Pediatric Annals

Special Issue Article 

Skills Versus Pills: Psychosocial Treatments for ADHD in Childhood and Adolescence

Erin N. Schoenfelder, PhD; Tyler Sasser, MA

Abstract

Although side effects and family concerns are common and long-term medication adherence is low, stimulant medications are a front-line treatment for attention-deficit/hyperactivity disorder (ADHD). Psychosocial treatments include classroom, family, and child-focused interventions that teach caregivers and teachers how to implement contingencies to shape behavior and provide children with skills to compensate for ADHD deficits. Such programs have a growing evidence-base and can be implemented alone or in conjunction with pharmacological treatments. The most efficacious psychosocial treatments for children with ADHD include Behavioral Parent Training, Behavioral Classroom Management, and Behavioral Peer Interventions, which all focus on contingency management by adults. Training interventions are increasingly used to teach organizational and interpersonal skills to children and adolescents. These treatments are found to improve functional outcomes associated with ADHD, including on-task behavior, compliance, academic performance, social relationships, and family functioning. Clinicians play an important role in educating families about psychosocial treatments for ADHD, increasing family motivation and engagement, and including these interventions in multimodal treatment plans for youth with ADHD across development. [Pediatr Ann. 2016;45(10):e367–e372.]

Abstract

Although side effects and family concerns are common and long-term medication adherence is low, stimulant medications are a front-line treatment for attention-deficit/hyperactivity disorder (ADHD). Psychosocial treatments include classroom, family, and child-focused interventions that teach caregivers and teachers how to implement contingencies to shape behavior and provide children with skills to compensate for ADHD deficits. Such programs have a growing evidence-base and can be implemented alone or in conjunction with pharmacological treatments. The most efficacious psychosocial treatments for children with ADHD include Behavioral Parent Training, Behavioral Classroom Management, and Behavioral Peer Interventions, which all focus on contingency management by adults. Training interventions are increasingly used to teach organizational and interpersonal skills to children and adolescents. These treatments are found to improve functional outcomes associated with ADHD, including on-task behavior, compliance, academic performance, social relationships, and family functioning. Clinicians play an important role in educating families about psychosocial treatments for ADHD, increasing family motivation and engagement, and including these interventions in multimodal treatment plans for youth with ADHD across development. [Pediatr Ann. 2016;45(10):e367–e372.]

Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood behavioral disorder, with risk for long-term problems in functioning across many domains.1 Although stimulant medication is an effective treatment for ADHD across development, adherence to medication is low and medications alone often do not address the complex sequelae of ADHD. Psychosocial treatments for ADHD are supported by research as effective alternatives or complementary treatments to medication, and are an important part of a multimodal treatment plan. This article reviews the rationale for using these treatments and describes the existing research evidence. Additionally, the article suggests ways for clinicians to increase patient engagement in psychosocial treatments for ADHD.

Why Use Psychosocial Treatments?

Evidence supports the use of psychostimulant (ie, d-amphetamine, methylphenidate) and nonstimulant medications (ie, atomoxetine) to treat ADHD symptoms.2 However, approximately 20% to 30% of children do not substantially benefit from stimulants,3 and common side effects such as insomnia and appetite suppression can lead to dissatisfaction with treatment.4 Many families of children with ADHD also have concerns about using medications due to risks and controversies reported in the media.5 Even for families who initiate stimulant treatment, adherence is poor, with between 30% and 80% of children prematurely discontinuing medication.6 As many as 90% of teenagers discontinue ADHD medications before age 18 years,7 making this population especially likely to forgo treatment and experience difficulties during a risky developmental period. Thus, in addition to better education and engagement strategies for families regarding ADHD medications, alternative treatment options are needed.

In general, psychosocial treatments include interventions designed to address the behavioral, emotional, and interpersonal aspects of a disorder using modalities such as psychotherapy, skills training, or family education. Besides being more acceptable than medication for many families, psychosocial treatments address aspects of a disorder that medications cannot, such as skill and functional deficits, environmental stressors, or relational conflicts that exacerbate difficulties.

ADHD symptoms contribute to functional and environmental problems that can compound across domains over time, creating a complicated treatment picture. Inattention and off-task behavior in class inhibits learning and school engagement and causes social problems with peers and teachers.8 Social skill deficits and impulsive behavior impair friendships and family relationships, leading to more conflict and stress.9 At home, caregivers of children with ADHD experience higher parenting demands, leading to marital and parental mental health problems, poor communication, and ineffective discipline.10 Such psychosocial difficulties are often not sufficiently addressed by medications, and indeed may limit the benefits of medication. Additionally, as children experience stress and frustration related to their psychosocial difficulties over time, psychiatric comorbidities emerge, including depression, anxiety, oppositional defiant, substance use abuse, and conduct disorders, that require additional intervention.11 Psychosocial impairments are best addressed with psychosocial treatments that occur within children's multiple environments, incorporate caregivers, and equip children and parents with new skills.

