cont. from

American Association of Pediatrics Clinical Practice Guideline:
Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder

Behavior Therapy

Behavior therapy represents a broad set of specific interventions that have a common goal of modifying the physical and social environment to alter or change behavior. Along with behavior therapy, most clinicians, parents, and schools address a variety of changes in the child's home and school environment, including more structure, closer attention, and limitations of distractions. Such environmental modifications have not undergone careful efficacy assessment, but most treatment plans include them.

Behavior therapy usually is implemented by training parents and teachers in specific techniques of improving behavior. Behavior therapy then involves providing rewards for demonstrating the desired behavior (eg, positive reinforcement) or consequences for failure to meet the goals (eg, punishment). Repetitive application of the rewards and consequences gradually shapes behavior. Although behavior therapy shares a set of principles, it includes different techniques with many of the strategies often combined into a comprehensive program.

Behavior therapy should be differentiated from psychological interventions directed to the child and designed to change the child's emotional status (eg, play therapy) or thought patterns (eg, cognitive therapy or cognitive-behavior therapy). Although these psychological interventions have great intuitive appeal, they have little documented efficacy in the treatment of children with ADHD,56 and gains achieved in the treatment setting usually do not transfer into the classroom or home. By contrast, parent training in behavior therapy and classroom behavior interventions have successfully changed the behavior of children with ADHD.⁶

Parent training typically begins with 8 to 12 weekly group sessions with a trained therapist. The focus is on the child's behavior problems and difficulties in family relationships. A typical program aims to improve the parents' or caregivers' understanding of the child's behavior and teach them skills to deal with the behavioral difficulties posed by ADHD. Programs offer specific techniques for giving commands, reinforcing adaptive and positive social behavior, and decreasing or eliminating inappropriate behavior. Programs plan for maintenance and relapse prevention. Parent training improves the child's functioning and decreases disruptive behavior but (as with stimulant medications) does not necessarily bring the behavior of a child with ADHD into the normal range on parent rating scales.^56-57

Classroom management also focuses on the child's behavior and may be integrated into classroom routines for all students or targeted for a selected child in the classroom. Classroom management often begins with increasing the structure of activities. Systematic rewards and consequences, including point systems or use of token economy (see Table 2), are included to increase appropriate behavior and eliminate inappropriate behavior. A periodic (often daily) report card can record the child's progress or performance with regard to goals and communicate the child's progress to the parents, who then provide reinforcers or consequences based on that day's performance. Classroom behavior management also may improve a child's functioning but may not bring the child's behavior into the normal range on teacher behavior rating scales.⁵⁷ Table 2 outlines specific behavior therapies that have been demonstrated as effective for ADHD.¹⁷

Evidence for the effectiveness of behavior therapy in children with ADHD comes from a variety of studies. The diversity of interventions and outcome measures makes meta-analysis of the effects of behavior therapy alone or in association with medications very difficult. Double-blind, randomized, placebo-controlled trials are difficult to perform, in part because of the difficulty of keeping examiners and participants unaware of whether the child is receiving treatment or placebo. Thus, the usual evidence-based medicine searches turn up few studies for review.2 Alternative experimental methods, such as rigorous single-subject designs, are used frequently in the psychological literature. Studies that compare the behavior of children during periods on and off behavior therapy demonstrate the effectiveness of behavior therapy¹⁷; however, behavior therapy has been demonstrated to be effective only while it is implemented and maintained.

A number of individual studies indicate positive effects of behavior therapy in addition to medications. Almost all studies comparing behavior therapy with stimulants alone indicate a much stronger effect from stimulants than from behavior therapy. When comparing behavior therapy to stimulant medications, efficacy of their combined treatment could not be demonstrated to be greater than medication alone for the core symptoms of ADHD.2 The MTA study3 found that the combined treatment (medication management with behavior therapy), compared with medication alone, offered improved scores on academic measures, measures of conduct, and some specific ADHD symptoms (although not on global ADHD symptom scales). Although these trends were consistent, few reached statistical significance. In addition, parents and teachers of children receiving combined therapy were significantly more satisfied with the treatment plan.^13,14,^58-60

A wide range of clinicians, including psychologists, school personnel, community mental health therapists, or the primary care clinician, can implement behavior therapy directly or train others to implement behavior therapy. Many clinicians prefer to refer to community resources for behavior therapy because behavior therapy with parents is time-consuming and often does not lend itself to the structure and schedule of the primary care office. Schools may provide behavior therapy with teachers in the context of a Rehabilitation Act (Section 504) plan or an individual education plan. Where ADHD has a significant impact on a child's educational abilities, Section 504 requires schools to make classroom adaptations to help children with ADHD function in that setting. Adaptations may include preferential seating, decreased assignment and homework load, and behavior therapy implemented by the teacher.

RECOMMENDATION 4: When the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and presence of coexisting conditions (strength of evidence: weak; strength of recommendation: strong).

