Pediatric Annals

Treating Attention-Deficit Hyperactivity Disorder: Medication and Behavior Management Training

Russell A Barkley, PhD; Jerome V Murphy, MD

Abstract

Attention-deficit hyperactivity disorder (ADHD) features developmentally inappropriate levels of sustained attention and impulse control, as well as the inability to regulate activity levels to situational demands.1 There is also a frequent association with other conditions, such as learning disabilities, oppos it ional -defiant disorder, conduct disorder, academic underachievement, and deficits in social skills.2 The disorder is believed to arise in early childhood and is relatively chronic throughout childhood and adolescence.2·* Although brain imaging procedures are normal in patients with ADHD, recent studies have demonstrated focal hypoperfusion4 and diminished glucose use5 in brains of patients with childhood ADHD.

Various treatments have been tried with ADHD, tar too numerous to review here. Those treatments with the most proven effectiveness at reducing symptoms include psychopharmacology (ie, stimulants) and training parents and teachers in behavior modification techniques- Reducing dietary intake of sucrose or food additives plays no role in controlling ADHD.6'7 No treatments have yet proven curative of this condition - all provide purely symptomatic relief. Moreover, no treatments have produced any enduring effects with these children once treatments have been withdrawn.8 As a result, ADHD is now considered a developmental disability requiring long-term symptomatic treatment if any impact on later outcome is to be made.

Both psychophannacology and parent training have as their goal to create a better fit between the child with ADHD and the demands made on that child by the social environment, especially at home and at school. With medication, this is achieved by altering those deficits experienced by the child in the domains of inattention, impulsivity, and overactivity by changing neurological substrate(s) believed to mediate these neurologic functions. With the other - training in child behavior techniques - this goal is achieved through restructuring the types of demands that caregivers place on the child with ADHD. This is done by diminishing stimuli the child receives and by using consequences (rewards) thai are known to motivate the child to increase work performance and compliance.

In this article, these two commonly used and effective therapies for the management of ADHD are discussed. Because of space limitations, an in-depth review of the literature related to these two treatments is not possible. Instead, the reader interested in a more thorough discussion of these treatments as well as the disorder itself and methods of its assessment is referred to a recent comprehensive textbook, Attention Deficit Hyperactiviry Disorder: A Handbook for Diagnosis and Treatment.2

STIMULANT THERAPY FOR ADHD

Psychostimulant medications (eg, methylphenidate) have been the most extensively studied intervention for ADHD. More than 75% of children with ADHD taking these medications exhibit behavioral, academic, and attentions! improvements on measures such as parent/teacher ratings, laboratory tasks, and direct behavioral observation.9 The stimulant medications most commonly used in treating ADHD are displayed in the Table, along with their generic names, tablet sizes, and typical dose ranges. Traditionally, recommended dosages for stimulant medications have been based on a child's body weight using a milligram per kilogram formula. However, recent studies indicate that the behavioral effects of methylphenidate are highly idiosyncratic and are not moderated by differences in body weight.10·" Thus, determining dosage on a milligram per kilogram basis is not accurate. For this reason, the Table represents recommended dosages in terms of fixed doses as typically prescribed.

Effects of Stimulant Medication

At the cellular level, psychostimulants enhance the action of certain neurotransmitters (ie, catecholamines) by increasing their concentration at the synaptic cleft. These drugs increase their release from the presynaptic neuron, block their re-uptake, and inhibit monoamine oxidase, the enzyme that hydrolyzes catecholamines.0 This stimulates the reticular activating system, the limbic system, striatum, and other related regions of…

Attention-deficit hyperactivity disorder (ADHD) features developmentally inappropriate levels of sustained attention and impulse control, as well as the inability to regulate activity levels to situational demands.1 There is also a frequent association with other conditions, such as learning disabilities, oppos it ional -defiant disorder, conduct disorder, academic underachievement, and deficits in social skills.2 The disorder is believed to arise in early childhood and is relatively chronic throughout childhood and adolescence.2·* Although brain imaging procedures are normal in patients with ADHD, recent studies have demonstrated focal hypoperfusion4 and diminished glucose use5 in brains of patients with childhood ADHD.