Which Psychosocial Treatments are Effective for ADHD?

Psychosocial treatments for children with ADHD generally rely on parents, teachers, or professionals to learn and implement contingency management procedures to address behavioral and functional problems associated with ADHD. Contingency management typically involves the strategic use of adult attention, praise, privileges, and rewards to foster skill development.

“Well-established” psychosocial treatments include behavioral parent training (BPT), behavioral classroom management (BCM), and behavioral peer interventions (BPIs),12,13 all of which focus on interventions to promote functional skill development.14,15

Psychosocial treatments generally do not decrease the core symptoms of ADHD, such as distractibility or fidgeting; however, and perhaps more importantly, psychosocial treatments do improve children's functioning across multiple settings. The largest randomized trial including psychosocial treatments for childhood ADHD is the Multimodal Treatment Study of ADHD (MTA Study).16 In the study, more than 500 school-aged children with ADHD-combined type received medication and/or behavioral treatment (ie, BPT, BCM, and BPI) or were referred to receive treatment by a provider in the community. Although medication alone significantly decreased the core symptoms of ADHD, only children who received behavioral treatment in addition to medication saw significant improvements in child social skills, parent-child relationships, and positive parenting practices during the 14-month study period.17 Since the MTA Study, many additional trials discussed later in this article have evaluated far-reaching benefits of these and other psychosocial treatments.

Behavioral Parent Training

In BPT, parents learn about the effects of ADHD on child conduct and use management procedures to reward positive behaviors, as well as disengage and set limits on those that are problematic. Numerous manualized BPT curricula exist with similar core components; those most studied with ADHD include sources by Barkley,18 Webster-Stratton et al.,19 and Aghebati et al.20 Such interventions yield improvements in children's oppositional and aggressive symptoms, increase positive parenting, and reduce parent criticism and conflict.19,21 BPT has rarely been evaluated with adolescents. One pilot of BPT with adolescents found positive effects on family relationships, although the authors suggest that outcomes may be enhanced when the program is used in combination with medication for ADHD.22

Behavioral Classroom Management

BCM interventions typically rely on teacher-implemented classroom rules, token systems, and response-cost or time-out procedures to address behavioral difficulties. A key component is the daily report card (DRC) that is used to track a child's progress toward behavioral goals (eg, “child starts on work when asked”) and reinforce performance. In typical classrooms, BCM is found to improve parent-rated adaptive behavior, teacher-rated attention, aggression, and social skills, and observer-rated externalizing problems.23 Recent enhancements of BCM strategies have also equipped teachers to foster peer relationships and to accept children with ADHD.24

Behavioral Peer Interventions

Children with ADHD have problems with social skills and peer relations that are not sufficiently addressed by traditional clinic-based social skills training.13 In BPI, staff or parents are trained to manage contingencies in children's social situations to improve their peer relations. The most heavily researched BPI is the summer treatment program (STP) model, which targets children's compliance and social functioning in recreational settings, typically day camps, conducted over 5 to 8 weeks. Daily activities in the STP involve social skills training, coached recreational activities (eg, soccer, swimming), and academic instruction, all with concurrent contingency management (eg, activity rules, point system, time-out, DRC). STPs have demonstrated broad improvements in children's behavioral and academic functioning, including parent- and staff-reported increased prosocial behavior.25 STPs have also recently been adapted for preschoolers26 and adolescents.27

Similarly, a weekly group-based BPI called Parent Friendship Coaching trains parents in a “coach” role and was found to increase the likelihood of teachers rating children as more accepted and less rejected by peers.28

Organization Skills Training

Organizational skills training (OST) teaches children skills that are inherently lacking and difficult to practice due to ADHD symptoms, such as arranging materials, tracking assignments, managing time, and planning tasks. In a study of third to fifth graders with ADHD,20 sessions of OST was equivalent to parent contingency management training and superior to a waitlist control condition to increase organizational skills, homework completion, and family functioning into the next school year.14 The Supporting Teens Academic Needs Daily program provides OST to adolescents as parents concurrently learn to monitor and reinforce their teenager's efforts and communicate effectively.15 This program is found to improve homework compliance and organizational skills, with some improvements in overall academic performance. OST implemented in an afterschool format for young adolescents with ADHD is also found to improve organizational skills and hyperactive symptoms, as well as social skills.29,30

Treatments with Limited Evidence

Several pilot studies of mindfulness training interventions, in which youth learn behavioral awareness and mindfulness meditation strategies, have demonstrated initial promise to improve ADHD symptoms but have yet to be sufficiently studied.31 Neurofeedback, in which the child learns skills to control particular brainwave patterns using feedback from electroencephalogram technology, has also demonstrated initial effects,32 but further research is needed to establish this as an evidence-based treatment for ADHD.

