Psychosocial Treatments for Children with Attention Deficit ...

Neuropsychol Rev (2007) 17:73–89 DOI 10.1007/s11065-006-9018-2

ORIGINAL PAPER

Psychosocial Treatments for Children with Attention Deficit/Hyperactivity Disorder Brian P. Daly · Torrey Creed · Melissa Xanthopoulos · Ronald T. Brown

Received: 30 November 2006 / Accepted: 30 November 2006 / Published online: 27 January 2007 C Springer Science+Business Media, LLC 2007

Abstract This article reviews studies examining the efficacy of behavioral interventions for the treatment of attention-deficit/hyperactivity disorder (ADHD). A specific emphasis is placed on evidence-based interventions that include parent training, classroom, academic, and peer interventions. Results indicate that school-aged children respond to behavioral interventions when they are appropriately implemented both at home and in the classroom setting. Combined treatments (behavioral management and stimulant medication) represent the gold standard in ADHD treatment and are often recommended as the first-line treatment option due to the many problems faced by children with ADHD. Diversity issues, although an important consideration in the treatment of ADHD, continue to remain an understudied area. Recommendations for future research are made pertaining to treatment sequencing with regard to behavior management as well as for subgroups of ADHD children who may respond best to specific treatments. Keywords ADHD . Behavior therapy . Parent training ADHD (attention-deficit/hyperactivity disorder) is a neurobehavioral disorder that may impede a child’s capacity to sustain attention and effort, and to exercise age-appropriate inhibition in behavioral settings or on cognitive tasks. The syndrome is characterized by developmentally inappropriate levels of symptoms that may include, but are not limited to, inattention; failure to follow instructions; inability to organize oneself and school work; fidgeting with hands and feet; talking too much; staying on task; leaving projects, chores, B. P. Daly () · T. Creed · M. Xanthopoulos · R. T. Brown Department of Public Health, Temple University, 3307 North Broad Street, Philadelphia, PA 19140, USA e-mail: [email protected]

and homework unfinished; and having trouble paying attention to and responding to details (American Psychiatric Association [APA], 2000). ADHD is the most commonly diagnosed behavioral disorder of childhood and is estimated to affect approximately 5% of the school-age children in the United States (American Psychiatric Association, 2000), with a male to female ratio ranging between 2:1 to 6:1 (Biederman, Lopez, Boellner, & Chandler, 2002). Although the course of ADHD may vary from individual to individual, research indicates that it is a chronic disorder in which cognitive and behavioral manifestations typically emerge during the childhood years, and consequently place children and adolescents at higher than average risk for academic, behavioral, and social difficulties. For example, despite some of the most intensive treatment efforts for the disorder, most children with ADHD (over 80%) still continue to evidence symptoms of the disorder at adolescence (Barkley, Fisher, Edelbrock, & Smallish, 1990) and even adulthood (Ingram, Hechtman, & Morgenstern, 1999). This article will briefly review those limitations associated with pharmacological management for ADHD in children. Next, we examine the effectiveness of the most widely employed and accepted behavioral treatment approaches (parent training, classroom interventions, academic interventions, and peer interventions) for this population. A brief review of the limitations associated with psychosocial treatments also are examined. Findings from studies that have employed combined or multimodal treatment approaches are reviewed. Subsequently, we review the evidence for alternative treatment approaches (metacognitive therapy, biofeedback, and neurofeedback) for children with ADHD. We also discuss diversity issues as they pertain to employing psychosocial treatments for children with ADHD and their families. Finally, we make specific recommendations for future research in this area. Springer

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Neuropsychol Rev (2007) 17:73–89

