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ADHD in Children: Diagnosis, Assessment, and Management
by Russell A. Barkley, Ph.D., ABPP

8 CE Hours - $119

Last revised: 08/01/2019

Course content © copyright 2019 by Russell A. Barkley, Ph.D., ABPP All rights reserved.


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Learning Objectives

The materials in this course are based on the most accurate information available to the author at the time of writing. The scientific literature on ADHD grows daily and new information may emerge that supersedes these course materials. This course will equip clinicians to have a basic understanding of the diagnosis, assessment, and management of ADHD. This course is adapted from the relevant chapters contained in Barkley, R. A. (2015), Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (4th ed.). New York: Guilford Press.

Outline

Introduction

Over the past century, numerous diagnostic labels have been given to clinically referred children having significant deficiencies in behavioral inhibition, sustained attention, resistance to distraction, and the regulation of activity level. Most recently, Attention Deficit-Hyperactivity Disorder (ADHD) (DSM-5, American Psychiatric Association, 2013) is the term used to capture this developmental disorder. Previously employed terms have been brain-injured child syndrome, hyperkinesis, hyperactive child syndrome, minimal brain dysfunction, and Attention Deficit Disorder (with or without Hyperactivity). Such relabeling every decade or so reflects a shifting emphasis in the primacy accorded certain symptom clusters within the disorder based, in part, on the substantial research conducted each year on ADHD and how investigators and theorists interpret those findings. A reasonably thorough history of ADHD can be found in the chapter on that topic in the author’s 4th edition of his Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment.

This course provides a summary of the major components involved in the assessment of ADHD followed by a critical overview of the treatments that have some efficacy for the management of ADHD as shown through scientific research. The literature on treatment is voluminous, however, and so space here permits only a brief discussion and critique of each of the major treatments. More detailed discussions of these treatments can be found in the textbooks by Barkley (2015) and Banaschewski, et al. (2018).

Primary Symptoms of ADHD

Children having ADHD, by definition, display difficulties with attention and/or impulse control relative to the non-ADHD population of children of the same age and sex. Attention is a multi-dimensional construct which can refer to problems with alertness, arousal, selective or focused attention, sustained attention, distractibility, or span of apprehension, among others. Research to date suggests that among these elements, children with ADHD most likely have their greatest difficulties with sustaining attention to tasks (persistence of responding), resisting distractions, and re-engagement in initial tasks once disrupted.

These difficulties are sometimes apparent in free-play settings but are much more evident in situations requiring sustained attention to dull, boring, and/or repetitive tasks. However, even when presented with apparently intrinsically interesting stimuli, such as a television program, or attractive distracting stimuli, such as toys, children who have ADHD may exhibit significantly impaired attention to and comprehension of events relative to children who do not have ADHD. More recently, research is suggesting that the attention problems evident in ADHD are part of a larger domain of cognitive activities known as executive functioning, and especially working memory (i.e., holding information in mind that is being used to guide performance). Specifically, evidence from the development of rating scales indicates that the DSM items used to define the attention deficits in ADHD load on a larger dimension containing items reflecting executive functioning and specifically, working memory.

Often coupled with this difficulty in sustained attention is a deficiency in inhibiting behavior, or impulsiveness. Like attention, impulsiveness is also multidimensional in nature. Rather than cognitive reflectiveness, the deficit in ADHD is mainly in the capacity to inhibit or delay prepotent or automatic responses, particularly in settings in which those responses compete with rules. A prepotent response is that which would gain the immediate reinforcement (reward or escape) available in a given context, or which has a strong history of such reinforcement in the past. Those with ADHD have difficulties with sustained inhibition of such dominant responses over time, as well as with poor delay of gratification, a steeper discounting of the value of delayed over immediate rewards, and impaired adherence to commands to inhibit behavior in social contexts. This inhibitory deficit may also include a difficulty with interrupting an already ongoing response pattern, particularly when given feedback about performance and errors. In the latter case, perseverative responding may be evident despite negative feedback concerning such responding. That problem may be reflecting an insensitivity to errors. Overall, individuals with ADHD have poorer inhibitory control and slower inhibitory processing than are normal.

Numerous studies have shown that children with ADHD tend to be more active, restless, and fidgety (i.e., hyperactive) than children without ADHD. As with the other symptoms, there are significant situational fluctuations in this symptom. It has not always been shown convincingly that hyperactivity distinguishes ADHD children from other clinic-referred groups of children. It may be the pervasiveness of the hyperactivity across settings that separates ADHD from other diagnostic categories.

ADHD symptoms of hyperactivity have been shown to decline significantly across the elementary school years, while problems with attention persist at relatively stable levels during this same period of development in children with ADHD. One explanation that may account for such a state of affairs is that the hyperactivity reflects an early developmental manifestation of a more central deficit in behavioral inhibition. Studies that factor in analyzed behavior ratings certainly show that hyperactivity and poor impulse control form a single dimension of behavior, as shown in the DSM-5. This deficit in inhibition, of which early hyperactivity is a part, may become increasingly reflected in poor self-regulation over various developmental stages, even though the difficulties with excessive activity level may wane with maturation.

Difficulties with adherence to rules and instructions are also evident in children with ADHD. Care is taken here to exclude poor rule-governed behavior that may stem from sensory handicaps (i.e., deafness), impaired language development, or defiance or oppositional behavior. Nevertheless, children with ADHD typically show significant problems with compliance with parental and teacher commands, following experimental instructions in the absence of the experimenter, and with adhering to directives to defer gratification or resist temptations. Like the other symptoms, this problem with rule-governed behavior is a multi-dimensional construct. It remains to be shown which aspects of this construct are specifically impaired in ADHD.

Diagnostic Criteria

Between 1980 and the present, efforts have been made to develop more specific guidelines for the classification of children as ADHD. These efforts have been based increasingly on an empirical approach to developing a taxonomy of child psychopathology. Although guidelines appeared in the DSM-II (American Psychiatric Association, 1968), these comprised merely a single sentence along with the admonition not to grant the diagnosis if demonstrable brain injury were present. A more concerted effort at developing criteria appeared in the DSM-III (American Psychiatric Association, 1980), though still unempirical. These criteria were not examined in any field trial but were developed primarily from expert opinion. In the next revision of the DSM-III (American Psychiatric Association, 1987), an attempt was made to draw upon the results of factor-analytic studies of child-behavior rating scales to aid the selection of symptoms that might be included for ADHD. A small-scale field trial employing 500 children from multiple clinical sites was conducted to narrow down the potential list of symptoms, and a cutoff score on this list was chosen that best differentiated children with ADHD from other diagnostic groups.

In DSM-IV (American Psychiatric Association, 2000), the criteria were based on a better field trial and more thorough analysis of its results. Despite the increasingly empirical foundation of the DSM, there remained a few problems with these criteria having to do with developmental sensitivity to the disorder, possible gender bias in diagnosis, an empirically unjustified age of onset of seven years old, and a vexing requirement for cross-setting impairment that is compounded with the problem of poor parent-teacher agreement. Also problematic for the generality of these criteria, is the fact that the field trial used primarily male children, ages four to 16 years old, who were largely of Caucasian ethnicity. Consequently, adjustments or allowances must be made when one wishes to apply the DSM criteria to females, young adults, and non-Caucasian ethnic groups. For example, the symptoms of “often leaves their seat” or difficulties with “playing quietly” may be less relevant to adults with ADHD. Moreover, children whose onset of symptoms was sometime during the childhood years (prior to 13) should be considered as having a valid disorder rather than adhering strictly to the DSM-IV age-of-onset of seven years old as the demarcation of a valid case of disorder.

Where sex differences exist, they indicate that girls with ADHD show less severe symptoms of both inattention and hyperactive-impulsive behavior, especially in school, fewer symptoms of Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD), greater intellectual deficits, and more symptoms of anxiety and depression than do ADHD boys. Some recent studies indicate that girls with ADHD may employ more relational aggression than their non-ADHD peers.

The publication of the DSM-5 in 2013 brought with it a few changes to the DSM-IV criteria. While the original 18 symptoms from the DSM-IV remain in use, as do the two dimensions for their presentation, they are followed by clarifications in parentheses to guide clinicians in applying those symptoms to teens and adults. The threshold of six of nine symptoms on either of the two lists of symptoms remains for application to children and teens. But for adults, this threshold is reduced to five symptoms. The requirements in DSM-IV that symptoms occur often or more frequently, that they be developmentally inappropriate, and that they have persisted for at least the prior six months are all carried forward into DSM-5. The age of onset has been adjusted upward from seven to 12 years of age, consistent with evidence that the lower onset was invalid, too restrictive, and contributed to clinical unreliability of diagnosis.

Also remaining are the requirements for symptoms to be impairing across several settings and that there be impairment in major life activities. A new requirement is that symptoms given by self-report must be corroborated through someone else who knows the subject well or through other sources. The subtypes have been removed respecting abundant evidence that ADHD is a single disorder that varies in severity in the human population, which is not changed by the fact that some people have more inattention than hyperactive-impulsive symptoms and vice-versa. Even so, clinicians will be provided the opportunity to specify which symptom dimension may be more predominant, as in ADHD Predominantly Inattentive Presentation. There is a Predominantly Hyperactive-Impulsive Presentation and then the traditional Combined Presentation. Finally, ADHD can now be diagnosed with autistic spectrum disorders, just as it can be with many other disorders; a comorbidity previously precluded in DSM-IV.

Assessment

Probably the four most important components of a comprehensive evaluation of a client with ADHD are the clinical interview, the medical examination, the completion and scoring of behavior rating scales, and the administration of certain psychological tests to rule in or out high-risk comorbid disorders such as developmental/intellectual delay and learning disabilities. When feasible, clinicians may wish to supplement these components of the evaluation with objective assessments of the ADHD symptoms, such as psychological tests of attention or direct behavioral observations. These tests are not essential to reaching a diagnosis, however, or to treatment planning, but when abnormal findings are detected, they may yield further information about the presence and severity of cognitive impairments that could be associated with some cases of ADHD. The problem is that the presence of normal scores are largely meaningless given the high proportion of ADHD cases that place in the normal range on such tests. In other words, abnormal scores may be meaningful in indicating the presence of a disorder (not necessarily ADHD) while normal scores should go uninterpreted given the high false negative rate of many ADHD tests.

In this course, I describe the details of conducting clinical interviews with parents, teachers, and children/adolescents when it is the child or adolescent who is presenting for evaluation of ADHD. I also briefly discuss the essential features of the medical examination of ADHD children and issues that examination needs to address. This discussion is followed by an overview of some of the most useful behavior-rating scales to incorporate into the clinical evaluation. A brief review of the role of psychological tests and direct observations in the evaluation is then presented. Readers wishing to acquire some of the clinical tools referenced here can find them listed in the Resource section. The information contained herein was initially drawn chiefly from my earlier chapters on assessment in my Handbook for Diagnosis and Treatment (Barkley, 2015).

Assessment Issues

Clinicians should bear in mind several goals when evaluating children for ADHD. A major goal of such an assessment is the determination of the presence or absence of ADHD as well as the differential diagnosis of ADHD from other childhood psychiatric disorders. This differential diagnosis requires extensive clinical knowledge of these other psychiatric disorders, and readers are referred to the DSM-5 for diagnostic criteria and to textbooks on child psychopathology for a review of the major childhood disorders (see Mash & Barkley, 2014). In any child evaluation, it may be necessary to draw on measures that are normed for the individual’s ethnic background, if such instruments are available, to preclude the over-diagnosis of minority children when diagnostic criteria developed on white American children are extrapolated to other ethnic groups. For further discussion on gender, socioeconomic status, and cross-cultural issues related to diagnosis and prevalence of ADHD, please see the first course in this series titled ADHD: Nature, Course, Outcomes, and Comorbidity.

A second purpose of the evaluation is to begin delineating the types of interventions needed to address the psychiatric disorders and psychological, academic, and social impairments identified in the course of assessment. As noted later, these may include individual counseling, parent training in behavior management, family therapy, classroom behavior modification, psychiatric medications, and formal special educational services, to name just a few.

Another important purpose of the evaluation is to determine conditions that often coexist with ADHD and the manner in which these conditions may affect prognosis or treatment decision-making. For instance, the presence of high levels of physically assaultive behavior by a child with ADHD may indicate that a parent training program is contraindicated, at least for the time being, because such training in limit-setting and behavior-modification could temporarily increase child violence toward parents when limits on noncompliance with parental commands are established.

Or, consider the presence of high levels of anxiety specifically – and internalizing symptoms more generally – in children with ADHD. Research shows that such symptoms may be a predictor of poorer responses to stimulant medication, although the point is arguable due to mixed results across studies on this issue. Similarly, the presence of high levels of irritable mood, severely hostile and defiant behavior, and periodic episodes of serious physical aggression and destructive behavior may be early markers for Disruptive Mood Dysregulation Disorder. If coupled with mania, grandiosity, and sleep or sexual disturbances, they may be early markers for later Bipolar Disorder (Manic-Depression) in children. Oppositional behavior is almost universal in both disorders, though of a more extreme nature than on its own. Such a disorder is likely to require the use of several psychiatric medications in conjunction with a parent training program and occasionally even inpatient hospitalization.

A further objective of the evaluation is to identify the pattern of the child’s psychological strengths and weaknesses and to consider how these strengths and weaknesses may affect treatment planning. This identification may also include gaining some impression as to the parents’ own abilities to carry out the treatment program as well as the family’s social and economic circumstances and the treatment resources that may (or may not) be available within their community and cultural group. Some determination also must be made as to the child’s eligibility for special educational services within his or her school district if eligible disorders such as developmental delay, learning disabilities, or speech and language problems, are present.

As the foregoing discussion illustrates, the evaluation of a child for the presence of diagnosable ADHD is but one of many purposes of the clinical evaluation. A brief discussion now follows regarding the different methods of assessment that may be used in the evaluation of ADHD children.

Information Obtained at the Time of Referral

The initial phase of a diagnostic interview might not be conducted by the clinician but by a support staff member. The initial phone intake provides invaluable information when conducted by a well-trained individual; otherwise, it is a lost opportunity. When a parent calls to request an evaluation, it is useful to collect the following information:

The content of the diagnostic interview is influenced by all these factors and important information can be collected and reviewed ahead of time when the reason for the referral is clear.

Once the child is referred for services, the clinician must glean some important details from the telephone interview. This information also allows the clinician to set in motion some initial procedures. In particular, it is important at this point to do the following:

Information Obtained in Advance of the Interview

Clinicians may want to send out a packet of questionnaires to parents and teachers following the parents’ call to their clinic but in advance of the scheduled appointment. In fact, the parents of children referred to our clinic are not given an appointment date until these packets of information are completed and returned to the clinic. This system ensures that the packets are completed reasonably promptly and that the information is available for review by the clinician prior to meeting with the family, making the evaluation process far more efficient in its collection of important information. In these days of increasing cost-consciousness concerning mental health evaluations, particularly in managed care environments, efficiency of the evaluation is paramount, and time spent directly with the family is often limited and at a premium. In addition to a form cover-letter from the professional asking the parents to complete and return the entire packet of information, the packet also contains the General Instruction Sheet, a Child and Family Information Form, and a Developmental and Medical History Form. This packet also includes a reasonably comprehensive child behavior rating scale that covers the major dimensions of child psychopathology, such as the Child Behavior Checklist (CBCL) or the Behavior Assessment System for Children (BASC-2). Also in this packet should be a copy of a rating scale that specifically assesses ADHD symptoms. Such a form can also be found in the clinical manual by DuPaul and colleagues (2014; see Resources).

If desired, a more comprehensive rating of executive function deficits, nearly always associated with ADHD, can be obtained using either the Barkley Deficits in Executive Functioning Scale – Children and Adolescents, or the Behavior Rating Inventory of Executive Functioning. Clinicians who wish to assess adaptive behavior via the use of a questionnaire might consider including the Normative Adaptive Behavior Checklist in this packet or have parents complete this form on the day of the evaluation. Impairment in major domains of life activities is a required criterion for all Axis I psychiatric disorders in the DSM-5. Some information on impairment can be gleaned from the face pages of the CBCL or BASC-2. More recently, a normed rating scale of impairment has been created that can be included with this packet for obtaining information on 15 different domains of life activities in children (Barkley Functional Impairment Scale – Children and Adolescents). Such information is of clinical interest not only for indications of pervasiveness and severity of behavior problems, but also for focusing discussions around these situations during the evaluation and subsequent parent-training program. These rating scales are discussed later.

It is useful to collect and review previous records before the interview. They might include any one or combination of the following: report cards, standardized testing results, medical records (including neurology, audiology, optometry, speech, and occupational therapy), individual educational plans, psychoeducational testing, psychological testing, and psychotherapy summaries.

A similar packet of information is sent to the teachers of this child, with prior parental written permission, of course. This packet does not contain the Medical and Developmental History Form or any adaptive behavior survey that may have been included for parents. This packet could contain the teacher version of the CBCL or BASC, and the same rating scale for assessing ADHD symptoms noted above. The Social Skills Rating System might also be included if the clinician desires information about the child’s social problems in school as well as his or her academic competence. The clinician can quickly see, for example, if the teacher feels the child is functioning at grade level in various subject areas, how the child has performed on group-administered achievement or aptitude tests, or subjective impressions of the child’s general mood and behavioral functioning. If possible, it is quite useful to contact the child’s teachers for a brief telephone interview prior to meeting with the family. Otherwise, a meeting can take place following the family’s appointment.

Once the parent and teacher packets are returned, the family should be contacted by telephone and given their appointment date. It is our custom also to send out a letter confirming this appointment date with directions for driving to the clinic.

On the day of the appointment, the following is to be done: (1) parental and child interview, (2) completion of self-report rating scales by the parents, and (3) any psychological testing that may be indicated by the nature of the referral (intelligence and achievement testing, etc.).

Parent Interview

The parent interview, although often criticized for its unreliability and subjectivity, is an indispensable part of the evaluation of children and adolescents presenting with concerns about ADHD. No adult is likely to have more wealth of knowledge about, history of interactions with, or sheer time spent with a child than the parents.

Whether wholly accurate or not, parent reports provide the most ecologically valid and important source of information concerning the child’s difficulties. It is the parents’ complaints that often lead to the referral of the child, will affect the parents’ perceptions of and reactions to the child, and will influence the parents’ adherence to the treatment recommendations to be made. Moreover, the reliability and accuracy of the parental interview have much to do with the manner in which it is conducted and the specificity of the questions offered by the examiner. An interview that uses highly specific questions about symptoms of psychopathology that have been empirically demonstrated to have a high degree of association with particular disorders greatly enhances diagnostic reliability.

The interview, particularly a semi-structured interview, allows the clinician in a sense to become another instrument in the assessment process. While scorable data are obtained, the small details and nuances of parent and child reporting resonates with clinician-acquired knowledge (from previous interviews, research, readings, workshops, etc.) in such a way as to flesh out and support final diagnostic conclusions. In other words, the interview provides the phenomenological data that rating scales cannot capture. The interview must also, however, focus on the specific complaints about the child’s psychological adjustment and any functional parameters (eliciting events and their consequences) associated with those problems if psychosocial and educational treatment planning is to be based on the evaluation.

Purposes

The parental interview often serves several purposes:

  1. It establishes a necessary rapport among the parents, the child, and the examiner that will prove invaluable in enlisting parental cooperation with later aspects of assessment and treatment.
  2. The interview is an obvious source of highly descriptive information about the child and family, revealing the parents’ particular views of the child’s apparent problems and narrowing the focus of later stages and components of the evaluation.
  3. It can readily reveal the degree of distress the child’s problems are presenting to the family, especially the parent being interviewed, as well as the overall psychological integrity of the parent. Hypotheses as to the presence of parental personality or psychiatric problems (depression, hostility, marital discord, etc.) may be revealed that will require further evaluation in subsequent components of the evaluation and consideration in formulating treatment recommendations.
    1. Examiners must be cautious not to over-interpret any informal observations of the child’s behavior during this clinic visit. The office behavior of ADHD children is often far better than that observed at home. Such observations merely raise hypotheses about potential parent-child interaction problems that can be explored in more detail with parents toward the end of this interview as well as during later direct behavioral observations of parent and child during play and task performance together. At this point in  the interview, the examiner should inquire how representative the child’s immediate behavior is compared to that seen at home when the parent speaks with other adults in the child’s presence.
    2. I do not typically have the child in the same room when I conduct the parental interview. Other clinicians, however, may choose to do so. The presence of the child during the parental interview, however, raises thorny issues for the evaluation to which the examiner must be sensitive. Some parents are less forthcoming about their concerns and the details of the child’s specific problems when the child is present, not wishing to sensitize or embarrass the child unnecessarily or to create another reason for arguments at home about the nature of the child’s problems. Others are heedless of the potential problems posed for their child by this procedure, making it even more imperative that the examiner reviews these issues with them before beginning the evaluation. Still other parents may use the child’s presence to further publicly humiliate the child about his or her deficiencies or the distress the child has created for the family by behaving the way he or she does. Suffice it to say here that before starting the interview, the examiner must discuss and review with each unique family whether the advantages of having the child present are outweighed by these potential negative effects.
  4. The initial parent interview can help to focus the parent’s perceptions of the child’s problems on more important and more specific controlling events within the family. Parents often tend to emphasize historical or developmental causes of a global nature in discussing their children’s problems, such as what they did or failed to do with the child earlier in development that has led to this problem (i.e., placing the child in infant daycare, an earlier divorce, the child’s diet in earlier years, etc.). The interactional interview discussed later can serve to shift the parents’ attention to more immediate antecedents and consequences surrounding child behaviors, thereby preparing the parents for the initial stages of parent training in child management skills.
  5. The interview is designed to formulate a diagnosis and to develop treatment recommendations. Although diagnosis is not always considered necessary for treatment planning (a statement of the child’s developmental and behavioral deficits is often adequate), the diagnosis of ADHD, however, does provide some utility in terms of predicting a developmental course and prognosis for the child, determining eligibility for some special educational placements, and predicting potential response to a trial on stimulant medication. Many child behavior problems are believed to remit over short periods in as many as 75% of the cases. However, ADHD is a relatively chronic condition warranting much more cautious conclusions about eventual prognosis, and preparation of the family for coping with these later problems.
  6. A parental interview may serve as sheer catharsis, especially if this is the first professional evaluation of the child or when previous evaluations have proven highly conflicting in their results and recommendations. Ample time should be permitted to allow parents to ventilate this distress, hostility, or frustration. It may be helpful to note at this point that many parents of ADHD children have reported similarly distressing, confusing, or outright hostile previous encounters with professionals and educators about their child, as well as with well-intentioned but overly enmeshed or misinformed relatives. Compassion and empathy for the plight of the parents at this point can often result in a substantial degree of rapport with and gratitude toward the examiner and a greater motivation to follow subsequent treatment recommendations. At the very least, parents are likely to feel that they have finally found someone who truly understands the nature of their child’s problems and the distress they have experienced in trying to assist the child and has recommendations to do something about them.

The suggestions that follow for interviewing parents of ADHD children are not intended as rigid guidelines, only as areas that clinicians should consider. Each interview clearly differs according to individual child and family circumstances. Generally, those areas of importance to an evaluation include demographic information, child-related information, school-related information, and details about the parents, other family members, and community resources that may be available to the family.

Demographic Information

If not obtained in advance, routine demographic data concerning the child and family (e.g., ages of child and family members; child’s date of birth; parents’ names, addresses, employers, and occupations; and the child’s school, teachers, and physician) should be obtained at the outset of the appointment. I also use this initial introductory period to review with the family any legal constraints on the confidentiality of information obtained during the interview, such as the clinician’s legal duty (as required by state law) to report to state authorities any instances of suspected child abuse, threats the child (or parents) may make to cause physical harm to other specific individuals (the duty to inform), and threats the child (or parents) may make to harm themselves (e.g., suicide threats).

Major Parental Concerns

The interview then proceeds to the major referral concerns of the parents, and of the professional referring the child when appropriate. General descriptions of concerns by parents must be followed with specific questions by the examiner to elucidate the details of the problems and any apparent precipitants. Such an interview probes for the specific nature, frequency, age of onset, and chronicity of the problematic behaviors. Although some children with ADHD are reported to have been difficult in their temperament since birth or early infancy, the majority appear to be identifiable as deviant from normal by their caregivers between 3 and 4 years of age. However, it may be several years later before such children are brought to the attention of professionals. Although the diagnosis of ADHD among preschoolers may be more difficult due to higher rates of disruptive behavior among the normal population at this age, a few recent studies suggest that reliable and valid diagnosis can be made for children as young as 3 years, 7 months old.  The parent interview can also obtain information, as needed, on the situational and temporal variation in the behaviors and their consequences. If the problems are chronic, which they often are, determining what prompted the referral at this time reveals much about parental perceptions of the children’s problems, current family circumstances related to the problems’ severity, and parental motivation for treatment.

Review of Major Developmental Domains

Following this part of the interview, the examiner should review with the parents any potential problems that might exist in the developmental domains of motor, language, intellectual, academic, emotional, and social functioning. Such information greatly aids in the differential diagnosis of the child’s problems. Achieving this differential diagnosis requires the examiner to have an adequate knowledge of the diagnostic features of other childhood disorders, some of which may present as ADHD. For instance, many children with Autistic Spectrum Disorders or early Bipolar Disorder may be viewed by their parents as ADHD, as the parents are more likely to have heard about the latter disorder than the former ones and will recognize some of those qualities in their children. Questioning about inappropriate thinking, affect, social relations, and motor peculiarities may reveal a more seriously and pervasively disturbed child. If such symptoms seem to be present, the clinician might consider employing the Child Bipolar Parent Questionnaire (Papolos, Hennen, Cockerham, Thode Jr., & Youngstrom, 2006) to obtain a more thorough review of these symptoms. Inquiry also must be made as to the presence or history of tics or Tourette’s Disorder in the child or the immediate biological family members. When noted, these disorders would result in a recommendation for the more cautious use of stimulant drugs in the treatment of ADHD or, perhaps, lower doses of such medicine than typical to preclude the exacerbation of the child’s tic disorder.

School, Family, and Treatment Histories

The examiner should also obtain information on the school and family histories. The family history must include a discussion of potential psychiatric difficulties in the parents and siblings, marital difficulties, and any family problems centered on chronic medical conditions, employment problems, or other potential stress events within the family. Of course, the examiner will want to obtain some information about prior treatments received by the child and his or her family for these presenting problems. When the history suggests potentially treatable medical or neurological conditions (allergies, seizures, Tourette’s Disorder, etc.), a referral to a physician is essential. Without evidence of such problems, however, referral to a physician for examination usually fails to reveal any further useful treatment information. But when the use of psychiatric medications is contemplated, a referral to a physician is clearly indicated.

Information about the child’s family is essential for two reasons. First, while ADHD is not caused by family stress or dysfunction, such adverse family factors can contribute to oppositional behavior or frank ODD. Therefore, the family history can help to clarify whether the child’s attentional or behavioral problems are developmental or rather a reaction to or product of stressful events that have taken place. Second, a history of certain psychiatric disorders in the extended family might influence diagnostic impressions or treatment recommendations. For example, because ADHD is hereditary, a strong family history of ADHD in biological relatives lends weight to the ADHD diagnosis, especially when other diagnostic factors are questionable. A family history of Bipolar Disorder in a child with severe behavioral problems might suggest that the child may be at higher risk for the disorder (an eight-fold increase in risk) and particular medication choices that otherwise might not be considered.

