Psychosocial Treatments for Attention-Deficit/Hyperactivity Disorder

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Attention-deficit/hyperactivity disorder (ADHD) is a chronic disorder requiring developmentally sensitive interventions across the lifespan. Although pharmaco-.
Psychosocial Treatments for Attention-Deficit/Hyperactivity Disorder Laura A. Knight, PhD, Mary Rooney, MA, and Andrea Chronis-Tuscano, PhD

Corresponding author Andrea Chronis-Tuscano, PhD Department of Psychology, University of Maryland, 1123K Biology-Psychology Building, College Park, MD 20742, USA. E-mail: [email protected] Current Psychiatry Reports 2008, 10:412– 418 Current Medicine Group LLC ISSN 1523-3812 Copyright © 2008 by Current Medicine Group LLC

Attention-deficit/hyperactivity disorder (ADHD) is a chronic disorder requiring developmentally sensitive interventions across the lifespan. Although pharmacotherapy traditionally has been considered the first-line treatment for ADHD, many individuals continue to experience significant functional impairment or choose not to pursue pharmacotherapy. Thus, evidence-based alternatives or adjuncts to pharmacologic treatment for individuals with ADHD are needed. Behavioral parent training and behavioral school interventions are the only empirically supported nonpharmacologic interventions for children and adolescents with ADHD. This article reviews recent additions to the ADHD literature, including evaluations of behavioral interventions in traditional clinical practice and schools, treatment efficacy for preschool-aged children and adults, and the investigation of a novel treatment for individuals with the predominantly inattentive subtype of ADHD.

Introduction Attention-deficit/hyperactivity disorder (ADHD) is a chronic disorder that begins in early childhood and is characterized by developmentally inappropriate levels of inattention, impulsivity, and hyperactivity [1]. Estimates of ADHD’s persistence into adulthood range from 15% for full diagnosis to 40% to 60% for cases in partial remission [2], suggesting a need for developmentally sensitive interventions that address symptom expression and associated functional impairments across the lifespan. Although pharmacotherapy traditionally has been considered the fi rst-line treatment for ADHD [3], an exclusively pharmacologic approach is limited in several ways. First, approximately 30% of individuals with

ADHD do not experience symptom improvement in response to medication [4] or, despite some improvement, continue to experience significant impairment [5,6•]. Second, side effects such as appetite suppression, stomachaches, headaches, and insomnia [4] lead many to discontinue pharmacotherapy. Common comorbid conditions, such as mood, anxiety, and disruptive behavior disorders [7,8], necessitate adjunctive psychosocial treatment. Furthermore, many parents, particularly those with preschool-aged children [9] and members of minority groups [10,11], prefer behavioral or combined medication and behavioral interventions [10–12]. This has significant implications for treatment adherence [13] and highlights the need for evidence-based alternatives or adjuncts to pharmacologic treatment for individuals with ADHD. Behavioral treatment (BT) is the only nonpharmacologic intervention to have demonstrated efficacy in the treatment of children with ADHD [14•]. Behavioral parent training (BPT) and behavioral school interventions have received sufficient empiric support to be classified as “well-established treatments” for ADHD [14•]. BPT also has a long, successful history as a treatment for children with oppositional defiant disorder and conduct disorder [15], thus addressing common comorbidities. No empirically supported treatments have been identified specifically for adolescents [16] or adults [17 ]. Many nonbehavioral approaches to ADHD treatment are widely used, including individual therapy, play therapy, and electroencephalographic biofeedback, but no evidence to date supports their efficacy [14•,18]. Social skills training has received a great deal of attention, but despite voluminous research, only one unreplicated study [19] has reported beneficial effects on parent-reported social behaviors. However, a social skills intervention delivered in a recreational setting as part of a comprehensive summer treatment program (STP) [20], which includes behavioral interventions, has been found to improve social functioning, suggesting that the intervention’s format and intensity may affect its efficacy [14•]. In summary, despite their widespread use, nonbehavioral approaches to ADHD treatment have received little to no empiric support. In contrast, behavioral interventions have a solid foundation within the empiric literature.

