Attention Deficit Hyperactivity Disorder: Module 3
Treatment , Family and the ADHD Child, and Your ADHD
Child and School
The information in this training module was taken
from an online article by the National Institute of Mental
The Treatment of ADHD
Every family wants to
determine what treatment will be most effective for their child. This question
needs to be answered by each family in consultation with their health care
professional. To help families make this important decision, the National
Institute of Mental Health (NIMH) has funded many studies of treatments for ADHD
and has conducted the most intensive study ever undertaken for evaluating the
treatment of this disorder. This study is known as the Multimodal Treatment
Study of Children with Attention Deficit Hyperactivity Disorder (MTA).12
The NIMH is now conducting a clinical trial for younger children ages 3 to 5.5
years (Treatment of ADHD in Preschool-Age Children).
The Multimodal Treatment
Study of Children with Attention Deficit Hyperactivity Disorder
The MTA study included 579
(95-98 at each of 6 treatment sites) elementary school boys and girls with ADHD,
who were randomly assigned to one of four treatment programs: (1) medication
management alone; (2) behavioral treatment alone; (3) a combination of both; or
(4) routine community care. In each of the study sites, three groups were
treated for the first 14 months in a specified protocol and the fourth group was
referred for community treatment of the parents’ choosing. All of the children
were reassessed regularly throughout the study period. An essential part of the
program was the cooperation of the schools, including principals and teachers.
Both teachers and parents rated the children on hyperactivity, impulsivity, and
inattention, and symptoms of anxiety and depression, as well as social skills.
The children in two groups
(medication management alone and the combination treatment) were seen monthly
for one-half hour at each medication visit. During the treatment visits, the
prescribing physician spoke with the parent, met with the child, and sought to
determine any concerns that the family might have regarding the medication or
the child’s ADHD-related difficulties. The physicians, in addition, sought input
from the teachers on a monthly basis. The physicians in the medication-only
group did not provide behavioral therapy but did advise the parents when
necessary concerning any problems the child might have.
In the behavior
treatment-only group, families met up to 35 times with a behavior therapist,
mostly in group sessions. These therapists also made repeated visits to schools
to consult with children’s teachers and to supervise a special aide assigned to
each child in the group. In addition, children attended a special 8-week summer
treatment program where they worked on academic, social, and sports skills, and
where intensive behavioral therapy was delivered to assist children in improving
Children in the combined
therapy group received both treatments, that is, all the same assistance that
the medication-only received, as well as all of the behavior therapy treatments.
In routine community care,
the children saw the community-treatment doctor of their parents’ choice one to
two times per year for short periods of time. Also, the community-treatment
doctor did not have any interaction with the teachers.
The results of the study
indicated that long-term combination treatments and the medication-management
alone were superior to intensive behavioral treatment and routine community
treatment. And in some areas—anxiety, academic performance, oppositionality,
parent-child relations, and social skills—the combined treatment was usually
superior. Another advantage of combined treatment was that children could be
successfully treated with lower doses of medicine, compared with the
Treatment of Attention
Deficit Hyperactivity Disorder in Preschool-Age Children (PATS)
Because many children in
the preschool years are diagnosed with ADHD and are given medication, it is
important to know the safety and efficacy of such treatment. The NIMH is
sponsoring an ongoing multi-site study, “Preschool ADHD Treatment Study” (PATS).
It is the first major effort to examine the safety and efficacy of a stimulant,
methylphenidate, for ADHD in this age group. The PATS study uses a randomized,
placebo-controlled, double-blind design. Children ages 3 to 5 who have severe
and persistent symptoms of ADHD that impair their functioning are eligible for
this study. To avoid using medications at such an early age, all children who
enter the study are first treated with behavioral therapy. Only children who do
not show sufficient improvement with behavior therapy are considered for the
medication part of the study. The study is being conducted at New York State
Psychiatric Institute, Duke University, Johns Hopkins University, New York
University, the University of California at Los Angeles, and the University of
California at Irvine. Enrollment in the study will total 165 children.
1. In the MTA study
results of the MTA study indicated
Which Treatment Should My
For children with ADHD, no
single treatment is the answer for every child. A child may sometimes have
undesirable side effects to a medication that would make that particular
treatment unacceptable. And if a child with ADHD also has anxiety or depression,
a treatment combining medication and behavioral therapy might be best. Each
child’s needs and personal history must be carefully considered.