The interviewer can organize this section of the parental interview by first asking about the child’s siblings (whether there is anything significant about sibling relationships, whether siblings have any health or developmental problems). Then, questions about the parents may include how long they have been married, the overall stability of their marriage, whether each parent is in good physical health, whether either parent has ever been given a psychiatric diagnosis, and whether either parent has had a learning disability. The clinician should always be cautious of inquiring too much into the parents’ personal concerns. The purpose is to rule out family stress as a cause for the child’s difficulties and to determine what treatment recommendations may be appropriate.

In asking about extended family history, the interviewer should include maternal and paternal relatives.
Although it may seem tedious, it is extremely useful to go through the child’s school history year by year, starting with preschool. The examiner should ask parents open-ended questions: “What did his teachers have to say about him?”, “How did he do academically?”, or “How did he get along socially?” The examiner should avoid pointed, leading questions (e.g., “Did the teacher think he had ADHD?”). Examiners should allow parents to tell them their child’s story and listen for the red flags (e.g., the teacher thought he was immature, he had trouble with work completion, his organizational skills were terrible, he could not keep his hands to himself, or he would not do homework).

Gathering a reliable school history gives the clinician two crucial pieces of the diagnostic puzzle. First, is there evidence of symptoms or characteristics of ADHD in school previous to adolescence? Second, is there evidence of impairment in the child’s academic functioning as a result of these characteristics?
Examiners should ask parents what strategies teachers may have attempted to help the child in class. They should also inquire about tutoring services, school counselors, study skills classes, or peer helpers. The examiner should find out when and why teachers referred the child for psychoeducational testing. If the child is not doing well in school, the examiner should ask whether school personnel have ever offered an explanation. As always, the examiner should listen for clues about possible problems with behavioral regulation, impulse control, or sustained attention. If the child has a diagnosed learning disability, are there problems in school that cannot be explained by that learning disability?

Review of Childhood Psychiatric Disorders

As part of the general interview of the parent, the examiner must cover the symptoms of the major child psychiatric disorders likely to be seen in ADHD children. A review of the major childhood disorders in the DSM-5 in some semi-structured or structured way is imperative if any semblance of a reliable and differential approach to diagnosis and the documentation of comorbid disorders is to occur. The examiner must exercise care in the evaluation of minority children to avoid over-diagnosing psychiatric disorders simply by virtue of ignoring differing cultural standards for child behavior. Should the parent indicate that a symptom is present, one means of precluding over-identification of psychopathology in minority children is to ask the following question: “Do you consider this to be a problem for your child compared to other children of your same ethnicity?” Only if the parent answers “yes” is the symptom to be considered present for purposes of psychiatric diagnosis.

Before proceeding, an explanation is in order as to why ODD and CD are queried first. Many parents arrive at the diagnostic evaluation overwhelmed by emotional stress, frustrations with home behaviors, or endless criticisms about the child from the school; thus they may be inclined to say yes to anything. Starting with ODD and CD questions allows these parents to get some of this frustration out of their system. Thus, when they are asked questions about ADHD, the answers are potentially more reliable and accurate.

In addition, unfortunately some parents actually “shop” for the ADHD diagnosis. They may have an agenda that involves obtaining a diagnosis for their child that is not entirely objective. Beginning the clinical interview with the reason for referral and then the ODD questions may assist the clinician in gaining important clinical impressions about the parents’ agenda. This is also why it can be extremely useful for clinicians to completely eliminate the word “attention” from their vocabulary during the interview. When the clinician asks specific questions about ADHD symptoms, the questions should be phrased in such a way that they are concrete and descriptive.

As noted above, adjustments have been made to the DSM-IV criteria for ADHD that now appear in the DSM-5:

  1. The cutoff scores on both symptom lists (six of nine) were primarily based on children ages 4 to 16 in the DSM-IV field trial, making the extrapolation of these thresholds to age ranges outside those in the field trial of uncertain validity. For instance, no adults were involved in that field trial. Additional research on adults with ADHD has shown that a threshold of four or five symptoms would be better for detecting the adult stage of this disorder. So DSM-5 recommends a threshold of five on either symptom list for adults. Also, ADHD behaviors tend to decline in frequency within the child population over development, again suggesting that a somewhat higher threshold may be needed for preschool children (ages two to four years old) than is now recommended in DSM-5.
  2. The specific age of onset of seven years old is not particularly critical for identifying ADHD children. Thus, DSM-5 has stipulated that an onset of symptoms occurring before age 12 in childhood is sufficient for purposes of clinical diagnosis.
  3. The criterion that the duration of symptoms be at least six months was not specifically studied in the field trial and was held over from earlier DSMs, primarily out of tradition. Some research on preschool children suggests that a large number of two- to three-year-olds may manifest the symptoms of ADHD as part of that developmental period and that they may remain present for periods of three to six months or longer. Children whose symptoms persisted for at least one year or more, however, were likely to remain deviant in their behavior pattern into the elementary school years. Although the DSM-5 did not change this requirement, adjusting the duration criterion to 12 months for ADHD, especially when evaluating preschool children, would seem to make good clinical sense.
  4. The criterion that symptoms must be evident in at least two of three settings (home, school, work) has been misinterpreted by clinicians to mean that children have sufficient symptoms of ADHD by both parent and teacher report before they can qualify for the diagnosis. This requirement bumps up against a methodological problem inherent in comparing parent and teacher reports. On average, the relationship of behavior ratings from these two sources tends to be fairly modest, averaging about 0.30. However, if parent and teacher ratings are unlikely to agree across the various behavioral domains being rated, the number of children qualifying for the diagnosis of ADHD is unnecessarily limited, due mainly to measurement artifact. Fortunately, some evidence demonstrates that children who meet DSM criteria by parent reports have a high probability of meeting the criteria by teacher reports. Even so, stipulating that parents and teachers must agree on the diagnostic criteria before a diagnosis can be rendered is probably unwise and unnecessarily restrictive. Clinicians are advised to seek evidence that some symptoms of the disorder existed at some time in the past or present of the child in several settings rather than insisting on the agreement of the parents with a current teacher. Moreover, clinicians should count the number of different symptoms reported by one source (e.g., parent) and then add to it any additional symptoms endorsed by the other (e.g. teacher) not reported by the first source. In sum, the number of symptoms used to make a diagnosis of ADHD is the number of different symptoms reported across all sources of information.

The foregoing issues should be kept in mind when applying the DSM criteria to particular clinical cases. It helps to appreciate the fact that the DSM represents guidelines for diagnosis, not rules of law or dogmatic prescriptions. Some clinical judgment is always going to be needed in the application of such guidelines to individual cases in clinical practice.

To assist clinicians with the differential diagnosis of ADHD from other childhood mental disorders, I compiled a list of differential diagnostic tips (see Table 1, below). Under each disorder, I list those features that would distinguish this disorder, in its pure form, from ADHD. However, many ADHD children may have one or more of these disorders as comorbid conditions with their ADHD; thus the issue here is not which single or primary disorder the child has but what other disorders besides ADHD are present and how they affect treatment planning.

Table 1. Differential Diagnostic Tips for Distinguishing Other Mental Disorders from ADHD


Oppositional Defiant Disorder and Conduct Disorder

  • Lacks impulsive, disinhibited behavior
  • Defiance primarily directed toward mother initially
  • Able to cooperate and complete tasks requested by others
  • Lacks poor sustained attention and marked restlessness
  • Resists initiating demands, whereas ADHD children may initiate but cannot stay on task
  • Often associated with parental child management deficits or family dysfunction
  • Lacks neuromaturational delays in motor abilities

Learning Disabilities

  • Has a significant IQ/achievement discrepancy (+1 standard deviation)
  • Places below the 7th percentile in an academic achievement skill
  • Lacks an early childhood history of hyperactivity
  • Attention problems arise in middle childhood and appear to be task or subject specific
  • Not socially aggressive or disruptive
  • Not impulsive or disinhibited

Anxiety/Affective Disorders

  • Likely to have a focused not sustained attention deficit
  • Not impulsive or aggressive; often overinhibited
  • Has a strong family history of anxiety disorders
  • Restlessness is more like fretful, worrisome behavior, not the “driven,” inquisitive, or overstimulated type
  • Lacks preschool history of hyperactive, impulsive behavior
  • Not socially disruptive; typically socially reticent

Autism Spectrum Disorder

  • Demonstrates significant impairment in social relationships with others manifested by lack of interest in such interactions, lack of eye contact, lack of responsiveness to their name, preference for attending to and interacting with physical features of the environment, and other symptoms of impaired sociability
  • Demonstrates impaired language development such that language may not develop, develops late, and may include bizarre use of language and syntax
  • May show unusual patterns of stereotyped motor actions and speech that include repetitive gestures, odd posturing and motions, and peculiar facial expressions

Schizotypal Personality Disorder

  • Shows oddities/atypical patterns of thinking not seen in ADHD
  • Peculiar sensory reactions
  • Odd fascinations and strange aversions
  • Socially aloof, schizoid, disinterested
  • Lacks concern for personal hygiene/dress in adolescence
  • Atypical motor mannerisms, stereotypies, and postures
  • Labile, capricious, unpredictable moods not tied to reality
  • Poor empathy, cause-effect perception
  • Poor perception of meaningfulness of events

Juvenile-Onset Mania or Bipolar I Disorder

  • Characterized by severe and persistent irritability
  • Depressed mood exists more days than not
  • Irritable/depressed mood typically punctuated by rage outbursts
  • Mood swings often unpredictable or related to minimal events
  • Severe temper outbursts and aggression with minimal provocation (thus, ODD is often present and severe)
  • Later onset of symptoms than ADHD (but comorbid with early ADHD is commonplace)
  • Press of speech and flight of ideas often present
  • Psychotic-like symptoms often present during manic episodes
  • Family history of Bipolar I Disorder more common
  • Expansive mood, grandiosity of ideas, inflated self-esteem, hypersexuality often seen in adults with Bipolar Disorder are sometimes present though not as well formed; children may have the dysphoric type of disorder, however
  • Requires that sufficient symptoms of Bipolar Disorder be present after excluding distractibility and hyperactivity (motor agitation) from Bipolar symptom list in DSM-5 before granting Bipolar I diagnosis to a child with symptoms of ADHD
  • Suicidal ideation is more common than average in child (and suicide attempts more common in family history)

For years, some clinicians eschewed diagnosing children, viewing it as a mechanistic and dehumanizing practice that merely results in unnecessary labeling. Moreover, they felt that it got in the way of appreciating the clinical uniqueness of each case, unnecessarily homogenizing the heterogeneity of clinical cases. Some believed that labeling a child’s condition with a diagnosis is unnecessary as it is far more important to articulate the child’s pattern of behavioral and developmental excesses and deficits in planning behavioral treatments. Although there may have been some justification for these views in the past, particularly prior to the development of more empirically based diagnostic criteria, this is no longer the case in view of the wealth of research that went into creating the DSM-5 childhood disorders and their criteria. This is not to say that clinicians should not document patterns of behavioral deficits and excesses, as such documentation is important for treatment planning; only that this documentation should not be used as an excuse not to diagnose at all.

Furthermore, given that the protection of civil rights and entitlements such as access to educational and other services may actually hinge on awarding or withholding the diagnosis of ADHD, dispensing with diagnosis altogether could well be considered professional negligence. Moreover, billing insurance companies or government agencies for professional services requires the specification of a DSM diagnosis. For these reasons and others, clinicians, along with the parent of each child referred to them, must review in some systematic way the symptom lists and other diagnostic criteria for various childhood mental disorders.

The parental interview may also reveal that one parent, usually the mother, has more difficulty managing the ADHD child than does the other. Care should be taken to discuss differences in the parents’ approaches to management and any marital problems these differences may have spawned. Such difficulties in child management can often lead to reduced leisure and recreational time for the parents and increased conflict within the marriage and often within the extended family should relatives live nearby. It is often helpful to inquire as to what the parents attribute the causes or origins of their child’s behavioral difficulties, because such exploration may unveil areas of ignorance or misinformation that will require attention during the initial counseling of the family about the child’s disorder(s) and their likely causes. The examiner also should briefly inquire about the nature of parental and family social activities to determine how isolated, or insular, the parents are from the usual social support networks in which many parents are involved. Research shows that the degree of maternal social insularity is significantly associated with failure in subsequent parent training programs. When present to a significant degree, such a finding might support addressing the isolation as an initial goal of treatment rather than progressing directly to child behavior management training with that family.

Psychosocial Functioning

The first topic in this portion of the interview involves peer relationships and recreational activities. A clinical diagnosis of ADHD requires impairment in the child’s functioning in at least two important areas. This area could certainly be one of them. In addition, evidence of impaired peer relationships may lead to important treatment recommendations such as participation in a peer social skills training group or a peer support group.
Parents are asked if the child has trouble making or keeping friends, how the child behaves around other children, and how well the child fits in at school. Parents are also asked if they have concerns about the friends with whom their child spends time (e.g., do parents view them as “troublemakers”). Finally, they are asked about recreational activities in which the child participates outside school and any problems that occurred during those activities.
Compliance with parental requests and parental use of compensatory or motivational strategies also can be explored, especially if the clinician anticipates conducting parent training in child management skills with this family. These questions also substantiate evidence of impairment in family functioning as well as possible treatment recommendations for parent management training. If the interview on parent-child interactions discussed later is not to be used, parents are asked to describe how quickly their child complies with parental requests, if there are discrepancies in the child’s behavior with mother and father, and if parents generally agree on how to manage their child. They are also asked to describe the types of disciplinary strategies they use and whether or not they have tried incentive systems to encourage more appropriate behavior.

At a later appointment, perhaps even during the initial session of parent training, the examiner may wish to pursue more details about the nature of the parent-child interactions surrounding the following of rules by the child. If so, parents should be questioned about the child’s ability to accomplish commands and requests in a satisfactory manner in various settings, to adhere to rules of conduct governing behavior in various situations, and to demonstrate self-control (rule-following) appropriate to the child’s age in the absence of adult supervision. When problems are said to occur, the examiner follows up with the list of questions in Table 2, below. I have found it useful to follow the format set forth in Table 2 in which parents are questioned about their interactions with their children in a variety of home and public situations. When time constraints are problematic, the Home Situations Questionnaire HSQ rating scale (from my book, Defiant Children, 2013) can be used to provide similar types of information. After parents complete the scale, they can be questioned about one or two of the problem situations using the same follow-up questions as in Table 2. The HSQ scale is discussed later.

Table 2. Parental Interview Format for Assessing Child Behavior Problems at Home and in Public

Situation to be discussed

If a problem, follow-up questions to ask

Overall parent-child interactions

Playing alone

Playing with other children

Mealtimes

Getting dressed/undressed

Washing and bathing

When parent is on telephone

Child is watching television

When visitors are in your home

When you are visiting someone else’s home

In public places (stores, restaurants, church, etc.)

When father is in the home

When child is asked to do chores

When child is asked to do school homework

At bedtime

When child is riding in the car

When child is left with a baby-sitter

Any other problem situations

1. Is this a problem area? If so, then proceed with questions 2-9.

2. What does the child do in this situation that bothers you?

3. What is your response likely to be?

4. What will the child do in response to you?

5. If the problem continues, what will you do next?

6. What is usually the outcome of this situation?

7. How often do these problems occur in this situation?

8. How do you feel about these problems?

9. On a scale of 1 (no problem) to 9 (severe), how severe is this problem for you?

Such an approach yields a wealth of information on the nature of parent-child interactions across settings, the type of noncompliance shown by the child (stalling, starting the task but failing to finish it, outright opposition and defiance, etc.), the particular management style employed by parents to deal with noncompliance, and the particular types of coercive behaviors used by the child as part of the noncompliance.

The parental interview can then conclude with a discussion of the child’s positive characteristics and attributes as well as potential rewards and reinforcers desired by the child that will prove useful in later parent training on contingency management methods. Some parents of ADHD children have had such chronic and pervasive management problems that upon initial questioning they may find it hard to report anything positive about their child. Getting them to begin thinking of such attributes is actually an initial step toward treatment as the early phases of parent training will teach parents to focus on and attend to desirable child behaviors.

Child Interview

Some time should always be spent directly interacting with the referred child. The length of this interview depends on the age, intellectual level, and language abilities of the child. For preschool children, the interview may serve merely as a time to become acquainted with the child, noting his or her appearance, behavior, developmental characteristics, and general demeanor. For older children and adolescents, this time can be fruitfully spent inquiring about the child’s views of the reasons for the referral and evaluation, how they see the family functioning, any additional problems they feel they may have, how well they are performing at school, their degree of acceptance by peers and classmates, and what changes in the family they believe might make life at home happier for them. As with the parents, the children can be queried as to potential rewards and reinforcers they find desirable which will prove useful in later contingency management programs.

Children below the age of 9 to 12 are not especially reliable in their reports of their own disruptive behavior. The problem is compounded by the frequently diminished self-awareness and impulse control typical of defiant children with ADHD. Such ODD/ADHD children often show little reflection about the examiner’s questions and may lie or distort information in a more socially pleasing direction. Some will report that they have many friends, have no interaction problems at home with their parents, and are doing well at school, in direct contrast with the extensive parental and teacher complaints of inappropriate behavior by these children. Because of this tendency of ADHD children to underreport the seriousness of their behavior, particularly in the realm of disruptive or externalizing behaviors, the diagnosis of ODD or ADHD is never based on the reports of the child. Nevertheless, children’s reports of their internalizing symptoms, such as anxiety and depression, may be more reliable and thus should play some role in the diagnosis of comorbid anxiety or mood disorders in children with ADHD.

Although notation of children’s behavior, compliance, attention span, activity level, and impulse control in the clinic is useful, clinicians must guard against drawing any diagnostic conclusions when the children are not problematic in the clinic or office. Many ODD and ADHD children do not misbehave in the clinician’s office; thus reliance on such observations would clearly lead to false negatives in the diagnosis. In some instances, the behavior of the children with their parents in the waiting area prior to the appointment may be a better indication of management problems at home than is the children’s behavior toward the clinician, particularly when the interaction between child and examiner is one to one.

This is not to say that the office behavior of a child is entirely meaningless. When it is grossly inappropriate or extreme, it may well signal the likelihood of problems in the child’s natural settings, particularly school. It is the presence of relatively normal conduct by the child that may be an unreliable indicator of the child’s normalcy elsewhere. For instance, in a study of 205 four- to six-year-old children, I examined the relationship of office behavior to parent and teacher ratings. Of these children, 158 were identified at kindergarten registration as being 1.5 standard deviations above the mean (93rd percentile) on parent ratings of ADHD and ODD (aggressive) symptoms. These children were subsequently evaluated for nearly four hours in a clinic setting, after which the examiner completed a rating scale of the children’s behavior in the clinic. I then classified the children as falling below or above the 93rd percentile on these clinic ratings using data from a normal control group. The children were also classified as falling above or below this threshold on parent ratings of home behavior and teacher ratings of school behavior using the CBCL. I have found that no significant relationship exists between the children’s clinic behavior (normal or abnormal) and the ratings by their parents. However, a significant relationship exists between abnormal ratings in the clinic and abnormal ratings by the teacher: 70% of the children classified as abnormal in their clinic behavior were also classified as such by the teacher ratings of class behavior, particularly on the externalizing behavior dimension. Normal behavior, however, was not necessarily predictive of normal behavior in either parent or teacher ratings. This finding suggests that abnormal or significantly disruptive behavior during a lengthy clinical evaluation may be a marker for similar behavioral difficulties in a school setting. Nevertheless, the wise clinician will contact the child’s teacher directly to learn about the child’s school adjustment rather than relying entirely on such inferences about school behavior from clinic office behavior. Since this study was completed, standard observation forms for recording child behavior during testing and in school settings have been developed and made commercially available: The Test Observation Form by McConaughy and Achenbach (2004).

Teacher Interview

At some point before or soon after the initial evaluation session with the family, contact with the child’s teachers may be helpful to further clarify the nature of the child’s problems. This contact will most likely occur by telephone unless the clinician works within the child’s school system. Interviews with teachers have all of the same merits as interviews with parents, providing a second ecologically valid source of indispensable information about the child’s psychological adjustment, in this case in the school setting. Like parent reports, teacher reports are also subject to bias, and the integrity of the informant, whether it be the parent or teacher, must always be weighed by judging the validity of the information itself.

Many ADHD children have problems with academic performance and classroom behavior and the details of these difficulties need to be obtained. Initially this information may be obtained by telephone; however, when time and resources permit, a visit to the classroom and direct observation and recording of the child’s behavior can prove quite useful if further documentation of ADHD behaviors is necessary for planning later contingency management programs for the classroom. Although this scenario is unlikely to prove feasible for clinicians working outside school systems, particularly in the climate of increasingly prevalent managed health care plans which severely restrict the evaluation time that will be compensated, for those professionals working within school systems, direct behavioral observations can prove very fruitful for diagnosis, and especially for treatment planning. As noted above, standardized behavioral observation forms have recently been published to permit recording such behavior: The Direct Observation Form also by McConaughy & Achenbach (2004).

Teachers should also be sent the rating scales mentioned earlier. They can be sent as a packet prior to the actual evaluation so that the results are available for discussion with the parents during the interview, as well as with the teacher during the subsequent telephone contact or school visit.

The teacher interview also should focus on the specific nature of the child’s problems in the school environment, again following a behavioral format. The settings, nature, frequency, consequences, and eliciting events for the major behavioral problems also can be explored. The follow-up questions used in the parental interview on parent-child interactions (shown in Table 2, above) may prove useful here as well. Given the greater likelihood of the occurrence of learning disabilities in this population, teachers should be questioned about such potential disorders. When evidence suggests their existence, the evaluation of the child should be expanded to explore the nature and degree of such deficits as viewed by the teacher. Even when learning disabilities do not exist, children who have ADHD are more likely to have problems with sloppy handwriting, careless approaches to tasks, poor organization of their work materials, and academic underachievement relative to their tested abilities. Time should be taken with the teachers to explore the possibility of these problems.

Rating Scales

Child Behavior Rating Scales for Parent and Teacher Reports

Child behavior checklists and rating scales have become an essential element in the evaluation and diagnosis of children with behavior problems. The availability of several scales with excellent reliable and valid normative data across a wide age range of children makes their incorporation into the assessment protocol quite convenient and extremely useful. Such information is invaluable in determining the statistical deviance of the children’s problem behaviors and the degree to which other problems may be present. As a result, it is useful to mail out a packet of these scales to parents prior to the initial appointment, asking that they be returned on or before the day of the evaluation, as described earlier. Thus the examiner can review and score the scales before interviewing the parents, allowing vague or significant answers to be elucidated in the subsequent interview and focusing the interview on those areas of abnormality highlighted in the responses to scale items.

Numerous child behavior rating scales exist. Despite their limitations, they offer a means of gathering information from informants who may have spent months or years with the child. Apart from interviews, there is no other means of obtaining such a wealth of information with so little investment of time. The fact that such scales provide a means to quantify the opinions of others, often along qualitative dimensions, and to compare these scores to norms collected on large groups of children, is further affirmation of the merits of these instruments. Nevertheless, behavior rating scales are opinions and are subject to the oversights, prejudices, and limitations on reliability and validity that such opinions may have.

Initially, it is advisable to utilize a “broad-band” rating scale that provides coverage of the major dimensions of child psychopathology known to exist, such as depression, anxiety, withdrawal, aggression, delinquent conduct, and, of course, inattentive and hyperactive-impulsive behavior. These scales should be completed by parents and teachers. Such scales would be the BASC-2 and the CBCL, both of which have versions for parents and teachers and satisfactory normative information.

Narrow-band scales that focus specifically on the assessment of symptoms of ADHD should also be employed in the initial screening of children. DuPaul and colleagues collected U.S. norms for another version of an ADHD rating scale, the ADHD-V Rating Scale (DuPaul et al., 2014).

The clinician should also examine the pervasiveness of the child’s behavior problems within the home and school settings, as such measures of situational pervasiveness appear to have as much or more stability over time than do the aforementioned scales. The Home Situations Questionnaire (HSQ) (see my book, Defiant Children, 2013) provides a means for doing so, and normative information for these scales is available. The HSQ requires parents to rate their child’s behavioral problems across 16 different home and public situations. The School Situations Questionnaire (SSQ) similarly obtains teacher reports of problems in 12 different school situations (also in Defiant Children).

As noted earlier, abundant research shows that ADHD is associated with substantial and pervasive deficits in executive functioning (EF) in daily life, even if those deficits are not always evident on neuropsychological tests used with either children or adults. It is therefore recommended that clinicians wishing to evaluate EF in children having ADHD use rating scales of EF in daily life that provide a better (more ecologically valid) means of doing so than do tests. One recent scale developed to do so is my own (Barkley, 2012a), but clinicians may find the earlier BRIEF (Gioia et al., 2000) to be useful for this purpose as well, although its norms are not a nationally representative sample of U.S. children as are those in the former scale.

Clinicians should also formally evaluate impairment in major life activities in some standardized way. To that end, my new rating scale (Barkley Functional Impairment Scale – Children and Adolescents, 2012b) can help assess a child’s impairment in 15 major life activities relative to norms collected on a U.S. representative sample of children ages 6 to 18 years old.

The more specialized or narrow-band scales focusing on symptoms of ADHD as well as the HSQ and SSQ can be used to monitor treatment response when given prior to, throughout, and at the end of parent training. They can also be used to monitor the behavioral effects of medication on children with ADHD.

Self-Report Behavior Rating Scales for Children

Achenbach has developed a rating scale quite similar to the CBCL, which is completed by children ages 11 to 18 (Youth Self-Report Form). Most items are similar to those on the parent and teacher forms of the CBCL except that they are worded in the first person. A later revision of this scale (Cross-Informant Version; Achenbach, 2001) now permits direct comparisons of results among the parent, teacher, and youth self-report forms of this popular rating scale. Research suggests that although such self-reports of ADHD children and teens are more deviant than the self-reports of youth without ADHD, the self-reports of problems by the ADHD youth, whether by interview or the CBCL Self-Report Form, are often less severe than the reports provided by parents and teachers. The BASC-2, noted earlier, also has a self-report form that may serve much the same purpose as that for the CBCL.

The reports of children about internalizing symptoms, such as anxiety and depression, are more reliable and likely to be more valid than the reports of parents and teachers about these symptoms in their children. For this reason, the self-reports of defiant children and youth should still be collected, as they may have more pertinence to the diagnosis of comorbid internalizing disorders in children than to the defiant behavior itself.

Adaptive Behavior Scales and Inventories

Research shows that a major area of life functioning affected by ADHD is the realm of general adaptive behavior. Adaptive behavior often refers to the child’s development of skills and abilities that will assist them in becoming more independent, responsible, and self-caring individuals. This domain often includes:

  1. self-help skills, such as dressing, bathing, feeding, and toileting requirements, as well as telling and using time and understanding and using money;
  2. interpersonal skills, such as sharing, cooperation, and trust;
  3. motor skills, such as fine motor (zipping, buttoning, drawing, printing, use of scissors, etc.) and gross motor abilities (walking, hopping, negotiating stairs, bike riding, etc.);
  4. communication skills; and
  5. social responsibility, such as degree of freedom permitted within and outside the home, running errands, performing chores, and so on.