Various treatments have been tried with ADHD, tar too numerous to review here. Those treatments with the most proven effectiveness at reducing symptoms include psychopharmacology (ie, stimulants) and training parents and teachers in behavior modification techniques- Reducing dietary intake of sucrose or food additives plays no role in controlling ADHD.6'7 No treatments have yet proven curative of this condition - all provide purely symptomatic relief. Moreover, no treatments have produced any enduring effects with these children once treatments have been withdrawn.8 As a result, ADHD is now considered a developmental disability requiring long-term symptomatic treatment if any impact on later outcome is to be made.

Both psychophannacology and parent training have as their goal to create a better fit between the child with ADHD and the demands made on that child by the social environment, especially at home and at school. With medication, this is achieved by altering those deficits experienced by the child in the domains of inattention, impulsivity, and overactivity by changing neurological substrate(s) believed to mediate these neurologic functions. With the other - training in child behavior techniques - this goal is achieved through restructuring the types of demands that caregivers place on the child with ADHD. This is done by diminishing stimuli the child receives and by using consequences (rewards) thai are known to motivate the child to increase work performance and compliance.

In this article, these two commonly used and effective therapies for the management of ADHD are discussed. Because of space limitations, an in-depth review of the literature related to these two treatments is not possible. Instead, the reader interested in a more thorough discussion of these treatments as well as the disorder itself and methods of its assessment is referred to a recent comprehensive textbook, Attention Deficit Hyperactiviry Disorder: A Handbook for Diagnosis and Treatment.2

STIMULANT THERAPY FOR ADHD

Psychostimulant medications (eg, methylphenidate) have been the most extensively studied intervention for ADHD. More than 75% of children with ADHD taking these medications exhibit behavioral, academic, and attentions! improvements on measures such as parent/teacher ratings, laboratory tasks, and direct behavioral observation.9 The stimulant medications most commonly used in treating ADHD are displayed in the Table, along with their generic names, tablet sizes, and typical dose ranges. Traditionally, recommended dosages for stimulant medications have been based on a child's body weight using a milligram per kilogram formula. However, recent studies indicate that the behavioral effects of methylphenidate are highly idiosyncratic and are not moderated by differences in body weight.10·" Thus, determining dosage on a milligram per kilogram basis is not accurate. For this reason, the Table represents recommended dosages in terms of fixed doses as typically prescribed.

Effects of Stimulant Medication

At the cellular level, psychostimulants enhance the action of certain neurotransmitters (ie, catecholamines) by increasing their concentration at the synaptic cleft. These drugs increase their release from the presynaptic neuron, block their re-uptake, and inhibit monoamine oxidase, the enzyme that hydrolyzes catecholamines.0 This stimulates the reticular activating system, the limbic system, striatum, and other related regions of the brain (ie, or hi tal -iron tal lobes) that control attention, arousal, and inhibitory processes. 'There is also evidence that the behavioral effects may be caused by lowering the central nervous system threshold for reinforcement and by prolonging the sensitivity to reinforcement beyond when satiation or habituation would typically occur.13 The cellular locus for this effect is not clear. Methylphentdate blood levels peak between 1 and 2'/2 hours postingestion. Optimal therapeutic effects occur within 4 hours and last up to 7 hours.

Substantial research indicates that psychostimulants enhance certain behavioral, cognitive, and academic processes among children with ADHD. The stimulants have been found to improve the performance on laboratory tests of sustained attention, impulsiviry, short-term recall, and associative learning.9·14 Children's on-task behavior, academic productivity, work accuracy in the classroom, and disruptive, out-of-seat behavior also have been noted to improve on stimulants.15·16 Other behavioral improvements are increased compliance, independent play, and responsiveness to social interactions with parents, teachers, and peers.2·17 In response, the amount of commands, criticism, punishment, and censure directed at the children by adults is often reduced. As a result of all of these changes, the child's acceptance by his or her peers is enhanced.

Because ADHD typically fails to remit in adolescence or adulthood in the majority of cases,2 studies have explored the clinical efficacy of stimulant medications with teenagers18 and adults19 who have residual ADHD symptoms. The findings have been generally positive. This treatment may therefore be used on a long-term basis as needed throughout the life of an individual with ADHD.20

Side Effects of Stimulant Medication

Despite recent controversy in the media regarding severe side effects associated with psychostimulants,2 the actual side effects are typically quite mild relative to other classes of medications.21 The most frequent side effects are decreased appetite and insomnia. A minority of patients report somatic symptoms (eg, headaches or stomachaches), increased tension, growth inhibition, and increases in heart rate or blood pressure. In general, most of these treatment-related effects are dose -dependent and diminish with reductions in dosage and passage of time.

