Barkley - 2004 - Adolescents With Attention-Deficithyperactivity Disorder an Overview of Empirically...

Journal of Psychiatric Practice Vol. 10, No. 1 January 2004 39

Teens who are inattentive, impulsive, and restless andwho possess these attributes to a degree that is marked-ly deviant for their age and sufficient to create impair-ments in major life activities are currently diagnosed ashaving attention-deficit/hyperactivity disorder (ADHD).1

Their problematic behavior often arises early in child-hood (before they are 12 years of age) and typically per-sists across developmental phases.2 Some cases mayarise secondary to brain injury at later stages of devel-opment, but this is uncommon. The disorder is amongthe most well studied psychiatric conditions in children,yet the public struggles to accept the idea that it may belargely a biologically based developmental disability.This article first presents a brief overview of ADHD as itpresents in adolescents and then reviews treatments forteens with ADHD for which there is some empirical sup-port in the scientific literature. Due to space constraints,

issues pertaining to the assessment and diagnosis ofteens with ADHD will not be covered in this article.Interested readers can find information on these topicsin other, more extensive sources.3,4

Adolescents with Attention-Deficit/Hyperactivity

Disorder: An Overview of Empirically

Based Treatments

The author first presents an overview of attention-deficit/hyperactivity disorder (ADHD) as it presents in ado-lescents. He reviews what is known about the predominantly inattentive subtype in adolescents, the persist-ence of symptoms into this developmental phase, and comorbid disorders in adolescent patients with ADHD.The author then reviews treatments for adolescents with ADHD for which there is some empirical support inthe scientific literature. He first discusses common assumptions concerning the treatment of ADHD and evi-dence for or against these assumptions. Information on therapies that have been shown to be ineffective or thebenefit of which is unproven are then described. These include cognitive-behavioral therapy and social skillstraining. The author then presents an overview of what is known about the medication treatment of ADHD anddiscusses how this information is applicable to adolescents with the disorder. Four main classes of drugs arediscussed: stimulants, noradrenergic reuptake inhibitors, tricyclic antidepressants, and antihypertensiveagents. The author then reviews the use of several psychosocial interventions, including contingency man-agement strategies, parent training in behavior management methods, and teacher training in classroom man-agement, and discusses how these strategies can best be used for adolescents with ADHD. The author thendiscusses the use of combined treatment with psychosocial interventions and medication. Finally, informationon the use of physical exercise as therapy for adolescents with ADHD is discussed. (Journal of PsychiatricPractice 2004;10:3956)

KEY WORDS: attention-deficit/hyperactivity disorder, adolescents, comorbid disorders, oppositional defiant disor-der, conduct disorder, stimulant medications, methylphenidate, d-amphetamine, bupropion, atomoxetine, tricyclicantidepressants, clonidine, contingency management, parent training, teacher training

BARKLEY: Medical University of South Carolina.

Copyright 2004 Lippincott Williams & Wilkins Inc.

Please send correspondence and reprint requests to: Russell A.Barkley, PhD, Department of Psychiatry, Medical University ofSouth Carolina, 19 Hagood Ave., Room 910, Charleston, SC 29425.

Author support: While preparing this paper, the author was sup-ported by the Office of Research, College of Health Professions,Medical University of South Carolina and by a grant from theNational Institute of Child Health and Human Development. Theauthor serves occasionally as a consultant to Shire Pharma-ceuticals, Eli Lilly Co., and Pfizer and also receives book andnewsletter royalties from Guilford Publications.

RUSSELL A. BARKLEY, PhD

ADHD IN ADOLESCENCE

Differences in Presentation in Adolescent ADHD

Much of what is known about ADHD is drawn fromstudies in children. Far fewer studies, particular treat-ment studies, have been conducted in adolescents withADHD. Research suggests, however, that the adolescentstage of the disorder may be sufficiently continuouswith the childhood stage that much of what is knownabout ADHD in children can be extrapolated to adoles-cence. In fact, there is currently no compelling evidencethat ADHD in teens is qualitatively different from thedisorder in children, or in adults for that matter. This isnot to argue that the disorder is identical across thesemajor stages of developmentbut that there is somecontinuity in the disorder and its management. One dif-ference across stages of development is that quantita-tive declines in symptom severity occur,5,6 particularlyin the domain of hyperactive behavior,7 so that, forexample, it is highly unlikely that teens with ADHDwould be characterized as frequently climbing onthings or unable to play quietly. At the same time, othersymptoms, such as those reflecting poor persistence ofeffort, impaired self-control and organization, and defi-cient time management, may become more prominent.Changes in neurological and hormonal developmentare also likely to have an impact on the neuropsycholo-gy of the disorder and the way in which its symptomsare expressed in adolescence. Cognitive domains, suchas verbal working memory, internalized speech, emo-tional self-control, and cross-temporal organization ofbehavior, become progressively more elaborate and bet-ter developed by this age and consequently may bemore affected by the disorder than they were in child-hood.8 The risk of certain comorbid disorders (e.g., con-duct disorder, substance use disorders, depression) mayalso change as the disorder progresses into adolescence.At the same time, new domains of potential impairments(e.g., dating, sexual risks, driving risks) become evidentthat were not relevant in childhood. While the constructscomprising the disorder (inattention, poor inhibition) donot appear to change qualitatively, their surface mani-festations may change due to biological-developmentalchanges as well as changes in social expectations andresponsibilities that occur at this developmental stage.

The clinical presentation of ADHD in adolescenceappears to become more complex in its potential forimpairments. It also becomes more complicated and diffi-cult to manage owing to factors such as teens increasingindependence from family influences and growing peer

influence. Although few studies on the etiology of ADHDhave sought to replicate results in teens with the disor-der, there is little evidence from the fields of neuroanato-my, neuroimaging, and behavioral and molecular geneticsto suggest that large qualitative shifts occur at this age.While quantitative changes in symptoms are likely tooccur in this age group, such changes would not precludeextrapolation of childhood evidence to adolescent ADHD.In short, a wholly new disorder does not spring forth atpuberty. However, a widening of social ecological effects,a shift in emphasis to some symptom constructs over oth-ers, the likely emergence of greater deficits in executivefunctioning, coupled with a progressive capacity for self-determination, add new layers of complexity to impair-ments and treatments in adolescence.

Longitudinal studies of hyperactive children pub-lished over the past two decades have done much tooverturn the view of the disorder as a benign, transientcondition, as it was believed to be in earlier decades.6,911

It is now realized that ADHD persists in most childreninto their adolescence. At the same time, the growingrecognition of adolescence as a separate stage of humanpsychological development has also contributed to therecognition and acceptance of an adolescent stage ofADHD. Even so, the scientific study of ADHD in teens(and adults) lags far behind research in children withthe disorder. However, studies of clinically referred teensdiagnosed with ADHD12,13 as well as studies that havefollowed clinically diagnosed children into adoles-cence,5,6,14 all suggest that the disorder exists in teens.