So substantial and prevalent is this area of impairment among children with ADHD that some researchers have even argued that a significant discrepancy between IQ and adaptive behavior scores (expressed as standard scores) may be a hallmark of ADHD.

Several instruments are available for the assessment of this domain of functioning. The Vineland Adaptive Behavior Inventory is probably the most commonly used measure for assessing adaptive functioning. It is an interview, however, and takes considerable time to administer. For other scales assessing adaptive behavior, see the review by Evans & Bradley-Johnson ( 2007). The CBCL and the BASC completed by parents also contains several short scales that provide a cursory screening of several areas of adaptive functioning (Activities, Social, and School) in children, but are no substitute for the in-depth coverage provided by the Vineland or NABC scales.

Peer Relationship Measures

As noted earlier, children with ADHD often demonstrate significant difficulties in their interactions with peers, and such difficulties are associated with an increased likelihood of persistence of their disorder. A number of different methods for assessing peer relations have been employed in research with behavior-problem children, such as direct observation and recording of social interactions, peer and subject completed sociometric ratings, and parent and teacher rating scales of children’s social behavior. Most of these assessment methods have no norms and thus would not be appropriate for use in the clinical evaluation of children with ADHD. For clinical purposes, rating scales may offer the most convenient and cost-effective means for evaluating this important domain of childhood functioning. The CBCL and BASC-2 rating forms described earlier contain scales that evaluate children’s social behavior and norms are available for these scales, permitting their use in clinical settings. The more recently developed Barkley Functional Impairment Scale – Children and Adolescents also covers various domains of social life and has U.S. representative norms (see Resources). Three other scales that focus specifically on social skills are the Matson Evaluation of Social Skills with Youngsters (MESSY; Matson, Rotatori, & Helsel, 1983), the Taxonomy of Problem Social Situations for Children (TOPS; Dodge, McClaskey, & Fledman, 1985), and the Social Skills Rating System. The latter also has norms and a software scoring system, making it useful in clinical contexts. I have used it extensively in our research and clinical evaluations.

Parent Self-Report Measures

It has become increasingly apparent that child behavioral disorders, their level of severity, and their response to interventions are, in part, a function of factors affecting parents and the family at large. Several types of psychiatric disorders are likely to occur more often among family members of a child with ADHD than in matched groups of control children. Numerous studies over the past 30 years have demonstrated the further influence of these disorders on the frequency and severity of behavioral problems in ADHD children.

As discussed earlier, the extent of social isolation in mothers of behaviorally disturbed children influences the severity of the children’s behavioral disorders as well as the outcomes of parent training. Separate and interactive contributions of parental psychopathology and marital discord affect the decision to refer children for clinical assistance, the degree of conflict in parent-child interactions, and child antisocial behavior. The degree of parental resistance to training also depends on such factors. Assessing the psychological integrity of parents, therefore, is an essential part of the clinical evaluation of defiant children, the differential diagnosis of their prevailing disorders, and the planning of treatments stemming from such assessments. Thus, the evaluation of children for ADHD is often a family assessment rather than one of the child alone. Although space does not permit a thorough discussion of the clinical assessment of adults and their disorders here, this section provides a brief mention of some assessment methods clinicians may find useful as a preliminary screening for certain variables of import to treatment in ADHD children.

The parents can complete these instruments in the waiting room, during the time their child is being interviewed. (To save time, some professionals may prefer to send these self-report scales out to parents in advance of their appointment, at the same time they send the child-behavior questionnaires to the parents. If so, the clinician needs to prepare a cover letter sensitively explaining to parents the need for obtaining such information.) On the day of the interview, the clinician can indicate to parents that having a complete understanding of a child’s behavior problems requires learning more about both the children and their parents. This process includes gaining more information about the parents’ own psychological adjustment and how they view themselves as succeeding in their role as parents. The rating scales can then be introduced as one means of gaining such information. Few parents refuse to complete these scales after an introduction of this type.

Parental ADHD

Family studies of the aggregation of psychiatric disorders among the biological relatives of children with ADHD and ODD clearly demonstrate an increased prevalence of ADHD and ODD among the parents of these children. In general, there seems to be at least a 40%–50% chance that one of the two parents of the child with ADHD will also have adult ADHD (15%–20% of mothers and 25%–30% of fathers). The manner in which ADHD in a parent might influence the behavior of an ADHD child specifically and the family environment more generally has now been studied. It indicates that such parents are less attentive and responsive to their children, monitor their activities less often, and may be less rewarding of their children’s positive behavior. Adults with ADHD also have been shown to be more likely to have problems with anxiety, depression, personality disorders, alcohol use and abuse, and marital difficulties; to change their employment and residence more often; and to have less education and socioeconomic status than adults without ADHD, all of which can have an impact on the functioning of an ADHD child within such a family.

Greater diversity and severity of psychopathology among parents is particularly apparent among the subgroup of ADHD children with comorbid ODD or CD. More severe ADHD seems to also be associated with younger-age parents, suggesting that pregnancy during their own teenage or young adult years is more characteristic of parents of ADHD than non-ADHD children. It is not difficult to see that these factors, as well as the primary symptoms of ADHD, could influence the manner in which child behavior is managed within the family as well as the quality of home life for such children more generally. Some research in our clinic suggests that when the parent has ADHD, the probability that the child with ADHD will also have ODD increases markedly. Studies suggest that ADHD in a parent may interfere with the ability of that parent to benefit from a typical behavioral parent training program. Treatment of the parent’s ADHD (with medication) may result in greater success in subsequent retraining of the parent. These preliminary findings suggest the importance of determining the presence of ADHD in the parents of children undergoing evaluation for the disorder.

The DSM-5 symptom list for ADHD has been cast in the form of two behavior rating scales for use in screening adults for ADHD, one for current behavior and the other for recall of behavior during childhood (see Barkley Adult ADHD Rating Scale in Resources; alternatively, Conners has a rating scale for adult ADHD at MultihealthSystems.com). Norms are available for a representative sample of the U.S. adult population and the scale has excellent psychometric properties. Again, clinically significant scores on these scales do not, by themselves, grant the diagnosis of ADHD to a parent, but they should raise suspicion in the clinician’s mind about such a possibility. If so, consideration should be given to referring the parent for further evaluation and, possibly, treatment of adult ADHD.

The use of such scales in screening parents of ADHD children would be a helpful first step in determining whether the parents have ADHD. If the child meets diagnostic criteria for ADHD and these screening scales for ADHD in the parents prove positive (clinically significant), referral of the parents for a more thorough evaluation and differential diagnosis might be in order. At the very least, positive findings from the screening would suggest the need to take them into account in treatment planning and parent training.

Marital Discord

Many instruments exist for evaluating marital discord. The one most often used in research on childhood disorders has been the Locke-Wallace Marital Adjustment Scale (Locke & Wallace, 1959). Marital discord, parental separation, and parental divorce are more common in parents of ADHD children. Parents with such marital difficulties may have children with more severe defiant and aggressive behavior and such parents may also be less successful in parent training programs. Screening parents for marital problems, therefore, provides important clinical information to therapists contemplating a parent training program for such parents. Clinicians are encouraged to incorporate a screening instrument for marital discord into their assessment battery for parents of children with defiant behavior.

Parental Depression and General Psychological Distress

Parents of ADHD children, especially those with comorbid ODD or CD, are frequently more depressed than parents of  children without ADHD, which may affect their responsiveness to behavioral parent training programs. The Beck Depression Inventory is often used to provide a quick assessment of parental depression. Greater levels of psychopathology generally, and psychiatric disorders specifically, also have been found in parents of children with ADHD, many of whom also have ADHD. One means of assessing this area of parental difficulties is through the use of the Symptom Checklist 90 – Revised (or the shorter, 27-item version). This instrument not only has a scale assessing depression in adults, but also has scales measuring other dimensions of adult psychopathology and psychological distress. Whether clinicians use this or some other scale, the assessment of parental psychological distress generally, and psychiatric disorders particularly, makes sense in view of their likely impact on the child’s course and the implementation of the child’s treatments typically delivered via the parents.

Parental Stress

Research over the past 15 years suggests that parents of children with behavior problems, especially those children with comorbid ODD and ADHD, report more stress in their families and in their parental role than those of normal or clinic-referred non-ADHD children. One measure frequently used in such research to evaluate this construct has been the Parenting Stress Index (PSI). The original PSI is a 150-item multiple-choice questionnaire which can yield six scores pertaining to child behavioral characteristics (distractibility, mood, etc.), eight scores pertaining to maternal characteristics (e.g., depression, sense of competence as a parent, etc.), and two scores pertaining to situational and life stress events. These scores can be summed to yield three domain or summary scores: Child Domain, Mother Domain, and Total Stress. A shorter version of this scale is available and clinicians are encouraged to utilize it in evaluating parents of defiant children.

The Role of Psychological Testing (with Michael Gordon, Ph.D.)

This section was originally taken from my chapter with Michael Gordon in the 3rd edition (2006) of my ADHD Handbook for Diagnosis and Treatment (see Resources) for the initial edition of this course, but has been updated in 2013 and again in 2018 based on subsequent chapters in later versions of this same Handbook (2015). Despite advances in our knowledge about psychological testing and the allure of numbers over perception, the search for accurate and reliable measures of ADHD symptoms has not yielded a litmus test. To date there are no psychological or neuropsychological tests sufficiently reliable and valid enough for use in the diagnosis of ADHD, either in children or adults. Among the available tests, the score of reaction time variability on a continuous performance test seems to have the greatest utility, though even it has limitations. Ratings of ADHD and of executive functioning (EF) are far more useful in both documenting the developmental inappropriateness of these symptoms in children as well as in supporting the diagnosis of ADHD. The fact that there is no significant correlation between the neuropsychological tests of EF and ratings of EF in daily life helps account for why ratings may be clinically useful while tests of EF are not clinically helpful to diagnosis.

The absence of a gold standard for the diagnosis as well as the heterogeneity of the disorder itself precludes any one test (and, for that matter, any one rating scale or interview format) from claiming pinpoint accuracy. At best, research in this arena has produced techniques that can have some clinical utility but cannot supplant other sources of information. That is because at this time, no psychological tests have been shown to be sufficiently accurate in making the diagnosis of ADHD or in ruling out those who do not have the disorder (positive and negative predictive power) so as to warrant their adoption in clinical practice for diagnosing ADHD. Perhaps their strongest contributions are in identifying comorbid conditions.

If psychological testing is to be done, the following points should be kept in mind:

The last two points on this list warrant some elaboration. Much of the scientific focus on psychological testing falls, appropriately, on the capacity of a test to predict group status. Most studies explore the degree of agreement among various clinical measures, often with a selected combination established as the benchmark. However, a psychological test can be of significant value even if it does not wholly agree with other measures. For example, a test may provide unique information regarding the severity of pathology or the amenability of a child to certain treatments. A test might also have value in predicting outcome in unique populations or age groups. Therefore, a single-minded focus on discriminative power may overlook other possible contributions of testing. Nevertheless, when test developers argue for the value of their tests in making diagnostic classifications, data must be provided from peer-reviewed scientific studies that the test, in fact, achieves those aims. Many developers report the sensitivity and specificity of their measures, but these indices are not relevant to how the tests are actually used by clinicians. They merely indicate what percentage of cases with and without ADHD do poorly or well on the tests. This sequence is the reverse of what happens in clinical practice where the clinician knows the test score first and then wants to predict the diagnosis, in which case statistics pertaining to positive and negative predictive power are the relevant ones. Rarely are they provided by test publishers. When such data are provided, which in my experience is rare, they indicate marginally acceptable positive predictive power but unacceptable negative predictive power due to the large percentages of cases with ADHD that can pass such tests. As a result, there are no psychological tests that can be recommended at this time to diagnose ADHD and the presence of a normal score on a putative “ADHD” or EF test cannot be used to rule out the diagnosis.

The requirement that tests should be practical to administer and interpret reflects the realities of modern clinical practice. As demands for cost efficiency mount, practitioners cannot afford to use measures that are unwieldy, time-consuming, or complicated. The ever-increasing focus on practicality has influenced our recommendations for psychological testing and observational techniques. Simply put, it makes little sense to consider approaches that are impractical, even if they might offer meaningful information.

The value of psychological testing may therefore be greatest for ruling in or out the presence of intellectual delay or learning disorders (LD) as associated conditions in cases of ADHD. In those instances, brief screening tests of IQ and academic achievement can be given. While only a small percentage of cases of ADHD have intellectual delay, slightly higher than the national average, up to half of them may have learning disabilities. Given this high prevalence of LD in ADHD, all cases of ADHD should receive screening on academic achievement tests.

Legal and Ethical Issues

Apart from the legal and ethical issues involved in the general practice of providing mental health services to children, several such issues may be somewhat more likely to occur in the evaluation of ADHD children. The first involves the issue of custody or guardianship of the child as it pertains to who can request the evaluation of the child for ADHD. Children with ODD, ADHD, or CD are more likely than average to come from families in which the parents have separated or divorced or in which significant marital discord may exist between the biological parents. As a result, the clinician must take care at the point of contact between the family and the clinic or professional to determine who has legal custody of the child and particularly the right to request mental health services on behalf of the minor. It must also be determined in cases of joint custody – an increasingly common status in divorce/custody situations – whether the nonresident parent has the right to dispute the referral for the evaluation, to consent to the evaluation, to attend on the day of appointment, and/or to have access to the final report. This right to review or dispute mental health services may also extend to the provision of treatment to the child. Failing to attend to these issues before the evaluation can lead to contentiousness, frustration, and even legal action among the parties to the evaluation that could have been avoided had greater care been taken to iron out these issues beforehand. Although these issues apply to all evaluations of children, they may be more likely to arise in families seeking assistance for ADHD children.

A second issue that also arises in all evaluations, but may be more likely in cases involving ADHD, is the duty of the clinician to disclose to state agencies any suspected physical or sexual abuse or neglect of the child. Clinicians should routinely forewarn parents of this duty to report when it applies in a particular state before starting the formal evaluation procedures. In view of the greater stress that ADHD or ODD children appear to pose for their parents, as well as the greater psychological distress their parents are likely to report, the risk for abuse of ADHD children, especially those with ODD, Bipolar disorder, or Disruptive Mood Dysregulation Disorder, may be higher than average. The greater likelihood of parental ADHD or other psychiatric disorders may further contribute to this risk, resulting in a greater likelihood that evaluations of children with disruptive behavior disorders will involve suspicions of abuse. Understanding such legal duties as they apply in a given state or region and taking care to exercise them properly, yet with sensitivity to the larger clinical issues, are the responsibility of any clinician involved in providing mental health services to children.

Over the past 20 years, ADHD children have been gaining access to government entitlements, sometimes thought of as legal rights, which makes it necessary for clinicians to be well informed about the legal issues if they are to properly and correctly advise the parents and school staff. For instance, children with ADHD in the United States are now entitled to formal special educational services under the Other Health Impaired Category of the Individuals with Disabilities in Education Act, provided of course that their ADHD is sufficiently serious to interfere significantly with school performance. In addition, such children also have legal protections and entitlements under Section 504 of the Disability Rights Act or the more recent Americans with Disabilities Act as it applies to the provision of an appropriate education for children with disabilities. And should ADHD children have a sufficiently severe disorder and reside in a family of low economic means, they may also be eligible for financial assistance under the Social Security Act. Space precludes a more complete explication of these legal entitlements here. Suffice it to say here that clinicians working with ADHD children need to familiarize themselves with these various rights and entitlements if they are to be effective advocates for the children they serve.

A final legal issue related to ADHD children is that of legal accountability for their actions in view of the argument made elsewhere that their ADHD is a developmental disorder of self-control. Should children with ADHD be held legally responsible for the damage they may cause to property, the injury they may inflict on others, or the crimes they may commit? In short, is ADHD an excuse to behave irresponsibly without being held accountable for the consequences? The answer is unclear and deserves the attention of sharper legal minds than ours. It is my opinion, however, that ADHD explains why certain impulsive acts may have been committed, but it does not sufficiently disturb mental faculties to the point of excusing legal accountability, as might occur, for example, under the insanity defense. Nor should ADHD be permitted to serve as an extenuating factor in the determination of guilt or the sentencing of an individual involved in criminal activities, particularly those involving violent crime. This opinion is predicated on the fact that the vast majority of children with ADHD, even those with comorbid ODD, do not become involved in violent crime, especially predatory crime, as they grow up. A substantial minority are prone to engage in reactive aggression when provoked, however. Moreover, studies attempting to predict criminal conduct within samples of ADHD children followed to adulthood either have not been able to find adequate predictors of such outcomes or have found them to be so weak as to account for a paltry amount of variance in such outcomes. Moreover, those variables that may make a significant contribution to the prediction of criminal or delinquent behavior more often involve measures of parental and family dysfunction as well as social disadvantage and much less so, if at all, measures of ADHD symptoms.

Until this matter receives greater legal scrutiny, it seems wise to view ADHD as one of several explanations for impulsive conduct, but not a direct, primary, or immediate cause of criminal conduct for which the individual should not be held accountable. Individuals with ADHD often know right from wrong as well as do most typical people of similar intellectual ability. Yet they may fail to give due contemplation to such moral matters when faced with a situation that provokes them to criminal action, especially one arising from their impulsive nature.

The Pediatric Medical Examination (with assistance from Mary McMurray, M.D. and Michelle Macias, MD)

It is essential that children being considered for a diagnosis of ADHD have a complete pediatric physical examination. However, traditionally such examinations are brief, relatively superficial, and as a result often unreliable and invalid for achieving a diagnosis of ADHD or identifying other comorbid behavioral, psychiatric, and educational conditions. This is often the result of ignoring the other two essential features of the evaluation of ADHD children: a thorough clinical interview, reviewed earlier, and the use of behavior-rating scales. To properly diagnose and treat these children and adolescents, it is imperative that adequate time be committed to the evaluation for completion of these components. If this is not possible, the physician is compelled to conduct the appropriate medical examination, but withhold the diagnosis until the other components can be accomplished by referral to a mental health professional.

The features of the pediatric examination and the issues that must be entertained therein are described next.

The Medical Interview

Most of the contents of an adequate medical interview are identical to those described previously for the parental interview. However, greater time will clearly be devoted to a more thorough review of the child’s genetic background, pre- and peri-natal events, and developmental and medical history, as well as the child’s current health, nutritional status, and gross sensory-motor development. The time to listen to the parents’ story and the child’s feelings and to explain the nature of the disorder is one of the most important things a physician can offer a family. In this way, the evaluation process itself can often be therapeutic.
One major purpose of the medical interview that distinguishes it from the psychological interview noted previously is its focus on differential diagnosis of ADHD from other medical conditions, particularly those that may be treatable. In rare cases, the ADHD may have arisen secondary to a clear biologically compromising event, such as recovery from severe Reye’s syndrome, surviving an hypoxic-anoxic event such as near-drowning or severe smoke inhalation, significant head trauma, or recovery from an central nervous system infection or cerebral-vascular disease. The physician should obtain details of these surrounding events as well as the child’s developmental, psychiatric, and educational status prior to the event, and any significant changes in these domains of adjustment since the event. The physician should also document ongoing treatments related to such events. In other cases, the ADHD may be associated with significant lead or other metal or toxic poisonings, which will require treatment in their own right.

It is also necessary to determine whether the child’s conduct or learning problems are related to the emergence of a seizure disorder or are secondary to the medication being used to treat the disorder. As many as 20% of epileptic children may have ADHD as a comorbid condition and up to 30% may develop ADHD or have it exacerbated by the use of phenobarbital or dilantin as anticonvulsants. In such cases, changing to a different anticonvulsant may greatly reduce or even ameliorate the attentional deficits and hyperactivity of such children.

A second purpose of the medical exam is to thoroughly evaluate any coexisting conditions that may require medical management. In this case, the child’s ADHD is not seen as arising from these other conditions, but as being comorbid with it. ADHD is often associated with higher risks not only for other psychiatric or learning disorders, but also for motor incoordination, enuresis, encopresis, allergies, otitis media, and greater somatic complaints in general. A pediatric evaluation is desirable or even required for many of these comorbid conditions. For instance, the eligibility of the child for physical or occupational therapy at school or in a rehabilitation center may require a physician’s assessment and written recommendation of the need for such. And, although most cases of enuresis and encopresis are not due to underlying physiological disorders, all cases of these elimination problems should be evaluated by a physician before beginning nutritional and behavioral interventions. Even though many of these cases are “functional” in origin, medications may be prescribed to aid in their treatment, as in the use of atomoxetine, oxybutynin, or imipramine for bedwetting. Certainly children with significant allergies or asthma require frequent medical consultation and management of these conditions, often by specialists who appreciate the behavioral side effects of medications commonly used to treat them. Theophyline, for example, is increasingly recognized as affecting children’s attention span and may exacerbate a preexisting case of ADHD. For these and other reasons, the role of the physician in the evaluation of ADHD should not be underestimated despite overwhelming evidence that by itself it is inadequate as the sole basis for a diagnosis of ADHD.

A third purpose of the medical examination is to determine whether physical conditions exist that are contraindications for treatment with medications. For instance, a history of high blood pressure or cardiac difficulties warrants careful consideration about a trial on a stimulant drug given the known presser effects of these drugs on the cardiovascular system. Some children may have a personal or family history of tic disorders or Tourette’s Disorder, which would dictate a somewhat more cautious approach in prescribing stimulants in view of their greater likelihood of bringing out such movement disorders or increasing the occurrence of those that already exist in about a third of such cases comorbid with ADHD. Note however, that the majority of cases having a tic disorder with ADHD can be prescribed such medications without exacerbating their tic disorder. Instead, the non-stimulants such as atomoxetine or guanfacine XR may be more appropriate if there is concern about tic exacerbation. These examples merely illustrate the myriad medical and developmental factors that need to be carefully assessed in considering whether a particular ADHD child is an appropriate candidate for drug treatment.

Physical Examination

In the course of the physical examination, height, weight, and head circumference require measurement and comparison to standardized graphs. Hearing and vision, as well as blood pressure, should be screened. Findings suggestive of hyper- or hypothyroidism, lead poisoning, anemia, or other chronic illness clearly need to be documented and further workup should be pursued. The formal neurological examination often includes testing of cranial nerves, gross and fine motor coordination, eye movements, finger sequencing, rapid alternating movements, impersistence, synkinesia, motor overflow, choreiform movements, and tandem gait tasks. The exam is often used to look for signs of previous central nervous system insult or of a progressive neurological condition, abnormalities of muscle tone, and a difference in strength, tone, or deep tendon reflex response between the two sides of the body. The existence of nystagmus, ataxia, tremor, decreased visual field, or fundal abnormalities should be determined and further investigation pursued when found. This evaluation should be followed by a careful neurodevelopmental exam covering the following areas: motor coordination, visual-perceptual skills, language skills, and cognitive functioning. Although these tests are certainly not intended to be comprehensive or even moderately in-depth evaluations of these functions, they are invaluable as quick screening methods for relatively gross deficiencies in these neuropsychological functions. When deficits are noted, follow-up with more careful and extensive neuropsychological, speech and language, motor, and academic evaluations may be necessary to more fully document their nature and extent.

Results of routine physical examinations of ADHD children are frequently normal and of little help in diagnosing the condition or suggesting its management. However, the physician certainly needs to rule out the rare possibility of visual or hearing deficits which may give rise to ADHD-like symptoms. Also, on physical inspection, ADHD children may have a greater number of minor physical anomalies in outward appearance (e.g., an unusual palmar crease, two whirls of hair on the head, increased epicanthal fold, or hyperteliorism). However, studies conflict on whether such findings occur more often in ADHD, but certainly they are nonspecific to it, being found in other psychiatric and developmental disorders. Examining for these minor congenital anomalies may only be beneficial when the physician suspects maternal alcohol abuse during pregnancy so as to determine the presence of fetal alcohol syndrome. The existence of small palpebral fissures and midfacial hypoplasia with growth deficiency supports this diagnosis.

Finally, given the considerably greater distress ADHD children present to their caregivers, their risk of being physically abused would seem to be higher than normal. Greater attention by physicians to physical or other signs of abuse during the examination is therefore required.

Results from the routine examination for growth in height and weight is also often normal, although one study reported a younger bone age in children with minimal brain dysfunction, including hyperactivity. Nevertheless, when the physician contemplates a trial on a stimulant drug, it is necessary to have accurate baseline data on physical growth, heart rate, and blood pressure against which to compare subsequent repeat exams during the drug trial or during long-term maintenance on these medications.

Similarly, findings from the routine neurological examination are frequently normal in ADHD children. These children may display a greater prevalence of soft neurological signs suggestive of immature neuromaturational development, but again, these are nonspecific for ADHD and can often be found in learning-disabled, psychotic, autistic, and intellectually disabled children, not to mention a small minority of normal children. Such findings are therefore not diagnostic of ADHD, nor does their absence rule out the condition. Instead, findings of choreiform movements, delayed laterality development, fine or gross motor incoordination, dysdiadochokinesis, or other soft signs may suggest that the child requires more thorough testing by occupational or physical therapists and may be in need of some assistance in school with fine motor tasks or adaptive physical education.

ADHD children may also have a somewhat higher number of abnormal findings on brief mental status examinations or screening tests of higher cortical functions, especially those related to frontal lobe functions (e.g., sequential hand movement tests, spontaneous verbal fluency tests, and go-no-go tests of impulse control). When these are found, more thorough neuropsychological testing may be useful in further delineating the nature of these deficits and providing useful information to educators for making curriculum adjustments for these children. In some cases, findings on brief mental status exams may have more to do with a coexisting learning disability in a particular case than with the child’s ADHD. When problems with visual-spatial-constructional skills or simple language abilities are noted, they are most likely signs of a comorbid learning disorder, as they are not typical of ADHD children generally. It is often the case that these brief mental status examinations show normal behaviors. This does not necessarily imply that all higher cortical functions are intact, as these screening exams are often relatively brief and are crude methods of assessing neuropsychological functions. More sensitive – and lengthier – neuropsychological tests may often reveal deficits not detected during a brief neurological screening or mental status exam. Even so, the routine assessment of ADHD children with extensive neuropsychological test batteries is also likely to have a low yield, as discussed above. It should be undertaken only when there is a question of coexisting learning or processing deficits that require further clarification, and even then tests should be selected carefully to address these specific hypotheses.

Laboratory Tests

A number of studies of ADHD children have used a variety of physical, physiological, and psychophysiological measures to assess potential differences between ADHD and other clinical or control groups of children. Although some of these studies have demonstrated such differences, as in reduced cerebral blood flow to the striatum or diminished orienting galvanic skin responses, none of these laboratory measures are of value in the diagnostic process as yet. Parents, teachers, or even other mental health professionals are sometimes misled by reports of such findings or by the conclusion that ADHD is a biologically based disorder, and they frequently ask for their children to be tested medically to confirm the diagnosis. At this moment, no such tests exist. Consequently, laboratory studies such as blood work, urinalysis, chromosome studies, electroencephalograms, averaged evoked responses, cerebral blood flow, magnetic resonance imaging (MRI), positron emission tomography (PET), or computerized axial tomograms (CT scans) should not be used routinely in the evaluation of ADHD children. Only when the medical and developmental history or physical exam suggests that a treatable medical problem exists, such as a seizure disorder, or that a genetic syndrome is a possibility, would these laboratory procedures be recommended, although such cases are quite rare.

Blood assays of levels of medication have so far proven unhelpful in determining appropriate dosage and therefore are not recommended as part of routine clinical titration and long-term management of these medications.

