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Issue Links: ADHD 6302

Topics: ADHD | Psychotherapy

Evidence-based treatments for attention-deficit/hyperactivity disorder (ADHD) include medication and behavioral interventions. While medications have been shown to reduce ADHD-related symptoms and functional impairments across settings, effects tend to last only as long as the medication is active within the body and brain (Paykina N and Greenhill LL. Attention-Deficit/Hyperactivity Disorder: Pharmacological Treatments. In: Nathan PE and Gorman JM, eds. A Guide to Treatments that Work, third edition, New York, NY: Oxford University Press; 2007:29–70). As a result, non-pharmacological treatments are often recommended as well. In fact, research suggests that the greatest likelihood for normalization or improvement in symptoms occurs through a combination of medication and psychosocial approaches (Majewicz-Hefley A and Carlson JS, J Atten Disord 2007;10(3):239–250). Behavioral therapy is the only consistently evidence-based intervention for ADHD aside from medication (Hinshaw SP, et al. Childhood Attention-Deficit/Hyperactivity Disorder: Nonpharmacologic Treatments and Their Combination with Medication. In: Nathan and Gorman ibid:3–27). Behavioral treatments for children with ADHD include (Fabiano GA et al, Clin Psychol Rev 2009;29(2):129–140):

• Parent training
• Educational interventions or classroom or contingency management
• Social skills training
• Intensive summer programs

Treatment of adult ADHD is typically based on cognitive behavioral therapy (CBT) approaches, mainly to address executive dysfunction (poor organizational and planning skills) and associated negative thoughts, pessimism, self-criticism, and feelings of frustration that create additional barriers to task follow through. Parent Training Training for parents involves educating parents on behavior management, including positive parental attention, rewards for appropriate behavior, and negative consequences for misbehavior. This method can also be used to train teachers on the use of prompts and rewards in the classroom. Parents are taught to use effective commands (those that are specific, direct, and positively stated), as well as positive reinforcement, often in the form of attention, praise, or small rewards, to promote preferred behaviors and reduce undesired behaviors in both the home and classroom. The key to positive reinforcement is to praise and reward children while they are demonstrating good behavior, such as sitting quietly, focusing on a task, or playing gently with a sibling. The purpose of positive reinforcement is for the child to connect good behavior to the reward. Conversely, giving attention to a child’s negative behaviors may unintentionally reinforce those problem behaviors in a way that encourages more frequent occurrences of those behaviors. Parent training also emphasizes the use of selective attention or active ignoring, of minor disruptive behaviors. By consistently changing the ways that parents and teachers respond to a child’s impulsive or defiant behaviors, children learn new, appropriate ways of behaving. Parent training for teenagers requires a slightly different approach, as behavioral techniques are modified to be age-appropriate for adolescents. For example, parents use loss of privileges (such as driving the car) or assignment of work chores instead of the timeout, which is less effective for this age group (though beneficial for younger children). Parents negotiate for improvements in the teenagers’ target behaviors in exchange for rewards that they can control. For example, if the teen completes all homework assignments in a given day, then she can go out with her friends. The give and take between parents and teenager, as well as frequent problem solving around these issues, can be helpful in motivating the teenager to work with the parents in making changes in behavior. Classroom Interventions Classroom interventions for ADHD also use behavioral techniques, such as praise, planned ignoring, and effective commands, as well as direct “contingency management,” including rewards for target behaviors and consequences for problematic behaviors. In addition, teachers learn to manage ADHD by setting clear and consistent, positively stated rules for behavior, redirecting the child toward a goal or task, and finding activities that keep the child busy, such as passing out homework and tests or collecting assignments. Ignoring minor disturbances and other negative behaviors, and then praising the demonstration of attentive or cooperative behaviors, also works in the classroom. Another school-focused technique addressing behavioral issues is the daily report card: the teacher sets behavior goals for the child, based on age, developmental level, and severity of the symptoms. For example, a younger student will have fewer goals on the daily report card and receive more reinforcement than an older student. The teacher monitors and records the student’s ability to meet these goals and marks them on the report card each day. The child brings the report card home for the parents to sign. When the child fulfills the goals on the daily report card, he or she receives a tangible reward that the teacher and student agree upon. Teenagers with ADHD need to be more involved in goal planning and implementation of interventions at school than do younger children. For example, teachers expect teenagers to be more responsible for belongings and assignments, but may need to teach adolescents with ADHD organizational strategies and study skills to enable this. In addition, the daily report card may become the weekly report card for adolescents, and emphasis is placed on earning long-term rewards instead. Parent involvement with the school, however, is as important at the middle and high school levels as it is in elementary school. Parents will often work with guidance counselors, who can coordinate intervention among several teachers, rather than individual teachers. Social Skills Interventions Although social skills interventions do not directly address core ADHD symptoms, they can be a critical component of treatment, as these youth often have serious problems in this area (Bagwell CL et al, J Am Acad Child Adolesc Psychiatry 2001;40(11):1285–1292). Effective approaches include the following:

• Systematic teaching of social skills (Webster-Stratton C et al, J Child Psychol Psychiatry 2001;42(7):943–952)
• Social problem solving (Kazdin AE et al, J Consult Clin Psychol 1989;57(4):522–535)
• Teaching other behavioral skills often considered important by children, such as sports skills and board game rules (American Academy of Child and Adolescent Psychiatry, J Amer Acad Child Adolesc Psychiatry 1997;36 (Suppl. 10):85–121)
• Decreasing undesirable and antisocial behaviors
• Developing a close friendship

CBT for Adult ADHD While adults with ADHD tend to display diminished impulsive behavior and hyperactivity, problems with attention and executive functioning, including difficulty initiating, organizing, and following through with tasks, persist. CBT for ADHD is most effective as part of a treatment plan that includes the consistent practice of compensatory skills along with cognitive interventions for dealing with thought distortions and resulting negative emotions which contribute to avoidance and procrastination (Knouse LE and Safren SA, Psychiatr Clin North Am 2010;33(3):497–509). The development of compensatory strategies for ADHD involves training patients in a number of specific, as well as higher-order, skills (Safren SA et al, Behav Res Ther 2005;43(7):831–842; Solanto MV et al, Am J Psychiatry 2010; 167(8):958–968), some of which include the following:

• Increasing organization and planning. Patients are encouraged to maintain a notebook or planner with a task list and prioritize those tasks based on importance and time until completion.
• Breaking down large projects into smaller, more manageable parts. Patients are also taught to develop a step-by-step action plan for approaching overwhelming tasks, including working on more complex tasks well before their deadline.
• Managing time effectively. Patients learn to anticipate and plan how long each task will take (and identify any factors or barriers that might disrupt follow through), and use tools such as alarms, programmable watches, and timers as reminders and to help stay on task.
• Reducing distractibility. Patients are encouraged to write down distractions when they emerge rather than act on them, and then return to the task. They learn to minimize visual distractions, such as electronics and smart phones, in their organizational space.
• Providing self-rewards. Patients provide themselves small rewards for working through aversive tasks, such as grabbing coffee with a friend or visiting the gym after finishing the first draft of a research paper. They maintain motivation by visualizing long-term rewards (eg, vacation).

TCRBH’s Take: The many psychosocial approaches to ADHD may require the cooperation of others, including educators and/or employers. While one hopes that such cooperation occurs, that is not always the case. You may need to advocate for patients and help them (or the parents of young patients) to understand their rights (including the right to reasonable accommodations) as outlined in the Americans with Disabilities Act (ADA) and the Individuals with Disabilities Education Act (IDEA).