The Predominantly Inattentive Subtype

Controversy continues concerning the appropriate clas-sification of a subtype composed primarily of inattentionwithin the larger construct of ADHD (see the specialissue of Clinical Psychology: Science and Practice15 for adebate on this subtype), and this controversy is also rel-evant to the adolescent stage of the disorder. Some sci-entists argue that the inattentive subtype is actually anew disorder, unique from ADHD,15 while others arguethat this distinction may be premature or is not espe-cially important in treatment planning. However, oneopinion is relatively consistent across viewpoints: that asubset of children who have only high levels of inatten-tion associated with cognitive sluggishness and behav-ioral passivity probably represent a qualitativelydifferent attention problem from that seen in ADHD(poor persistence, inhibition, and resistance to distrac-tion). Nonetheless, there are no studies of this subtype inteens with ADHD.

ADOLESCENTS WITH ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

Journal of Psychiatric Practice Vol. 10, No. 140 January 2004

Persistence of Symptoms into Adolescence

It is likely that 50%80% of those who are clinically diag-nosed with ADHD in childhood will continue to have thedisorder in adolescence, with most studies supporting thehigher figure.5,1619 Using the same parent rating scalesat both childhood and adolescent evaluation points,Fischer et al.20 were able to show that inattention, hyper-active-impulsive behavior, and home conflicts declined byadolescence. The hyperactive group showed far moremarked declines than the control group, mainly becausethe former were so far from the mean of the normativegroup to begin with in childhood. Nevertheless, even inadolescence, the groups remained significantly differentin each domain, with the mean for the hyperactive groupremaining two standard deviations or more above themean for the controls. The persistence of ADHD symp-toms across childhood as well as into early adolescenceappears to be associated with the initial degree of hyper-active-impulsive behavior in childhood, the coexistence ofconduct problems or oppositional hostile behavior, andpoor family relationsspecifically conflict in parent-childinteractionsas well as maternal depression and dura-tion of mental health interventions.21,22

Comorbidity in Adolescent ADHD

Teens diagnosed with ADHD often have a number ofother disorders besides ADHD. Our knowledge of ADHDcomorbidity is largely confined to individuals with thecombined subtype of ADHD. In community derived sam-ples, up to 44% of children and teens with ADHD havebeen found to have at least one other disorder, and 43%had two or more additional disorders.23 The figure ishigher, of course, in samples drawn from clinic popula-tions. As many as 87% of children who have been clini-cally diagnosed with ADHD may have at least one otherdisorder and 67% at least two other disorders.24

The most common comorbid disorders found in ado-lescents with the combined subtype of ADHD are oppo-sitional defiant disorder (ODD) and, to a lesser extent,conduct disorder (CD). General population studies havefound that the presence of ADHD increases the odds ofODD/CD by 10.7 fold (95% confidence interval [CI] =7.714.8).25 Studies of children and teens with ADHDwho were referred to clinics have found that 54%67%meet criteria for a diagnosis of ODD by 715 years ofage. ODD is a frequent precursor of CD, a more severeand often (though not always) later stage of ODD.26

Having both CD and ADHD is the strongest predictor ofrisk for substance use and abuse disorders (SUDs) in

ADHD children when they reach adolescence andadulthood.2729 While an elevated risk for alcohol abusehas not been consistently documented in follow-upstudies into adulthood, the risk for other SUDs amonghyperactive children followed to adulthood ranges from12%24%.18,19,30

Anxiety disorders have been found to co-occur withADHD in 10%40% of clinic-referred children, averag-ing about 25%.3133 However, in longitudinal studies ofchildren with ADHD, the risk of anxiety disorders wasfound to be no greater than in control groups in eitheradolescence or young adulthood.11,19,30 General popula-tion studies of children, however, do suggest an elevat-ed odds ratio of 3.0 (95% CI = 2.14.3) of having ananxiety disorder in the presence of ADHD, with thisrelationship significant even after controlling forcomorbid ODD/CD.25

The evidence for the co-occurrence of mood disorders,such as major depression or dysthymia, with ADHD isnow fairly substantial.3436 Of those with ADHD,15%75% may have a mood disorder, although moststudies place the rate between 20% and 30%.30,37,38 Thelink between ADHD and depression seems to be medi-ated entirely by the linkage of both disorders to CD.25 Inthe absence of CD, ADHD is not more likely to be asso-ciated with depression.

The comorbidity of ADHD with bipolar disorder iscontroversial.39 Some studies of children and teens withADHD indicate that 10%20% may have bipolar disor-der,4042 a figure that is substantially higher than the1% risk found in the general population.43 Follow-upstudies of hyperactive children, however, have not docu-mented any significant increase in the risk of bipolardisorder by adulthood.11,19,30 A 4-year follow-up study ofchildren with ADHD reported that 12% met criteria forbipolar disorder in adolescence,44 but this associationwith bipolar disorder has not been found in other follow-up studies and remains to be replicated. In any case, theoverlap of ADHD with bipolar disorder appears, for nowat least, to be unidirectionala diagnosis of ADHD doesnot appear to cause much increase in the risk for bipo-lar disorder, whereas a diagnosis of childhood bipolardisorder seems to dramatically elevate the risk of a hav-ing a prior or concurrent diagnosis of ADHD.36

TREATING THE ADOLESCENT WITH ADHD

The vast majority of ADHD treatment research hasalso been conducted in children, while strikingly lessattention has been given to studies of treatment effica-cy in teens with the disorder.45 For instance, fewer than



5% of studies on medication management of ADHDhave been done with teens; and only a handful of fami-ly training studies have focused on this age group. Inaddition, only a few studies on educational manage-ment strategies for ADHD have looked at teens. Thisdoes not mean that no recommendations can be madefor teens with ADHDbut it does mean that many ofthese recommendations will be based largely, if notentirely, on extrapolating (with caution!) from researchin children as well as what little research has beendone in teens. Clinicians must keep in mind that, due toadolescents psychological and physical stages of matu-rity, their developing sense of autonomy, and theiremergence into the larger community, adjustmentsmust be made to even the most effective treatments forchildhood ADHD. Teens are also far less likely thanchildren to receive mental health services of any kind.35

This may due to their increased autonomy and capaci-ty to counteract their parents efforts to obtain treat-ment for them, but may also reflect the greater costs ofthe more extensive treatment that teens with ADHDand their families are likely to need.45

This section briefly describes the major interventionsthat are likely to benefit teens with ADHD and discuss-es issues clinicians need to address in treating this agegroup. It must be said at the outset, however, that nointervention has been found to cure this disorder.Treatment is therefore focused on symptom manage-ment and the reduction of secondary problems that mayarise if the disorder is left unmanaged. In this sense,treating ADHD is comparable to treating diabetes. Acombination of medication and psychosocial accommo-dations may work very well to contain the disorder andpreclude the occurrence of secondary problems and evensome comorbid disordersbut treatment only workswhen it is used and often does not produce any endur-ing benefits if removed.