The Feedback Session

The feedback session with parents concludes the diagnostic evaluation. This session should take place after all the direct testing with the child is completed and scored and after the clinician has reviewed all the data and drawn diagnostic conclusions (the family may need to wait until after the clinician makes any necessary collateral phone calls to the school, current therapist, etc.). As with the parent interview, children under the age of 16 years old are not generally included in the feedback session, but they may be invited in at the end of the session to be given diagnostic conclusions at a level appropriate to their age and cognitive development.

The first step in the feedback session is to give parents some information about ADHD. I generally explain to parents that ADHD is defined as a developmental disorder, not mental illness or the result of stress in families. The developmental delay affects the child’s ability to regulate behavior, control activity level, inhibit impulsive responding, or sustain attention. In other words, the child with ADHD will be more active, impulsive, and less attentive than other children of the same age.

I then explain that there is no direct test for ADHD – no lab test, X-ray, or psychological test that definitely tells us that a child has ADHD. What has to be done instead is to collect a lot of information and analyze it statistically. Everything that has been learned about their child has been scored, and these scores are compared with the scores that have been collected on hundreds if not thousands of children of the same age. If their child’s scores are consistently placing him or her at or above the 95th percentile in the areas of activity level, impulse control, or attention span, those scores suggest ADHD because it suggests that the child is having more difficulty than 95 of 100 children of the same age. This is the level of “developmental deviance” that must be established.

The second step is to establish a history consistent with the notion of a “developmental” problem. Do these symptoms have a long-standing history that stretches back over time, for at least the past year, or since before the age of 12 – not something that cropped up last week or last month, or something that only came about after a trauma occurred in the child’s life.

The third step is to rule out any other logical explanation for the problem. Is there anything else going on that would overrule ADHD as a diagnosis or be a better explanation than ADHD for the problems the child is having?

I then walk parents through the data obtained about their child, step by step, so they can see clearly how the diagnostic conclusion was reached. These steps include the following:

Before any discussion of a treatment plan occurs, parents are asked if they have any questions about the diagnostic process or any comments about the conclusions that were drawn. Parents are always asked if they are surprised that their child was (or was not) diagnosed with ADHD.

By walking parents through the data this way, any confusion can be quickly clarified. Parents should leave the diagnostic interview with the impression that the clinician was comprehensive and competent. This sense of security will help them cope with the grief and disappointment they may experience at being told that their child has a developmental disability, as well as the confidence to follow any treatment recommendations that are made.

Conclusion on Assessment

It should be clear from the foregoing that the assessment of ADHD children is a complex and serious endeavor requiring adequate time (approximately three hours, exclusive of medical exam and psychological testing), knowledge of the relevant research and clinical literature, as well as differential diagnosis, skillful clinical judgment in sorting out the pertinent issues, and sufficient resources to obtain multiple types of information from multiple sources (parents, child, teacher) using a variety of assessment methods. When time and resources permit, direct observations of defiant and ADHD behaviors in the classroom could also be made by school personnel. At the very least, telephone contact with a child’s teacher should be made to follow up on his or her responses to the child behavior rating scales and to obtain greater detail about the classroom behavior problems of the defiant child. To this list of assessment methods would be added others necessary to address any comorbid problems often found in conjunction with ADHD in children.

Treatment Approaches

Research on the treatment of ADHD over the past two decades has focused largely on evaluating multi-modal treatment packages. Innovations have mainly occurred in (a) new delivery systems within psychopharmacology and even new drug development, and (b) evaluating cognitive rehabilitation software aimed at symptoms of inattention and deficient working memory, such as CogMed. This is not to say that more information on the prevailing treatments has not been gained over the past decade; that is hardly the case. For instance, more rigorous research using sham biofeedback as a placebo control has shown the ineffectiveness of neurofeedback (EEG biofeedback) in reducing or alleviating the symptoms of ADHD, especially when blinded evaluations of symptoms by caregivers is employed. Also, behavioral parent training has been shown to be far more beneficial for parent-child conflict and child oppositional behavior than for ADHD symptom reduction. This is to say that few significant breakthroughs in the psychosocial treatment of the disorder have been forthcoming, with perhaps the exception of a new social skills training approach, developed by Amori Mikami, entitled Friendship Coaching (for parents) and MOSAIC (for teachers). Most of the psychosocial treatment research has served to clarify the efficacy (or lack thereof) of already extant treatment approaches, or their combinations.

A major problem in the ADHD treatment literature is a lack of documentation of long-term treatment effectiveness. Almost all of the research has focused on short-term effects (i.e., within three months), with a few studies providing intervention for up to 14 months with follow-up evaluations going on for several years thereafter. Thus, at the time of initial writing of this course, long-term effects beyond a few years had been largely unstudied. This situation has been remedied somewhat by the Multimodal Treatment Study of ADHD, commonly called the MTA study, that has now followed children for 16+ years after receiving 14 months of treatment, and the New York-Montreal multimodal treatment study. These long-term studies have shed some important insight on treatment, especially regarding the efficacy of combining psychosocial and pharmacological treatment, yet they have also shown that treatment gains do not endure once treatment is discontinued. This does not mean one should abandon treatment but that one should approach it like a chronic medical illness, such as diabetes, in which treatment must be continued as needed to control impairing symptoms and reduce the risk for secondary harm from an unmanaged disorder.

Another concern regarding the treatment research on ADHD has been that despite consistent findings of improvement in core symptoms of ADHD, there have been few reports of psychosocial treatment effects on key indicators of functioning such as academic achievement or social skills. For treatment of ADHD to be considered truly effective, there needs to be documentation of effectiveness on key ecological indicators of functioning in major life activities, such as school grades, sustained peer relations, etc. Again, this situation has been somewhat remedied by the MTA and, to a lesser extent, by the New York-Montreal multimodal studies.

Before venturing into a more detailed discussion of the efficacy of specific treatments for ADHD, it will be helpful to re-examine some traditional assumptions about the treatment of this disorder. They are being called into question not only by the theoretical model of Barkley concerning ADHD as a disorder of executive functioning, but by the results of research on etiologies, as well as the results of follow-up studies of children who had received effective treatments for various periods of time and were then followed.

Re-examining Treatment Assumptions

Advances in research on the etiologies of ADHD and in theoretical models about the disorder seem to suggest why few treatment breakthroughs, especially in the psychosocial arena, have occurred. The information yielded from these sources increasingly points to ADHD as being a developmental disorder of probable neuro-genetic and neurological origins in which some unique environmental factors (mainly bio-hazards such as toxins and brain injuries) play a role in the expression of the disorder, though far less than do genetic ones. Therefore, unless new treatments address the underlying neurological substrates or genetic mechanisms that are contributing so strongly to it, the treatment will have fleeting or minimal impact on remedying this disorder.

We are not suggesting that prevention of ADHD is an impossible goal. For instance, some have suggested that reshaping the environments of young preschoolers – such as limiting television watching – might help to prevent some cases of ADHD, although the direction of causation in this correlational relationship remains to be completely understood (children with ADHD are prone to use more televised and Internet media than typical children). Others have made a more compelling case for the reduction of environmental lead given the contribution of lead poisoning before age three years to the risk for later ADHD (see Nigg, 2006). Certainly the reduction of maternal use of alcohol and tobacco products during pregnancy would seem to be useful in view of the linkages noted earlier between these fetal neuro-toxins and risk for ADHD in the offspring of those pregnancies.

This type of preventative research and related interventions should be encouraged. However, this is a course on treatment, and by the time individuals meet diagnostic criteria for ADHD, we believe that they are on a chronic course and need to be treated accordingly. Therefore, the treatment of ADHD is actually symptomatic management as in diabetes. It is management of a chronic developmental condition and involves finding means to cope with, compensate for, and accommodate the developmental deficiencies so as to reduce the numerous secondary harms that can accrue from unmanaged disorder. These means also include the provision of symptomatic relief such as that obtained by various medications.

Given the relatively greater contribution of genotype to environment in explaining individual differences in the symptoms of the disorder, it is highly likely that treatments for ADHD, while providing improvements in the symptoms, do little to change the rank ordering of such individuals relative to each other in their post-treatment levels of ADHD. It is also likely that such treatments, particularly in the psychosocial realm, will prove to be specific to the treatment setting and agents, showing minimal generalization to other agents or settings without actively arranging for its occurrence in those other settings or with those other caregivers.
Some of the psychosocial treatments for ADHD may have carry-over effects, mostly in the form of parents or teachers providing external structure that reduces ADHD-related symptoms and especially related impairments in major life activities. Ideally, these environmental adjustments will alter the developmental trajectory of the child or adolescent with ADHD. However, such interventions are not expected to produce fundamental changes in the underlying deficits of ADHD, rather they only prevent an accumulation of failures and problems secondary to ADHD. Thus, researchers and clinicians should anticipate that long-term studies are more likely to find treatment effects on problems secondary to ADHD than on deficits specific to ADHD.

The results of the MTA study lend some support to the assertions above. For instance, the study has found stronger treatment effects on core symptoms of ADHD during the intensive phases of treatment. Also, the trend in the follow-up seems to be leaning toward advantages of combined pharmacological and psychosocial treatment on constructs other than core symptoms of ADHD. However, such findings were not evident in the 24-month New York-Montreal multimodal study. One possible explanation for the difference is that the psychosocial treatments in the MTA were much more intensive, whereas the efficacy of the psychosocial treatments used in the New York-Montreal study was not established by the authors. Thus, only strong, empirically supported treatments might be expected to have the kind of carry-over effects discussed above. Yet such treatment effects may not persist for long after the withdrawal of the formal interventions.

The theoretical model of ADHD discussed above suggests other reasons why treatment effects may be so limited. This is largely because, according to this model, ADHD does not result from a lack of skill, knowledge, or information. It is, therefore, not going to respond well to interventions emphasizing the transfer of knowledge or of skills, as might occur in psychotherapy, social skills training, cognitive therapies, or academic tutoring. Instead, in Barkley’s (2012, 2015) model, ADHD is viewed as being a disorder of performance – of doing what one knows rather than knowing what to do. Like patients with injuries to the frontal lobes, those with ADHD find that the disorder has partially cleaved or dissociated intellect from action, or knowledge from performance. Thus, the individual with ADHD may know how to act but may not act that way when placed in social settings where such action would be beneficial to them. The timing and timeliness of behavior is also being disrupted more in ADHD than is the basic knowledge or skill about that behavior.

From this vantage point, treatments for ADHD will be most helpful when they assist with the performance of a particular behavior at the point of performance in the natural environments where and when such behavior should be performed. A corollary of this is that the further away in space and time a treatment is from this point of performance, the less effective it is likely to be in assisting with the management of ADHD. Not only is assistance at the “point of performance” going to prove critical to treatment efficacy, but so is assistance with the time, timing, and timeliness of behavior in those with ADHD, not just in the training of the behavior itself. Nor will there necessarily be any lasting value or maintenance of treatment effects from such assistance if it is summarily removed within a short period of time once the individual is performing the desired behavior. The value of such treatments lies not only in providing assistance with eliciting behavior that is likely to already be in the individual’s repertoire at the point of performance where its display is critical, but in maintaining the performance of that behavior over time in that natural setting.

Disorders of performance like ADHD pose great consternation for the mental health and educational arenas of service. At the core of such problems is the vexing issue of just how to get people to behave in ways that they know are good for them; yet they seem to be unlikely, unable, or unwilling to perform in those ways. Conveying more knowledge does not prove as helpful as altering the motivational parameters and external cues or sources of control associated with the performance of that behavior at its appropriate point of performance. Coupled with this is the realization that such changes in behavior are maintained only so long as those environmental adjustments or accommodations are maintained as well. To expect otherwise would seem to approach the treatment of ADHD with outdated or misguided assumptions about its essential nature.

The conceptual model of executive functioning by this author as extended to ADHD brings with it many other implications for the management of ADHD (see Barkley, 2015). Some of these are briefly mentioned below:

  1. If the process of regulating behavior by internally represented forms of information (working memory and thinking) is delayed in those with ADHD, then they will be best assisted by “externalizing” those forms of information. Externalizing means providing physical representations of that information in the person’s sensory fields that will be needed in the setting at the point of performance to remind them to show what they know. Since covert or private information (thinking) is weak as a source of stimulus control, making that information overt and public may assist with strengthening control of behavior by that information.
  2. The organization of the individual’s behavior both within and across time is one of the ultimate disabilities rendered by the disorder. ADHD is to time what nearsightedness is to spatial vision; it has created a temporal myopia in which the individual’s behavior is governed even more than normal by events close to or within the temporal now and immediate context rather than by internal information that pertains to longer term, future events. Those with ADHD could be expected to be “blind to time,” and so assisted by making time itself more externally represented, by reducing or eliminating gaps in time among the components of a behavioral contingency (event, response, outcome), and by serving to bridge such temporal gaps related to future events with the assistance of caregivers and others.
  3. Given that the model hypothesizes a deficit in internally generated and represented forms of motivation that are needed to support goal-directed behavior, those with ADHD will require the provision of externalized sources of motivation. For instance, the provision of artificial rewards, such as tokens, may be needed throughout the performance of a task or other goal-directed behavior when there is otherwise little or no such immediate consequences associated with that performance. Such artificial reward programs become for the ADHD child similar to what prosthetic devices such as mechanical limbs are to the physically disabled, allowing them to perform more effectively in some tasks and settings with which they otherwise would have considerable difficulty. The motivational disability created by ADHD makes such motivational prostheses nearly essential for most children with ADHD.
  4. Given the above-listed considerations, parents and teachers should reject any approach to intervention for ADHD that does not involve helping them deal with a child or adolescent by implementing an active intervention at the point of performance. Many parents and teachers seek what might be called the “garage mechanic approach.” According to this model, a child can be dropped off someplace and be “fixed” by the “mechanic” (health care professional) without the parent or teacher “getting their hands dirty.” Such an approach is untenable, and a hands-on approach to intervention by caregivers is strongly recommended. This is true for all interventions, including pharmacotherapy.

Treatments for ADHD: Introduction

The provision of treatment services to children with ADHD has increased dramatically over the past 20 years, owing in large part to four national trends:

  1. the recognition by special education laws that ADHD is an eligible condition for identification and services in public schools (circa 1991),
  2. the growth of formally organized advocacy groups (such as Children and Adults with ADHD, see chadd.org) in the late 1980s and 1990s,
  3. the growth of advertising and educational efforts by pharmaceutical companies promoting new stimulant delivery systems over the past three decades, and more recently new types of medication and new delivery systems for existing medications for the management of ADHD, and
  4. increased continuing education programs for educational and mental health professionals on the disorder.

For instance, between 1986 and 1996, stimulant prescriptions for ADHD increased to accounting for three-fourths of all physician visits for children with ADHD, with a ten-fold increase in related services such as health counseling, and a three-fold increase in diagnostic services. This trend has continued into the mid-2010s. Nevertheless, this report also documented a decline in the use of follow-up care, apparently due to insurance obstacles, lengthy waiting lists, and limited access to pediatric specialists. Treatment appears to be increasingly provided by primary care professionals who are likely to utilize only medication management, with only 30%-40% of ADHD children being referred to and treated by mental health professionals with programs such as behavioral parent training. Those who are referred to specialists are more likely to have comorbid disorders, greater impairment, and greater family burdens. Such trends have also undoubtedly continued to the present time.

We now present the major treatment approaches employed with ADHD that have some scientifically established effectiveness. These include:

  1. psychopharmacology;
  2. parent training in child behavior (contingency) management methods;
  3. teacher implementation of these and other child behavior management tactics; and
  4. combinations of these approaches into a multi-modal therapy program.

Given the weaknesses inherent in any single treatment modality, the multi-modal approach is preferred here for treating most cases of ADHD because of the inability of medication to adequately address all cases of ADHD, especially those with coexisting disorders, such as learning disabilities, anxiety, depression, or conduct disorder, and all domains of ADHD-related impairment.

Psychopharmacology

The three most commonly used drugs for the management of ADHD symptoms are the stimulants, the nonstimulant atomoxetine, and the antihypertensives (extended release formulations of guanfacine and clonidine, (see Conner’s chapter in my ADHD Handbook, 2015). All of the FDA-approved medications for child ADHD are shown in Table 3 in the Appendix.

Of these, the stimulants are by far the most utilized and most effective in terms of degree of improvement rendered in ADHD symptoms. Use of the stimulants, however, was founded on a virtual chance discovery of their effectiveness and not on any theoretical rationale. A rationale may be emerging though, in view of recent theoretical models that emphasize poor executive functioning more generally as probably being central to the nature of the disorder. Brain regions under-serving inhibition and EF appear to be involved in the etiology of ADHD, these regions are largely dopaminergic, although not entirely, and stimulants (which increase extracellular dopamine and norepinephrine) seem to produce their greatest effects within these same brain regions. Atomoxetine increases extracellular norepinephrine, but produces an indirect increase in dopamine in the prefrontal cortex that may also explain its therapeutic benefit. In contrast, guanfacine and clonidine XR work primarily by fine-tuning the alpha-2 receptors on nerve cells in the frontal cortex, or executive brain, thereby enhancing signal strength and conductivity.

Until recently, it was not clear precisely how these medications affected brain function and particularly their sites and neurochemical modes of action. It now appears as if the major therapeutic effects of the drugs are achieved through alterations in frontal-striatal activity via their impact on at least three or more neurotransmitters important to the functioning of this region and related to response inhibition, these being dopamine, norepinephrine, and epinephrine. The direct rationale, then, for employing some medications with children with ADHD may be that they directly, if only temporarily, improve the deficiencies in these neural systems related to behavioral inhibition, EF, and self-regulation.

Stimulant Medication

Since Bradley (1937) first discovered (accidentally) their successful use with behavior-problem children, the stimulants have received an enormous amount of research with meta-analyses indicating a clear benefit in managing the disorder in the short-term, and some continuing benefit to symptomatic management, risk reduction (accidental injuries, adverse driving outcomes, substance use disorders), comorbidity (especially for oppositional defiant disorder), and academic achievement when used over a longer term. As long as clients comply with treatment, benefits can be found over as long as five years (and likely more, though this has been the limited period studied in research). The results of research on stimulants overwhelmingly indicate that these medications are quite effective for the management of ADHD symptoms in most children older than five years old. Between four and five years of age, the drugs are equally as effective as in older children, with some 82% of cases responding positively. Research in the past decade has shown these medications to be safe and effective down to age three, although with somewhat fewer children responding (55% vs. 75%-80%) and with a slightly lower degree of improvement, and somewhat more cases having side effects than is usually evident in school-age children. Guidelines for the use of stimulant medications with ADHD children have been issued by both the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry.

The most commonly prescribed stimulants are shown in Table 3 in the Appendix. There are six different delivery systems used to convey these drugs into the body. These are shown in Table 4 in the Appendix. The stimulants include methlyphenidate (e.g., Ritalin), d-amphetamine (e.g., Dexedrine), and a combination of amphetamine salts marketed under the name Adderall. Pemoline had been available for treatment of ADHD in earlier decades, but its manufacture was discontinued more than two decades ago as a result of liver complications or failure in a small percentage of cases. It receives no further attention here. Because methylphenidate and the amphetamines share similar characteristics, these drugs are discussed collectively in this section. Bear in mind, however, that amphetamine is a more potent medication and thus produces more improvement in ADHD symptoms (and likely more side effects) than does methylphenidate in equivalent doses.

Methylphenidate and amphetamines are rapidly acting stimulants. In their immediate release (IR) formulations, the stimulants produce effects on behavior within 30 to 45 minutes after oral ingestion and peaking in their behavioral effects within two to four hours. The utility of these IR formulations in managing behavior quickly dissipates within three to seven hours, although minuscule amounts of the medication may remain in the blood for up to 24 hours. Because of their short half-life, they are often prescribed in twice- or thrice-daily doses.

An important development in treatment of ADHD is effective extended release forms of both medications. These do not represent new drugs but new delivery systems for sustaining blood levels of the drug over longer periods so as to reduce dosing to once per day, where possible. Intermediate duration versions of methylphenidate that have therapeutic effects for six to eight hours include Ritalin-SR, based on a wax matrix coating, Metadate-ER, which uses a time-release pellet technology, as do Methylin-ER, Ritalin-LA, Focalin-LA, and Metadate-CD. Adderall is considered by some to be an intermediate-duration stimulant. Once-daily stimulants include Dexedrine Spansules (d-amphetamine), Concerta (OROS methyphenidate, using an osmotic pump), and Adderall XR (a mixture of d- and l-amphetamines, using a time-release pellet technology) that may last up to 10-12 hours. More recently, lisdexamfetamine (Vyvanse) is a variation of Adderall in which the amphetamine is bound up with lysine such that the drug is only activated in the human gut and intestinal lining where an enzyme operates to cleave the lysine from the amphetamine, thereby activating the latter. The drug is as effective as Adderall XR for children. This mechanism may extend the effects of this version of amphetamine for an additional hour or two beyond that of Adderall XR. There is also an FDA-approved liquid form of extended-release methylphenidate (Quillivant XR) and now an orally dissolvable gelatin form that should be useful for children who may have difficulty swallowing tablets or capsules. In late 2018, the FDA approved a delayed-release version of both stimulant medications (Jornay PM) that can be taken at bedtime but does not activate until nine hours later. It then provides all-day symptom management for as long as the other extended release forms of the stimulants do. The advantage to such a delivery system is that it provides treatment upon the child’s awakening, whereas the other delivery systems, when taken in the morning, require time to activate. That leaves an interval in the morning when the child is essentially untreated, thus contributing to increased family conflicts, especially on school mornings.

There is some variability in the effectiveness of these longer-acting preparations. For example, the initial version of sustained-release methylphenidate (Ritalin-SR) using a wax matrix coating had erratic effects on some children and often reduced therapeutic efficacy relative to IR forms of the medication resulting from a truncation of the peak blood level below that required for an acceptable treatment response. This limitation has been overcome in other ER preparations, such as Concerta, Metadate CD, Adderall XR, and Vyvanse. Another unique feature of some of these new delivery packages such as Concerta is that they provide a steady increase in the amount of medicine delivered during the day, thus overcoming problems with diminished effect later in the day. Possibly due to the emphasis on sustained effects, some of the once-daily preparations may have limited effectiveness in the first hour or so following administration. The newly approved Jornay PM serves to overcome this problem.

Although once used predominantly for school days, there has been an increasing clinical trend toward usage throughout the week as well as on school vacations, particularly for the more moderately to severely ADHD and conduct-problem children. This treatment option appears to have a favorable benefit-to-cost ratio. Benefits have been supported by some well-designed, randomized studies. Putative costs of treatment over weekends and school holidays, mostly the concern about possible growth suppression, may not be as serious as was once believed. And treatment seven days a week helps to produce reductions in risk, and improvements in impairments, in various major life activities occurring outside of school.

The behavioral improvements produced by stimulants are in sustained attention, impulse control, and reduction of task-irrelevant activity, especially in settings demanding restraint of behavior. Generally noisy and disruptive behavior also diminishes with medication. Children with ADHD may become more compliant with parental and teacher commands, are better able to sustain such compliance, and often increase their cooperative behavior toward others with whom they may have to accomplish a task as a consequence of stimulant treatment. Research also suggests that children with ADHD are able to perceive the medication as beneficial to the reduction of ADHD symptoms and even describe improvements in their self-esteem, though they may report somewhat more side effects than do their parents and teachers.

Improvements in other domains of behavior in children with ADHD have also been demonstrated. Both overt and covert aggressive behaviors are often reduced by stimulant treatment of children with ADHD who demonstrate abnormally high levels of pre-treatment aggressiveness, although the effect on overt aggression may be somewhat less if conduct disorder is present. The quality of the children's handwriting may also improve with medication. Academic productivity – or the number of problems completed – and accuracy of work completion also increase, in some cases dramatically, as a function of medication. In general, classroom behavior is significantly improved, as is work productivity, although there is less of an impact on academic accuracy, which is usually not as problematic for children with ADHD as is productivity. For many years, stimulants were thought not to impact academic achievement significantly, but longer-term effects on academic achievement if treatment lasts at least two years have now been documented.

It should be strongly emphasized that the effects of stimulant medication are idiosyncratic. Although reported response rates vary across studies, many reviewers have concluded that 70%-82% of children show a clinically beneficial response to any single stimulant. However, with a trial of a second stimulant, the positive response rate may approach 90%. Unfortunately, there is no way to predict in advance which children will respond to which stimulant. Similarly, among the students who do respond positively to stimulants, there is no basis for predicting which dose will be best. Most children and adolescents show maximal improvement at low to moderate doses of stimulants, but others are most improved at higher doses. In addition to this between-subject variability in doses, there is considerable variability in the domains that respond to medication. For instance, some children may improve in one domain (e.g., behavior) when treated with stimulants, but show no change, or even deteriorate, in other domains (e.g., academic performance). For this reason, I strongly recommend that treatment with stimulant medication be assessed on a case-by-case basis using measures that sample a broad range of domains of functioning.

The most frequently occurring side effects of the stimulants are mild insomnia and appetite reduction, particularly at the noon meal, and subjective reports of stomach ache, headache, and dizziness or jitteriness. These subjective side effects tend to dissipate within a few weeks of beginning medication or can be managed by reducing the dose. Temporary growth suppression (less likely to gain weight or height than unmedicated children) may accompany stimulant treatment, but is not generally severe and is transient with no evidence of growth differences by late adolescence or early adulthood in stimulant treated vs. untreated cases of ADHD. The risk of growth suppression can be managed by ensuring that adequate caloric and nutritional intake is maintained by shifting the distribution of food intake to other times of the day when the child is more amenable to eating.

Some children become irritable and prone to crying late in the afternoon as their medication may be wearing off. This may be accompanied by an increase in hyperactivity. This apparent “rebound” phenomenon appears to be rare and might be controlled by adjusting doses and dose schedules.

In approximately 1% to 2% of children with ADHD treated with stimulants, motor or vocal tics may occur. This is well within the base rate prevalence for tics in the normal population. In others where tics already exist, they can be mildly exacerbated by stimulant treatment in some cases, but may be improved in others. Reviews suggest that the risk for increasing tics in such comorbid children is mostly associated with high doses of amphetamine and not with methylphenidate. It now appears to be relatively safe to use stimulant medications with children with ADHD and comorbid tic disorders, but be prepared to reduce the dose or discontinue medication should the child experience a drug-related exacerbation of their tic symptoms that usually dissipate once medication is stopped.

To avoid potential dose-dependent side effects, I recommend a start-low-and-go-slow approach to titrating doses. That is, one begins with a low dose, slowly titrates the dose upward, and goes higher until finding the most appropriate dose for that child. I believe that dose should be the lowest possible level that produces satisfactory clinical improvement. This is contrary to some clinical practices that titrate doses to the highest tolerable level. Finding the lowest effective dose may be more difficult, but has the potential to save money in medication costs, to reduce risk of side effects, and perhaps improve compliance due to increased comfort with medication.

As mentioned previously, it has been difficult to establish any reliable predictors of response to stimulant medication in children with ADHD. Those characteristics having the most consistent relationship to predicting a positive response have been pre-treatment levels of poor sustained attention and hyperactivity. The more deviant is a child's level on such factors, the better their response to medication. Predictors of poor or adverse responding have not been as well studied. Some research suggests that higher pre-treatment levels of anxiety are associated with poorer responding to stimulants. The results of more recent research remains mixed on this issue, with some studies finding no relationship of anxiety to stimulant response, while others do. More recently, higher symptoms of comorbid Sluggish Cognitive Tempo (see my ADHD Handbook, 2015) predict a poorer or more limited response to stimulants.