In very rare cases, symptoms of Gilles de la Tourette's syndrome have occurred while a patient is receiving stimulant medication.2 However, it is probable that the stimulant therapy- related Tourette's syndrome is not secondary to the drug. The pediatrician needs to consider that symptoms of Tourette's syndrome occur (when they do occur) after variable times of exposure to stimulant therapy, that not all children with previously diagnosed Tourette's syndrome deteriorate when exposed to stimulant therapy, and that children with Tourette's syndrome frequently have an attention -deficit disorder.22 Stimulant therapy may only accelerate the onset of symptoms in a patient destined to have the disorder.23 Nevertheless, stimulant therapy should not be used when there is a family or individual history of Tourette's syndrome, multiple tic disorder, or obsessive compulsive disorders, which are a feature of Tourette's syndrome.

Assessment of Medication Effects

Although stimulant medications have been found to significantly enhance behavioral and academic functioning among groups of children with ADHD, their effects on the behavior of individual children are idiosyncratic and depend on several factors including the specific task or activity under investigation as well as the drug dose.10'16 Thus, the clinical evaluation of drug response must involve the use of multiple measures collected across several doses of medication.

Ideally, this assessment should take place in the context of a double-blind, placebo-controlled trial.2 Measures of attention should be taken across clinic and classroom settings and might include a continuous performance test, parent and teacher ratings of behavior, direct observations of classroom on-task behavior, and academic productivity and accuracy.

Unfortunately, this ideal is impractical in most active medical practices. In such cases, obtaining parent and teacher ratings of ADHD behavior before therapy, during placebo, and during medication conditions is desirable. Using a rating scale of medication side effects2·21 in such a trial also is recommended. If the above are not used, the prescribing physician must be satisfied that there is a dramatic benefit from the therapy - one that is promptly reversed when the medication is omitted and one that is apparent to multiple observers, ie, parents and teachers.

Other Promising Medications

In addition to stimulants, several other classes of psychoactive drugs are beginning to show promise in the management of ADHD symptoms. Among these, tricyclic antidepressants have the strongest evidence for efficacy when tested against placebo conditions in placebo controlled studies.24'25 These drugs are not as effective as stimulants in altering ADHD symptoms, but their effects are clearly better than the effects produced by placebos. Tricyclic antidepressants are worth clinical consideration when children with ADHD have coexisting anxiety or depression, or when stimulants are contra indicated, are ineffective, or cause adversity. Recently, clonidine, an antihypertensive, has shown some promising effects in a few studies with aggressive ADHD children.26 However, these results need to be replicated before this drug can be recommended.

Table

TABLE 1Stimulant Medications, Tablet Sizes, and Dose*

TABLE 1

Stimulant Medications, Tablet Sizes, and Dose*

TRAINING IN CHILD BEHAVIOR MANAGEMENT SKILLS

In addition to stimulant medication, training parents and teachers in behavior modification techniques has proven invaluable in providing symptomatic management of ADHD children, especially at times when medication cannot be taken (eg, when the dose has worn off for that day or when the child is on a drug holiday). There are two essential components to this approach, the first being the education of caregivers about ADHD and the second being the training of these caregivers in social learning principles and skills.

Parent and Teacher Counseling

It is crucial as a step in treatment to provide parents and teachers with as comprehensive and up-to-date information as possible on the nature of ADHD, its developmental course, and available treatments.2 The attitude of these primary care givers toward ADHD children and their disability is critical to the success of subsequent treatments. These caregivers must be educated to view this disorder as a developmental Iy handicapping condition that is unlikely to remit, although it can be successfully managed. Like many chronic pediatrie medical conditions, ADHD is a relatively stable disorder that requires considerable involvement of parents and teachers in its management and periodic reassessment by professionals to effectively deal with its impact on the adaptive functioning of these children.

Providing parents and teachers with recent books and videotapes2 on the subject greatly assists this educational counseling and prepares them for the hard work ahead. Referring them to one of the increasingly greater number of parent support associations for ADHD, such as Children with ADD (CHADD) and Attention Deficit Disorders Association (ADDA)2 is also highly recommended for ongoing social support in caring for and raising a behaviorally disabled child.