For decades, medications
have been used to treat the symptoms of ADHD.
The medications that seem
to be the most effective are a class of drugs known as stimulants. Following is
a list of the stimulants, their trade (or brand) names, and their generic names.
“Approved age” means that the drug has been tested and found safe and effective
in children of that age.
3 and older
6 and older
6 and older
*Because of its potential
for serious side effects affecting the liver, Cylert should not
ordinarily be considered as first-line drug therapy for ADHD.
The U.S. Food and Drug
Administration (FDA) recently approved a medication for ADHD that is not a
stimulant. The medication, Strattera®, or atomoxetine, works on the
neurotransmitter norepinephrine, whereas the stimulants primarily work on
dopamine. Both of theses neurotransmitters are believed to play a role in ADHD.
More studies will need to be done to contrast Strattera with the medications
already available, but the evidence to date indicates that over 70 percent of
children with ADHD given Strattera manifest significant improvement in their
Some people get better
results from one medication, some from another. It is important to work with the
prescribing physician to find the right medication and the right dosage. For
many people, the stimulants dramatically reduce their hyperactivity and
impulsivity and improve their ability to focus, work, and learn. The medications
may also improve physical coordination, such as that needed in handwriting and
The stimulant drugs, when
used with medical supervision, are usually considered quite safe. Stimulants do
not make the child feel “high,” although some children say they feel different
or funny. Such changes are usually very minor. Although some parents worry that
their child may become addicted to the medication, to date there is no
convincing evidence that stimulant medications, when used for treatment of ADHD,
cause drug abuse or dependence. A review of all long-term studies on stimulant
medication and substance abuse, conducted by researchers at Massachusetts
General Hospital and Harvard Medical School, found that teenagers with ADHD who
remained on their medication during the teen years had a lower likelihood of
substance use or abuse than did ADHD adolescents who were not taking
The stimulant drugs come
in long- and short-term forms. The newer sustained-release stimulants can be
taken before school and are long-lasting so that the child does not need to go
to the school nurse every day for a pill. The doctor can discuss with the
parents the child’s needs and decide which preparation to use and whether the
child needs to take the medicine during school hours only or in the evening and
on weekends too.
If the child does not show
symptom improvement after taking a medication for a week, the doctor may try
adjusting the dosage. If there is still no improvement, the child may be
switched to another medication. About one out of ten children is not helped by a
stimulant medication. Other types of medication may be used if stimulants don’t
work or if the ADHD occurs with another disorder. Antidepressants and other
medications can help control accompanying depression or anxiety.
Sometimes the doctor may
prescribe for a young child a medication that has been approved by the FDA for
use in adults or older children. This use of the medication is called “off
label.” Many of the newer medications that are proving helpful for child mental
disorders are prescribed off label because only a few of them have been
systematically studied for safety and efficacy in children. Medications that
have not undergone such testing are dispensed with the statement that “safety
and efficacy have not been established in pediatric patients.”
Side Effects of the
Most side effects of the
stimulant medications are minor and are usually related to the dosage of the
medication being taken. Higher doses produce more side effects. The most common
side effects are decreased appetite, insomnia, increased anxiety, and/or
irritability. Some children report mild stomach aches or headaches.
Appetite seems to
fluctuate, usually being low during the middle of the day and more normal by
suppertime. Adequate amounts of food that is nutritional should be available for
the child, especially at peak appetite times.
If the child has
difficulty falling asleep, several options may be tried—a lower dosage of the
stimulant, giving the stimulant earlier in the day, discontinuing the afternoon
or evening dosage, or giving an adjunct medication such as a low-dosage
antidepressant or clonidine. A few children develop tics during treatment. These
can often be lessened by changing the medication dosage. A very few children
cannot tolerate any stimulant, no matter how low the dosage. In such cases, the
child is often given an antidepressant instead of the stimulant.
When a child’s schoolwork
and behavior improve soon after starting medication, the child, parents, and
teachers tend to applaud the drug for causing the sudden changes. Unfortunately,
when people see such immediate improvement, they often think medication is all
that’s needed. But medications don’t cure ADHD; they only control the symptoms
on the day they are taken. Although the medications help the child pay better
attention and complete school work, they can’t increase knowledge or improve
academic skills. The medications help the child to use those skills he or she
emotional counseling, and practical support will help ADHD children cope with
everyday problems and feel better about themselves.