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Behavioral Interventions Behavioral interventions are based on social learning principles and involve teaching parents and teachers to identify and modify the antecedents and consequences of children’s behavior; target and monitor problematic behaviors; reward prosocial behavior through praise, positive attention, and tangible rewards; and decrease unwanted behavior through planned ignoring, time-out, and other nonphysical discipline techniques [14•]. Treatment for ADHD is most effective when consistently implemented in all settings in which individuals experience impairment, which for children and adolescents typically include home and school. The efficacy of BPT in treating the behavioral deficits of children with ADHD is supported by a wealth of empiric literature [14•], demonstrating improvements for children with ADHD in several important areas, including parent ratings of problem behavior, observed negative parent and child behaviors, and parenting stress. Existing literature further supports BPT’s efficacy for treating ADHD symptoms and disruptive behavior problems in diverse cultural groups [21]. Like BPT, behavioral classroom management is a well-established treatment for ADHD [14•] that addresses the behavioral deficits that often impair academic functioning. Students with ADHD spend significantly more time off-task compared with their non-ADHD peers and are more likely to demonstrate disruptive and inattentive behaviors that interfere with their academic productivity and social relationships [22]. Contingency management procedures (eg, teacher-implemented reward systems) and daily school behavior report cards (SBRCs) are behavioral interventions that have been shown to be effective compared with control conditions for improving classroom behavior in students with ADHD [14•,16, 23]. Daily report cards contain teacher ratings of children’s behavior based on pre-established criteria. In conjunction with a home-based reward program, children earn privileges contingent upon school behavior, allowing parents to assist teachers with the difficult task of managing problematic school behavior. The National Institute of Mental Health Multimodal Treatment Study of Children with ADHD (MTA) [12] is the largest clinical trial of treatment efficacy focused on a childhood mental disorder and the largest long-term treatment study of children with ADHD conducted to date. Using a 4-group parallel design, 579 children, ages 7 to 9 years, diagnosed with ADHD, combined type (ADHD-C) were randomly assigned to receive medication management (MEDMGMT), intensive BT, combined medication management and behavioral treatment (COMB), or standard community care over 14 months [12]. The large number of MTA study participants, treatment arms, and study investigators has resulted in a proliferation of publications that provide important information about the place of psychosocial interventions in the treatment of ADHD. Although a comprehensive summary of the MTA

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study is beyond the scope of this paper, we briefly review some key fi ndings regarding BT. The BT package of the MTA study was comprised of 3 carefully integrated components: 27 group and 8 individual BPT sessions, a school intervention including teacher consultation and a behaviorally trained paraprofessional aide, and an 8-week STP. Post-treatment, all groups showed reduced ADHD symptoms, but groups receiving medication, alone or in combination with BT, showed greater improvement in ADHD symptoms compared with BT alone and/or community care. However, when outcomes including important domains of life functioning, such as teacher-rated social skills, reading achievement, and parent-child relations, and cooccurring problems such as oppositional and aggressive behaviors and internalizing symptoms were considered, COMB was superior to BT and/or community care, whereas MEDMGMT alone was not. Additionally, participants in the COMB group required lower doses of medication to achieve results that were equivalent or superior to those of the MEDMGMT group [12]. This suggests that whereas medication effectively reduces core symptoms of ADHD, combined behavioral and pharmacologic intervention has a more profound impact on a child’s functioning and may reduce the level of medication needed to achieve optimal results. The superiority of the MEDMGMT and COMB groups was maintained at 24-month follow-up; however, at 36 months, significant differences no longer existed among the groups in ADHD symptoms or related impairment [24, 25•]. Although all groups experienced substantial symptom reduction over time, none improved to levels comparable to the non-ADHD comparison group, suggesting that factors predicting long-term treatment response warrant careful consideration. The MTA study has provided important preliminary information regarding what types of treatment work best for select subgroups of children with ADHD. Specifically, children with a comorbid anxiety disorder responded best to the BT component, whereas those with comorbid anxiety and disruptive behavior problems responded best to COMB [26], suggesting that BT may be an appropriate fi rst-line treatment for children with ADHD and comorbid anxiety. However, when disruptive behavior problems are also present, combined treatment is likely to be more effective. Furthermore, African American children were most likely to benefit from COMB relative to other treatment groups, even after other relevant background factors were controlled [21]. Overall, the complex pattern of results indicates that in the case of ADHD treatment, one size does not fit all. As follow-up data are collected and disseminated, the MTA study will further address questions about which ADHD treatments work for whom and long-term effects of different types of treatment for ADHD, thereby providing data-driven recommendations for practitioners.