There is little doubt now that the stimulant medications are the most studied and most effective treatment for the symptomatic management of ADHD and its secondary consequences. As a result, for many children with moderate to severe levels of ADHD, this may be the first treatment employed in their clinical management. And for some, where little or no significant comorbid disorders exist, it may be the only treatment required. One multi-site study, in fact, found that among stimulant-responsive children with ADHD, adding various forms of psychosocial treatments, such as parent training, social skills training, psychotherapy, or academic tutoring, added no additional benefits beyond that achieved by medication alone. On the other hand, the results of the MTA study suggest that a more intensive multi-modal treatment may produce a broader range of positive results than are achieved by medication alone, at least for a slightly greater percentage of cases.

Despite some conflicting studies and opinions, there seems to be a general consensus that stimulant treatment is not always effective (i.e., the 20% to 30% non-response rate), nor necessary (i.e., in some cases, psychosocial treatment is sufficient), nor is it always sufficient (i.e., many children meet criteria for improved, but not recovered, when on stimulants). The issue of lack of sufficiency is particularly salient with regard to the appropriate management of the comorbid conditions often seen in ADHD, such as LD, depression, anxiety, or conduct disorder. Given that medication typically does not address all of these presenting problems shown by many children with ADHD, other treatments may be required as adjuncts.

The following issues should be considered in the decision to employ medication for the management of ADHD:

  1. the age of the child;
  2. duration and severity of symptoms;
  3. the risk of injury to the child if untreated (either by accident or abuse) by the present severity of symptoms;
  4. the success of prior treatments;
  5. relatively normal levels of anxiety (perhaps);
  6. the absence of stimulant abuse by the child or adolescent or their caregivers;
  7. the likelihood that the parents will employ the medication responsibly, in compliance with physician recommendations; and
  8. the child does not live in a group setting such as a dormitory where supervision of the medication is poor and diversion of the medication to non-ADHD students may be more likely.

Some of these latter concerns related to stimulant abuse (i.e., points 6 to 8) may be somewhat ameliorated by the longer-acting preparations of stimulants, such as Concerta or Vyvanse, that have lower abuse potential than immediate release preparations.

Several suggested paradigms for evaluating stimulant drug response in individual cases have been reported. I recognize that these are not always practical or available in clinical practice but recommend them as exemplars toward which practitioners should strive. The trial includes the traditional and mandatory initial medical check-up of the child to insure that there are no pre-existing conditions that might contra-indicate or complicate the medication trial, such as cardiac problems, unusually high levels of anxiety, and prior history of stimulant abuse, among others. This is followed by the child’s receiving a baseline evaluation on the measures (often rating scales) to be collected across the weeks of the trial (highly recommended). Such baseline evaluations must include ratings of potential side effects of the medication, given that many of these are frequently pre-existing problems with ADHD children that, if not assessed at baseline, could be misconstrued as drug side effects. The child’s participation is then scheduled for a four-week drug-placebo trial during which the child is tested on three different doses of medication (typically methylphenidate at 5, 10, and 15 mg given morning and noon) and a placebo (lactose powder placed in gelatin capsule) (optional). Arrangements are made to have the noon dose of medication given at school on schooldays, if this is an IR formulation of the medication. The parents, teachers, child, and clinical assistant conducting the assessments of the child are all kept blind to the order of medication doses and placebo until the end of the trial.

The major outcome variables are typically ratings completed by parents, teachers, and for children over eight years old, the child receiving the medication. The frequency of ratings should match the frequency of switches between dose levels in the medication trial.

One rating scale assesses the symptoms of ADHD while another is used to obtain information about side effects the child may have experienced that week. These can be given to both parents and teachers. A third rating scale (for parents) assessing functional impairment in 15 domains of life (the Barkley Functional Impairment Scale) should also be included in the trial. Furthermore, the clinical team should solicit non-standardized information relevant to impairment and other clinically or academically meaningful phenomenon. For example, teacher comments can be collected by telephone or the Internet, as are parent comments during weekly clinic visits during the medication assessment.

The ratings may be supplemented by objective data (if available and practical) such as grades and direct observations of behavior in school or in a clinic room. For example, during each weekly clinic visit, the child can be given a set of math problems of appropriate grade level to perform while seated alone in a clinic playroom. Observations can be taken of the child from behind a one-way mirror or with a video camera and the observations can be coded using the Direct Observation Form of the CBCL described above or on the Restricted Academic Situation coding sheet (see my ADHD Clinical Workbooks) for behaviors related to ADHD (i.e., off-task, fidgets, plays with objects, out of seat, etc.). In addition, the amount of work attempted and the accuracy of that work can be scored. Computerized measures such as continuous-performance tasks may also be used to assess response to medication, but the ecological validity of these measures is questionable, and therefore the value of such measures may be limited. We recognize that for the busy private or clinic-based practitioner, these supplemental measures may not be available or cost effective. But the use of rating scales to evaluate ADHD and related symptoms, side effects, and even impairments is strongly recommended.

Different dosing schedules can be evaluated. For example, in one protocol, each drug condition lasts for seven to 10 days before the child progresses to the next drug condition. The order of the drug conditions is random except that the middle and high doses, say 10 and 15 mg of IR methylphenidate, are paired such that the 10 mg condition always precedes the 15 mg condition. This is done to reduce the possibility of unnecessary side effects being provoked by beginning the trial at an initially excessive dose. An alternative approach is to switch doses daily in a counterbalanced, random order. Compared to the former, the daily crossover design helps to better control for unusual events or spurious improvement over time. However, it incurs a much higher response burden compared to weekly ratings and may reduce compliance to the protocol. Furthermore, the daily crossover design may also miss cumulative effects.

At the end of the four-week trial, the results are tabulated and a recommendation is made concerning possible continuation of the medication and which dose seems most effective. Children not found to be responsive to this stimulant may be tried on another, and if a second stimulant does not work, other medications such as atomoxetine might be considered. Furthermore, consistent with the “start-low-go-slow” approach, children should be routinely tested on a lower dose than selected in the titration trial to see if the lower dose is sufficient. If there is still a need for improvement relative to the higher dose, then the higher dose is well-justified.

Effectiveness, Safety, and Practicality of Stimulant Medication

The rise in the use of stimulant medication is supported by numerous studies documenting the efficacy of these medications. A meta-analytic review of 62 high-quality studies found a medium-sized effect of stimulants on parent-rated behavior (mean .54) and a large effect on teacher-rated behavior (.78). Later reviews have found much the same results. Most of these studies were conducted by experts in university or medical school research programs and therefore they speak more to treatment efficacy than effectiveness as applied in typical community settings. Yet the substantial supportive research across labs, investigators, regions, and even countries, combined with the longstanding successful and ever-increasing use of this treatment in clinical practice, speaks, albeit indirectly, to both effectiveness and practicality. According to the Biglan et al. (2003) criteria, stimulant treatment is a Grade A intervention, meaning that stimulants have a level of support most appropriate for widespread dissemination.

Stimulants used to treat ADHD are very safe. At therapeutic doses, stimulants produce few negative side effects and almost all of these negative effects are symptoms youth either develop tolerance for or are reduced to a tolerable level by lowering the dose or changing to a different stimulant or non-stimulant, such as atomoxetine. Long-term negative consequences are not evident in the research literature, but the potential for mild and transient growth suppression is an issue of ongoing investigation and debate. Concerns about predisposing stimulant-treated children to later substance-use disorders have been refuted by more than 15 studies, despite a single study implying otherwise. When absorbed rapidly (e.g., inhaled nasally or injected intravenously) or taken at high doses, stimulants may result in euphoric effects and health risks similar to cocaine. Such use is uncommon and less likely with longer-acting preparations. Mortality or serious morbidity from prescribed stimulants is rare. Indeed, compared to many other commonly prescribed psychiatric medications, stimulants are among the safest drugs given to children. Nevertheless, safety may be diminished when taking stimulants in combination with other medications (e.g., clonidine) or when potent stimulants, such as Adderall XR or Vyvanse, or high doses are used with children having pre-existing cardiac abnormalities or family histories of sudden cardiac arrest.

Research specific to practical issues with stimulant medication is limited and the preliminary findings raise some questions about the effectiveness of this treatment in primary-care settings. Although taking pills seems to be a simple intervention, there are some significant barriers to daily administration of stimulant medication, including limited access to prescribing physicians, cost, inconvenience, uncertainty about dose or type of medication, side effects, and parent or child resistance to taking medication. Research on compliance is limited, but suggests that children and adolescents with ADHD tend to take less medication than prescribed due to missed doses and termination of treatment against medical advice. The high cost of some new formulations of stimulants ($60-$100 per month) may contribute to an already tenuous compliance situation, though their once-daily extended release delivery systems may counteract such a problem. The problems with compliance have high clinical liability because stimulants exert their effects only when taken as prescribed. Even the longest acting stimulants have no measurable effect 24 hours after administration, so missed doses mean the child is essentially untreated. Thus, while stimulants get high marks for safety and effectiveness, there are some practical barriers to effective use of stimulant medication.

Special Considerations with Adolescents

Although there has been much less research on stimulant treatment for adolescents than children, there is enough research to document that stimulants have similar efficacy from childhood to adolescence. However, due to increased involvement with recreational drugs that could be associated with stimulant abuse or could lead to interactions between therapeutic stimulants and recreational drugs, caution should be taken when prescribing stimulants to adolescents. Also, clinicians need to be aware of the potential for diversion of prescribed stimulant medication by an ADHD teen to other teens for recreational misuse when the ADHD teen resides in a dormitory or other group living situation with other teens, or simply has friends!

A major threat to the effectiveness of stimulant medication is the tendency for adolescents to discontinue their medication as they get older. Thus, compared to children, more vigorous monitoring and promotion of compliance is necessary when working with adolescents. To avoid premature termination of effective stimulant treatment, parents and physicians should encourage adolescents to participate in treatment decisions and self-monitoring during periodic trials of stimulants. For adolescents who do not recognize the value of taking stimulants (assuming an individualized medication trial unambiguously supports the efficacy of the stimulant), it may be necessary to negotiate behavioral contingency contracts related to the appropriate use of stimulants. Thus, in some cases, multimodal treatment with an emphasis on compliance issues may be necessary for effective stimulant treatment of ADHD in adolescents. Unfortunately, the efficacy of multimodal treatments for adolescents with ADHD has yet to be tested in a major controlled trial.

Atomoxetine (Strattera®)

Atomoxetine was approved by the U. S. Food and Drug Administration in January of 2003 for use in children with ADHD six years of age and older, and in adolescents and adults having ADHD. This makes it the first such drug so approved for use in the adult stage of the disorder, and the first new drug for ADHD in more than 25 years (pemoline having been the last such medication). The drug is a highly selective inhibitor of norepinephrine reuptake with minimal to no action at other neurotransmitter sites. Its effectiveness has been established in more than ten large-scale published studies done before or shortly following FDA approval and involving various randomized, controlled clinical trials. These samples included 3,264 children and adolescents and 471 adults with all types of ADHD. The clinical trials clearly established both the efficacy and safety of atomoxetine for use in the management of ADHD. Many studies have been conducted since 2003 demonstrating the safety and effectiveness of this drug for ADHD management.

Atomoxetine is not a stimulant in that it is not a dopamine agonist. It has no abuse potential as studies show that it is not preferred over placebo by stimulant abusers and does not result in symptoms of craving, dependence, or addiction. It is therefore not scheduled, whereas the stimulants are classified as Schedule II agents. Consequently, atomoxetine is a more convenient medication as it can be prescribed without special prescription pads needed in the U.S. for Schedule II agents, can be prescribed with refills, and can be distributed to patients by physicians as samples. The fact that it is unscheduled and has no abuse potential can make it an attractive alternative to families of ADHD children concerned about the use of Schedule II medications for their child.

Atomoxetine may assist in the management of ADHD via its inhibition of the norepinephrine transporter, thereby making more norepinephrine available in the extracellular space. This results in a secondary increase of dopamine in the prefrontal cortex. The fact that it does not increase dopamine levels in the nucleus accumbens (the primary dopamine-mediated reward pathway) may explain why it does not have reinforcing or otherwise addictive properties. Because it does not appear to increase dopamine levels in the striatum that helps control motor movements, it seems to have no exacerbating effect on motor and vocal tics.

Research shows that atomoxetine reduces both inattentive and hyperactive-impulsive symptoms of ADHD in more than 70% of cases. The overall effect size (degree of change in group mean scores) of atomoxetine appears to be the same as a methylphenidate preparation, such as Concerta, among children previously untreated with stimulants, but may have a smaller effect size than that seen with the stimulants in the treatment of individuals with ADHD who have had prior stimulant exposure. In controlled studies, atomoxetine has an effect size of about 0.9 to 1.0 among stimulant naïve cases, but an effect size of 0.6 to 0.8 (standard deviations) in cases with prior stimulant treatment. The effect size for the stimulants ranges from 0.8 to 1.2. Peak plasma concentrations for atomoxetine occur in one to two hours after oral ingestion and persist for six to ten hours (half-life of four hours). The medication may therefore be given in either once- or twice-daily dosing. When given in twice-daily divided doses, atomoxetine shows much longer daily coverage for ADHD symptoms than do stimulant medications. In contrast to the tricyclic antidepressants that can also affect norepinephrine re-uptake, atomoxetine demonstrates no cardiovascular toxicity or abnormalities on electrocardiogram. Atomoxetine appears to improve ODD symptoms as well in ADHD children having significant levels of these symptoms. It also results in significant improvements in parent-child relations, peer relations, school behavior and academic performance, and co-existing internalizing symptoms such as depression or anxiety.

Atomoxetine can be considered a first-line agent in the treatment of ADHD in children, adolescents, and adults. Whether it is the first or second choice of a starting medication will depend upon several patient and social ecological characteristics that may exist at the time of a clinical trial. For instance, in ADHD patients with comorbid anxiety, obsessive-compulsive behavior, or tic disorders or Tourette’s syndrome, atomoxetine may be a first-choice agent given that the stimulants may exacerbate such pre-existing conditions. In cases where someone with a history of drug abuse resides with the child or where the child or adolescent has a substance-use disorder or history of such, atomoxetine may be the preferred agent because of its absence of abuse potential. Where the child or teen with ADHD may reside in a dormitory for their school year (boarding school or college), atomoxetine might be considered ahead of stimulants because of its lack of potential for diversion to dorm-mates for their own recreational use. Obviously, in cases where prior stimulant response has been poor, atomoxetine would be the next medication in line to consider, well ahead of the tricyclic antidepressants or antihypertensive agents such as clonidine that have a greater potential for more serious side effects. And because atomoxetine does not adversely impact sleep onset, it should be considered as an alternative to stimulants where stimulant-induced insomnia is significantly problematic or in cases where sleep problems are pre-existing. Also, in cases where parents are concerned about the use of a Schedule II agent in the management of their child’s behavior – often as a consequence of adverse publicity in the popular media against Ritalin and other stimulants – atomoxetine may prove useful given its unscheduled status and hence greater acceptability among such consumers. However, where there exists an urgent need to gain control over disruptive, hyperactive-impulsive, or otherwise externalizing behavior due to imminent adverse consequences (school suspension, potential abuse of the child by caregivers, etc.), or where none of the pre-existing condition mentioned above are problematic, then stimulants would be the first choice agent due to the shorter titration period and apparently greater rapidity of an onset of a therapeutic response.

Atomoxetine is prescribed by weight in young children (mg/kg). In children and adolescents up to 70 kg body weight, atomoxetine is initiated at a total daily dose of 0.5 mg/kg. Dose titration occurs at a minimum of every three days to a target total daily dose of approximately 1.2 mg/kg administered either as a single daily dose in the morning or as evenly divided doses in the morning and late afternoon or early evening. In children, adolescents, and adults who weigh more than 70 kg, atomoxetine is initiated at a total daily dose of 40 mg and increased after a minimum of three days to a target total daily dose of approximately 80 mg, given in the morning as two evenly divided daily doses. If no treatment benefit occurs after two to four weeks, the dose of atomoxetine may be increased to a maximum of 100 mg/day. The total daily dose of atomoxetine in children and adolescents should not exceed 1.4 mg/kg/day or 100 mg, whichever is less. During atomoxetine initiation and dose titration, contact with the prescribing physician should occur regularly. Pulse and blood pressure should be assessed on full dose. Height and weight should be followed twice yearly.

The side effects of atomoxetine are well-documented and generally benign, like the stimulants. They include chiefly sedation, gastrointestinal disturbance (nausea), decreased appetite, and upper abdominal pain. Some weight loss may be present over the first two to four months of atomoxetine treatment but tends not to persist beyond the first year. Slight increases in blood pressure and heart rate may occur, as they do with the stimulants, but are typically benign unless hypertension was a pre-existing problem, in which case neither stimulants nor atomoxetine should be considered.

To summarize, atomoxetine should be considered at least a Grade A treatment in terms of efficacy and safety.

Antihypertensive Medications

Two drugs originally marketed as alpha-andrenergic agonists for treating hypertension – clonidine and guanfacine – now come in an extended release formula (Capvay and Intuniv, respectively), and have become increasingly popular for the treatment of ADHD. These drugs have primarily been used as an alternative or adjunctive medication to stimulants such as methylphenidate. Studies have found that clonidine is superior to placebo in reducing ADHD symptoms and conduct problems. Empirical support for guanfacine exists as well, but was similarly weak, earning these drugs a grade of C (i.e., efficacy based primarily on studies with serious methodological limitations and on a few randomized, controlled studies).

The most commonly reported side effect of these medications is drowsiness, which occurs in about 50% of cases. This side effect is sometimes used to therapeutic advantage with children with ADHD who have difficulty falling asleep or exhibit symptom rebound after a day of taking stimulant medication. Safety concerns about the combination of stimulants and clonidine appear to be diminishing over time following some reports of deaths in the mid-1990s that were associated with, but not proven to be caused by, combining clonidine and methylphenidate. Nevertheless, there are lingering concerns about the potential electrocardiographic effects of clonidine and the potential to worsen pre-existing cardiac arrhythmias.

The need for electrocardiograms at baseline, at every dose change, and every six months when taking an anti-hypertensive agent, is a serious threat to the practicality of this medication. Also, due to possible decreased glucose tolerance, monitoring of blood glucose levels at least every six months is warranted. Furthermore, there are many unpleasant side effects reported with this drug that may hamper compliance, including headache, dry mouth, itchy eyes, weight gain, dizziness, and postural hypotension. In some cases, treatment with anti-hypertensive drugs may create new problems that mimic psychiatric disorders. For instance, there have been some reports of irritability, dysphoria, and attention impairment while on clonidine. Although side effects may be reduced and compliance may be improved with the availability of a patch, this delivery system runs the risk of causing a rash at the site of the patch. Finally, rapid withdrawal from an anti-hypertensive may cause serious problems with symptom rebound and tachycardia. Adverse effects of guanfacine appear to be similar to those of clonidine, with possibly less sedation and more agitation and headaches.

To summarize, compared to all other medications evaluated in this course, the risk-to-benefit ratio of clonidine appears to be fair, while that of guanfacine specifically is better given its lower likelihood of affecting cardiovascular functioning.

Behavioral Interventions – A Rationale

These methods were initially employed with ADHD children largely on an atheoretical basis – their success with children with intellectual deficiencies and other developmentally disabled populations (e.g., autism) encouraged their use with behaviorally disordered children. The more recent theory of ADHD as a problem in response inhibition, EF, and self-regulation however, and the secondary consequences this may create for poor self-motivation to persist at assigned tasks, provides a persuasive theoretically based rationale for employing behavioral interventions with ADHD. ADHD appears to be a developmental delay in the self-regulation of behavior by internal means of representing information (working memory) and motivating goal-directed behavior. If so, then interventions that provide for more externally represented information that can serve to prompt and guide behavior and that enhance motivation via an increased density of external consequences, greater immediacy in their timing, and greater salience for the child, would be useful, at least for symptomatic reduction in some settings and tasks. Such procedures for the artificial manipulation of antecedent and consequent events are precisely those provided by the behavior therapies.

A logical extension of this argument holds, however, that such socially arranged means of addressing this neurologically-based disorder of self-regulation would not likely alter the underlying neurophysiological basis for it. These techniques must be employed across situations over extended time intervals (months to years) much as prosthetic devices (e.g., hearing aids, mechanical limbs, etc.) are employed to compensate for physically handicapping conditions. Premature removal of the socially arranged stimulus prompts and motivational programs would predictably result in an eventual return to pre-treatment levels of the behavioral symptoms, just as removal of a ramp that permits physically disabled persons in wheelchairs to enter public buildings would cease allowing them such successful entry. Also, use of the behavioral techniques in only one environment would be unlikely to affect rates of ADHD symptoms in other, untreated settings unless generalization had been intentionally programmed to occur across such settings. The research reviewed below for the various behavioral techniques seems to support this interpretation.

Important to note from my theoretical stance is that behavioral interventions are not being done chiefly to increase skills or information, as if children with ADHD were ignorant of them. Instead, they are being done to prompt internally (mentally) mediated information that can guide performance as well as enhance the motivation of these children to show what they already know. From this perspective, ADHD is a disorder of performance, not of knowledge or skills, and thus behavioral interventions are used to cue the use of those skills at key points of performance in natural settings and to motivate their display through the use of artificial consequences that ordinarily do not exist at those points of performance in natural settings.

Direct Application of Behavior Therapy Methods in the Laboratory

A number of early studies evaluated the effects of reinforcement and punishment, usually response cost, on the behavior and cognitive performance of ADHD children. These studies usually indicated that the performance of ADHD children on lab tasks measuring vigilance or impulse control can be immediately and significantly improved by the use of contingent consequences. In some cases, the behavior of ADHD children approximated that of normal control children. However, none of these studies examined the degree to which such changes generalized to the natural environments of the children, calling into question the clinical effectiveness of such an approach. It is highly unlikely that behavioral techniques implemented only in the clinic or laboratory would carry over into the home or school settings of these children without formal programming for such generalization. As a result, there has been no further research interest shown in the direct training of children with ADHD using behavioral means in clinical or laboratory settings.

This early work remains of historical significance however. It presaged and instigated later efforts to train parents and teachers in the application of behavioral methods in home and school settings, thereby partly addressing the problem of generalization of treatment effects that limited these early laboratory demonstrations.

Direct Training of Attention in the Clinic

A few neuropsychologists have explored the direct training of attention for children with ADHD in clinical settings founded largely on the success of cognitive rehabilitation and training programs for head-injured or other neurologically impaired populations. One specific cognitive rehabilitation protocol for attention training is the Attention Process Training (APT) system developed for brain-injured adults by Sohlberg and Mateer (1989). The APT involves a series of cards containing drawings of family situations involving different ages, sexes, dress, and social circumstances and using different colors such that the cards can be sorted according to a variety of stimulus characteristics as specified by the trainer. The APT also includes auditory tasks of a similar nature that require trainees to attend to specified stimuli on a sound track. The tasks become faster over the training sessions and include distracting stimuli. Children were reinforced for meeting specific success criterion during each session, but no strategies were taught to the children as to how to attend to and succeed at these tasks. Studies to date have involved very small samples of children with ADHD (ages 6-14) with training occurring two to four times per week in ½- to 2-hour sessions over periods of 5 to 18 weeks. These studies typically find significant improvement on both the attention-training tasks (as one might expect) and on untrained comparable tasks used to assess attention that were given by the same examiners in the clinical lab setting. But none have been able to document significant improvements on measures of academic efficiency given in the same clinic or in parent or teacher rating scales of ADHD symptoms or related behavior at home or school. Hence, it appears that training effects are limited to the training environment and tasks (known as “near transfer”) with no evidence to date of generalization to untreated settings or more ecologically important activities such as academic performance (known as “far transfer”).

Training Parents in Child Behavior Management Methods

A plethora of research exists on parent training in child behavior modification, primarily conducted with children having conduct or disruptive behavior problems. More recent studies have shown the behavioral parent training (BPT) programs to be effective for such children whether or not they have co-occurring attentional/hyperactive difficulties. A growing number of studies have examined the efficacy of this approach with children specifically diagnosed as ADHD or having high levels of hyperactive or ADHD symptoms. What research exists supports the clinical efficacy of BPT with ADHD children, but with some apparent caveats.

One such caveat is that most studies were of a short duration and did not examine for either generalization of treatment effects to no-treatment settings or for maintenance of treatment effects once training was discontinued. One of the few studies to conduct a follow-up re-evaluation one year after treatment, however, found that the families receiving BPT were no longer different from the control group, although the child’s school behavior was rated by teachers as significantly better than the control group. Another caveat is that the studies to date have been largely university- or medical school-based programs implemented by expert trainers, thus attesting to the efficacy of BPT, but with little research on its effectiveness in more natural clinical service delivery settings.

A third caveat is that these training programs produce larger effects on disruptive, defiant, or oppositional behavior and smaller, sometimes non-significant effects on ADHD symptoms. Thus, BPT could hardly be considered a stand-alone treatment for children with ADHD.

A further caveat is that the high genetic contribution to the disorder insures that a number of parents undergoing training may have ADHD themselves. Some research has found that maternal ADHD can significantly limit the improvement shown by children having ADHD during a BPT. Hence the treatment of parental ADHD may be a prerequisite to successful training outcomes for children with ADHD. Other forms of parental psychological maladjustment – such as maternal depression, antisocial personality and drug use, parenting stress, or marital distress – exist with greater frequency among parents of children with ADHD and could likewise limit the success of behavioral parent training, but have been largely unstudied in families with ADHD children.

Studies that supplement basic BPT with additional psychological treatments designed to address such parental problems in children with ADHD have shown mixed success at doing so, with apparently most families benefiting from the supplemented intervention whether or not they had these pre-existing parental problems. Single-parent status and lack of father participation in treatment have also been shown to limit the effectiveness of BPT with disruptive children, but have not been directly investigated in children specifically having ADHD.

A third caveat is that parent training appears in some studies to result in more dramatic improvements in child oppositional behavior rather than in ADHD symptoms specifically, suggesting that the treatment is most useful where parent-child conflict exists in families having children with ADHD.

Those treatment techniques used to date have primarily consisted of training parents in general contingency management tactics, such as contingent application of reinforcement or punishment following appropriate/inappropriate behaviors. Reinforcement procedures have typically relied on praise, privileges, or tokens while punishment methods have usually been loss of positive attention, privileges, or tokens or formal time-out from reinforcement.

Several similar, though not identical, parent training programs have been studied with children having ADHD, including Cunningham’s COPE program (Community Parent Education Program), The Incredible Years by Webster-Stratton, Eyberg’s Parent-Child Interaction Therapy, and my own program, Defiant Children,among others. The core methods taught in these programs are quite similar, not surprisingly, since all of the developers trained either directly with Constance Hanf at the Oregon Health Sciences University or with one of her former students. Hanf developed one of the original parent training programs for disruptive children based largely on two procedures, those being enhanced parental attention to compliant child behavior coupled with immediate time-out for noncompliant behavior. Though these subsequent programs vary in their format from this original program by Hanf, and in the procedures they have added to supplement the basic two steps, all are founded on a social learning model of disruptive child behavior (disrupted parenting and social coercion). And all have demonstrated efficacy for disruptive children, including those with ADHD, but again, the greatest effects are on the reduction in oppositional behavior rather than in ADHD symptoms.

