variety of settings, including school, home and the community
- Behavioral strategies may be the only options if the child has an adverse reaction to medication
This type of treatment does have some limitations, and research on the effectiveness of behavioral techniques is mixed. On the positive side, three separate studies found systematic programs of intensive contingency management conducted in specialized classrooms and summer camps with the setting controlled by highly trained individuals to be highly effective. Additionally, a 1998 study found parent training in behavior therapy and classroom behavior interventions to be successful in changing the behavior of children with ADHD, and interactions at home and school that support a consistent approach are important to the success of behavioral approaches.
While studies that compare the behavior of children during periods on and off behavior therapy demonstrate the effectiveness of behavior therapy, researchers have had difficulty isolating its effectiveness. Because so many different behavioral interventions and outcome measures exist, it's difficult to make careful analyses of the effects of behavior therapy alone or in association with medications. Although some research suggests behavioral methods offer the opportunity for children to work on their strengths and learn self-management, other research indicates behavioral interventions are less effective than medication therapy with stimulants.
Not surprisingly, then, behavior therapy has been found to be effective only when it is implemented and maintained. Unfortunately, implementing the strategies consistently across all settings for the therapy to be most effective can be difficult. Although behavioral management programs have been shown to enhance the academic performance and behavior of children with ADHD, follow-up and maintenance of the treatment is often lacking.
Some research has shown that behavioral techniques may fail to reduce ADHD's core characteristics: hyperactivity, impulsivity and inattention. That said, the problems of children with ADHD are seldom limited to the core symptoms themselves. Children frequently demonstrate other types of psychosocial difficulties, such as aggression, oppositional defiant behavior, academic underachievement and depression. Because many of these other difficulties cannot be managed through stimulant medications, behavioral interventions may be useful in addressing ADHD and other problems a child may be exhibiting.
Treating ADHD with prescription medication is one of the most common forms of ADHD treatment. While the rise of children taking Ritalin (methylphenidate) and other similar medications to manage ADHD is often attributed to a push by teachers to make difficult children easier to deal with in the classroom, the decision to prescribe any medicine is the responsibility of medical--not educational--professionals, after consultation with the family and agreement on the most appropriate treatment plan.
Medications prescribed to treat ADHD include stimulants, antidepressants, anti-anxiety medications, antipsychotics and mood stabilizers. Stimulants are the dominat class prescribed and have been found to be effective with 75 to 90 percent of children with ADHD. In addition to Ritalin, these drugs include Dexedrine (dextroamphetamine) and Cylert (pemoline). In January 2003, the FDA approved Straterra (atomoxetine), a new type of nonstimulant medication for treating children and adults with ADHD. The other classes of medication are used primarily for patients who don't respond to stimulants or who have coexisting disorders.
Although some critics of medication therapy for ADHD argue that the drugs simply lull children into complacency, the results of the Multimodal Treatment Study, first published in December 1999, confirmed previous research findings that medication therapy was almost as effective as the multimodal treatment of medication and behavioral interventions.
Treating a disorder characterized by hyperactivity with a stimulant drug might seem counterintuitive. Researchers believe stimulants affect the portion of the brain responsible for producing neurotransmitters, the chemical agents at nerve endings that help electrical impulses travel among nerve cells. Neurotransmitters are responsible for helping people pay attention to important aspects of their environment. The appropriate medication stimulates these underfunctioning chemicals to produce extra neurotransmitters, thus increasing a child's capacity to pay attention, control his or her impulses and be less hyperactive.
Although the positive effects of stimulant medication are immediate, all medications have side effects. Some of the more common side effects of ADHD medications include insomnia, nervousness, headaches and weight loss. In fewer cases, patients have reported slowed growth, tic disorders and problems thinking or interacting with others. Medication also can be expensive, depending on the medicine prescribed, the frequency of administration and the subsequent frequency of refills.