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Recent Additions to the Psychosocial Treatment Literature In this article, we review the recent literature on psychosocial treatments for ADHD, focusing specifically on studies published since 2007. As the efficacy of behavioral interventions for school-aged children (ie, 6–12 years old) with ADHD is well-established, researchers have now turned their attention to other important issues, such as the real world implementation of empirically based treatments. We review recent evaluations of behavioral interventions’ effectiveness in traditional clinical practice and schools. We also review a recent investigation of a novel treatment for children diagnosed with the predominantly inattentive (PI) subtype of ADHD. Finally, we review recent investigations of treatment efficacy for other age groups, including preschoolers and adults.

Effectiveness of behavioral interventions in real world settings Clinical practice As most treatment for ADHD is delivered in clinical practice, the paucity of research evaluating BPT as implemented in real world clinical settings is a significant shortcoming in the literature. To address this concern, Van den Hoofdakker and colleagues [27•] conducted a randomized, controlled trial to evaluate the effectiveness of a 12-week BPT group delivered in a mental health outpatient clinic by experienced clinicians as an adjunct to routine clinical care (RCC) provided by a child psychiatrist compared with RCC alone (ie, pharmacotherapy, psychoeducation, and family support). For clinic-referred 4- to 12-year-old children with ADHD, adjunctive BPT was more effective than RCC alone in reducing individual parent-identified target behaviors and overall child externalizing and internalizing behaviors. However, the BPT and RCC-alone groups did not differ on parent-rated ADHD symptoms or parenting stress at post-treatment. Although the groups did not differ in the number of children receiving pharmacologic treatment for ADHD, significantly more children in the RCC-alone group were receiving polypharmacologic treatment at post-treatment. Furthermore, families in the RCC-alone group had significantly more psychiatrist contacts over the course of the study [27•]. Overall, results of this study conducted in a real world clinical setting mirrored the fi ndings of studies conducted in controlled research settings, suggesting that BPT is an efficacious and cost-effective treatment for children with ADHD. Classroom interventions Despite substantial empiric support for SBRCs, their utility for underserved populations has received little research attention. Jurbergs and colleagues [28•] evaluated the effectiveness of SBRC with and without response cost for increasing the attention and academic performance of low-income African American children with ADHD. Six