The rationale for my version as applied to children with ADHD, however, is twofold and is not based solely on social learning theory. First, I hypothesized that ADHD children may have deficits in self-regulation and executive functioning, specifically in rule-governed behavior, or the stimulus control of behavior by commands, rules, and self-directed speech. As noted earlier when discussing a theoretical rationale for behavior therapy, children with ADHD have limitations in internally represented information and motivation that instructs, guides, and supports behavior, and therefore require more externally represented information and artificially arranged consequences to compensate for these executive deficits. Consequently, parents are going to need to use more explicit, systematic, externalized, and compelling forms of presenting rules and instructions to ADHD children and providing consequences for their compliance with them than are likely to be needed with children without ADHD.

A second unique feature of my approach to parent training is that there exists a considerable overlap of oppositional/defiant behavior with clinic-referred ADHD children, and such children are recognized to have poorer adolescent and young adult outcomes. ODD is recognized to at least partially originate in disrupted parenting and coercive family interactions. Hence, appropriate training of parents must be provided for the oppositional/defiant behaviors associated with ADHD in such cases. The most useful vehicle for accomplishing both purposes seems to be training parents in behavioral techniques applied contingently for compliance or noncompliance.

My BPT program, for instance, consists of 10 steps, with one- to two-hour weekly training sessions provided either to individual families or in groups. Each step is described in detail in the clinical manual (see Resources), but is briefly presented below:

1. Review of Information on ADHD

In the first session, the therapist provides a succinct overview of the nature, developmental course, prognosis, and etiologies of ADHD. Providing the parents with additional reading materials, such as an accompanying trade book for parents (Your Defiant Child), can be a useful addition to this session. Professional DVDs are also available that present such an overview and can be loaned to parents for review at home and sharing with relatives or teachers, as needed. Such a session is essential in parent training to dispel a number of misconceptions parents often have about ADHD in children. Research suggests that this provision of information can result not only in improved knowledge of parents about ADHD but also in improved parental perceptions of the degree of deviance of their child’s behavioral difficulties.

2. The Causes of Oppositional/Defiant Behavior

Next, parents are provided with an in-depth discussion of those factors identified in past research as contributing to the development of defiant behavior in children. Essentially, four major contributors are discussed, these being:

  1. Child characteristics, such as health, developmental disabilities, and temperament;
  2. Parent characteristics similar to those described for the child;
  3. Situational consequences for oppositional and coercive behavior; and
  4. Stressful family events.

Parents are taught that where problems exist in (a), (b), and (d), they increase the probability of children displaying bouts of coercive, defiant behavior. However, the consequences for such defiance, (c) above, seem to determine whether that behavior will be maintained or even increased in subsequent situations where commands and rules are given. Such behavior appears to primarily function as escape/avoidance learning in which oppositional behavior results in the child escaping from aversive parent interactions and task demands, negatively reinforcing the child's coercion. As in the first session, this content is covered so as to correct potential misconceptions that parents have about defiance (i.e., that it is primarily attention-getting in nature). This session can be augmented by the use of two of my professional DVDs on the nature of oppositional defiant behavior and its management (www.Guilford.com).

3. Developing and Enhancing Parental Attention

Gerald Patterson (1965) suggested that the value of verbal praise and social reinforcement to oppositional or hyperactive children is greatly reduced, making it weak as a reinforcer for compliance. In this session, parents are trained in more effective ways of attending to child behavior so as to enhance the value of their attention to their children. The technique consists of verbal narration and occasional positive statements to the child with attention being strategically deployed only when appropriate behaviors are displayed by the child. Parents are taught to reduce the amount of attention to inappropriate behaviors, including ignoring as much negative behavior as possible, while greatly increasing their attention to ongoing prosocial and compliant child behaviors. This is a critical step because many parenting programs result in reductions of rates of negative behavior without corresponding increases in rates of positive behavior. One of the most effective results of parent training is to increase rates of positive behaviors that are incompatible with the negative behaviors the parents wish to terminate.

4. Attending to Child Compliance and Independent Play

This session extends the techniques developed in Session 3 to instances when parents issue direct commands to children. Parents are trained in methods of giving effective commands, such as reducing question-like commands (e.g., Why don't you pick up your toys now?), increasing imperatives, eliminating setting activities which compete with task performance (e.g., television), reducing task complexity, etc. They are then encouraged to begin using a more effective commanding style and to pay immediate positive attention when compliance is initiated by the child. As part of this assignment, parents are asked to increase the frequency with which they give brief commands to their child this week and to reinforce each command obeyed. Research suggests that these brief commands are more likely to be obeyed, thereby providing excellent training opportunities for attending to compliance. In this session, parents are also trained to provide more positive attention frequently and systematically when their children are engaged in nondisruptive activities while parents are occupied with some other work or activity. Essentially, the method taught here amounts to a shaping procedure in which parents provide frequent praise and attention for progressively longer periods of child nondisruptive activities.

5. Establishing a Home Token Economy

As noted above in discussing the theoretical model of ADHD, children with the disorder may require more frequent, immediate, and salient consequences for appropriate behavior and compliance in order to maintain it. If this is correct, then instituting a home token economy is critical to addressing these difficulties with intrinsically generated and represented motivation by bringing more salient external consequences to bear on child compliance more immediately and more frequently than is typically the case. In establishing this program, the parents list most of the children's home responsibilities and privileges and then assign point or chip values to each. The parents are encouraged to have at least 12 to 15 reinforcers on the menu so as to maintain the motivating properties of the program. Generally, plastic chips are used with children ages eight or younger as they seem to value the tangible features of the token. For nine-year-olds or older, points recorded in a notebook seem sufficient.

During the first week of this program, the parents are not to fine the child or remove points for misconduct. The program is for rewarding good behavior only. Parents are also asked to be liberal in awarding chips to children for even minor instances of appropriate conduct. However, chips are given only for obeying first requests. If a command must be repeated, it must still be obeyed but the opportunity to earn chips has been forfeited. Parents are also encouraged to give bonus chips for good attitude or emotional regulation in their children. For instance, if a command is obeyed quickly, without complaint, and with a positive attitude, parents may give the child additional chips beyond those typically given for that job. Where this is used, parents are to expressly note that the awarding of the additional chips is for a positive attitude. Families are encouraged to establish and maintain such programs for at least six to eight weeks to allow for the newly developed interaction patterns spawned by such programs to become habitual patterns.

6. Implementing Time Out for Noncompliance

Parents are now trained to use response cost (removal of points or chips) contingent on noncompliance. In addition, they are trained in an effective time-out-from-reinforcement technique for use with two serious forms of defiance that may continue to be problematic despite the use of the home-token economy. These two misbehaviors are selected in consultation with the parents and typically involve a type of command or household rule that the child continues to defy despite parental use of previous treatment strategies. Time out is limited to these two forms of misconduct so as to keep it from being used excessively during the next week.

The time-out procedure taught to parents often differs from that commonly used by them. First, the time out is to be implemented shortly after noncompliance by a child begins. Parents often wait until they are very upset with a child before instituting punishment, often repeating their commands frequently to a child in the interim. In this program, parents issue a command, wait five seconds, issue a warning, wait another five seconds, and then take the child to time out immediately should compliance not have begun to these commands or warnings. Second, children are not given control over the time-out interval as they often are in many households. For instance, parents often place a child in time out, then say the child can leave time out when they are quiet, ready to do as the parent asked, or when a timer signals the end of the interval. In each of these cases, determination as to when the time-out interval ends is no longer under the parent’s control. This program teaches parents to simply tell the child to not leave the time-out chair until the parent tells them to. Three conditions must be met by the child before time out ends and these are in a hierarchy:

  1. The child must serve a minimum sentence in time out, usually one to two minutes for each year of their age;
  2. the child must then become quiet for a brief period of time so as not to have disruption associated with the parents approaching the time-out chair and talking to the child; and
  3. the child must then agree to obey the command.

Failure of the child to remain in time out until all three conditions are met is dealt with by additional punishment. The consequence is tailored to meet parental wishes, but may consist of a fine within the home token system, extension of the time out interval an additional five or 10 minutes, or placement of the child in his or her bedroom. In the latter case, toys or other entertaining activities are previously removed from the bedroom and the door to the room may be closed and locked to preclude further escape from the punishment.

7. Extending Time Out to Additional Noncompliant Behaviors

In this session, no new material is taught to parents. Instead, any previous problems with implementing time out are reviewed and corrected. Parents may then extend their use of time out to one or two additional noncompliant behaviors with which the child may still have trouble.

8. Managing Noncompliance in Public Places

Parents are now taught to extrapolate their home management methods to troublesome public places such as stores, church, restaurants, etc. Using a "think aloud-think ahead" paradigm, parents are taught to stop just before entering a public place, review two or three rules with the child which the child may have previously defied, explain to the child what reinforcers are available for obedience in the place, then explain what punishment may occur for disobedience, and finally assign the child an activity to perform during the outing. Parents then enter the public place and immediately begin attending to and reinforcing ongoing child compliance with the previously stated rules. Time out or response-cost are two methods used immediately for disobedience.

Time out in a public place may require slight modification from its use at home. For instance, parents may be taught to stand the child against the farthest wall from the central aisle of a store to serve as the time-out location. If inconvenient, taking the child to a restroom or having him face the side of a display cabinet may be adequate substitutes. If unavailable, then taking the child outside of the building to face the front wall or returning to the car can be used for time out. When none of these locations seem appropriate, parents can be trained to use a delayed punishment contingency. In this case, the parent carries a small spiral notebook to the public place and, before entering the building, indicates that rule violations will be recorded in the book and the child will serve time out for them upon return home from this trip. This author encourages parents to keep a picture of the child sitting at home in time out with this notebook and to show it to the child before entering the public building. This serves as a reminder to the child of what may be in store should a rule be violated. Whenever time out is used in a public place, it need not be for as long an interval as at home. The author suggests that that half of the usual time-out interval may be sufficient for public misbehavior given the richly reinforcing activities in public places from which the child has just been removed.

9. Improving Child School Behavior from Home

The Daily School Behavior Report Card: This session was designed to help parents assist their child’s teacher with the management of classroom behavior problems. The session focuses on training parents in the use of a home-based reward program. Children are evaluated by their teachers on a daily school behavior report card. This card serves as the means by which consequences later in the day will be dispensed at home for classroom conduct. The card can be designed to address class behavior, recess or free-time behavior, or more specific behavioral or academic targets for any given child. The consequence provided at home typically consists of the rewarding or removal of tokens or points within the home token system as a function of the ratings the child has received from their teachers on this daily behavioral report card. To emphasize the importance of the school-to-home communication and to avoid escaping consequences if the child “loses” their school behavior report card, it is best to set up a contingency such that “no news is worse than bad news.” Thus, the most austere level in the contingency system should be when the card is incomplete or missing.

10. Managing Future Misconduct

By now, parents should have acquired an effective repertoire of child management techniques. The goal of this session is to get parents to think about how these might be implemented in the future if some other forms of noncompliance developed. The therapist challenges the parents with misbehaviors they have not seen yet and asks them to explain how they might use their recently acquired skills to manage these problems. Behavioral rehearsal (i.e., role playing) surrounding anticipated barriers to implementation of existing parenting plans, or making modifications or innovations to deal with new and different behaviors, are strongly recommended as a means to prepare for future misconduct.

One Month Review/Booster Session

In what is typically the final session, the concepts taught in earlier sessions are briefly reviewed, problems which have arisen in the last month are discussed, and plans made for their correction. Other sessions may be needed to deal with additional issues that persist, but for most families, the previous 10 sessions appear adequate for improving rates of compliant behavior in ADHD children.

The program is intended for children ages two to 11 where oppositional or defiant behavior is an issue. Studies examining the efficacy of this particular BPT with ADHD children have consistently reported significant improvements in child behavior as a function of the parents’ acquisition of these child-management skills. Indeed, this was the program that was selected, and modified, for use in the MTA study. Results suggest that up to 64% of families experience clinically significant change or recovery (normalization) of their child’s disruptive behavior as a consequence of this program. However, improvements in behavior may be more concentrated in the realm of aggressive and defiant child behavior than in inattentive/hyperactive symptoms. All of these studies have relied on clinic-referred families, most of whom sought the assistance of mental health professionals for their children.

In contrast to the results of research with such motivated families, my colleagues and I found that if such a clinic-based parent-training program is offered to parents whose preschool children were identified at kindergarten enrollment as having significant levels of aggressive-hyperactive-impulsive behavior, most do not attend training or do not attend reliably and no treatment effect is evident. Moreover, no significant improvements in child behavior were found even among those who did attend at least some of the training sessions. Studies with disruptive children or those at high risk for externalizing behavior suggest that BPT may be more cost-effective, reach more severely disruptive children and more minority families, and possibly be more effective for them if they are provided as group training classes offered through neighborhood public schools in the evenings using para-professionals as trainers. This might prove to be the case for children specifically having ADHD as well.

For teenagers with ADHD and oppositional behavior, there is little research on BPT. We have often recommended a family training program that includes the Problem Solving Communication Training Program (PSCT) developed by Robin and Foster (1989) combined with variations of Barkley’s BPT program. The efficacy of the Robin and Foster program used specifically with ADHD teenagers has been examined. This program was compared against my parent training program described above that was modified somewhat for use with adolescents (e.g., token systems became point systems, time out was changed to grounding to the home, etc.). It was also compared against the family therapy program developed by Minuchin. Families in each group received eight to 10 sessions of therapy, and multiple outcome measures of family conflict were collected, including videotaped parent-teen interactions. Results indicated that all three treatments produced statistically significant improvements in the various self-report ratings of family conflict but no significant improvements in the direct observation of parent-teen interactions. When statistics evaluating individual change and recovery were applied to these data, they revealed that only 5%-30% of the families in these programs improved reliably from treatment and that only 5%-20% had recovered (normalization) in their level of conflicts, with no significant differences among the groups in these reliable change and recovery percentages. Such results are quite disappointing and suggest that the power of treatment needs to be enhanced in various ways if it is to be of much value to most families of ADHD adolescents experiencing significant family conflict.

A subsequent study of mine and my colleagues enhanced this treatment by increasing the number of sessions to 18, encouraging greater father involvement in therapy, and combining the behavioral parent training and PSCT programs together, among other changes. The study compared PSCT/BPT with PSCT alone using clinically referred teenagers having ADHD and ODD. Results were essentially the same as the initial study, with both treated groups showing improvement over time at the group level of analysis with there being no differences between them. But only 30% or fewer families in these groups were demonstrating clinically reliable change at the end of treatment. The combined PSCT/BPT approach was superior to the PSCT-alone approach in just one respect, that being fewer dropouts from treatment. The program is available as a published clinical manual for practitioners wishing to implement this approach to therapy (See the clinical manual Defiant Teens, in the Resources).

To summarize the efficacy of training parents in behavior management methods, these methods receive a grade of B+ to A (from this author) for use with elementary-school-aged children, depending on which parenting approach is used. Compared to elementary-school-aged children, these approaches have not been as effective with preschoolers or adolescents with ADHD. Practical barriers, such as parental engagement, have seemed to limit studies with preschoolers. Innovations that improve the efficacy of parent-based interventions with teenagers with ADHD are sorely needed. Parent management training suffers from several practical limitations, such as the need for training providers, numerous demands placed on families, a commitment to use the methods consistently and persistently over a long period of time, and the need to tailor techniques in response to changing developmental and social factors. When used properly, these techniques can be very safe, but overly punitive or haphazard programs can actually make things worse. Paradoxically, some worsening of behavior (e.g., transient increases in tantrums when a parent starts ignoring the behavior) may suggest that parents are on the right track. This example of tantrums illustrates the fact that the behavior methods that seem so simple at their basic conceptual level can be fraught with subtleties that confuse and frustrate parents.

A limitation of these approaches is that many therapists do not have the skills and training to provide the sophisticated guidance that most parents need. Consequently, even though behavior methods can be used to get killer whales and dolphins to jump through burning hoops, due to past failures with other providers, many parents complain that their children’s behavior is completely impervious to change through behavioral methods. This is a significant limitation to the effectiveness of parent management training that must be handled delicately to recruit and retain parents in behavior management training. Intensive professional education and widespread public education to overcome ignorance and stigma associated with parent management training may be necessary for this to become truly grade A intervention for ADHD and related problems.

Training Teachers in Classroom Behavior Management

Somewhat more research has occurred on the application of behavior management methods in the classroom with ADHD children than with parent training. Moreover, there is voluminous literature on the application of classroom management methods to disruptive child behaviors, many of which include the typical symptoms of ADHD. This research clearly indicates the effectiveness of behavioral techniques in the short-term treatment of academic performance problems in ADHD children. I have an entirely separate course on this website on managing ADHD in school, entitled ADHD Goes to School – The Best Evidence-Based Methods. Please consult that course for specific recommendations on classroom management of ADHD.

A meta-analysis of the research literature on school interventions for ADHD was conducted that comprised 70 separate experiments of various within- and between-subjects designs as well as single-case designs.  It found an overall mean effect size for contingency management procedures of 0.60 for between-subject designs, nearly 1.00 for within-subject designs, and approximately 1.40 for single-case experimental designs. Interventions aimed at improving academic performance through the manipulation of the curriculum, antecedent conditions, or peer-tutoring produced approximately equal or greater effects sizes. In contrast, cognitive-behavioral treatments when used in the school setting were significantly less effective than these other two forms of interventions. Thus, despite some initial findings of rather limited impact of classroom behavior management on children with ADHD, later studies – and the totality of the extant literature – suggest that behavioral and academic interventions in the classroom can be effective in improving behavioral problems and academic performance in children with ADHD. The greatest and most reliable improvements across studies are evident with contingency management and peer-tutoring approaches, while studies of curriculum modifications, strategy training, and other cognitive-behavioral approaches are less reliable. Moreover, even with the most effective classroom interventions, the behavior of children with ADHD may not be fully normalized by these interventions.

As noted above in discussing laboratory applications of behavior therapy techniques, research suggests some promise in the use of stimulus control procedures with ADHD children, many of which can be readily adapted to the classroom. By reducing task length, "chunking" tasks into smaller units to fit more within the child's attention span, and setting quotas for the child to achieve within shorter time intervals, some stimulus control methods may increase the success of the ADHD child with academic work. The use of increased stimulation within the task (e.g., color, shape, texture, rate of stimulus presentation) may enhance attention to academic tasks in ADHD children. Teaching styles may play an important role in how well ADHD children attend to lectures by a teacher. More vibrant, enthusiastic teachers who move about more, engage children frequently while teaching, and allow greater participation of the children in the teaching activity may increase sustained attention to the task at hand. Studies have shown that permitting ADHD children to move or participate motorically while learning a task may improve attention and performance. The use of written, displayed rules and timers for setting task time limits, as already described, may further benefit ADHD children in the classroom.

A number of studies have also shown that the contingent application of reinforcers for reduced activity level or increased sustained attention can rapidly alter the levels of these ADHD symptoms. Usually, these programs incorporate token rewards, as some research suggests that praise may not be sufficient to increase or maintain normal levels of on-task behavior in hyperactive children. Early studies in this area showed that group-administered rewards, where all children in class receive a reward contingent on the performance of one child, are as effective as individually administered rewards. One of the problems arising in such research, however, is the demonstration that simply reinforcing greater on-task behavior and decreased activity level did not necessarily translate into increased work productivity or accuracy. Since the latter are the ultimate goals of behavioral intervention in the classroom, these results were somewhat dismaying. Research now suggests that reinforcing the products of classroom behavior (i.e., number and accuracy of problems completed) not only results in increased productivity and accuracy but also indirectly in declines in off-task and hyperactive behavior.

A serious limitation to these promising results has been the lack of follow-up on the maintenance of these treatment gains over time. In addition, none of these studies examined whether generalization of behavioral control occurred in other school settings where no treatment procedures were in effect. Other studies employing a mixture of cognitive-behavioral and contingency-management techniques have failed to find such generalization with ADHD children, suggesting that improvements derived from classroom management methods are quite situation-specific and may not generalize or be maintained once treatment has been terminated.

The role of punishment in the management of classroom behavior in ADHD children has been less well studied. For instance, one study evaluated the effects of continuous and intermittent verbal reprimands and response cost on off-task classroom behaviors. It found that while each of these treatments significantly reduced disruptive and off-task behavior, the continuous use of response cost (loss of recess time, for example) was most effective.

Studies have determined that the sole use of positive reinforcement for controlling ADHD behaviors in the classroom was not sufficient to maintain improved behavior in these children unless punishment in the form of response cost was added to the program. The addition of response cost further increased rates of on-task behavior and academic accuracy. Those gains in behavior could then be maintained by an all-positive program once the response cost procedure was gradually withdrawn. However, abrupt withdrawal of the punishment contingency resulted in declines in on-task behavior and accuracy, suggesting that the manner in which response cost techniques are implemented and then faded out of classroom management programs is important in the maintenance of initial treatment gains. In general, the efficacy of response cost procedures with ADHD children has been well-documented.

What conclusions can be drawn from this literature indicate that contingency management methods can produce immediate, significant, short-term improvement in the behavior, productivity, and accuracy of ADHD children in the classroom. Secondary or tangible reinforcers are more effective in reducing disruptive behavior and increasing performance than are attention or other social reinforcers. The use of positive reinforcement programs alone does not seem to result in as much improvement nor does it maintain that improvement over time as well as does the combination of token reinforcement systems with punishment, such as response cost (i.e., removal of tokens or privileges). Such findings would be expected from the theories of ADHD discussed earlier that suggest a decreased power to self-regulate motivation and a delay in the development of internalized speech and the rule-governed behavior it affords in children with this disorder. What little evidence there is, however, suggests that treatment gains are unlikely to be maintained in these children once treatment has been withdrawn, and that improvements in behavior probably do not generalize to other settings where no treatment is in effect.

Another promising method deserving of further evaluation is the use of daily school behavior report cards employing home-based contingencies for in-class behavior and performance. As discussed above under the author’s parent training program, the method involves having a teacher rate a child's daily school performance, either one or more times throughout a school day. These ratings are then sent home with the child for review by the parents. The parents then dispense rewards and punishments (usually response cost) at home contingent upon the content of these daily ratings. Many studies have found such home/school behavioral report cards to be useful, either alone or in combination with parent and teacher training in behavior management, in the treatment of ADHD and its related school behavioral problems.

One study examined the effects of using game-like math software to supplement mathematics instruction in three students with ADHD, again using a multiple-baseline-across-participants design. Behavioral observations and curriculum-based math probes revealed significant improvements in math performance from the software supplementation. This method offers some promise of additional supplemental interventions to those discussed above.

Other recent innovative interventions for ADHD children in school settings which have some positive effects include consultation-based support provided to school teachers by school psychologists and other qualified staff, a cost-effective approach that deserves further study. The Challenging Horizons Program uses well-trained paraprofessionals to provide multi-method behavioral treatment, tutoring, teacher consultation, and parent training using a format of group meetings with ADHD teens after school several times per week. The program is instituted at the school, thus enhancing the likelihood of teen participation. Results to date have been impressive. Power et al. (2012) combined parent and teacher behavioral consultations, daily behavior report cards, and behavioral homework interventions into a Family-School Success intervention. Results showed significant benefits for students with ADHD in grades 2-6. The use of peers as tutors has likewise shown some promise in improving the academic performance of students with behavioral disorders.

To summarize the efficacy of classroom-focused contingency management, this should be considered a grade A or B+ treatment depending on which techniques are used. Cognitive techniques and skills training appear to be failed interventions unless the techniques or skills are specifically reinforced at the point of performance. Behavior modification methods that use a combination of reward and punishment seem to have the best results, but there is still some uncertainty about which methods are best and for whom. It does seem to be clear that effects of these interventions are transient and need to be implemented over a very long term. Approaches that train parents to set up reinforcement contingencies based on teacher-to-parent communication (e.g., daily behavior reports) may be the best hope for sustained intervention across the life span of the treatment.

All of the significant barriers to the effectiveness of behavioral management discussed previously for parents apply to teachers as well. There is widespread ignorance, neglect, or poor implementation of these methods. Intensive efforts to educate and support parents and teachers in the use of these methods could make a huge difference in the functioning of many children with learning or behavior problems at school. Unfortunately, even school psychologists may not have the time or expertise to assist in setting up proper behavior management programs, so there is quite a bit of work to be done to make this a grade A intervention that is widely available. Those interested in more specific details on school management of ADHD should take my other course, ADHD Goes to School.

Behind these recommendations lie nine principles that need to be considered in planning management programs for children and teens with ADHD in school settings:

1.Rules and instructions provided to children with ADHD must be clear, brief, and often delivered through more visible and external modes of presentation than is required for the management of a non ADHD population of children.

Stating directions clearly, having the child repeat them out loud, having the child utter them softly to himself or herself while following through on the instruction, and displaying sets of rules or rule‑prompts (e.g., stop signs, big eyes, and big ears for "stop, look, and listen" reminders) prominently throughout the classroom are essential to proper management of ADHD children. Relying on the child's recollection of the rules as well as upon purely verbal reminders is often ineffective.

2. Consequences used to manage the behavior of ADHD children must be delivered swiftly and more immediately than is needed for those children without ADHD.

Delays in consequences greatly degrade their efficacy for children with ADHD. As will be noted throughout this chapter, the timing and strategic application of consequences with children with ADHD must be more systematic and is far more crucial to their management than in children without ADHD. This is not just true for rewards, but is especially so for punishment, which can be kept mild and still be effective by delivering it as quickly upon the misbehavior as possible – swift, not harsh, justice is the essence of effective punishment.

3. Consequences must be delivered more frequently, not just more immediately, to children with ADHD in view of their motivational deficits.

Behavioral tracking, or the ongoing adherence to rules after the rule has been stated and compliance initiated, appears to be problematic for children with ADHD. Frequent feedback or consequences for rule adherence seems helpful in maintaining appropriate degrees of tracking to rules over time.

4. The type of consequences used with children with ADHD must often be of a higher magnitude, or more powerful, than that needed to manage the behavior of those children without ADHD.

The relative insensitivity of children with ADHD to response consequences dictates that those chosen for inclusion in a behavior management program must have sufficient reinforcement value or magnitude to motivate children with ADHD to perform the desired behaviors. Suffice it to say, then, that mere occasional praise or reprimands are simply not enough to effectively manage children with ADHD.

5. An appropriate and often richer degree of incentives must be provided within a setting or task to reinforce appropriate behavior before punishment can be implemented.

This means that punishment must remain within a relative balance with rewards or it is unlikely to succeed. It is therefore imperative that powerful reinforcement programs be established first and instituted over one to two weeks before implementing punishment in order for the punishment, sparingly used, to be maximally effective. Often children with ADHD will not improve with the use of response cost or time out if the availability of reinforcement is low in the classroom and hence removal from it is unlikely to be punitive. "Positives before negatives" is the order of the day with children with ADHD. When punishment fails, this is the first area that clinicians, consultations, or educators should explore for problems before instituting higher magnitude or more frequent punishment programs.

6. Those reinforcers or particular rewards which are employed must be changed or rotated more frequently with ADHD children than with other children given the penchant of the former for more rapid habituation or satiation to response consequences; apparently rewards in particular.