There is no evidence of the effects of individual or play therapy approaches on ADHD-related deficits. Clinic-based social skills training is also found to have little to no efficacy to improve peer relations of children with ADHD.12 Cognitive-behavioral therapy (CBT), which is perhaps the best-studied and most efficacious psychosocial treatment for a wide range of mental health diagnoses, has not been found to significantly impact childhood ADHD difficulties. However, it is effective for treating problems that are commonly comorbid with ADHD, such as anxiety and depression (eg, Coping Cat, a CBT treatment program33).Additionally, cognitive training games marketed to improve focus and working memory have shown little generalization to affect real-world problems associated with ADHD.34

Implications for Clinicians: Engaging Families in Psychosocial Treatments

When Are Psychosocial Treatments Needed?

Although psychosocial treatments are a safe and likely beneficial approach for families of children with ADHD, they should be prioritized in this way:

  1. The American Academy of Pediatrics recommends psychosocial interventions as the front-line treatment for children with ADHD younger than age 6 years35 before a trial of medication. There is also evidence of BPT to reduce ADHD symptoms in preschool-aged children who are at high risk for the diagnosis,19,21 indicating that there may be potential benefits of behavioral interventions to prevent or delay the onset of ADHD.

  2. For school-aged children with mild-to-moderate ADHD and minimal impairment,36 psychosocial treatments may also be recommended for a trial period (eg, 3 or 6 months) for families reticent to try medication.

  3. Youth with poor tolerance or response to a medication trial.

  4. Families experiencing stress, conflict, and ineffective or negative parenting. BPT is recommended to prevent escalation of negative relational cycles; parent stress, conflict, and mental health problems can intensify child externalizing behaviors and comorbidities if left unaddressed.37

  5. For children with emerging psychiatric comorbidities such as depression or anxiety, symptoms may be ameliorated with ADHD-focused psychosocial treatments or other diagnosis-specific CBT-based interventions.

Which Treatment Should Be Recommended?

The presentation of and challenges caused by ADHD change throughout development and so, too, does the timing and sequencing of psychosocial treatment (Figure 1). Given its strong research support,13 BPT is appropriate as a first and primary behavioral intervention for children up to age 12 years. Although there is less evidence for BPT with adolescents, it may be helpful with oppositional behavior and relational conflict in particular. BCM, with a DRC as the primary component, are optimal for behavioral or academic problems in elementary school. DRCs become increasingly challenging to implement in middle school as children have multiple teachers daily, so it may be employed in the form of a weekly home-school note with feedback from each teacher.


            Functional outcomes of “well-established” psychosocial treatments for attention-deficit/hyperactivity disorder throughout development.

Figure 1.

Functional outcomes of “well-established” psychosocial treatments for attention-deficit/hyperactivity disorder throughout development.

Although availability can be limited, BPIs and STPs in particular are effective for school-aged children with social problems, with some emerging evidence at the high school level.15 Interventions involving OST have been evaluated with children in the third grade but have greater empirical support with middle and high school-aged youth. Thus, OST is the primary psychosocial treatment for middle and high school students with ADHD, as well as for families of younger children when organizational difficulties are primary to other behavioral problems.

How Can Clinicians Engage Families?

Clinicians play a crucial role in educating families about risks associated with untreated ADHD, explaining medication and behavioral treatment approaches, and troubleshooting treatment barriers.38 For primary care clinicians, who often have limited availability to address relational and family problems related to ADHD, including psychosocial interventions in treatment planning, will be particularly helpful to support families and long-term functioning. It is important for clinicians to thoroughly understand and process families' questions or concerns about treatment to maximize engagement. Motivational interviewing is an effective brief psychosocial strategy that can be used flexibly in medical or mental health appointments to increase family willingness to prioritize treatment.39 Additionally, families will need updated treatment plans as children enter adolescence, at which time the risk for treatment drop-out and unhealthy behaviors increase. Clinicians can give adolescents personal agency in their treatment by presenting a menu of options and explaining risks and benefits associated with psychosocial and pharmacological treatments.

Conclusions

Psychosocial treatments for ADHD are effective evidence-based approaches to improve functional problems associated with ADHD. They are generally acceptable and even preferred by families as stand-alone or adjunct treatments to medication. Importantly, they improve areas of functioning that are not directly affected by medications, including family functioning and social and emotional competencies. Clinicians can include psychosocial interventions in treatment plans with medications or without, and can educate families about these approaches to enhance engagement.

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Authors

Erin N. Schoenfelder, PhD, is an Assistant Professor. Tyler Sasser, MA, is a Psychology Resident. Both contributors are affiliated with the Department of Psychiatry, University of Washington School of Medicine.

Address correspondence to Erin N. Schoenfelder, PhD, 4800 Sand Point Way NE, OA.5.161, Seattle, WA 98105; email: Erin.Schoenfelder@SeattleChildrens.org.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/19382359-20160920-04

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