Stimulant medicines don't "normalize" the entire range of behavior problems, and children under treatment may still manifest higher levels of behavioral problems than their peers. Nevertheless, the American Academy of Pediatrics (AAP) finds that at least 80 percent of children respond to one of the stimulants if they are administered in a systematic way. Under medical care, children who fail to show positive effects or who experience intolerable side effects on one type of medication may find another medication helpful. The AAP reports that children who don't respond to one medication may respond to another medication and concludes that stimulants may be a safe and effective way to treat ADHD in children.
For many children with ADHD, research indicates, the best way to mitigate symptoms of their disorder is using a combined therapy approach. Results of the Multimodal Treatment Study help support this finding. The study compared the effects of four interventions: medication provided by the researchers, behavioral intervention, a combination of medication and behavioral intervention and no intervention aside from typical medical care. The researchers working on this study found multimodal intervention improves academic performance, parent-child interaction and school-related behavior while reducing anxiety and oppositional behavior.
Of the four interventions investigated, the researchers found the combined medication/behavior treatment and the medication treatment work significantly better than behavioral therapy alone or medical care alone at reducing the symptoms of ADHD. Multimodal treatments were especially effective in improving social skills for students coming from high-stress environments and children with ADHD in combination with symptoms of anxiety or depression. The study also revealed a lower medication dosage is effective in multimodal treatments, whereas higher doses were needed to achieve similar results in the medication-only treatment.
Researchers also observed positive results in school-related behavior when multimodal treatment is coupled with improved parenting skills, including more effective disciplinary responses, and appropriate reinforcements. The Multimodal Treatment Study's overall results appear to apply to a range of children and families identified as in need of treatment services for ADHD from all social, ethnic and economic backgrounds. Other studies in addition to the Multimodal Treatment Study have demonstrated that multimodal treatments hold value for children for whom medication therapy alone is not sufficient.
The Therapy Plan
In late 2001, the AAP released evidence-based recommendations for treating children diagnosed with ADHD. The report stressed that the treatment of ADHD--whether behavioral therapy, medication therapy or a multimodal approach--requires the development of a child-specific treatment plan that describes not only the methods and goals of treatment but also include means of monitoring treatment over time and specific plans for follow-up. The AAP concluded that parents, children, and educators should agree on at least three to six key targets and desired changes as requisites for constructing the treatment plan. The goals should be realistic, attainable and measurable.
The process of developing target outcomes requires careful input from the patient and her or his parents and teachers, along with other school personnel where available and appropriate. Numerous studies have found that positive results occur when the major stakeholders in a student's education collaborate to address a child's ADHD. Effective collaboration and communication between home and school provide structure across the two major settings in the child's life. Common rewards, reinforcement strategies and language help to promote consistency across settings.
Parents and teachers can share information with one another if they work together to plan behavioral and academic strategies for the student. Parents can offer information about the child--including his or her medical history, hobbies and interests, effective reinforcers and behavior in other settings--that may inform the decisions made by the teacher. The teacher can keep parents informed about their child's progress, performance and behavior in school. If the child is taking medication, the teacher can offer feedback to parents regarding how the medication affects the student's performance and the duration of the medicine's effectiveness. This information also can be used to help medical professionals make more informed decisions about the child.
Students also can take some of the responsibility for their educational and behavioral adaptations. One study found that students as young as 5 can communicate ways to make their school experience more pleasurable and learning easier. Student input also helps to promote a sense of ownership and responsibility for the new strategies and adaptations set forth in the therapy plan.
Caring for a child with ADHD can be challenging, but parents, teachers and other caregivers must remember that these children can learn successfully. It is critical that these adults remember that some of the child's disruptive behavior is a manifestation of the disorder, thus the challenge is to find ways to help the child change the inappropriate behavior. Focusing on the child's need for structure and routine in her or his daily schedule and reinforcing the importance of learning self-control and self-regulation are two keys to the child's success.
More information about effective strategies can be found in "Teaching Children With Attention Deficit Hyperactivity Disorder: Instructional Strategies and Practices," published by the U.S. Department of Education.