Behavior Modification

A well-substantiated approach to managing ADHD is the training of parents and teachers in child behavior management methods/·4'27 These approaches typically involve the rearrangement of environmental contingencies for increasing (reinforcing) desirable behavior while diminishing (punishing) undesirable behavior. Adjustments to the magnitude, frequency, and timing of the consequences used by caregivers are often made as are enhancements to the methods by which rules and instructions are delivered to the children. Alterations in the structure of the home or classroom setting also may be incorporated into these treatment programs, such as rearranging where the child sits in class or where the child completes homework, adding computers to assist with curriculum instructions, and increasing the attractiveness of instructional materials. Unfortunately, as with psychopharmacologie approaches, cessation of these management methods often results in a return to pretreatment levels of misbehavior, and persistence requires a stable and supportive family environment.

Training parents in behavior management skills often takes 8 to 10 counseling sessions of 1 to 2 hours per week.28·29 Although time consuming, such training is quite effective in reducing levels of behavioral deviance in ADHD children.2·8·50 Within such a program, a number of recommendations are made to parents to alter the manner in which they manage the conduct of their ADHD child. These recommendations include:

* increasing the amount of attention, praise, and privileges or rewards parents provide for compliance with commands and household rules as through a home poker-chip program or point system,

* learning to deliver commands more effectively so that there is greater compliance from the child (eg, using imperatives, not giving too many commands at once, setting time limits for compliance, not repeating the commands excessively, and breaking large jobs down into small steps),

* increasing the immediacy of consequences so that long delays do not occur between appropriate or unacceptable behavior and the consequences parents should be employing to manage them,

* instituting response costs (ie, loss of privileges or points) and time out consequences (eg, isolation to a chair in a corner) immediately following misbehavior,

* reducing the length and complexity of work assignments to the ADHD child to fit better within the child's attention span,

* learning to anticipate in what settings child misconduct may arise (eg, stores, restaurants, and visitors to the home) and reviewing with the child a plan to manage the situation before misconduct begins, and

* reducing parenting stress using routine stress management principles (eg, exercise, adequate sleep, self-directed positive statements about the role of being a parent, equitable sharing of parenting with spouse, and relaxation and deep breathing exercises).

Training teachers may involve less clinical time but follows a similar set of recommendations as those given to parents. A number of more specific recommendations also can be made for the classroom behavior management of ADHD children.2 These may include:

* adjusting the length of work assignments provided in class and for homework to fit within the child's attentional capacity,

* altering classroom seating arrangements to facilitate closer teacher supervision of and feedback to the ADHD child while working,

* adjusting the quantity, timing, and consistency of behavioral consequences provided to ADHD children for their work performance, their adherence to classroom rules, and their prosocial conduct toward peers,

* altering teaching sytle to decrease the length of didactic lectures and increase the vibrancy, appeal, and interest in the lesson plans being presented as well as increasing the degree of child participation in the teaching process,

* closely coordinating child behavior management methods across different teachers working with the ADHD child,

* incorporating more specific organizational techniques to aid the organizational problems of the ADHD child, eg, homework assignment notebooks formally checked by teachers, parent-teacher journals, daily school behavior report cards linked to home-based token reinforcement programs, second sets of textbooks kept at home by parents, and training children in "think aloud-think ahead" se If- instruct ion methods,

* communicating closely with parents concerning behavior management problems with ADHD children, and

* assigning a "case manager" at school to oversee the implementation of special programs and services across teachers and subjects for ADHD children and with whom parents can have frequent and regular consultations concerning their child's educational program.

CONCLUSION

Treating 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 children. Among the available treatments, stimulant medication and training parents and teachers in child management skills remain the most popular and effective approaches for providing symptomatic relief and for preparing caregivers to cope with this developmental disorder. Using special education services, training ADHD children in anger control and self-control, and counseling them on social skills may be additional adjunctive procedures having some effectiveness. Research to date has clearly shown that these treatments must be maintained over longer time intervals than has heretofore been the case, if greater impact is to be made on the long-term outcome of these children.

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17. 13arkk-y RA, Karlssnn J. Sttielecki E, ???f?? J. Effects of age and ri tal m dosage on the mother-child interactions irf hyperactive children. J Consul! Clin Psjcdnl. 1984:52:750-758.

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TABLE 1

Stimulant Medications, Tablet Sizes, and Dose*

10.3928/0090-4481-19910501-09

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