Facts to Remember About
Medication for ADHD
Medications for ADHD
help many children focus and be more successful at school, home, and play.
Avoiding negative experiences now may actually help prevent addictions and
other emotional problems later.
About 80 percent of
children who need medication for ADHD still need it as teenagers. Over 50
percent need medication as adults.
Medication for the Child
with Both ADHD and Bipolar Disorder
Since a child with bipolar
disorder will probably be prescribed a mood stabilizer such as lithium or
Depakote®, the doctor will carefully consider whether the child should take one
of the medications usually prescribed for ADHD. If a stimulant medication is
prescribed, it may be given in a lower dosage than usual.
The Family and the ADHD
Medication can help the
ADHD child in everyday life. He or she may be better able to control some of the
behavior problems that have led to trouble with parents and siblings. But it
takes time to undo the frustration, blame, and anger that may have gone on for
so long. Both parents and children may need special help to develop techniques
for managing the patterns of behavior. In such cases, mental health
professionals can counsel the child and the family, helping them to develop new
skills, attitudes, and ways of relating to each other. In individual counseling,
the therapist helps children with ADHD learn to feel better about themselves.
The therapist can also help them to identify and build on their strengths, cope
with daily problems, and control their attention and aggression. Sometimes only
the child with ADHD needs counseling support. But in many cases, because the
problem affects the family as a whole, the entire family may need help. The
therapist assists the family in finding better ways to handle the disruptive
behaviors and promote change. If the child is young, most of the therapist’s
work is with the parents, teaching them techniques for coping with and improving
their child’s behavior.
approaches are available. Knowing something about the various types of
interventions makes it easier for families to choose a therapist that is right
for their needs.
works to help people with ADHD to like and accept themselves despite their
disorder. It does not address the symptoms or underlying causes of the disorder.
In psychotherapy, patients talk with the therapist about upsetting thoughts and
feelings, explore self-defeating patterns of behavior, and learn alternative
ways to handle their emotions. As they talk, the therapist tries to help them
understand how they can change or better cope with their disorder.
Behavioral therapy (BT)
helps people develop more effective ways to work on immediate issues. Rather
than helping the child understand his or her feelings and actions, it helps
directly in changing their thinking and coping and thus may lead to changes in
behavior. The support might be practical assistance, like help in organizing
tasks or schoolwork or dealing with emotionally charged events. Or the support
might be in self-monitoring one’s own behavior and giving self-praise or rewards
for acting in a desired way such as controlling anger or thinking before acting.
Social skills training
can also help children learn new behaviors. In social skills training, the
therapist discusses and models appropriate behaviors important in developing and
maintaining social relationships, like waiting for a turn, sharing toys, asking
for help, or responding to teasing, then gives children a chance to practice.
For example, a child might learn to “read” other people’s facial expression and
tone of voice in order to respond appropriately. Social skills training helps
the child to develop better ways to play and work with other children.
help parents connect with other people who have similar problems and concerns
with their ADHD children. Members of support groups often meet on a regular
basis (such as monthly) to hear lectures from experts on ADHD, share
frustrations and successes, and obtain referrals to qualified specialists and
information about what works. There is strength in numbers, and sharing
experiences with others who have similar problems helps people know that they
aren’t alone. National organizations are listed at the end of this document.
Parenting skills training,
offered by therapists or in special classes, gives parents tools and techniques
for managing their child’s behavior. One such technique is the use of token or
point systems for immediately rewarding good behavior or work. Another is the
use of “time-out” or isolation to a chair or bedroom when the child becomes too
unruly or out of control. During time-outs, the child is removed from the
agitating situation and sits alone quietly for a short time to calm down.
Parents may also be taught to give the child “quality time” each day, in which
they share a pleasurable or relaxing activity. During this time together, the
parent looks for opportunities to notice and point out what the child does well,
and praise his or her strengths and abilities.
This system of rewards and
penalties can be an effective way to modify a child’s behavior. The parents (or
teacher) identify a few desirable behaviors that they want to encourage in the
child—such as asking for a toy instead of grabbing it, or completing a simple
task. The child is told exactly what is expected in order to earn the reward.
The child receives the reward when he performs the desired behavior and a mild
penalty when he doesn’t. A reward can be small, perhaps a token that can be
exchanged for special privileges, but it should be something the child wants and
is eager to earn. The penalty might be removal of a token or a brief time-out.
effort to find your child being good.