Most school-aged children with ADHD respond to a therapeutic regimen that includes stimulant medications and/or behavioral/environmental interventions. As noted in 3A, when one stimulant medication appears ineffective (despite appropriate titration), clinicians should carry out a trial of a second stimulant medication. Continuing lack of response to treatment may reflect 1) unrealistic target symptoms; 2) lack of information about the child's behavior; 3) an incorrect diagnosis; 4) a coexisting condition affecting the treatment of the ADHD; 5) lack of adherence to the treatment regimen; or 6) a treatment failure. As discussed previously, treatment of ADHD, while decreasing a child's level of impairment, may not fully eliminate the core symptoms of inattention, hyperactivity, and impulsivity. Similarly, children with ADHD may continue to have difficulties with peer relationships despite adequate treatment, and treatment for ADHD frequently shows no association with improvements in academic achievement as measured by standardized instruments.

Evaluation of treatment outcomes requires a careful collection of information from multiple sources, including parents, teachers, other adults in the child's environment (eg, coaches), and the child. If the target symptoms are realistic and the lack of effectiveness is clear, the primary care clinician should reassess the accuracy of the diagnosis of ADHD. This reassessment should include review of the data initially obtained to make the diagnosis, as described in the AAP clinical practice guideline for the diagnosis of children with ADHD.1 Reassessment usually will require gathering new information from the child, school, and family about the core symptoms of ADHD and their impact on the child's functioning. Clinicians should reconsider other conditions that can mimic ADHD.

Treatment plans for ADHD typically require children, families, and schools to enter into a long-term plan that includes a complex medication schedule along with environmental and behavioral interventions. Environmental and behavioral interventions will require ongoing efforts by parents, teachers, and the child. A common cause of nonresponse to treatment is lack of adherence to the treatment plan. Ongoing monitoring of a child's progress should assess the implementation of the plan and determine key problems with, and barriers to, implementation. The clinician should assess adherence to medication and behavior therapy. Lack of adherence is not the equivalent of treatment failure; clinicians should help families find solutions to adherence problems before considering a plan as a failure.

The following can be considered true treatment failure: 1) lack of response to 2 or 3 stimulant medications at maximum dose without side effects or at any dose with intolerable side effects; 2) inability of behavioral therapy or combination therapy to control the child's behaviors; and 3) the interference of a coexisting condition. In each of these situations, referral to mental health specialists who are knowledgeable about behavioral interventions in children is the next step unless the primary care clinician has expertise and experience in managing these situations.

RECOMMENDATION 5: The clinician should periodically provide a systematic follow-up for the child with ADHD. Monitoring should be directed to target outcomes and adverse effects by obtaining specific information from parents, teachers, and the child (strength of evidence: fair; strength of recommendation: strong).

Clinicians should establish a plan for periodic monitoring of the effects of treatment. Research on adherence to medical regimens in chronic diseases highlights the importance of identifying patient and family concerns and goals and jointly designing a management plan in a way that addresses these concerns and promotes these goals.61 Plans should include obtaining information about target behaviors, educational output, and medication side effects periodically through office visits, written reports, and phone calls. Monitoring data should include the date of refills, the medication type, dosage, frequency, quantity, and responses to treatment (both medication and behavior therapy). Data can be recorded in a flow sheet, ideally, or in a progress note within each patient's chart. The plan also should include a system for communication among parent, child, and clinician between visits as well as a method for periodic contact with the teacher or other school personnel before a follow-up visit. The monitoring plan should consider normal developmental changes in behavior over time, educational expectations that increase with each grade, and the dynamic nature of a child's home and school environment, because changes in any of these factors may alter target behaviors. All participants should share the plan agenda. Clinicians should provide information and support at frequent intervals in a way that enables the child and family to make informed decisions that promote the child's long-term health and well-being.

Information about target symptoms will continue to come from the parents, child, and teacher. Office interviews, telephone conversations, teacher narratives, and periodic behavior report cards and checklists are among the methods used to obtain needed information. As with the diagnosis of ADHD, clinicians should have active and direct communication with schools. The MTA study indicates the benefit of teacher information over parent-derived information when titrating the medication to maximum benefit.3,62 Adherence to medication and the behavior therapy program should be reviewed at each encounter.

The frequency of monitoring depends on the degree of dysfunction, complications, and adherence. No controlled trials clearly document the appropriate frequency of follow-up visits. In the MTA trial, children in the medical management groups had better outcomes and more frequent follow-up than those in the standard community category, but whether the frequency of follow-up was a determining factor in outcomes cannot be determined from currently published materials.³ Once the child is stable, an office visit every 3 to 6 months allows for assessment of learning and behavior. These visits also allow assessment of potential side effects of stimulants, such as decreased appetite and alteration of weight, height, and growth velocity. Periodic requests for medication refills offer an additional opportunity for communication with the family. At the refill request, the family can be asked about the child's functioning in school and interpersonal relationships, as well as updates on communication from the school. If any of the follow-up evaluations reveal a decrease in the targeted outcomes, the clinician must first establish that the family is adhering to the treatment plan.