Advances in the treatment of ADHD over the past 20years have been relatively circumscribed and havemainly occurred in psychopharmacology rather thanpsychosocial treatment. This is not to say that we havenot learned more about the psychosocial treatment ofADHD, but no significant breakthroughs in this areahave been forthcoming. Most research has clarified theefficacy (or lack of it) of already available treatmentapproaches or combinations of those approaches.Findings concerning multi-modality treatments havebeen especially sobering46,47 although all of these stud-ies have been conducted in children, not teens. Beforediscussing the efficacy of specific treatments for teenswith ADHD, it is helpful to re-examine some tradition-

al assumptions about the treatment of ADHD. Theseassumptions are being called into question not only bynewer theoretical models8 but also as a result ofresearch on the etiologies of the disorder (behavioralgenetics and neuroimaging) and on the efficacy of par-ticular treatments.3

Re-examining Treatment Assumptions

Advances in research on the etiologies of ADHD andnew theoretical models of the disorder may explain whythere have been few treatment breakthroughs, especial-ly in the psychosocial arena. Information from thesesources increasingly points to ADHD being a develop-mental disorder that is probably of neurogenetic origin,in the expression of which some unique environmentalfactors (including biological hazards affecting braindevelopment) play a role, though far less than geneticfactors.3 Common family environment factors, oncethought to have a major effect on the disorder, nowappear to have a minor and often insignificant role indetermining individual variation in the traits that makeup ADHD.48 Yet such shared environmental factors mayplay an important role in risk for comorbid conditions,such as ODD, CD, or depression. Thus, it is unlikely thatnew family-focused treatments will be discovered thatwould result in the amelioration or even containment ofthe disorder, since such treatments are unlikely to cor-rect the underlying neurological substrates or geneticmechanisms that contribute so strongly to it. They may,however, have a greater impact on associated comorbid-ity. Contrary to the social learning models on which fam-ily interventions for ADHD were originally based,children with ADHD are not tabulae rasae on whichsocialization makes the major contribution to psycho-logical development. The disorder is not learnedthrough imitation of poor role models, and it does notarise from exposure to faulty contingencies, such as pooror disrupted parenting. As with learning disabilities andmental retardation, which appear to have relativelyanalogous etiologies, treatment is symptomatic manage-ment or containment of a chronic developmental condi-tion and involves finding the means to cope with,compensate for, and accommodate to developmentaldeficiencies. These means include provision of sympto-matic relief, such as that obtained through the use ofvarious medications. The goal of treatment, then, is thecontainment of the disorder (symptomatic reduction)and the prevention of or reduction in risk for secondaryharms (e.g., school failure, auto accidents, peer rejection,antisocial activities), not the cure or amelioration of the



disorder. Given the greater relative contribution of geno-type compared with environment in explaining individ-ual differences in ADHD symptoms, it is highly likelythat treatments for the disorder, while improving symp-toms, do little to change the rank ordering of such indi-viduals relative to each other in their post-treatmentlevels of ADHD. This is not to say that environmental orpsychosocial therapies may not result in clinical bene-fits to individuals, since the effects of many geneticallybased disorders can be altered by environmental treat-ments, but that such therapies do not strike at the causeof the disorder and will have limitations as a conse-quence. It is also likely that treatments, particularly inthe psychosocial realm, will prove to be specific to thetreatment setting and will show minimal generalizationunless specific strategies are implemented to promotesuch generalization.

The theoretical model of ADHD proposed by Barkley8

suggests other reasons why treatment effects may be solimited. According to this model, ADHD is not the resultof a lack of skill, knowledge, or information. Therefore, itwill not respond well to interventions that emphasizethe transfer of knowledge or skills, as might occur inpsychotherapy, social skills training, cognitive therapies,or academic tutoring. All of these interventions involve atacit assumption that the client with ADHD is naveabout or ignorant of these skills; yet no research hasactually examined this issue in detail. Instead, ADHDcan be viewed as a disorder of performanceof doingwhat one knows rather than knowing what to do. It ismore a question of when behavior should be performedrather than how to perform it. As in patients withinjuries to the frontal lobes, in individuals with ADHD,the disorder appears to have partially cleaved or dissoci-ated intellect from action, or knowledge from perform-ance. Thus, individuals with ADHD may know how to actbut may not act that way when placed in social settingsin which such action would be beneficial to them. InADHD, it is the timing and timeliness of behavior that isbeing disrupted more than basic knowledge or skillabout that behavior.

From this vantage point, treatments for ADHD will bemost helpful when they assist with the performance of aparticular behavior at the point (place and time) of per-formance in the natural environments where and whensuch behavior should be performed. A corollary of this isthat the further away in space and time a treatment isfrom this point of performance, the less likely it is to beeffective in assisting with the management of ADHD.Consequently, it is important not just to train the personin the behavior but to provide assistance with the time,

timing, and timeliness of behavior at the actual point ofperformance. Nor will there necessarily be any lastingvalue or maintenance of treatment effects from suchassistance if it is summarily removed within a shortperiod of time once the individual is performing thedesired behavior. The value of such treatments lies notonly in eliciting behavior, which is likely already in theindividuals repertoire, at the point of performancewhere its display is critical, but in maintaining the per-formance of that behavior over time in that natural set-ting. Disorders of performance like ADHD pose greatchallenges for mental health care and educational serv-ices, since the core of the problem is how to get people tobehave in ways that they know are good for them yetwhich they seem unlikely, unable, or unwilling to do. Ithas been found that altering the motivational parame-ters associated with the performance of the behavior atits appropriate point of performance is more helpfulthan just conveying more information to the person.However, it is important to realize that such changes inbehavior are maintained only so long as those environ-mental adjustments or accommodations are also main-tained. To expect otherwise would be to approach thetreatment of ADHD with outdated or misguidedassumptions about its essential nature.

This conceptual model of ADHD as a disorder of per-formance (executive functioning) has numerous otherimplications for management that can only be brieflytouched on here:

If the process of regulating behavior by internally rep-resented forms of information (the internalization ofbehavior) is delayed in those with ADHD, it is helpfulto externalize those forms of information by provid-ing external, physical representations of that infor-mation in the setting at the point of performance.Since covert or private information is a weak source ofstimulus control in these individuals, making theinformation overt and public may help strengthencontrol of behavior.Difficulty organizing behavior across time is one ofthe ultimate disabilities associated with ADHD.ADHD is to time what nearsightedness is to spatialvision: it creates a temporal myopia in which the indi-viduals behavior is governed even more than normalby events close to or within the temporal now and theimmediate context, rather than by internal informa-tion that pertains to longer term, future events. Itshould therefore be helpful to provide a physicalexternal representation of time, such as by using atimer or clock placed in the work setting. It will alsobe of benefit to reduce or eliminate gaps in time



among the components of a behavioral contingency(i.e., event, response, outcome), for example, by havingthe teen do small amounts of reading now and writeseveral sentences now, for which they receive 50points now, instead of assigning a book report forthem to do on their own over the next month.The performance model of ADHD hypothesizes adeficit in internally generated and represented formsof motivation that are needed to support goal-directedbehavior; consequently, those with ADHD will need tobe provided with externalized sources of motivation.For instance, one may need to provide artificialrewards, such as tokens, throughout the performanceof a task or goal-directed behavior when there are fewor no immediate consequences associated with thatperformance. For the teen with ADHD, such artificialreward programs become like prosthetic devices ormechanical limbs for the physically disabled, allowingthem to perform more effectively in some tasks andsettings where they otherwise would have consider-able difficulty. The motivational disability created byADHD makes such motivational prostheses nearlyessential for most individuals with ADHD. Yet diffi-culties arise in providing such prosthetic motivation-al devices to teens, because of their greater autonomyfrom parents and teachers, the fact that they areinteracting with many more adults, and the increas-ing time they spend with peers and in unsupervisedcommunity settings. For instance, when a teen is driv-ing home from a high school dance late on Saturdaynight, no one else is in the car to provide externalizedinformation and prosthetic motivation, such astokens, for the use of safe driving behavior. Manyother similar scenariosin which the delivery of psy-chosocial interventions is difficult if not impossiblearise in the lives of teens with ADHD. Medication isoften needed in such settings and during such activi-ties to insure control of ADHD symptoms and mini-mize their impact on functioning.