The goal, over time, is to help children learn to control their own behavior and
to choose the more desired behavior. The technique works well with all children,
although children with ADHD may need more frequent rewards.
In addition, parents may
learn to structure situations in ways that will allow their child to succeed.
This may include allowing only one or two playmates at a time, so that their
child doesn’t get overstimulated. Or if their child has trouble completing
tasks, they may learn to help the child divide a large task into small steps,
then praise the child as each step is completed. Regardless of the specific
technique parents may use to modify their child’s behavior, some general
principles appear to be useful for most children with ADHD. These include
providing more frequent and immediate feedback (including rewards and
punishment), setting up more structure in advance of potential problem
situations, and providing greater supervision and encouragement to children with
ADHD in relatively unrewarding or tedious situations.
Parents may also learn to
use stress management methods, such as meditation, relaxation techniques, and
exercise, to increase their own tolerance for frustration so that they can
respond more calmly to their child’s behavior.
Some Simple Behavioral
Children with ADHD may
need help in organizing. Therefore:
Have the same routine every day, from wake-up time to bedtime. The schedule
should include homework time and playtime (including outdoor recreation and
indoor activities such as computer games). Have the schedule on the refrigerator
or a bulletin board in the kitchen. If a schedule change must be made, make it
as far in advance as possible.
needed everyday items.
Have a place for everything and keep everything in its place. This includes
clothing, backpacks, and school supplies.
homework and notebook organizers.
Stress the importance of writing down assignments and bringing home needed
Children with ADHD need
consistent rules that they can understand and follow. If rules are followed,
give small rewards. Children with ADHD often receive, and expect, criticism.
Look for good behavior and praise it.
Your ADHD Child and
You are your child’s best
To be a good advocate for your child, learn as much as you can about ADHD and
how it affects your child at home, in school, and in social situations.
If your child has shown
symptoms of ADHD from an early age and has been evaluated, diagnosed, and
treated with either behavior modification or medication or a combination of
both, when your child enters the school system, let his or her teachers know.
They will be better prepared to help the child come into this new world away
If your child enters
school and experiences difficulties that lead you to suspect that he or she has
ADHD, you can either seek the services of an outside professional or you can ask
the local school district to conduct an evaluation. Some parents prefer to go to
a professional of their own choice. But it is the school’s obligation to
evaluate children that they suspect have ADHD or some other disability that is
affecting not only their academic work but their interactions with classmates
If you feel that your
child has ADHD and isn’t learning in school as he or she should, you should find
out just who in the school system you should contact. Your child’s teacher
should be able to help you with this information. Then you can request—in
writing—that the school system evaluate your child. The letter should include
the date, your and your child’s names, and the reason for requesting an
evaluation. Keep a copy of the letter in your own files.
Until the last few years,
many school systems were reluctant to evaluate a child with ADHD. But recent
laws have made clear the school’s obligation to the child suspected of having
ADHD that is affecting adversely his or her performance in school. If the school
persists in refusing to evaluate your child, you can either get a private
evaluation or enlist some help in negotiating with the school. Help is often as
close as a local parent group. Each state has a Parent Training and Information
(PTI) center as well as a Protection and Advocacy (P&A) agency. (For information
on the law and on the PTI and P&A, see the section on support groups and
organizations at the end of this document.)
Once your child has been
diagnosed with ADHD and qualifies for special education services, the school,
working with you, must assess the child’s strengths and weaknesses and design an
Individualized Educational Program (IEP). You should be able periodically to
review and approve your child’s IEP. Each school year brings a new teacher and
new schoolwork, a transition that can be quite difficult for the child with
ADHD. Your child needs lots of support and encouragement at this time.
Never forget the cardinal
are your child’s best advocate.
Stimulants do not make the child feel “high,”
although some children say they feel different or funny.
one out of five children is not helped by a stimulant medication.
don’t cure ADHD; they only control the symptoms on the day they are taken.
the child is young, most of the therapist’s work is with the parents, teaching
them techniques for coping with and improving their child’s behavior.
helps directly in changing thinking and coping and thus may lead to changes in
a child has been diagnosed with ADHD and qualifies for special education
services, the school, working with the parent or guardian, must assess the
child’s strengths and weaknesses and design an Individualized Educational
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