AREAS FOR FUTURE RESEARCH
Tailoring Treatments to Children and Outcomes

At the present time, the clinician's initial choice of a specific treatment program—the exact stimulant medication and the precise form of behavior therapy—is an area of uncertainty. Research to date has not shown clear advantages of one stimulant medication over others. The process of prescribing an effective and comprehensive plan based on the characteristics of the child and family and tailored in terms of type, intensity, and frequency would help clinicians to improve treatment plans. What is required is information relating specific sociodemographic characteristics (eg, age or sex) or clinical characteristics (eg, subtype of ADHD) to optimal responses to stimulant medication or type of behavior therapy. Moreover, relating treatments to specific behaviors or components of ADHD rather than the whole symptom complex would allow the clinician to better tailor the treatment plan.

Many children with ADHD have coexisting conditions, including anxiety, depression, oppositional defiant disorder, conduct disorder, and learning disabilities. The literature provides minimal information about how to treat these coexisting conditions in conjunction with ADHD and how the conditions affect the effectiveness and safety of treatments. Research on how ADHD and coexisting conditions interact to affect treatment and outcomes will help determine if children require multiple concurrent treatments. Such studies can identify sensible, effective, and comprehensive treatment plans for children with these conditions.

Expanded Treatment Options

A major research challenge pertaining to the treatment of ADHD is the development and evaluation of new treatments for this condition. The 2 current treatments (stimulant medication and behavior therapy) reduce the symptoms and functional consequences of ADHD, but only for as long as they are administered. Treatments with more lasting or even curative effects are needed. A significant number of children do not respond to stimulant medications or have severe side effects. Some families cannot implement behavioral programs. Expanding the available medical and behavioral treatment regimens with additional safe and effective options would be useful for such a prevalent chronic condition where not all children respond to current treatments or adhere to them. Studying common-sense approaches, such as decreasing environmental distraction, should be done. There is also the need for well-designed rigorous studies of currently promoted but less well-established therapies such as occupational therapy, biofeedback, herbs, vitamins, and food supplements. These interventions are not supported by evidence-based studies at the present time.

Long-term Outcomes

Most studies about ADHD and its treatment have been short-term. The long-term outcome of children with ADHD with or without coexisting conditions has not been well studied. Furthermore, there is minimal information about the role of stimulant medication and/or behavior therapy in the natural history of the disorder. Future research should correct these deficits. For this chronic condition, efficacy and safety studies must be extended from weeks or months to years. Long-term outcome studies must be prospective in design and consider changes over time in core symptoms of ADHD, coexisting conditions, and functional outcomes such as occupational successes and long-term relationships.

Service Delivery

Another major research area should address the optimal services and procedures for successful management of ADHD in the real world (ie, in clinical practice and classrooms). Much of the popular controversy over the inappropriate use of stimulant medication relates to how clinicians actually prescribe them. Future research needs to study how medications are actually prescribed and what factors affect physician practice patterns. Research that includes monitoring the outcomes of training will lead to the ability to develop better methods to assist clinicians in using effective treatment practices. Specifically, basic information such as who are the most appropriate clinicians to manage ADHD; the best schedule for follow-up; and the most valid, reliable, sensitive, and cost-effective ways to monitor treatment is essential. Such research must go beyond physician self-reporting and into scrutinizing and evaluating actual practices in clinics and offices. The most effective and efficient methods for affecting change in clinician practices need to be determined. This determination must be broad, taking into account clinician, practice, family, community, and policy issues that affect treatment. Research also should evaluate the role of school- and community-based professionals, as well as primary care clinicians, in delivering treatment services. Little is known about how short- or long-term effectiveness varies as a function of the school and community-based professional involvement. Further, the studies of service delivery need to include a public health and service system approach. They should consider child and family outcomes and cost-effectiveness of care. Linking outcomes to service parameters is an important step in encouraging practice or system change.

Epidemiology and Etiology

The great growth in the diagnosis of ADHD has led to major new work in the study of treatments. As indicated previously, these efforts should continue and expand. Less investigation has addressed the etiology of ADHD (ie, its biological and socioenvironmental causes) and the opportunities arising from that understanding for prevention. For example, would different social and behavioral arrangements in young families affect the onset of ADHD symptoms? Would early intervention in some way decrease rates of ADHD? A clear need exists for active work in understanding the etiology and prevention of ADHD.

CONCLUSION

This clinical practice guideline offers recommendations for the treatment of school-aged children with ADHD in primary care practice. The guideline emphasizes 1) consideration of ADHD as a chronic condition; 2) explicit negotiations about target symptoms; 3) use of stimulant medication and behavior therapy; and 4) close monitoring of treatment outcomes and failures. The guideline further provides suggestions for pediatric office-based management of ADHD. It should help primary care clinicians in their treatment of a common child health problem.

*The effect size for classroom and social behavior in the CCOHTA meta-analysis averaged 0.81; for core symptoms, 0.78; and for intelligence and achievement, 0.34. The first two of these would be considered a large change, the third, a minor to moderate change.³⁴

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Reviewed: 02/2006