Ineffective or Unproved Therapies

A variety of treatments for children with ADHD, whichare far too numerous to review here, have been tried overthe past century.49 Vestibular stimulation,50 oral-motorchewing,51 EMG biofeedback and relaxation training,52

sensory integration training,53 and EEG biofeedback orneuro-feedback,54 among others, have been described aspotentially effective in uncontrolled case reports, smallseries of case studies, or in some treatment versus no-treatment comparisons, yet well-controlled experimental

replications of their efficacy are lacking. Many dietarytreatments, such as removal of additives, colorings, orsugar or addition of high doses of vitamins, minerals, orother health food supplements, have proven very popu-lar despite minimal or no scientific support.49,55

Traditional psychotherapy and play therapy have notproven very effective for ADHD or other externalizingdisorders.56

It was previously believed that cognitive-behavioraltreatment (CBT), or cognitive therapy, held some prom-ise for children with ADHD, and a few small-scale stud-ies did suggest some benefits for this form of treatmentin children with ADHD.57 However, cognitive treatmenthas been challenged as being seriously flawed from theconceptual (Vygotskian) point of view on which it wasinitially founded.58 In addition, the rather poor or limit-ed results of empirical research with CBT have repeat-edly called into question its efficacy for impulsivechildren or those with ADHD.59 In the most ambitiousCBT program ever undertaken in ADHD, whichinvolved training of parents, teachers, and children,researchers found no significant treatment-specificeffects on any of a variety of dependent measures, withthe exception of class observations of off-task/disruptivebehavior,60 and even this treatment effect was not main-tained at 6-week follow-up. Meta-analyses of the litera-ture on CBT and cognitive therapy have typically foundthat the effect sizes are only about a third of a standarddeviation and, in many studies, even less than that.61,62

While such treatment effects may at times rise to thelevel of statistical significance, they are of only modestclinical importance and are usually found mainly on rel-atively circumscribed lab measures rather than on moreclinically important measures of functioning in naturalsettings.

Similarly, reviews of the use of social skills training(SST) as applied specifically to children with ADHDhave reported quite discouraging findings.63,64 A recentstudy of SST in children with different subtypes ofADHD found some improvement on parent and childratings of assertion skills but no benefits on otherdomains of social competence.65 Children with comorbidODD appeared to derive little benefit from the pro-gram, while those with the inattentive subtype ofADHD improved more than those with the combinedtype in assertion skills (but not on other domains ofsocial competence). However, at follow-up, these fewgains in the inattentive type were not sustained. It isalso a cause of concern that a small subset of childrenwith the inattentive subtype were rated by their par-ents as significantly worse following SST, perhaps due



to the social contagion effect of being in training withmore aggressive peers.66 Consistent with findings fromother studies,67,68 the authors concluded that SST hadlittle efficacy in addressing the social problems ofADHD children.

The treatments with some proven efficacy for assist-ing teens with ADHD and their families are:1. medications2. parent training in contingency management meth-

ods69

3. parent-teen training in problem-solving and commu-nication skills4

4. classroom applications of contingency managementtechniques67

5. various combinations of these psychosocial approach-es with psychopharmacology.

Therapists should also be aware of the availability ofspecial educational programs for children with ADHDthat are now mandated under the Individuals withDisabilities in Education Act and Section 504 of theCivil Rights Act.70 Since parents and teachers who makereferrals are often very concerned about determinationof eligibility for such programs, it is important that cli-nicians be familiar with federal, state, and local regula-tions regarding placement in such programs.

Medications for Managing ADHD

Four classes of psychotropic drugs have proven useful inthe management of ADHD symptoms. Most of this evi-dence comes from children with ADHD, with far fewerstudies of adolescents. The four classes are stimulants,noradrenergic reuptake inhibitors, tricyclic antidepres-sants, and antihypertensive agents. All have beenshown to be significantly more effective than placebo inreducing ADHD symptoms in randomized, controlledtrials, mostly involving children.

Stimulant medication (dopamine agonists). SinceBradley first accidentally discovered the successful useof stimulants in children with behavior problems in1937,71 an enormous amount of research has been donewith these agents, far more than for any known treat-ment for any childhood psychiatric disorder. The resultsoverwhelmingly indicate that stimulant medicationsare quite effective in managing ADHD symptoms inmost children older than 5 years of age.72,73 Theresponse rate is probably much lower in childrenbetween 4 and 5 years of age, and the drugs are not rec-ommended for use in children under 3 years of age. The

effectiveness of these medications has led to their wide-spread use in children with ADHD. National figures forthe prevalence of such treatment are not available butreview of large scale regional databases suggests thatapproximately 2.8% of the school-age population arelikely being treated with stimulants for ADHD symp-toms.74 These medications may be nearly as useful foradolescents with ADHD,45 although fewer than 10 stud-ies have been done with this age group.

The most commonly prescribed stimulants are meth-lyphenidate (MPH) (Ritalin, Concerta, Medadate CD,Focalin), d-amphetamine (AMP) (Dexedrine or Dextro-stat), a d- and l-AMP combination (Adderall, AdderallXR), and pemoline (Cylert). MPH appears to work byslowing down dopamine reuptake from the extracellularspace. The amphetamines appear to work primarily byincreasing dopamine release but may also have someeffect on reuptake. It is not known how pemolineachieves its therapeutic effect. Because of the potentialfor liver complications,75 pemoline is no longer recom-mended for use with patients unless frequent monitor-ing of liver functioning is done. Pemoline is notdiscussed further here since it is so rarely used in treat-ing children. Adderall is a stimulant compound that wasrecently approved for the management of ADHD. It is acombination of different forms of AMP salts that is effec-tive in treating ADHD symptoms in children76,77 andadults.78

MPH (in various forms) and AMP are the most com-monly prescribed medications for ADHD. In their origi-nal forms, they are rapidly acting stimulants thatproduce effects on behavior within 3045 minutes afteroral ingestion of the standard preparations, with theirbehavioral effects peaking within 24 hours.72 Their util-ity in managing behavior quickly dissipates within 37hours, although minuscule amounts of the medicationmay remain in the blood for up to 24 hours.73,79 Becauseof their short half-life, they were often prescribed two tothree times per day, causing great inconvenience andrequiring that at least one dose (at noon) be adminis-tered at school. Although these agents were once usedpredominantly on school days, there is an increasingclinical trend toward using them throughout the week aswell as during school vacations. This is the result ofrecent discoveries that the growth of children withADHD who are taking stimulants is not as seriouslyaffected as was once believed,80 so that the rationale foruniversal drug holidays is no longer justifiable. Focalin,or dex-MPH, was recently approved for use in ADHD. Itis simply the right turning MPH molecule, which someresearch suggests may be the effective form of this med-



ication as opposed to the left turning molecule (levo-MPH). It is otherwise identical in effects and side effectsto MPH but requires only half the typical dose.