6- to 8-year-old children with ADHD referred by teachers for disruptive classroom behavior were randomly assigned to receive the SBRCs, alternating with and without response cost, to determine whether response cost impacted the SBRCs’ effectiveness. Teachers rated target behaviors for all children (“completing class work satisfactorily” and “staying on task”) and awarded points to children in both conditions based on their behavior. These points then were redeemed for rewards at home. In the response cost condition, children also lost points for off-task or disruptive behavior. Introduction of the SBRCs resulted in a significant increase in on-task performance and class work accuracy for the response cost and no response cost conditions. Withdrawal of the SBRCs, with and without response cost, resulted in decreased ontask performance for all students; on-task performance returned to treatment levels with the subsequent reinstatement of the SBRCs. Overall, both SBRC conditions were equally effective, but teachers and parents preferred the response cost component [28•]. Results suggest that the SBRCs are effective for improving the on-task performance and classwork accuracy of low-income African American children with ADHD. Secondary school students with ADHD have also received little attention in the classroom intervention literature [16]. Academic demands increase for middle school students, setting the stage for serious problems (eg, school dropout) that may manifest during high school and suggesting the need for treatment at this sensitive developmental stage [16, 29••]. Evans and colleagues [29••] evaluated the cumulative benefits of their school-based intervention for middle school students, administered continuously during students’ sixth through eighth grade years. In sixth grade, students were randomized to receive the training and consultation model of the Challenging Horizons Program (CHP-C) or treatment as usual (TAU). The CHP-C program targeted academic skills (eg, assignment tracking, note-taking, organization) and social skills (eg, conversational skills, social problem-solving). Teachers were trained to coordinate and implement the interventions with consultation from school psychologists. Results indicated that inattention symptoms improved over time for the CHP-C group, whereas symptoms increased for the TAU group. Furthermore, benefits from treatment continued to emerge from the fi rst to third year of the intervention, eventually reaching a moderate effect size for parent-rated inattention, hyperactivity, and social functioning. No clear patterns emerged in measures of school functioning, and parent ratings of academic functioning did not differ between groups. Changes in grade point average were inconsistent across grades. Both groups had declines in grade point average during the fi rst semester of sixth grade, but grade point average increased for the treatment group during the second semester, whereas it continued to decline in the TAU

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group. A similar pattern emerged during eighth grade, but groups did not differ in grade point average during the seventh grade. Parent-rated social functioning in the treatment group improved over time, whereas the TAU group showed increasing social impairment. Overall, the pattern of results suggests a cumulative long-term benefit in some domains for middle school students with ADHD who received the CHP-C but highlights the difficulties in treating this population, as students evidenced no long-term academic benefit despite receiving academic interventions across a 3-year period [29••].

ADHD, predominantly inattentive type Most of the existing literature, including the MTA study, has overwhelmingly focused on treatments for ADHD-C, the most commonly diagnosed subtype in clinic samples [30], with scant attention paid to treatment efficacy across subtypes [31••]. PI is characterized by persistent and developmentally inappropriate attentional deficits in the absence of hyperactive or impulsive behaviors [1]. Individuals with PI also tend to be more socially withdrawn and passive, have greater deficits in social knowledge [32], and have more academic deficits due to low motivation and poor persistence [33] compared with individuals with ADHD-C or the predominantly hyperactive-impulsive type. Furthermore, symptoms of “sluggish cognitive tempo,” such as daydreaming [34], and processing deficits [30] are common. Differences in symptom presentation and functional deficits between these subtypes [35] suggest that research is sorely needed to address this gap in the treatment literature. Pfi ffner and colleagues [31••] conducted the fi rst randomized, controlled trial of a treatment designed specifically for the PI subtype. The Child Life and Attention Skills (CLAS) Program is a 12-week intervention comprised of teacher consultation, BPT, and child skills training. Treatment components were adapted from existing evidence-based treatments for ADHD to address the specific deficits of PI. They also included interventions from rehabilitation psychology used with patients with mild closed head injury (eg, prompts, routinization). Teacher consultation included an overview of behavioral interventions and classroom-based accommodations for PI followed by four or five parent, teacher, child, and therapist meetings conducted over 12 weeks. Target behaviors for SBRCs were individualized to each child, and classroom accommodations were implemented as needed. BPT began with psychoeducation. A token economy with individualized target behaviors and rewards was then developed for each family. Concurrent child groups included modules focusing on skills for independence (eg, academic, study, organization, self-care, and daily living) and social competence. Child groups addressed deficits in knowledge and performance through didactic instruction, behavior rehearsal, and in vivo practice in the context of a contingency management program. Parents learned to facilitate and reinforce these skills at home.

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A total of 69 7- to 11-year-old children were randomly assigned to the CLAS Program or a TAU control group. Clinically and statistically significant post-treatment decreases in parent- and teacher-reported inattention symptoms were reported for the CLAS Program participants compared with control participants [31••]. Significant post-treatment improvements were also reported for the CLAS group in parent and teacher ratings of sluggish cognitive tempo, social functioning, and organizational skills and in child-reported knowledge of social and organizational skills. At 3 to 5 months’ posttreatment, parents continued to report fewer and less severe inattention symptoms, indicating that the CLAS participants maintained their gains. Thus, Pfi ffner and colleagues [31••] demonstrated the efficacy of the fi rst behaviorally based psychosocial treatment designed to address the challenges specific to individuals with PI.