This means that even though a particular reinforcer seems to be effective for the moment in motivating child compliance, it is likely that it will lose its reinforcement value more rapidly than normal over time. Reward menus in classes, such as those used to back up token systems, must therefore be changed periodically, say every two to three weeks, to maintain the efficacy of the program in motivating appropriate child behavior. Failure to do so is likely to result in the loss in power of the reward program and the premature abandonment of token technologies based on the false assumption that they simply will no longer work. Token systems can be maintained over an entire school year with minimal loss of power in the program provided that the reinforcers are changed frequently to accommodate to this problem of habituation. Such rewards can be returned later to the program once they have been set aside for a while, often with the result that their reinforcement value appears to have been improved by their temporary absence or unavailability.

7. Anticipation is the key with children with ADHD.

This means that teachers must be more mindful of planning ahead in managing children with this disorder, particularly during phases of transition across activities or classes, to insure that the children are cognizant of the shift in rules (and consequences) that is about to occur. It is useful for teachers to take a moment to prompt a child to recall the rules of conduct in the upcoming situation, repeat them orally, and recall what the rewards and punishments will be in the impending situation before entering into that activity or situation. “Think aloud, think ahead” is the important message to educators here. As noted later, by themselves such cognitive self‑instructions are unlikely to be of lasting benefit, but when combined with contingency management procedures can be of considerable aid to the classroom management of ADHD children.

8. Children with ADHD must be held more publicly accountable for their behavior and goal-attainment than children without ADHD.

The weaknesses in executive functioning associated with ADHD result in a child whose behavior is less regulated by internal information (mental representations) and less monitored via self-awareness than is the case in  children without ADHD. Addressing such weaknesses requires that the child with ADHD be provided with more external cues about performance demands at key “points of performance” in the school, be monitored more closely by teachers, and be provided with consequences more often across the school day for behavioral control and goal attainment than would be the case in  children without ADHD.

9. Behavioral interventions, while successful, only work while they are being implemented and, even then, require continued monitoring and modification over time for maximal effectiveness.

One common scenario is that a student responds initially to a well-tailored program, but then over time, the response deteriorates; in other cases, a behavioral program may fail to modify the behavior at all. This does not mean behavioral programs do not work. Instead, such difficulties signal that the program needs to be modified. It is likely that any one of a number of common problems occurred, such as the rewards lost their value, the program was not implemented consistently, or the program was not based on a functional analysis of the factors related to the problem behavior.

Cognitive Behavioral Therapy

The provision of cognitive-behavioral treatment (CBT), or cognitive therapy, was felt previously to hold some promise for children with ADHD. Such treatment involves training children to give themselves instructions overtly in how to approach a task, strategies to employ during the task, and self-statements of evaluation and self-reinforcement at the end of the task. A few small-scale studies suggested some benefits to this form of treatment when used with children with ADHD. But CBT has been challenged as being seriously flawed from the conceptual (Vygotskian) point of view on which the treatment was initially founded. Whether or not the self-statements of children with ADHD during task performance are actually deficient and in need of such correction is also open to question. And its efficacy for impulsive children or those with ADHD has been repeatedly questioned by the rather poor or limited results of empirical research.

Reviews of the CBT literature using meta-analyses have typically found the effect sizes to be only about a third of a standard deviation and, in many studies, even less than this. While such treatment effects may at times rise to the level of statistical significance, they are nonetheless of only modest clinical importance and are usually to be found mainly in relatively circumscribed lab measures rather than in more clinically important measures of functioning in natural settings.

A large-scale, well-controlled study of CBT conducted in the Minneapolis public school system found no effect on children with ADHD. The study involved substantial training of parents, teachers, and children, over two years of this multi-component intervention. But the researchers found no significant treatment effects on any of a variety of dependent measures at the one-year assessment, with the exception of class observations of off-task/disruptive behavior, and no effects after two years of treatment. Even the treatment effect on class observations was not maintained in follow-up. Therefore, given the extant research findings of limited effect sizes in most clinical studies, and the absence of treatment effects in the largest study, this treatment is given a grade of D and no further discussion of cognitive-behavioral treatments for ADHD will be presented here.

Social Skills Training

Reviews of social skills training (SST) as applied specifically to children with ADHD have been quite discouraging. Children with ADHD certainly have serious difficulties in their social interactions with peers. This seems to be especially so for that subgroup having significant levels of comorbid aggression, in which more than 50% of the variance in peer ratings of children whom they disliked was predicted by this behavior alone. The social interaction problems of children with ADHD are quite heterogeneous and are not likely to respond to a treatment package that focuses only on social approach strategies and that treats all children with ADHD as if they shared common problems in their peer relationship difficulties. Nor is it especially clear at this time what the actual source of these peer difficulties happens to be or the mechanism by which it operates, with the exception of aggressive behavior as noted above.

For instance, do children with ADHD actually lack the knowledge of proper social skills or is it that they know how to act with others but do not do so at the points of performance in social interactions where such skills would be useful to be performed? The theoretical model presented earlier would suggest that the latter is likely to be more of a problem than the former, at least for children having ADHD without significant aggression. Teaching additional skills is not so much the issue as is assisting them to perform the skills they have when it would be useful, that is at the point of performance where such skills are most likely to prove useful to the long-term social acceptance of the individual.

Those children with ADHD with comorbid aggression may well have additional problems with peer perceptions, particularly around the motives they attribute to others for their behavior, as well as in information processing about social interactions. This combination of both perceptual and information-processing deficits along with problems performing appropriate social skills in social interactions with others may make children with ADHD with aggression particularly resistant to social skills training.

Actual research on SST for ADHD contains rather mixed results. Early studies suggested that at-risk groups of children responded better (larger effect sizes) to such programs than did children with externalizing or disruptive behavioral problems. Some studies find evidence for the efficacy of an SST program for children with ADHD, but only on parent ratings and not teacher ratings. The addition of parent training in generalization strategies may not result in any additional benefits over social skills training alone.

All of these studies indicate some benefits of social skills training for conduct-problem children, including those with ADHD, particularly when parent ratings serve as the outcome measure. Yet many suffer from significant limitations in their methods. Bear in mind that several of these studies did not employ randomized assignment to treated or untreated groups (the Frankel studies) and that parents were not blind to the intervention being received (all studies). All of the studies used wait-list control groups for their comparisons. It is not clear if such positive results would be found if efforts were made to control for therapist attention, as in attention placebo groups, or if alternative treatment approaches were also employed. Effects on teacher ratings of school social behavior are also not as encouraging as results from parent ratings, but imply that some children in some studies may have demonstrated reduced social withdrawal and possibly aggression in school.

More sobering results are revealed in other studies of ADHD samples. They find no significant benefits for most ADHD children on a variety of measures of social functioning. That ADHD subtype having primarily inattention may improve in their assertion skills following treatment but not on any other measures of social interaction. Moreover, some evidence of peer deviancy training was evident in these studies. This refers to the peer reinforcement of aggressive and antisocial behavior among the children in the group such that children increase their levels of aggressive behavior as a result of group participation. Earlier studies did not examine this possibility of a detrimental impact of group social skills training. Such an adverse impact is certainly worthy of further examination in future research with children having ADHD.

At this time, social skills training for children with ADHD might be graded as a C- or D, reflecting the inconsistent nature of the results, the limited number of studies using randomized assignment to treatment groups, the lack of blindness of parents and teachers to treatment conditions, the absence of attention-placebo or alternative treatment groups, the limited evidence of generalization to the school setting, and the fact that studies to date have mainly involved efficacy rather than effectiveness in actual clinical contexts. In addition to the questionable efficacy of social skills training, it is worth noting that there may be some risk of accelerating antisocial behavior, or deviancy training, involved in social skills training when delinquent youth are placed together in groups.

Combined Interventions

Psychopharmacological and behavioral treatments are not, by themselves, typically nor completely adequate to address all of the difficulties likely to be presented by clinic-referred children or adolescents with ADHD. Optimal treatment is likely to comprise a combination of many of these approaches for maximal effectiveness. However, the extent to which combined treatments are superior to medication alone is a controversial issue, especially given the relatively high cost of many psychosocial interventions. Nevertheless, findings from the MTA study imply some potential advantages of combined treatment, tempered by other multi-site studies that may challenge that conclusion.

Some early research studies examined the utility of combining psychosocial and pharmacological treatment packages with interesting results. In many studies, the combination of contingency management training of parents or teachers with stimulant drug therapies is generally little better than either treatment alone for the management of ADHD symptoms. Several studies also found impressive results for classroom behavior management methods but found that the addition of medication provided some added improvements beyond that achieved by behavior management alone. Moreover, the combination may result in the need for less intense behavioral interventions or lower doses of medication than might be the case if either intervention were used alone.

Where there is an advantage to behavioral interventions, it appears to be related to functioning rather than symptom relief, such as reliably increasing rates of academic productivity and accuracy. Despite some failures to obtain additive effects for these two treatments, their combination may still be advantageous given that the stimulants are not usually used in the late afternoons or evenings when parents may need effective behavior management tactics to deal with the ADHD symptoms. Moreover, a minority of children (10%-25%) do not respond positively to the medications, making behavioral interventions one of the few scientifically proven alternatives for these cases.

Several early studies have examined the combined effects of stimulant medication with cognitive-behavioral interventions. The combined program was more effective in increasing on-task behavior during classwork, and decreasing teacher ratings of ADHD symptoms. However, academic productivity is improved only by the use of direct reinforcement for correct responses. In contrast, other research found no benefits of combined drug/cognitive behavioral interventions over either treatment alone on similar domains of functioning of ADHD children.

Some success for combined medication and self-evaluation procedures have been reported when social skills, such as cooperation, have been targets of intervention. Yet, when these same investigators attempted to teach anger-control strategies to ADHD children to enhance self-control during peer interactions, no benefits of combined intervention were found beyond that achieved by self-control training alone. The self-control techniques were the most successful in teaching these children specific coping strategies to employ in provocative interactions with peers which usually lead to angry reactions from the ADHD children. Medication, in contrast, served only to lower the overall level of anger responses but did not enhance the application of specific anger-control strategies. These studies suggest that each form of treatment may have highly specific and unique effects on some aspects of social behavior while not on others.

Limited research has evaluated the effects of behavioral parent training (BPT) alone and combined with child training in self-control strategies on home and school behavioral problems. The results failed to find any significant advantage for the combined treatments. BPT alone improved home behavior problems, but neither resulted in any generalization of treatment effects to the school, where no treatment had occurred. Other research did not find such a treatment combination to be superior to either treatment used alone in producing a significantly larger number of treatment responders. Once again, however, no generalization of the results to the school setting occurred.

Intensive, Multi-Modal Treatment Programs

Two of the most well-known and well-regarded multi-modality intervention programs are the summer treatment programs developed by William Pelham and colleagues and conducted at Western Psychiatric Institute in Pittsburgh (Pelham, & Hoza, 1996), and the University of California-Irvine /Orange County Department of Education intervention developed by James Swanson, Linda Pfiffner, Keith McBurnett, and Dennis Cantwell. The latter program incorporates a number of features of the program developed by Pelham as well as some components of the multi-modal program conducted by Stephen Hinshaw, Barbara Henker, and Carol Whalen at the University of California at Los Angeles. All of these programs rely on four major components of treatment, these being:

  1. parent training in child behavior management;
  2. classroom implementation of behavior modification techniques;
  3. social skills training (typically around sports); and
  4. stimulant medication, in some cases.

While the Pelham program is conducted during the summer months in a “day camp” style program, the UCI-OCDE program is a year-round day-school style program.

The Summer Day Treatment Program (STP)

This program was largely developed by Pelham and colleagues and is conducted in a day-treatment environment with a summer school/camp-like format. Daily activities include a few hours of classroom instruction which also incorporates behavior-modification methods such as token economies, response cost, and time out from reinforcement. In addition, three to four hours of sports and recreational activities are arranged each day during which behavioral management programs are operative. The program also includes parent training, peer relationship training, and a follow-up protocol to enhance the likelihood that treatment gains will be maintained after leaving the program. During their stay at the camp, some children may be tested on stimulant medication using a double-blind, placebo-controlled procedure in which the child is tested on several different doses of medication while teacher ratings and behavioral observations are collected across the different camp activities.

Pelham and colleagues have used this setting and larger programmatic context to conduct more focused research investigations into the effectiveness of classroom behavior-management procedures alone, stimulant medication alone, and their combination in managing ADHD symptoms and improving academic performance and social behavior. Some of the components of this day-treatment program have been evaluated previously, such as classroom contingency management, and have been found to produce significant short-term improvements in children with ADHD. And so they clearly seem to do so here. The STP program, in fact, was a part of the intensive multimodal treatment program for children with ADHD studied in the MTA project (see below). But other components of the program have not been so well evaluated previously for their efficacy with children having ADHD, such as social skills training. And while results from parent ratings before and after their children’s participation indicate that 86% believe their ADHD children improved from their participation in the program, no data have been published as yet on whether the gains made during the treatment program are maintained in the subsequent normal school and home settings after the children terminate their participation in this program.

The UCI/OCDE Program

This program provides weekday treatment for ADHD children in kindergarten through fifth grades in a school-like atmosphere using classes of 12-15 children. The clinical interventions rely chiefly on a token economy program for the management of behavior in the classrooms and a parent training program conducted through both group and individual treatment sessions. Some training in self-monitoring, evaluation, and reinforcement also occurs as part of the class program. Children also receive daily group instruction in social skills as part of the classroom curriculum and some of these behaviors may be targeted for modification outside of the group instruction time by using consequences within the classroom token economy. Before returning to their regular public school, some children may participate in a transition program that focuses on more advanced social skills as well as behavior modification programs to facilitate the transfer of learning to their regular school setting. Some children within this program also may receive stimulant medication as needed for management of their ADHD symptoms.

While this program has served as an exemplar for many others, published research on its efficacy is not available. Granted, the parent training program and classroom behavior modification methods are highly similar to those used in published studies that have found them to be effective, at least in the short-term, so long as they are in use. But the actual extent to which this particular program achieves its stated goals and, specifically, the generalization of treatment gains to non-treatment settings, as well as the maintenance of those gains after children return to their public schools, have not been systematically evaluated or published.

The UMASS/WPS Early Intervention Project

My colleagues and I completed a multi-method early intervention program for kindergarten children (ages 4-6) having significant problems with hyperactivity and aggression, at least 70% of whom qualified for a clinical diagnosis of ADHD. This program did not utilize clinic-referred children, whose parents and teachers may be highly motivated to cooperate with treatment. Instead, children were identified at kindergarten registration as displaying significantly high levels of hyperactive/aggressive behavior (93rd percentile) and being at high risk for both ADHD and ODD. Indeed, more than 70% of them met criteria for these disorders upon subsequent clinical evaluation using structured psychiatric interviews. They were randomly assigned to one of four intervention groups for their entire kindergarten year.

One group received a 10-week group parent training program followed by monthly booster session group meetings. Otherwise, the children participated in the standard public school kindergarten program offered by the Worcester, MA public schools (WPS). The second group was assigned to a special enrichment kindergarten classroom in which they received accelerated instruction in academic skills, social skills training, classroom contingency management procedures (token systems and other reinforcements, response cost, time out, etc.), and cognitive therapy (self-instruction training) as part of their full-day kindergarten program. These special classes contained 12-16 hyperactive-aggressive children in each and were held in two neighborhood elementary schools in the WPS system to which the children were provided bussing. Children in this special classroom also received several months of follow-up consultation to their teachers when they returned to their regular public schools for their first-grade year. A third group received both the parent training and enrichment classroom treatments, while a fourth group received no special services except for the initial evaluation and periodic re-evaluations.

All the children were followed for two years after their participation in these treatment programs. Results indicated no beneficial effect of the parent training program, in large part because more than 60% of the parents did not attend the training classes regularly, if at all. The enrichment classroom produced a significant improvement in the children’s classroom behavior and social skills during the kindergarten year but did not result in any change in behavior in the home as rated by parents. Nor did it produce greater gains in academic achievement skills than had been experienced by the control groups not receiving this classroom program. Moreover, the results of the classroom appear to have attenuated during the follow-up period.

Such results once again show that intensive classroom behavioral interventions can be effective in the short term for addressing the disruptive behavior of children. Yet these same results are rather sobering in view of the large investment of money, time, and staff training. Parent training programs for children at high-risk for school and home behavior problems may not be especially effective in families identified through such community screening programs, largely due to poor parental motivation and investment in the training program. And even where classroom interventions are successful in the short-term “active” treatment phase, their effects may diminish or disappear with time after children leave the treatment environment.

This study suggests that the rather positive treatment outcome results for families who seek treatment and, by inference, are motivated to change themselves and their ADHD children may not be readily extrapolated to families of similarly deviant children who have not sought treatment but were identified through community screening programs.

The NIMH Collaborative Multi-site Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (MTA)

The National Institute of Mental Health (NIMH) collaborative multi-site Multimodal Treatment Study of Children with ADHD (MTA) was the first major clinical trial by NIMH with a focus on a childhood disorder. While much research has documented the short-term effectiveness of medication and behavioral interventions to treat ADHD, significant questions remain unanswered about long-term effectiveness of these interventions, alone or in combination, on the multiple functional outcome areas impacted by ADHD. Questions also remain about which types of youth with ADHD may benefit most from which types of treatment. The ambitious and groundbreaking MTA study was designed to help answer some of these major questions by randomly assigning children to four treatment groups: medication alone (MedMgt), behavior modification alone (Beh), the combination of medication and behavior modification (Comb), and community comparison (CC). In order to obtain a sufficiently large and diverse sample of youth with ADHD to begin to address these questions, a multi-site study was initiated by NIMH along with funding from the U.S. Department of Education in 1992.

MTA Study Design/Methodology

Participants were randomly assigned to one of four conditions. Treatments were delivered over a 14-month period; comprehensive assessments of functioning in multiple domains were conducted at baseline prior to randomization as well as at three, nine, and 14 months, with the 14-month assessment constituting the treatment endpoint assessment (MTA Cooperative Group, 1999a). The CooperativeGroup published results of a 24-month follow-up, and results up to eight years after treatment termination.

Behavioral treatments (in both Beh and Comb conditions) encompassed parent, child, and school domains. Behavioral parent training was provided by experienced training consultants and based on models created by myself and those of Forehand and McMahon (2003). This intervention consisted of 27 group sessions and eight individual sessions. Child behavioral treatment consisted of an intensive summer treatment program (based on the Pelham STP model) as well as school consultation services (similar to the UCI model). The Summer Treatment Program was an intensive eight-week, nine-hour-per-day program; study training consultants supervised staff working with the children and continued to provide parent interventions during the summer. The same training consultants provided school consultation services (10-16 sessions of teacher consultation and establishment of a daily report card), and the staff working with the children in the summer treatment program worked in the schools in the fall as paraprofessional aides (12 weeks at half-time, under supervision of the training consultants and the child’s teacher). Families attended an average of 77.8% of parent training sessions, 36.2 of 40 possible STP days, 10.7 teacher consultation visits, and 47.6 of 60 possible days with a classroom aide. Delivery of behavioral treatments was faded out over the course of treatment, so that by the endpoint assessment at 14 months, therapist contact with parents had ended or was reduced to once per month.

Like the intensive behavioral interventions, the medication treatments (in both MedMgt and Comb conditions) provided in the MTA occurred in a much more rigorous and intensive way than is typical in clinical practice. All medication treatment provided by the MTA included an initial 28-day double-blind, placebo-controlled titration consisting of placebo plus four different doses of methylphenidate (5, 10, 15, and 20 mg) randomly given over the titration period. Three-times-per-day dosing was used in the titration (and typically during treatment) in which the full dose was given in the morning and at lunch, and a half dose in the mid-afternoon. Parent and teacher daily ratings were collected during the titration; graphs portraying the results were rated by a cross-site panel of experienced clinicians. A “best dose” was chosen and the blind was broken; that dose became the initial dose for treatment. If the dose chosen was placebo, alternative medications were openly titrated until a satisfactory medication was chosen (or in the case of a robust placebo response the child was not medicated). Approximately 89% of youth assigned to MedMgt or Comb successfully completed titration; of these, 68.5% were assigned to initial doses of methylphenidate averaging 30.5 mg/day given three times per day; of the remaining group of youth who completed titration but were not started on methylphenidate, 26 received an unblinded titration of dextroamphetamine because of unsatisfactory methylphenidate response and 32 were given no medication because of a robust placebo response. Of note is that of the 289 subjects assigned to MedMgt or Comb, 17 families refused titration, another 15 subjects did not complete titration (11 due to side effects or problems with titration) and 4 had inadequate amounts of titration data gathered.

Youth assigned to the CC condition received no intervention by the MTA staff, but sought treatment as usually provided in the community. Referrals to non-MTA providers were made as necessary for these families; all CC youth and families returned for assessments at the same time as youth in the other three conditions of the study. Initially, it was thought that the CC group would provide a minimal- or no-treatment comparison group. However, as described later in this section, about two-thirds of the children in the CC group received medication for ADHD.

Outcomes in this study were assessed using a large number of measures in multiple domains, including verbal-report information (via interview and paper/pencil measures) by parents, teachers, and children; direct observation in the clinic and school; and computerized assessments of attention. Given the large number of measures, settings, and informants used in the study, data reduction methods were conducted to condense measures into outcome domains. The major outcome domains that have received attention in the literature are:

Major Findings from the MTA on ADHD Symptoms

All four MTA groups showed symptom reduction over time. In our opinion, the trends in the data favored the Comb treatment over the other three conditions, but this conclusion may depend on how those data are analyzed. When using an idiographic approach that looks at individual outcomes, there is a clear advantage of combined treatment. A categorical measure of treatment outcome was created based on composite ADHD and ODD symptom scores from teachers and parents using the SNAP-IV. Successful treatment was identified as scoring on average 1 or below on a composite SNAP score at the end of treatment (representing symptoms falling in the “not at all” or “just a little” range of categories at treatment endpoint). Success rates were as follows: 68% for combined treatment (Comb), 56% for medication management alone (MedMgt), 34% for behavioral treatment alone (Beh), and 25% for treatment as usual in the community (CC). A similar, but less robust, pattern of results was observed at the 24-month follow-up. Specifically, the normalization rates were 48%, 37%, 32%, and 28%, for Comb, MedMgt, Beh, and CC respectively.

Another way to look at the MTA data is in terms of statistical significance of the group means, which is the analysis that has received the most attention in the published literature. When using this approach on the 14- and 24-month follow-up data, the MTA Collaborative Group reached the conclusion that treatments involving MedMgt (i.e., MedMgt and Comb) were superior to those that did not have the intensive medication management (i.e., Beh and CC). Based on significance tests of means, the Beh and CC conditions were statistically equivalent. Likewise, the MedMgt and Comb groups were comparable, thus indicating no advantage of Comb relative to intensive MedMgt. A few comments on these findings are warranted.

Some effects on ADHD symptoms were apparently mediated by medication effects. Therefore, it is important to note that 67% of the children in the CC group were taking medication. Thus, the CC group was an active treatment group rather than a no-treatment control. Thus, the group that received only behavior modification (Beh) was being compared to the CC group that received medications in the community. It is also important to consider the implications of the fact that there were some substantial differences in the doses of medication across the treatment groups. For instance, at the 14-month follow-up, the average daily dose for Comb was 31.2 mg while the average daily dose for MedMgt was 37.7 mg. Given that Comb and MedMgt had identical medication titration procedures, the difference in dose at 14-months suggests that the intensive behavioral intervention allowed individuals to take lower doses of medication. Lower doses are a considerable therapeutic advantage because most stimulant side effects, including the mild growth suppression observed in the MTA, are dose dependent (i.e., lower doses lessen the risk and severity of side effects).

When examining the group data, it is tempting to conclude that the MedMgt condition was superior to CC, even though most of the CC participants were medicated. Such a conclusion implies that the package of procedures in the MedMgt protocol, which includes monthly supportive contact and decisions supported by high-quality data, is superior to routine community care. Indeed, this has been one of the major messages from the MTA Cooperative group. However, it is noteworthy that the average dose of the CC group that sought treatment in the community was 22.6 mg/day. The fact that children receiving intensive medication management in the MTA (i.e., MedMgt and Comb) were taking the equivalent of 10 mg to 15 mg more methylphenidate each day than the community control group is perplexing. In this situation, it is unclear if the higher dose or some other aspect of the MedMgt intervention, such as dosing three times per day in some cases, resulted in the better outcomes.

were faded out by study endpoint. Due to this unequal treatment activity, it is plausible that the comparison of Beh and Comb to MedMgt at the 14-month follow-up may have been biased in favor of the MedMgt. This issue has been argued on theoretical grounds and is consistent with the observation that the therapeutic effect size of intensive MedMgt diminished by 50% from the intensive phase to the follow-up phase (i.e., from the 14- to 24-month follow-up).

In my reading of the MTA data, as the fading out becomes an increasingly distant past event, the trend in the data seems to be for the Comb group to outperform the other groups. However, according to the MTA Collaborative Group’s statistical conclusion criteria, the differences between Comb and MedMgt are not statistically significant. Moreover, it appears that all treatments have declined in effectiveness at all subsequent follow-ups. Therefore, my conclusions regarding the superior efficacy of combined treatment in the MTA are open to alternative interpretation, particularly in light of another multi-site study discussed below.

The New York-Montreal Multi-Modal Treatment Study

Although completed prior to the MTA study, the results of another multi-modal treatment study involving large samples and several treatment sites have recently been reported that conflict with the findings of the MTA study concerning the benefits of combined treatment over medication-management alone. The New York-Montreal (NYM) study selected 103 children with ADHD (ages 7-9) who were free of conduct and learning disorders and who had shown an initial positive response to methylphenidate (MPH) during a short-term trial. Hence, unlike the MTA study, the NYM study focused exclusively on stimulant-responsive children having far less comorbidity. These children were randomly assigned to receive two years of treatment in one of three treatment arms: (1) MPH alone; (2) MPH plus intensive multi-modal psychosocial treatment; or (3) MPH plus an attention-placebo psychosocial treatment. The latter approach to controlling for professional attention was not used in the MTA study. The intensive two-year psychosocial treatment consisted of BPT, parent counseling, social skills training, psychotherapy, and extra academic assistance. Treatment contact during the first year of treatment was twice weekly, with fading of treatment to a considerable degree during the second year.

Assessments involved parent, teacher, and psychiatrist ratings, children’s self-ratings, children’s ratings of their parents, observations collected in school settings, and academic tests. The domains assessed included symptoms of ADHD and other behavioral problems (ODD), home and school functioning, social functioning, and academic performance. The results were consistent across all domains. No support was found for combining intensive psychosocial treatments of any sort with MPH in children with ADHD initially shown to be responsive to MPH. Nor was it found that MPH could be discontinued successfully in those who were receiving the combination treatment. Thus, it appears that the set of psychosocial treatments used in this study produced no incremental benefit in children shown to be strong and unambiguous responders to stimulant medication. Although the authors made some statements that there may have been improvement from MPH, the study was not designed to test for benefit from medication. Uncontrolled confounds, such as maturation or regression to the mean, are plausible alternative explanations for what may seem like sustained improvement associated with MPH across the two years of treatment.