Both MPH and AMP later became available in slow-release preparations (Ritalin SR; Dexedrine spansules)that reduced the number of daily doses childrenrequired for management of their ADHD.72 However,control of behavior was less than ideal with these for-mulations because of sub-optimal blood levels duringthe sustained release of the medication. New and moreeffective delivery systems have been invented over thepast 5 years that make these earlier slow-release for-mulations nearly outdated. These include Concerta,Medadate CD, and Ritalin LA for MPH delivery andAdderall XR for mixed AMP delivery. Concerta is aminiature osmotic pump resembling a capsule thatoozes liquid MPH while transversing the gut for aninterval of 1012 hours.81 Medadate CD and Ritalin LAare tiny MPH pellets to which various time-release coat-ings have been applied so that they dissolve at increas-ingly longer time intervals as they course through thegut; they last for roughly 812 hours. Medadate CD hasthe advantage that it can be opened and sprinkled onsoft food for easier oral ingestion in patients who havedifficulties swallowing tablets or capsules withoutaffecting its pharmacokinetic properties.82 It is likelythat Ritalin LA, given its similar composition, has thissame advantage.

The behavioral improvements produced by MPH andAMP occur in sustained attention, impulse control, andreduction of task-irrelevant activity, especially in set-tings demanding restraint of behavior.72,73 Generally,noisy and disruptive behavior also diminishes withmedication. As a consequence of stimulant treatment,children with ADHD may become more compliant withparental and teacher instructions, be better able to sus-tain such compliance, and often increase cooperativebehavior toward others with whom they may have toaccomplish a task. ADHD children can perceive the ben-efit of the medication in reducing ADHD symptoms andeven describe improvements in their self-esteem,though they may report somewhat more side effectsthan do their parents and teachers.

Drug-related improvements also occur in otherdomains of behavior, including aggression, handwriting,academic productivity and accuracy, persistence ofeffort, working memory, peer relations, emotional con-trol, and participation in sports.72,73,79 The effects ofmedication are idiosyncratic, with some children show-ing maximal improvement at lower doses, while othersshow the most improvement at higher doses. Stimulants

appear to remain useful in managing ADHD overextended periods of time47 and can be used successfullyinto adulthood.

Side effects include mild insomnia and appetite reduc-tion, particular at the noon meal.72 Temporary suppres-sion of weight gain may initially accompany stimulanttreatment, but is not generally severe or especially com-mon, may rebound in the second year of treatment, andcan be managed by insuring that adequate caloric andnutritional intake is maintained by shifting the distri-bution of food intake to other times of the day when thechild is more amenable to eating. A small percentage ofchildren with ADHD complain of stomachaches andheadaches when treated with stimulants, but these tendto dissipate within a few weeks of beginning medicationor can be managed by reducing the dose. Motor or vocaltics may occur in approximately 1%2% of children withADHD who are treated with stimulants.73 In individu-als who already have tics, stimulants can mildly exacer-bate the tics in some cases, but may improve them inothers. It now appears to be relatively safe to use stim-ulant medications in children with ADHD and comorbidtic disorders; however, clinicians should be prepared toreduce the dose or discontinue medication should chil-dren experience drug-related exacerbations of their ticsymptoms.

The stimulant medications are the most studiedtreatment for the symptomatic management of ADHDand its secondary consequences and there is little doubtthat they are also the most effective. Their side effectsare relatively benign, particularly in comparison withother psychiatric drugs. For many children with moder-ate to severe levels of ADHD, this may be the first treat-ment employed in their clinical management. Othertreatments may then be added as adjuncts for domainsof impairment that are unaffected by the stimulantmedication or when medication-free periods arerequired.

Norepinephrine reuptake inhibitors. Several medica-tions that slow reuptake of norepinephrine have sometherapeutic benefit for the management of ADHD. Thenoradrenergic reuptake inhibitors are bupropion(Wellbutrin) and atomoxetine (Strattera), which wasintroduced in January 2003. Bupropion appears to affectboth the noradrenergic and dopaminergic systems.Several studies in children with ADHD and one morerecent study in adults have shown that bupropion pro-duces significant improvement in ADHD symptoms com-pared with placebo.83 However, the beneficial effects arenot as substantial or dramatic as those achieved by the



stimulants. Potential side effects include edema, rashes,irritability, loss of appetite, seizures (rare), and insom-nia. One study that examined bupropion in a samplethat included teens with ADHD found a significant effectrelative to placebo, with bupropion nearly as effective asMPH,84 while a second study involving an open trial for-mat found some efficacy in teens with ADHD and comor-bid substance use and conduct disorders.85

Atomoxetine is the first new molecule for the treat-ment of ADHD approved by the FDA since 1975.Indications for children, teens, and adults with ADHDhave been approved. Over the past 7 years, various stud-ies have compared atomoxetine to placebo and, in somecases, to MPH. Research continues to examine the effectof the drug on specific domains of functioning in children(family functioning) and adults (occupational function-ing, driving) with ADHD. Unlike bupropion, atomoxetineworks selectively on noradrenergic reuptake, therebymaking more norepinephrine available in the extra neu-ronal space. Atomoxetine has been studied in six acute,large, randomized, double-blind, placebo-controlled stud-ies (two studies in children,86,87 two in children and ado-lescents,88,89 and two in adults90). One trial in childrenwas conducted using once-a-day dosing for a period of 6weeks. The other three studies in children employedtwice-daily dosing for 89 weeks. All doses were deter-mined on a weight-adjusted basis. In the two studies inadults, dosing was twice daily for 10 weeks with doseescalation within a fixed range. In all studies, atomoxe-tine was superior to placebo in reducing mean symptomratings on the primary outcome measure. The effect sizefor once-daily treatment was similar to that of twice-dailytreatment. No serious safety concerns were observed andtolerability was good, with discontinuation rates foradverse events under 5% in the pediatric studies. Thelong-term safety of atomoxetine was assessed using datafrom clinical trials in children and adolescents treated forat least 1 year. Tolerability and safety were assessed byevaluating discontinuations, adverse events, weight, andheight. Over 4000 patients have been exposed to atomox-etine in these and other clinical trials, with over 400treated for at least 1 year. Discontinuations due toadverse events were uncommon (< 5%). Reports ofdecreased appetite and weight loss, which were reportedstatistically significantly more often than with placebo inacute trials, continued to decline during long-term treat-ment, as did other adverse events. After at least 1 year oftreatment, atomoxetine increased mean heart rate 6.4beats per minute and increased mean diastolic bloodpressure 2.8 mmHg. When patients lost weight, thistended to occur early in treatment (mean weight loss of

0.5 kg in acute studies). However, over longer treatmentperiods, weight increased (mean 4.0 kg after 1 year).Because 1 year is a relatively short period in the growthof many children, analyses of height increases are incon-clusive and require data from longer treatment periods.Atomoxetine appears to be safe and efficacious for thetreatment of ADHD in children, adolescents, and adultsand to produce a comparable proportion of clinicalresponders to MPH for the reduction of ADHD symp-toms. Examination of effect sizes suggests that they maybe somewhat lower than those achieved by MPH. Effectsizes also appear to be somewhat lower in teens andadults than in children with ADHD but these differencesfrom MPH were not statistically significant in studiesdone to date and no direct comparisons of effects betweenchildren, teens, and adults have been undertaken in thesame study.