Treatments across the lifespan Preschool-aged children Diagnosing ADHD in young children has been controversial; however, research suggests that ADHD can be reliably diagnosed in children as young as 3 years old [36]. Diagnosis in early childhood predicts symptoms and associated impairment persisting into middle childhood for both genders [37 ]. Maternal psychopathology and observed parenting behaviors are predictive of the developmental course of conduct problems for children diagnosed with ADHD during early childhood, with maternal depression predicting higher levels of conduct problems and positive parenting predicting lower levels [38]. This suggests that early identification and intervention for young children with ADHD may significantly impact their developmental trajectory. Parental objections to pharmacologic treatment for young children are common [9], and data supporting the safety and efficacy of stimulant use by preschool-aged children are limited [39]; thus, psychosocial interventions are often considered appropriate fi rst-line treatment for young children with ADHD symptoms [40]. The Incredible Years: Parents, Teachers, and Children Training Series (IY) is a set of multimodal behavioral interventions developed by Carolyn Webster-Stratton to promote social competence and reduce disruptive behavior problems in young children. IY is empirically supported for the treatment of young children with oppositional defiant disorder and conduct disorder and is effective for reducing parent-reported and observed behavioral problems [15]. Although it is typically targeted at children with early conduct problems [41], Jones and colleagues [42•] hypothesized that the BPT component of IY would show similar benefits for children evidencing early signs of ADHD. The BPT component of IY teaches parents positive parenting skills such as establishing a positive parent–child relationship through play and child-centered activities; providing praise and incentives for appropriate behavior; giving clear commands and setting limits; and

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managing noncompliance through the use of time-out, ignoring, and natural consequences [41]. Jones and colleagues [42•] tested the efficacy of the parent training component of IY for ADHD by randomly assigning a community sample of preschool-aged children (mean age, 46.28 months) with comorbid ADHD symptoms and conduct problems to IY or a wait-list control condition. Parents in the IY condition learned skills through facilitated discussion, videotaped modeling, role-playing, and rehearsal during a 12-week BPT group. At post-treatment, parents in the IY group reported significantly greater improvements in child inattention and hyperactivity compared with controls; furthermore, improvements in ADHD symptoms were independent of improvements in conduct problems [42•]. This improvement was maintained 18 months post-treatment [43]. Results suggest that the IY parent training component is an effective fi rst-line intervention for young children who demonstrate early symptoms of ADHD. Adults Comparatively little is known about effective psychosocial treatment of ADHD for adults. The limited literature indicates that cognitive-behavioral treatment (CBT) combined with medication is the predominant treatment of ADHD for adults [17 ]. Pharmacologic studies show that stimulant medication is moderately effective in treating adult ADHD, but residual symptoms are common, supporting the need for adjunctive behavioral interventions [44]. Safren et al. [45] developed a novel individual CBT intervention for adult ADHD that included psychoeducation about ADHD; skills training in organization, planning, and maximizing attention (eg, breaking down large tasks into smaller components); and cognitive restructuring to maximize adaptive thinking and reduce distractions. A study comparing Safren et al.’s [45] intervention plus psychopharmacology with psychopharmacology alone found that CBT resulted in fewer self- and clinician-reported ADHD and anxiety symptoms. Solanto and colleagues [6•] recently pilot-tested another new CBT intervention, meta-cognitive therapy (MCT), with 30 adults (mean age, 40.94; SD, 10.78) diagnosed with ADHD-C or PI to address deficits in planning and organization that cause significant occupational impairment for adults with ADHD. The intervention components provided skills training and cognitive restructuring in a group format. At post-treatment, clinically and statistically significant improvements in attention and working memory and statistically significant improvements in organization, sustained effort, and affect modulation were found, with no differences between “persisters” and “remitters” regarding the presence of medication or comorbid internalizing disorders. The results of this pilot study suggest that psychosocial treatment may result in incremental benefits beyond those obtained with medication [6•].