In contrast to the MTA study, this study did not include treatment within the children’s normal school setting nor did the children attend an intensive summer treatment program. Also unlike the MTA study, this study intervened over a 24-month rather than a 14-month period. Lacking in both the MTA and the New York Montreal (NYM) study was documentation that the psychosocial treatments were effective. This contrasts with the assessment of medication effects, because each child received very well-controlled individualized trials that determined whether medication worked. Based on the review in previous sections of this paper, several of the interventions in the NYM study are not thought to be effective for children with ADHD (e.g., social skills training and individual therapy). Furthermore, although the behavioral parent training was shown to achieve significant improvements in knowledge of behavioral methods, there was no reported change in parenting behavior. Thus, there was no evidence that the psychosocial treatments met the requirement of showing activity at the point of performance.

Overall, the results of the NYM study may not be a fair comparison because grade A treatment with methylphenidate was compared with psychosocial treatments of unknown quality. A reasonable comparison of medication and psychosocial treatment should pit equivalent quality treatments against each other (i.e., grade A medication and grade A psychosocial treatments). Such studies need to document that both treatments were delivered as intended with appropriate implementation at the point of performance. This is key with medication, because according to the NYM study, poor compliance as seen with the discontinuation probe very rapidly results in deterioration. Psychosocial treatments should be evaluated with equal rigor, such as experimental analysis of the effectiveness of behavior contingencies by using reversal designs in context in individual case studies. To our knowledge, no such study has yet been conducted, but some insights might be gained for further analysis of compliance data in the MTA and NYM studies. Until studies of the highest quality interventions and the most rigorous quality control are implemented and proper analyzed, there will be lingering questions about the relative merits of intensive multimodal treatment relative to excellent medication management for the treatment of ADHD and related problems.

Efficacy, Safety, and Practicality of Combined Treatment

Using the grading system for level of empirical validation described at the beginning of this course, I give the combination of stimulant medication and behavioral intervention the grade of B or lower. Let me clarify. Although the literature indicates that each of these treatments separately deserves a grade of A, what is being graded here is the superiority of their combination relative to either alone, based on the evidence. Is the evidence for the combined treatment sufficient to warrant this grade? Combined treatments have been shown to be superior to uni-modal treatment on some measures in some subsets of ADHD children in at least two well-designed studies by independent investigators. However, the recent NYM study that found no advantages of intensive multi-modal treatment may raise some doubts. Due to the relative methodological strengths of the MTA compared to the NYM study, I believe that greater weight should be given to the MTA study. Unfortunately, the studies that support the efficacy of combined treatment were conducted in research settings that do not necessarily replicate the “real world” settings in which most ADHD treatments are delivered. Thus, I am inclined to give intensive multi-modal treatment a grade of B for efficacy.

The grade of B to C for intensive multimodal treatment is also intended to convey the message that the practicality of combined treatments is unknown. Indeed, there are several reasons to believe that these treatments would be very difficult to replicate in most applied settings. For instance, the acceptance/attendance data from the MTA found 81% compliance for med component but only 64% compliance for behavioral component. This suggests that there are some important issues to work out related to therapist expectations and family participation in the treatment. Moreover, the studies of combined treatment used some very unique treatments that are difficult to find in many regions of the country or to replicate in applied clinical settings, such as Pelham and colleagues’ Summer Treatment Program. Until barriers to access to and participation in these treatments are overcome, the effectiveness of these treatments is open to doubt.

Generally speaking, combined treatment that uses family-based behavioral interventions and stimulant medication or atomoxetine should be very safe. There are some possible safety concerns related to the multimodal treatments of ADHD that have been studied. For example, some prominent theories related to conduct problems posit that placing children with behavior problems in groups with other disruptive children could lead to some harmful effects mediated by peer facilitation of antisocial behavior. This was recently found to occur in a social skills training program for ADHD children, particularly among those who were not manifesting significant conduct problems prior to treatment. Also, this author and colleagues have twice documented an adverse effect (escalation of conflicts) during behavioral family therapy for ADHD/ODD teens on a subset of participating families. Researchers studying behavioral interventions typically do not examine their data for such subsets of adverse responders, but should be encouraged by these results to do so. Two special issues of The ADHD Report (February and March, 2018) have focused on the myriad side effects associated with various psychosocial treatments for child and adult ADHD and I advise readers to study those reports to learn more about this topic that is in dire need of greater research.

Ineffective or Unproved Therapies

Numerous questionable treatments have been attempted with children with ADHD over the past century. Vestibular stimulation, biofeedback and relaxation training, and sensory-integration exercises among others, have been described as potentially effective in either uncontrolled case reports, small series of case studies, or in some-treatment vs. no-treatment comparisons, yet are lacking in well-controlled experimental replications of their efficacy. A meta-analysis of studies examining the benefits of physical exercise suggests that it may be preferentially beneficial for participants who are hyperactive and warrants further study of this effect in better-controlled research.

Two interventions that were once promising have not been supported by subsequent better-conducted research. These are EEG biofeedback (neurofeedback) and working memory training. EEG biofeedback or neurofeedback research has shown mixed results. Typically, impressive results are found by studies of low scientific rigor, such as evaluating participants merely pre- and post-treatment with no comparison to other treatments or blindness of raters to the treatment condition. But the more rigorous the methods of the study, the smaller and less likely are these results, particularly when actual EEG feedback is compared to sham EEG feedback. Thus, while some proponents of this treatment believe it has met the test of proven utility as a treatment for ADHD, we believe that more rigorous research finds far less benefit to this intervention. Clearly, more research is in order before the widespread adoption of this intervention for ADHD.

The status of research on working memory training is even less convincing. Initial studies by the developer were quite promising in showing that practicing working memory tasks for 45 minutes per day for weeks at a time resulted not only in improved working memory on related tasks, but also on ADHD symptoms as reported by parents and teachers. Subsequent studies, however, did not find such promising results and often found little evidence of generalization outside the treatment setting, especially to the school environment. Two reviews of this literature pointed out numerous shortcomings in the methodology of research into this treatment and concluded that far more research was needed to substantiate this intervention.

Many dietary treatments such as removal of additives, colorings, or sugar from the diet, or addition of high doses of vitamins, minerals, or other “health food” supplements to the diet, have proven very popular, and some reviews of research claim that there is evidence for their effectiveness. But a careful reading of such reviews and the existence of better-controlled research finds little or no scientific support. A recent meta-analysis of restrictive elimination diets finds that while some small improvements may be gained in eliminating artificial colors from children’s diets, the degree of improvement is quite modest, proving of value for only a minority of children with ADHD. Certainly, traditional psychotherapy and play therapy have not proven especially effective for ADHD.

Conclusion on Treatment

The treatment of children and teens with ADHD is an often complex and certainly longer-term enterprise than was previously thought to be necessary. Viewed now as a chronic disorder for most children, ADHD requires treatments that must be combined and sustained in order to have a long-term impact on the quality of life and developmental outcomes of these children. Treatments appear to succeed by temporarily reducing or normalizing symptoms for as long as treatments are in effect so as to reduce the numerous secondary harms associated with unmanaged ADHD. Though numerous therapies have been proposed for this disorder, those having the greatest empirical support are contingency-management methods applied in classrooms and elsewhere (summer camps); training of parents (BPT) in these same methods to be used in the home and elsewhere (community settings); psychopharmacology, particularly stimulants and atomoxetine; and to a lesser extent, the combination of behavioral treatments with medication.

Evidence for CBT is lacking at this time, while that for social skills training programs paints a mixed picture that is based mainly on studies having significant methodological limitations. Better-controlled and larger studies appear to show little or no treatment effects when the skills or behaviors are not cued and reinforced for occurring at the specific point of performance.

Popular treatments among laypeople, such as dietary manipulations, do not have compelling evidence for their efficacy, nor do several other professionally popular treatments, such as sensory integration training.

Most cases require a combination of the more effective treatments in order to provide effective management of the disorder and its comorbid conditions. Among children who are already stimulant-responsive, it is not clear to what extent intensive psychosocial treatments provide added benefit. Interventions will need to be of high quality and sustained over several years (or more), and re-intervention is highly likely as new developmental transitions occur and new domains of potential impairment now become available to the individual with ADHD across the lifespan.

Appendix

(Note: If you clicked a link to these Tables in the text of the course, click the back arrow of your internet browser to return to the text.)

Table 3. FDA-Approved Medications for ADHD Children

 

Methylphenidate formulations

Medication

Dose Range (mg/day)

Delivery System

Duration of Effect

FDA Approved Age

Comments

Short-acting formulations

Methylphenidate (Ritalin)

2.5 mg to 60 mg

Tablet

3 to 4 hours

Children ≥ 6 years

Give in multiple daily doses

Methylphenidate (Methylin)

5 mg to the lesser of 2.0 mg/kg/d or 60 mg

Solution*/chewable tablet

4 hours

Children ≥ 6 years

Give in multiple daily doses

d-Methylphenidate (Focalin)

2.5 mg to the lesser of 1.0 mg/kg/d or 20 mg

Tablet

4 hours

Children ≥ 6 years

Give in multiple daily doses

Intermediate-acting formulations

Methylphenidate (Ritalin SR)

20 mg to 60 mg

Slow-release tablet

5 to 6 hours

Children ≥ 6 years

Give in two daily doses

Methylphenidate (Metadate ER)

10 mg to the lesser of 2.0 mg/kg/d or 60 mg

Beaded capsule

6 to 8 hours

Children ≥ 6 years

Single-dose coverage for school hours

Methylphenidate (Methylin ER)

10 mg to the lesser of 2.0 mg/kg/d or 60 mg

Beaded capsule

6 to 8 hours

Children ≥ 6 years

Single-dose coverage for school hours

Methylphenidate (Ritalin LA)

10 mg to 60 mg

Beaded capsule

7 to 9 hours

Children ≥ 6 years

Single-dose coverage for school hours. May open capsule and sprinkle beads on applesauce.

Methylphenidate (Metadate CD)

10 mg to the lesser of 2.0 mg/kg/d or 60 mg

Beaded capsule

8 to 9 hours

Children ≥ 6 years

Single-dose coverage for school hours

Long-acting formulations

Methylphenidate (Concerta)

18 mg to the lesser of 2.0 mg/kg/d or 72 mg

OROS capsule

9 to 12 hours

Children ≥ 6 years

Single-dose coverage for school and after school hours

d-Methylphenidate (Focalin XR)

5 mg to the lesser of 1.0 mg/kg/d or 30 mg

Beaded capsule

9 to 12 hours

Children ≥ 6 years

Single-dose coverage for school and after school hours. May open capsule and sprinkle beads on applesauce.

Methylphenidate (Quillivant XR)

20 mg to 60 mg

Solution**

9 to 12 hours

Children ≥ 6 years

Shake bottle vigorously for at least 10 seconds before each use.

Methylphenidate (Daytrana Patch)

10 mg patch strength to the lesser of 1.0 mg/kg/d or 30 mg patch strength

Multipolymeric adhesive patch system

9 to 12 hours

Children ≥ 6 years

Patch wear time up to 9 hours for 12 hour effectiveness. Switch patch placement on hip daily.

*Methylin Solution: 5 mg/5 ml and 10 mg/5ml
** Quillivent XR: 25 mg/5ml

Amphetamine formulations

Medication

Dose Range (mg/day)

Delivery System

Duration of Effect

FDA Approved Age

Comments

Short-acting formulations

Mixed Amphetamine Salts (Adderall)

2.5 mg to the lesser of 1.0 mg/kg/d or 40 mg

Tablet

5 to 6 hours

Children ≥ 3 years

Give once or twice-daily

Amphetamine (Dexedrine)

2.5 mg to 40 mg

Tablet

4 hours

Children ≥ 3 years

Give in multiple daily doses

Amphetamine (Dextrostat)

2.5 mg to 40 mg

Tablet

4 hours

Children ≥ 6 years

Give in multiple daily doses

Long-acting formulations

Mixed Amphetamine Salts (Adderall XR)

5 mg to the lesser of 1.0 mg/kg/d or 30 mg

Beaded capsule

10 hours

Children ≥ 6 years

Single-dose coverage for school hours. May open capsule and sprinkle beads on applesauce.

Amphetamine (Dexedrine Spansule)

5 mg to the lesser of 1.0 mg/kg/d or 40 mg

Capsule

10 hours

Children ≥ 6 years

Single-dose coverage for school hours

Lisdexamfetamine (Vyvanse; prodrug)

20 mg to the lesser of 1.0 mg/kg/d or 70 mg

Capsule

10 hours

Children ≥ 6 years

Single-dose coverage for school hours

Nonstimulant formulations


Medication

Dose Range (mg/day)

Delivery System

Duration of Effect

FDA Approved Age

Approved for Co-Administration With Stimulants?

Comments

Atomoxetine (Strattera)

0.5 mg/kg/d to the lesser of 1.4 mg/kg/d or 100 mg

Capsule

24 hours

Children ≥ 6 years and adolescents

No

Give once-daily or in two evenly divided daily doses

Guanfacine XR (Intuniv)

1 mg to 4 mg

Extended release tablet

24 hours

Children ≥ 6 years and adolescents

Yes

May give dose in AM or evening

Clonidine ER (Kapvay)

0.1 mg to 0.4 mg

Extended release tablet

12 hours

Children ≥ 6 years and adolescents

Yes

Must give twice-daily in two evenly divided doses. If unequal doses give the higher dose at bedtime.

 

Table 4. The Six Stimulant Delivery Systems

Five of the six different delivery systems are the 5 Ps – pills, pumps, pellets, patches, and pro-drug. The sixth is a delayed release formulation. The various brand names of ADHD medicines clinicians will hear about are either one form or another of MPH or AMP and involve one of these delivery systems:

Pills: These are the original versions of these medicines that have been available for many decades. The first versions of AMP were discovered in the 1930s while the first version of MPH was discovered in the 1950s. In pill form, these medications are absorbed quickly, usually within 15-20 minutes, after being taken by mouth and swallowed. They can reach their peak level in the blood (and so in the brain) in 60-90 minutes usually, and may last three to five hours in controlling the symptoms of ADHD in most people. That was their problem. If clinicians wanted to control the symptoms of ADHD across the waking day of say 14-16 hours for most adults, clinicians had to give these medications two to four times per day or more often. The inconvenience that posed for people having to take these drugs is obvious, not to mention the fact that many had to remember to take these drugs so often they frequently forgot to do so. These and other problems with these immediate release pills led pharmaceutical companies to explore better ways to get the medicines into the body and keep them active there longer. The brand names clinicians are likely to hear about for these pills are Ritalin® (MPH, a mixture of d-MPH and l-MPH), Focalin® (just d-MPH), Dexedrine® (d-AMP), Benzedrine® (l-AMP), and Adderall® (a mixture of the d- and l-AMP forms or salts).

The Pump: Then came the invention of an ingenious water-pump system for delivering these drugs into the body and keeping them in the blood stream longer. The brand name for this system is Concerta® and it contains MPH. It is a capsule-appearing container with a small laser-drilled hole on one of its long ends. Inside there are two chambers. One chamber contains a paste-like sludge of MPH, and the other chamber is empty. There is also powdered MPH coating the outside of the capsule. Now here is the neat part: when clinicians swallow the capsule, the powder goes right to work just as it would in the pill form of MPH described above (i.e., Ritalin). That gives just enough time for the capsule to start to absorb water from your stomach (and later your intestines). The water is absorbed through the wall of the pump in a continuous, even flow into the empty chamber. As that chamber fills up, it presses against the other chamber that contains the MPH paste. That pressure then squeezes the MPH paste out of the hole in the capsule. It is designed to do that continuously for 8-12 hours or more. The end result is that many people, especially children, only need to take one capsule a day, and not the usual two to three (or more) they would have to take using the regular pills discussed above. The capsules come in various size doses of course so that physicians can adjust the dose to better suit the individual needs and responses of their ADHD patients. One problem though is that some older children and teens, and especially adults, may need a longer course of medication each day than what this provides. To deal with that issue, some physicians use the pills of MPH or AMP toward the end of the day. They do this to get an extra three to five hours of treatment with medication after the Concerta® may be losing its beneficial control of ADHD symptoms. Even so, clinicians just have to love the human ingenuity that led to the development of this delivery system.

The Pellets: At around the same time as the water-pump method was being invented, chemical (pharmacological) engineers were modifying a method that uses time-release pellets to create a way to keep medicines in the body and blood stream longer than the pills. This method had been used for years with some cold medicines, like the old Contac brand. But the system had to be modified in various ways for use with MPH and AMP. Now we have time-release pellets for both of these stimulants. Little beads of the drug are coated in such a way that some dissolve immediately after being swallowed, others dissolve one, two, three, or more hours later. This means that the drug can be more gradually activated and absorbed into the blood stream across 8-12 hours for most people. Here is another ingenious delivery system. It has the added advantage that if someone simply cannot or does not want to swallow the capsule that contains these pellets, they can open the capsule (pull it apart) and sprinkle it on a teaspoon of applesauce, yogurt, or other food and swallow it that way. It does not change the way the drug will work in the body, typically. Clinicians may have heard of these delivery systems by the brand names of Ritalin LA® (MPH), Focalin XR® (d-MPH), Medadate CD® (MPH), and Adderall XR® (AMP) here in the U.S. Again, there are different sizes (doses) to these capsules to permit a physician to adjust the dose for each individual to their optimum level. Like the water-pump method above, these time-release pellet systems sometimes have to be supplemented late in the day with a regular or immediate-release pill version of the same drug. That permits even longer symptom control if necessary. Some research exists that shows that this pellet system gives a little better control of ADHD symptoms in the morning than afternoon hours. In contrast, the pump system above provides a bit better control in the afternoon than morning hours. Both delivery systems provide good control of ADHD symptoms across the day but not at exactly the same hours of the day. This can be an issue sometimes in deciding which delivery system may be better for someone depending on when they need the greatest control of their ADHD symptoms during the day.

The Patch: The next invention of a delivery system for the stimulants was FDA-approved just a few years after the two above (pump and pellet). It is a patch with an adhesive coating that is applied directly to the skin, such as on the back of one’s shoulder or on the buttocks. The patch contains MPH. When applied to the skin, the MPH is absorbed through the skin and gets into the blood stream by that means. So long as clinicians wear the patch, MPH is being delivered into the body for as many hours during the day as one wants to do so. Because the stimulants can cause insomnia or trouble falling asleep, the patch needs to be removed several hours before bedtime to permit the drug left in the body to be broken down and removed without adversely affecting the onset of sleep. This delivery system used to go by the brand name Daytrana® (MPH), but the patent on the device is up for sale and may be purchased by another company and renamed in the future. Here is another clever invention for getting the stimulants into the blood stream and keeping them there for a sufficient time to control the symptoms of ADHD across most of the waking day. It has the advantages of not needing to be swallowed and of delivering the medicine into the blood stream as long as clinicians are wearing the patch that day. Of course, the disadvantage is that clinicians have to remember to take the patch off well before clinicians want to go to sleep. Another problem is that 15%-20% of people experience a skin rash at the site of the patch and may need to stop using the patch for this reason. As with the drugs above, the patch comes in different doses to better adjust the amount of the drug to each individual.

The Pro-Drug: In 2008, another delivery system received FDA-approval for use with adults with ADHD, and that system goes by the brand name of Vyvanse® (a form of AMP). Here is yet a further example of human inventiveness. One of the problems with the immediate release pills as well as the pellet systems discussed above is that they have the potential to be abused. That is usually done by crushing and inhaling the powder from the pills or the crushed beads from the pellet systems. That powder can also be mixed with water and injected into a blood vein. Whether snorted through the nose or injected into a vein, the stimulants get into the blood very quickly and so into the brain very rapidly. It is this rapid invasion of the brain by the drug and nearly as rapid decrease in certain brain regions that creates the “rush” or euphoria that people can experience with stimulants delivered in this fashion. This does not occur from the oral ingestion of the drug. This problem led a small biotech company near Albany, NY to invent a method in which the AMP (d-amphetamine) is locked up so that it cannot be activated unless it is in the human stomach or intestines. They achieved this by bonding a lysine compound to the d-AMP. This bonding of an active drug to another compound alters its typical pattern of activation and is called a pro-drug by the FDA. In this form, the AMP is inactive and will remain so until it is swallowed. Then, in the stomach and intestine and its blood supply, there is a chemical that naturally occurs there that splits the lysine from the d-AMP. Then the d-AMP can go to work and be absorbed into the blood stream. The drug is designed in such a way that the d-AMP lasts 10-14 hours, typically. This delivery system greatly reduces the abuse potential of this version of AMP while providing for the desired longer time course of action from a single dose.

The Delayed Onset Formulations: In 2018, the FDA approved a new medication delivery system that can be taken at bedtime and that will reliably activate the next morning, typically nine hours later. This system has been developed for delivery of both methylphenidate and amphetamines. Once activated, the system maintains therapeutic blood levels of these medications across the day and into evening hours.

Resources and References

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Achenbach, T. M. (1991/2001). Child Behavior Checklist – Cross-Informant Version. (Available from Thomas Achenbach, PhD, Child and Adolescent Psychiatry, Department of Psychiatry University of Vermont, 5 South Prospect Street, Burlington, VT 05401)

Achenbach, T. M. (2001). Manual for the Teacher Report Form and the Child Behavior Profile. Burlington, VT: Thomas Achenbach.

Achenbach, T. M., McConaughy, S. H., & Howell, C. T. (1987). Child/adolescent behavioral and emotional problems: Implications of cross informant correlations for situational specificity. Psychological Bulletin, 101, 213-232.

American Academy of Pediatrics (2011). ADHD: Clinical practice guideline for diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, Online first, doi:10.1542/peds.2011-2654.

American Academy of Child and Adolescent Psychiatry (2008). Practice parameter for the use of stimulant medications in the treatment children, adolescents, and adults. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 2 Supplement, 26S-49S.

American Psychiatric Association (2013). Diagnostic and Statistical Manual for Mental Disorders (5th edition, text revision). Washington, DC: American Psychiatric Association.

Banaschewski, T., Coghill, D. & Zuddas, A. (2018)_(Eds.), Oxford Textbook of Attention Deficit Hyperactivity Disorder (pp. 94-102). London: Oxford University Press.

Barkley, R. A. (1997). ADHD and the nature of self-control. New York: Guilford.

Barkley, R. A. (1997). Understanding the defiant child. (Videotape). New York: Guilford.

Barkley, R. A. (1997). Managing the defiant child. (Videotape). New York: Guilford.

Barkley, R. A. (2001). Taking charge of ADHD: The complete authoritative guide for parents. New York: Guilford.

Barkley, R. A. (2011). The Barkley Adult ADHD Rating Scale – IV. New York: Guilford Press.

Barkley, R. A. (2012). The Barkley Deficits in Executive Functioning Scale – Children and Adolescents. New York: Guilford Press.

Barkley, R. A. (2012). The Barkley Functional Impairment Scale – Children and Adolescents. New York: Guilford Press.

Barkley, R. A. (2012). Defiant children: A clinician’s manual for parent training. New York: Guilford Press.

Barkley, R. A. (2012). The executive functions: What they are, how they work, and why they evolved. New York: Guilford Press.

Barkley, R. A. (2013). Defiant Children: A Clinicians Manual for Parent Training (3rd edition). New York: Guilford Press.

Barkley, R. A. (2015). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment. New York: Guilford Press.

Barkley, R. A. & Benton (2013). Your Defiant Child: 8 Steps to Better Behavior. New York: Guilford Press

Barkley, R. A., DuPaul, G. J., & McMurray, M. B. (1990). A comprehensive evaluation of attention deficit disorder with and without hyperactivity. Journal of Consulting and Clinical Psychology, 58, 775-789.

Barkley, R. A., Edwards, G., & Robin, A. L. (2013). Defiant teens: A clinician’s manual for assessment and family intervention. New York: Guilford Press.

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Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in Adults: What the Science Says. New York: Guilford Press.

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CHADD (2001). The CHADD Information and Resource Guide to AD/HD. Landover, MD: CHADD (301-306-7070; chadd.org)

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McConaughy, S. H., & Achenbach, T. M. (2009). Manual for the ASEBA Direct Observation Form. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families.

McConaughy, S. H., Ivanova, M., Antshel, K., & Eiraldi, R. B. (2009). Standardized observational assessment of Attention Deficit/Hyperactivity Disorder Combined and Predominantly Inattentive Subtypes: I. Test session observations. School Psychology Review, 38, 45-66.

MTA Cooperative Group (2004a). National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: 24-month outcomes of treatment strategies for Attention-Deficit/Hyperactivity Disorder. Pediatrics, 113, 754-761.

MTA Cooperative Group (2004b). National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: Changes in effectiveness and growth after the end of treatment. Pediatrics, 113, 762-769.

Nigg, J. T. (2006). What Causes ADHD? New York: Guilford Press.

Papolos D, Hennen J, Cockerham MS, Thode HC, Jr., Youngstrom EA. (2006). The child bipolar questionnaire: a dimensional approach to screening for pediatric bipolar disorder. Journal of Affective Disorders, 95, 149-58.

Pliszka, S. R. (2009). Treating ADHD and comorbid disorders: psychological and psychopharmacological intereventions. New York: Guilford Press.

Reynolds, C., & Kamphaus, R. (2005). Behavioral Assessment System for Children - 2. (Available from American Guidance Service, 4201 Woodland Road, Circle Pines, MN 55014)

Robin, A. L. (1998). ADHD in adolescents: Diagnosis and treatment. New York, NY: The Guilford Press.

Robin, A. R., & Foster, S. (1989). Negotiating parent-adolescent conflict. New York: Guilford.

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Websites

Dr. Barkley: russellbarkley.org, adhdlectures.com
Dr. Barkley’s personal website containing fact sheets on ADHD, his speaking schedule, and information about his various books and newsletter. ADHDLectures.com contains 10 hours of lectures for parents and 25 hours for professionals addressing various topics related to ADHD and its management, all of which can be viewed for free.

ADD Warehouse: addwarehouse.com
Lists a variety of books, videos, and other products related to ADHD for sale.

American Academy of Child & Adolescent Psychiatry: aacap.org
Official website which also contains a separate directory of fact sheets on childhood and adolescent mental disorders.

American Academy of Pediatrics: aap.org
Official website on which one can find some factual information about ADHD and other developmental disorders.

ADDA Organization (Attention Deficit Disorders Association): add.org
This organization advocates for those with ADHD and has, over time, come to focus more on adults with the disorder.

ADD Resources: addresources.org
A nonprofit organization dedicated to providing information on ADHD. The website claims to host hundreds of service providers and its Information Site has a carefully curated assortment of articles, guides and helpful tips for ADHD, not to mention countless hours of recorded broadcasts and seminars.

CHADD Organization (Children and Adults with ADHD): chadd.org
The U.S. national nonprofit organization dedicated to advocating for children and adults with ADHD and their families. Contains fact sheets on ADHD, a directory of state and local CHADD chapters, and information on its annual conferences.

Every Day Health: everydayhealth.com/adhd/adult-adhd.aspx
Sponsored by Everyday Health Media, this page of this website has information on the symptoms and treatments for ADHD. The website does accept advertisements for products in the ADHD marketplace.

Help Guide: helpguide.org
Bills itself as a trusted non-profit guide to information on mental health and well-being created to the memory of Morgan Segal whose suicide may have been prevented by having better, factual information on mental health disorders and their treatment. The website notes that it collaborates with the Harvard Medical School concerning information posted to the site.

WebMD: webmd.com
This is a for-profit website providing information on many medical and mental health disorders including ADHD.

 

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