Antidepressant medication. Clinicians have also usedtricyclic antidepressants (TCAs), such as imipramine anddesipramine, for the management of ADHD symptoms.83

This has been partly due to the occasional negative (andoften undeserved) publicity in the popular media focus-ing on the stimulants, especially Ritalin. However, therise in antidepressant use for ADHD may also haveresulted from cases in which stimulants were contraindi-cated or were not especially effective or which involvedsignificant comorbid mood disturbance. Less is knownabout the pharmacokinetics and behavioral effects ofantidepressants in children with ADHD compared withstimulants. However, research on these compounds, par-ticularly desipramine, increased in the early 1990s andgenerally supports their efficacy in the management ofADHD. These medications, which are often given twicedaily (morning and evening), are longer acting than thestimulants. As a result, it takes longer to evaluate thetherapeutic value of any given dose. Some research sug-gests that low doses of the TCAs may mimic stimulantsin producing increased vigilance and sustained attentionand decreased impulsivity. As a result, disruptive andaggressive behavior may also be reduced. Improvementsin mood may also occur, particularly in children who hadsignificant pretreatment levels of depression and anxiety.Treatment effects may diminish over time, however, sothat the TCAs, unlike the stimulants, may not be usefulin some cases as long-term therapy for ADHD.

The most common side effects of the TCAs are drowsi-ness during the first few days of treatment, dry mouthand constipation, and flushing. Less common but moreimportant are cardiotoxic effects, such as possible tachy-cardia or arrhythmia, and in cases of overdose, coma or



death. Some children may develop sluggish reactions infocusing the optic lens which may mimic nearsighted-ness. This reaction is not permanent and dissipates whentreatment is withdrawn. Skin rash is occasionally report-ed and usually warrants discontinuation of the drug.

In general, it is probably preferable to use atomoxetinefirst as an alternative to the TCAs, since more informa-tion and safety data are available concerning this med-ication. The TCAs may be useful in the short-termtreatment of children with ADHD when the stimulants oratomoxetine are not effective. However, clinicians need toproperly evaluate the cardiac functioning of childrenbefore initiating treatment and then periodically monitorsuch functioning throughout the course of treatment,given the apparent risks of the TCAs for impairing car-diac functioning (see Wilens et al.91 for a review andguidelines for monitoring children who are receivingTCAs).

There has been minimal research on the effectivenessof selective serotonin reuptake inhibitors (SSRIs) formanagement of ADHD, largely owing to the lack of anyneurochemical rationale for doing so in view of the dearthof evidence that serotonin may be involved in this disor-der. One very small open study suggested that fluoxetinemay be beneficial, but it was the consensus opinion of theexpert panel at the NIMH conference on ADHD thatthese compounds were not useful for this disorder.83

Antihypertensive medication. In the late 1980s, a smallnumber of research papers appeared suggesting that theantihypertensive drug, clonidine (Catapres) may be ben-eficial in the management of ADHD symptoms, particu-larly in reducing hyperactivity and overarousal.92

Another antihypertensive drug, guanfacine (Tenex) mayalso have some utility in managing ADHD.92 Thesedrugs are believed to act as alpha-2 adrenergic agoniststhat ultimately inhibit the release of norepinephrine,increasing dopamine turnover and reducing blood sero-tonin levels.93 Although some changes in behavior maybe the result of the general sedation produced by themedication, others appear to be related to improvementsin activity regulation and attention. The limitedresearch to date suggests that clonidine is much lesseffective than the stimulants in improving inattentionand school productivity but may be equally efficacious inreducing hyperactivity and moodiness. The drug mayalso be useful in managing the sleep disturbances somechildren with ADHD experience. Side effects includedrowsiness, dizziness, weakness, and occasional sleepdisturbance. Rarer side effects include nausea, vomiting,cardiac arrhythmia, irritability, and orthostatic hypoten-

sion. Werry and Aman93 have recommended that cloni-dine be used in the treatment of ADHD only as a last lineof medical management when stimulants have provenineffective or are contraindicated. Given the availabilityand greater safety of atomoxetine, it would certainly beused ahead of the antihypertensives in the managementof ADHD.

Direct Applications of Contingency Management

A number of early studies evaluated the effects of rein-forcement and punishment, usually response cost, onthe behavior and cognitive performance of children withADHD. These studies usually indicated that the per-formance of children with ADHD on tasks measuringvigilance or impulse control or on academic tasks can beimmediately and significantly improved by the use ofstimulus control techniques or by the contingent appli-cation of consequences.3 In some cases, the behavior ofchildren with ADHD who are treated with these tech-niques approximates that of normal control children.However, none of these studies examined the degree towhich such changes endured after treatment was with-drawn or, more importantly, generalized to the naturalenvironments of the children, calling into question theclinical efficacy of such an approach. Given the findingsof highly limited generalization and maintenance oftreatment effects for the classroom interventionsdescribed below, it is unlikely that behavioral tech-niques implemented only in the clinic or laboratorywould carry over into the home or school settings ofthese children without formal programming for suchgeneralization and maintenance. Consequently, theywill not be discussed here further.

It is important to note that virtually no research hasfocused on the effectiveness of such behavioral treat-ments in teens with ADHD. Given the limited successand particularly limited generalization and mainte-nance of such approaches, it is unlikely that such stud-ies will be done in the future. The overall treatmentlimiting features of these approaches, and of the otherpsychosocial approaches discussed below, indicate whythey are likely to be of limited utility with teens:1. They rely on the compassion and willingness of others

to employ them with teenagers with ADHD, whenthose others may have little time or inclination to do so.

2. Teens spend progressively greater amounts of timeaway from caregivers, often with peers, who are fre-quently not part of the treatment team.

3. Teens are likely to take classes with a larger numberof educators than are children, increasing the likeli-



hood that these educators will not comply with rec-ommendations or will do so only half-heartedly.

4. Teens have increasing opportunities to spend timewith others in places (e.g., employment settings, driv-ing, shopping at the mall, playing sports) that arelargely out of reach of psychosocial treatments.

5. Teens have an increasing capacity and desire for self-determination and freedom from coercion by others.

This last feature means that teens can exert effectivecounter-control against attempts by others to alter theirbehavior. In this case, intervening with teens becomesmore akin to treating adults with mental disorders, sothat one must place far greater reliance on the willing-ness of the teen to cooperate with treatment recommen-dations. As in all other areas of adolescent medicine andclinical psychology, compliance with treatment becomesa, if not the, paramount issue in the management ofADHD in teensand it is fair to say that most teens donot necessarily want the help or will not fully investthemselves in the treatments their parents may seek forthem.

Training Parents in Behavior ManagementMethods

Despite the plethora of research on parent training inchild behavior modification,69 only a small number ofstudies have examined the efficacy of this approach inchildren specifically selected for hyperactive or ADHDsymptoms. Only two studies have examined the efficacyof such approaches specifically in teens with ADHD.94,95

However, the limited available research can be inter-preted with cautious optimism as supporting the use ofbehavioral parent training with ADHD children.69 Theresults for teens are less impressive but still suggestsome benefits for a minority of families.