Conclusions A substantial literature base supports the use of behavioral interventions as adjunctives or alternatives to pharmacologic treatment for children with ADHD. Substantially less is known about psychosocial treatments for ADHD in adolescence and adulthood, but the burgeoning research suggests that BT and CBT may provide gains above and beyond those achieved with medication alone [6•,16,17 ]. The MTA study set the new standard for child-focused treatment outcome studies, and although MTA psychosocial treatments were more extensive than what is typically provided in real world clinical practice, they enable us to see the outcome of gold standard treatment. Analyses of moderators and mediators of MTA treatments are particularly informative in identifying the treatments or combination of treatments that may work best for specific patients. Despite this leap forward, Hinshaw [46] commented that there is much we still do not know, including which factors predict positive outcomes for children and adolescents with PI, how children from diverse backgrounds respond to empirically supported treatments for ADHD, and which school environments promote optimal gains for children with ADHD. Academic problems such as poor comprehension, poor study skills, and poor grades may require a more comprehensive approach than behavioral classroom management, as these interventions are limited in the treatment of academic problems [16]. Rapport and colleagues [47 ] found that the relationship between ADHD, intelligence, and academic achievement was mediated by behavioral (eg, classroom performance) and cognitive factors (eg, memory), supporting a dual-pathway model of academic achievement for children with ADHD. Their results suggest that classroom interventions also may need to follow a dual-pathway model, with interventions to address academic and behavioral deficits in the classroom. Behavioral interventions are most effective while they are being used [13], and results are confl icting as to their effectiveness after active treatment is withdrawn [14•]. Results of the MTA suggest that given the chronic and pervasive nature of ADHD, continuous intervention in all settings in which impairment occurs is needed for treatment gains to be maintained. Treatment of ADHD must be considered a long-term investment to adequately address symptom expression as it manifests across developmental stages. As the MTA participants move through adolescence, the investigators will examine the relationship between treatment type and current substance use, risky sexual behavior, romantic relationships, driving habits, academic achievement, and other areas of functioning. These analyses will fi ll existing gaps in the adolescent ADHD literature and lay the foundation for the development of novel interventions for adolescents. An oft-ignored consideration in the treatment of ADHD in childhood and adolescence is parental func-

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tioning. Given that parents must obtain and consistently administer behavioral and pharmacologic treatments for ADHD, parental psychopathology is, not surprisingly, a predictor of poor child treatment response [48], and assessment of parental functioning thus may be considered a necessary component to a comprehensive child evaluation [49]. Existing ADHD treatments largely fail to directly address environmental–contextual factors that may undermine or substantially reduce treatment effectiveness [49]. To address one contributor to poor outcomes in BPT—maternal depression—the Maryland ADHD Program is conducting a National Institute of Mental Health–funded, randomized clinical trial comparing a novel approach to BPT for women with elevated depressive symptoms who have children with ADHD [49]. This treatment outcome study, currently under way, compares a treatment that integrates BPT and CBT for depression. This integrated framework addresses the depression symptoms that are thought to impair parenting and the challenging behaviors of children with ADHD, with the ultimate goal of improving the developmental and treatment outcomes of children with ADHD. Although great strides have been made in establishing psychosocial treatments for ADHD, additional work is still needed. Particular areas of need include the development of effective treatments for adults with ADHD and interventions specific to those with comorbid conditions such as anxiety, depression, and substance use disorders. BT is currently the only empirically supported psychosocial treatment for ADHD. Given the serious long-term functional deficits associated with ADHD, dissemination and adaptation of BT for different populations and in real world settings represents a major public health agenda.

Disclosures Dr. Chronis-Tuscano has received a grant sponsored by McNeil Pediatrics. No other potential confl icts of interest relevant to this article were reported.

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