The parent training treatment techniques used todate for children with ADHD have primarily consistedof training parents in general contingency managementtactics, such as contingent application of reinforcementor punishment following appropriate/inappropriatebehaviors. Reinforcement procedures have typicallyrelied on praise or tokens, while punishment methodshave usually been loss of tokens or time out from rein-forcement. Why these particular methods were chosenor what specific target behaviors they were used withhave often gone unreported.

I have developed a parent-training program for chil-dren with ADHD. This program borrows methods thathave been shown to be efficacious in studies of defiant

and oppositional children.69 The program has been mod-ified somewhat for families of teens with ADHD4 andhas been tested in combination with training of bothparents and teens in problem-solving and communica-tion skills.94,95 Such treatments appear to be more rele-vant for the oppositional/defiant behaviors associatedwith ADHD rather than being likely to change thesymptoms of ADHD or their underlying causes. The con-tingency management portion of the program consists of8 steps, with 12 hour weekly training sessions provid-ed either in groups or to individual families. Each stepis described in detail elsewhere.95 The program focuseson teaching parents about ADHD and ODD, how toimplement greater use of positive attention, praise, andtangible reinforcers, improving commands and instruc-tions, setting up a home point system, home punishmenttactics, managing children in public places, and imple-menting a daily school behavior report card. The pro-gram includes several booster sessions.

Research suggests that up to 64% of families experi-ence clinically significant change or recovery (normal-ization) of their childs disruptive behavior as aconsequence of this program.96 However, improvementsin behavior may be more concentrated in the realm ofaggressive and defiant child behavior than in inatten-tive-hyperactive symptoms. All of these studies haverelied on clinic-referred families, most of whom soughtout the assistance of mental health professionals fortheir children. In two studies of this program slightlymodified for teens, my colleagues and I found significantimprovement at the group level of analysisthat is, alltreatment groups improved from pre- to post-treatment.However, at the individual level of analysis, a mixed pic-ture emerged. While 31%70% of families were broughtto within the normal range (75th percentile or lower),only 23%30% of treated families actually showed whatcould be considered reliable changes (unlikely to be dueto unreliability of measurement alone) on measures ofparent-teen conflict. These results did not differ fromthose with the problem-solving approach discussednext.94,95

We have also examined a family training programthat includes Problem Solving Communication TrainingProgram (PSCT) procedures developed by Robin andFoster.4,95 This treatment program contains three majorcomponents for changing parent-adolescent conflict:1. Problem-solving: training parents and teens in a 5-

step problem solving approach (i.e., problem defini-tion, brainstorming of possible solutions, negotiation,decision making about a solution, implementation ofthe solution)



2. Communication training: helping parents and teensdevelop more effective communication skills whilediscussing family conflicts, such as speaking in aneven tone of voice, paraphrasing others concernsbefore speaking ones own, providing approval to oth-ers for positive communication, and avoiding insults,put-downs, ultimatums, and other poor communica-tion skills

3. Cognitive restructuring: helping families detect, con-front, and restructure irrational, extreme, or rigidbelief systems held by parents or teens about theirown or others conduct.

These skills are practiced with the therapist duringeach session using direct instruction, modeling, behav-ior rehearsal, role-playing, and feedback. Homeworkassignments are also given that involve the family usingPSCT skills during a conflict discussion at home andaudio taping these discussions for later review by thetherapist.

This procedure has been studied both separately andin combination with the behavioral parent trainingprocedure described above. The combination of the twoapproaches was superior to PSCT alone in just onerespect, though it was an important one. Significantlymore families in the combined group, who receivedbehavioral management training (BMT) first, stayed intreatment than did those receiving just PSCT.95

Otherwise, the groups did not differ, either in improve-ments on the group level or in rates of normalizationand reliable change. At most, 23% showed reliablechange while 31%70% showed normalization. Webelieve the former is a better indicator of true changeoccurring as a function of treatment over and above theexpected unreliability of the measures used to assesstreatment effects. It is of some concern that up to 17%of families showed significant worsening of family con-flicts as a function of treatment, especially with PSCT,perhaps because treatment forces them to confrontissues of conflict that they may otherwise have avoideddirectly discussing at home.

In sum, family treatments do not appear to be usefulfor the management of ADHD symptoms, but they maybe useful in addressing the parent-teen conflicts thatoften arise in such families, especially when comorbidODD is present. Family training may be maximallyeffective for elementary-age children with ADHD. Itsutility may decline in adolescents, where only a minor-ity of families (< 30%) derive clinically reliable changedue to treatment. The combination of BMT with PSCTseems to be the most useful approach, if only in reduc-

ing rates of dropouts from treatment. Yet some familiesmay actually show a worsening of conflicts as a func-tion of treatment, apparently more so with PSCT.

Training Teachers in Classroom Management

More research has been done on the application ofbehavior management methods for children with ADHDin the classroom than with parent training. There is avoluminous literature on the application of classroommanagement methods to disruptive child behaviors,many of which include the typical symptoms of ADHD.This research clearly indicates the effectiveness ofbehavioral techniques in the short-term treatment ofacademic performance problems in children withADHD. However, I am not aware of any studies thathave tested these procedures directly with teens withADHD in school settings.

A meta-analysis of the research literature on schoolinterventions for children with ADHD examined 70separate studies that used various within- andbetween-subjects designs as well as single-casedesigns.67,70 This review found an overall mean effectsize for contingency management procedures of 0.60 forbetween-subject designs, nearly 1.00 for within-subjectdesigns, and approximately 1.40 for single-case experi-mental designs. Interventions aimed at improving aca-demic performance through the manipulation of thecurriculum or of surrounding task-related environmen-tal conditions, or peer-tutoring produced approximatelyequal or greater effect sizes. In contrast, cognitive-behavioral treatments (e.g., self-instruction) when usedin the school setting were significantly less effectivethan curriculum adjustments, in-class behavior modifi-cation, or peer-tutoring interventions. Thus, all theavailable literature suggests that behavioral and aca-demic interventions in the classroom can be effective inimproving behavioral problems and academic perform-ance in children with ADHD. The behavior of these chil-dren, however, may not be fully normalized by theseinterventions. Although very encouraging, such resultsneed to be directly tested with teens who have ADHD intheir school environments. Given the large number ofteachers teenagers must typically deal with each week(as many as 6 to 8 different teachers), the more limitedtime they spend with each, the greater periods of unsu-pervised time at school, and the larger school buildingswhere teens are likely to be taught, it is not clear thatsimilar levels of success would be achieved by theseapproaches when used with teens as would be the casefor children with ADHD. Only two studies have direct-



ly tested behavioral treatments with teens. Both stud-ies primarily used note-taking training in combinationwith an intensive summer treatment program, withsome success.97,98

A serious limitation of these results has been thelack of follow-up on the maintenance of these treat-ment gains over time. In addition, none of these stud-ies examined whether generalization of behavioralcontrol occurred in other school settings where notreatment procedures were in effect. Other studies thathave employed a mixture of cognitive-behavioral andcontingency management techniques have failed tofind such generalization in children with ADHD, sug-gesting that improvements derived from classroommanagement methods are quite situation specific andmay not generalize or be maintained once treatmenthas been terminated.

The range of accommodations that can be suggestedto help individuals with ADHD in the classroom is sub-stantial. To illustrate the point, Table 1 provides a listof treatment recommendations that might be conveyedto school staff who deal with children or adolescentswith ADHD. Such recommendations range from alter-ing productivity requirements, classroom seatingarrangements, and even teaching style, to institutingclassroom token systems and daily school report cardslinked to home-based token reward programs, to sug-gestions concerning classroom punishment methods.Some of the recommendations are based mainly oncommon sense and clinical wisdom while others arederived from the scientific literature on treatmentsused with children in the classroom. Not all of theserecommendations will prove appropriate or effective inall cases, and any school intervention plan must be tai-lored to the situation of the specific individual withADHD.

Combined Interventions

Optimal treatment is likely to involve a combination ofpsychosocial and medication approaches for maximaleffectiveness.47,98 Some research studies have examinedthe utility of such treatment packages with interestingresults, although none was done with teens with ADHD.In many studies, it appears that the combination of con-tingency management training for parents or teacherswith stimulant drug therapies is generally little betterthan either treatment alone for the management ofADHD symptoms. Classroom behavioral interventionsmay mildly improve the deviant behavior of childrenwith ADHD but may not bring such levels of behavior

within the normal range. In contrast, medication ren-ders most children normal in classroom behavior.Others have found more impressive results for class-room behavior management methods67 but have alsofound that the addition of medication provides addition-al improvement beyond that achieved by behavior man-agement alone.98 Moreover, the combination may resultin the need for less intense behavioral interventions orlower doses of medication than might be the case ifeither intervention were used alone. Where behavioralinterventions do appear to have an advantage is in reli-ably increasing rates of academic productivity and accu-racyyet here too stimulant medication has shownpositive effects. Despite some failures to obtain additiveeffects for these two treatments, their combination maystill be advantageous since stimulants are not usuallyused in late afternoons or evenings when parents mayneed effective behavior management tactics to deal withADHD symptoms. Moreover, 8%25% of children withADHD do not respond positively to stimulant medica-tions,72 making behavioral intervention one of the fewscientifically proven alternatives for these cases.

A historic collaboration across 7 sites spearheaded bythe National Institute of Mental Health systematicallyevaluated the effects of intensive, multi-method behav-ioral intervention alone (for 14 months), rigorous psy-chopharmacological testing, titration, and monitoring(for 14 months), and their combination compared with acommunity treatment group (treatment as available inthe childrens normal community setting).47 The studyinvolved 579 elementary age children (ages 79 years)with combined type ADHD. One- and 2-year post-treat-ment follow-up evaluations were also conducted.Results indicated that, for the management of ADHD,medication only and combination therapy were equallyeffective and were superior to the intensive behavioraland community control groups, which did not differ fromone another. The results suggested that combined man-agement may have been slightly superior to medicationfor certain subgroups of children or for other outcomedomains. Over the 2 years the children have been fol-lowed since intensive treatment ended, only the med-ication management group has continued to benefitfrom ongoing treatment. The results of this study con-tinue to reinforce the notion that medication continuesto provide benefit for the management of ADHD symp-toms specifically as long as it is sustained. Gains frombehavioral interventions when combined with medica-tion do occur for some subgroups and for some other out-come domains but can only be sustained if theinterventions are continued.





Table 1. A typical range of treatment suggestions for classroom behavior management of childrenand adolescents with ADHD

Educational Management Principles

Decrease work load to fit childs attentional capacity

Use smaller quotas for productivity

Use more frequent but shorter work periods

Use lower accuracy quotas that increase over timewith childs success

Dont send unfinished classwork home

Eliminate high appeal distractors

Alter teaching style and curriculum

Allow some restlessness at work area

Be animated, theatrical, and responsive

Use participatory teaching with activities

Use computer based drills and instructions

Stay flexible, open to unusual teaching approaches tolessons

Dont reinforce speed of responding

Reward thoughtful think aloud approach

Seat child close to teachers work area

Intersperse low with high interest tasks

Use occasional brief exercise breaks

Schedule more difficult subjects in AM

Use direct instruction type curriculum materials

Make rules external

Use signs that signal rule periods

Use posters listing rules for work periods

Use cards on desks with rules for desk work

Have child verbally restate rules before entering thenext activity

Have child use self-instruction during work

Have child recite rules to others before work

Use tape-recorded cues to facilitate on-task behaviorwhich child listens to privately on a portable tape-player while working

Have child pre-state goals for work periods

Increase frequency of rewards and fines

Use token economies

Use Attention Trainer99

Use tape recorded tones for self-reward (see Barkleyet al. 1980100)

Have access to rewards several times/day

Increase immediacy of consequencesAct dont yack!

Stop repeating your commands

Avoid lengthy reasoning over misbehavior

Increase magnitude/power of rewards

Use token systems, which are great for this

Have parents send in preferred toys or games

Have a videogame donated to classroom

Use home-based reward program (daily school behav-ior report card) (see Barkley 19983)

Try group rewards if child meets quotas

Set time limits for work completion

Use timers if possible for external time references

Use tape recorded time prompts with decreasing timecounts

Develop hierarchy of classroom punishments

Head down at desk

Response cost (fines in token system)

Time out in corner

Time out at school office

Suspension to office (in school)

If all these strategies fail

Schedule meeting with parents and consider spe-cial educational referralCoordinate home and school consequencesDaily school report card/rating formDaily home-school journalGradually move to weekly monitoring

Tips to improve teen school performance

Use daily school assignment notebook with verifi-cation and cross checkingUse in-class cuing system for off-task behavior anddisruption Assign a daily case manager or organizationalcoachUse daily/weekly school conduct card withhome/school point system Provide extra set of books for use at homeProvide additional school/home tutoring as needed

Physical Exercise

One intervention that has received limited attention forthe management of disruptive behavior is antecedentphysical exercise, such as routine running,101 other aer-obic activities, weight training, or just simple move-ment.102 Such exercise is not contingent on anyparticular behavior, such as aerobic exercise as punish-ment, but instead is conducted periodically and noncon-tingently. Few studies have focused specifically onchildren or teens with ADHD but a meta-analyticreview of the available literature found significantresults concerning reductions in disruptive behaviorwith mean effect sizes ranging from 0.33 (analysis ofgroup studies) to 1.99 (analysis of single case designs)and evidence of greater effects in participants withhyperactivity.102 Further and more rigorous study ofthis relatively harmless, socially acceptable form oftreatment for teens with ADHD that has a benign pro-file of side effects seems in order.

CONCLUSION

The treatment of ADHD requires expertise in many dif-ferent treatment modalities, no single one of which canaddress all of the difficulties likely to be experienced byindividuals with this disorder. Among the availabletreatments, education of parents, family members, andteachers about the disorder, psychopharmacology(chiefly stimulant medications), parent training in effec-tive behavior management methods, classroom behaviormodification methods and academic interventions, andspecial educational placement appear to have the great-est efficacy or promise for dealing with children withADHD. To these must often be added family therapyfocused on problem-solving and communication skills,the coordination of multiple teachers and school-staffacross the high school day, assisting the teen withADHD with his or her expanded responsibilities, oppor-tunities and privileges, and the preparation of the teenfor eventual independent living and self-support. To beeffective in altering eventual prognosis, treatmentsmust be maintained over extended periods (months toyears) with periodic re-intervention as needed acrossthe life course. It is also important to increasingly enlistthe individuals cooperation with and investment in thelong-term intervention program.

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