Pharmacotherapy Stimulant medication in children and adolescents has been the most widely investigated and frequently used class of psychotropic agents in behavioral pediatrics and child and adolescent psychiatry (Brown & Daly, in press). For example, approximately 80% of children receiving pharmacotherapy agents for the management of ADHD are prescribed stimulants. The stimulants represent the class of psychotropic medication most commonly prescribed for school-aged children and adolescents, and are indicated for the management of attention deficit/hyperactivity disorder (Jensen et al., 1999; Teitelbaum et al., 2001; Zito et al., 2003). Research has clearly demonstrated that stimulants are effective in the management of those cognitive and behavioral symptoms associated with ADHD, which include inattention, impulsivity and overactivity that occur in multiple settings such as the classroom, at home, and in social settings involving peers (Brown & Daly, in press). One of the primary criticisms of stimulant drug therapy, however, is the lack of evidence that stimulants produce either short- or long-term changes in academic achievement. Moreover, there is not a compelling literature to suggest that the stimulants improve the rather guarded long-term prognosis of the disorder (MTA Cooperative Group, 1999a; Weiss & Hechtman, 1993). Therefore, given that many children and adolescents with learning or behavioral problems are frequently managed with stimulants, it is important to be aware of both the safety and efficacy of these agents (see Pliszka, 2006 in this issue) as well as potential limitations regarding safety and efficacy. Limitations—Physical The most frequently reported adverse effects of stimulant drug therapy are decreased appetite, headaches, abdominal discomfort, problems falling asleep, irritability, motor tics, nausea, fatigue, and social withdrawal (McMaster University Evidence-Based Practice Center, 1999; Pliszka, 2000). Many of the adverse side effects associated with stimulants in the school-age population appear to be relatively mild, shortlived, and linearly associated with dose (McMaster University Evidence-Based Practice Center, 1999). However, there is some evidence to suggest that the adverse side effects of stimulants can be of sufficient magnitude to warrant discontinuation of the medication. The most common manifestations of adverse effects necessitating discontinuation of medication include delayed sleep onset, reduced appetite, stomachache, and headache (Santosh & Taylor, 2000), which occur in 4–10% of children treated with stimulants. Furthermore, there are some reports to indicate that approximately 20–30% of children do not demonstrate significant benefits from stimulant drug therapy (Pelham, 2000; Swanson, McBurnett, Christian, & Wigal, 1995), although there is Springer

some inconsistency with regard to these reports (for review see, Brown & Daly, in press). Academic achievement Although stimulants improve short-term gains in academic efficiency and productivity (Carlson, Pelham, Milich, & Dixon, 1992; DuPaul & Rapport, 1993), the long-term efficacy of stimulants on academic achievement has yet to be demonstrated (Bennett, Brown, Craver, & Anderson, 1999; Jadad et al., 1999; McCormick, 2003). Results from studies that evaluated the effects of stimulants on children with specific learning disabilities failed to demonstrate any compelling evidence to suggest that stimulants improved basic learning disabilities (Alto & Frankenberger, 1994; Barkley & Cunningham, 1978; Weber, Frankenberger, & Heilman, 1992). In addition, several studies suggested that there is little or no improvement for children with reading disorders who are treated with stimulant medication (Aman & Werry, 1982; Ballinger, Varley, & Nolen, 1984; Cooter, 1988; Gittelman, Klein, & Feingold, 1983). Peer relationships Stimulants often are associated with improved social functioning, but they rarely normalize the behavior of ADHD children to that of their typically-developing peers (Hoza et al., 2005; Pfiffner, Calzada, & McBurnett, 2000). It also is noteworthy that one study actually reported adverse effects on children’s social behavior following the initiation of stimulant drug therapy. Specifically, in a placebo-controlled trial of methylphenidate, children who received active medication displayed muted social behavior, decreased social engagement, and increased dysphoria relative to those receiving placebo doses (Buhrmester, Camparo, Christensen, Gonzalez, & Hinshaw, 1992). Family problems Another limitation of stimulant treatment alone is that the duration of action for most long-acting stimulant medications is eight hours (some agents may have longer duration), thereby leaving a significant period of time during evening or weekend hours in which caregivers must help children manage their behavior. Parents often struggle in their efforts to manage children’s impulsive, oppositional, and disruptive behaviors that may occur in the afternoons and evenings, weekends, and summers. Moreover, there is evidence to suggest that some parents may choose not to medicate their child due to adverse side effects or personal preferences. Frequently, many caregivers report that psychosocial treatments are more acceptable than medication (e.g., Reimers, Wacker, Cooper, & De Raad, 1992). Although stimulant drug


therapy remains the most prevalent treatment option for children with ADHD, the clear limitations associated with medication management provide an important rationale to employ evidence-based psychosocial treatment with these children and their families either as an alternative or in combination to medication.

Behavior management Parent training Symptoms of ADHD, such as inattention, hyperactivity, and impulsivity not only affect a child’s daily functioning but also may influence the functioning of the parent-child relationship, as well as increase stress in caregivers of children with the disorder (Baldwin, Brown, & Milan, 1995; Wells et al., 2006). Parental coping and parenting strategies may become maladaptive and counterproductive in the attempt to manage their child’s problematic behaviors, and may even maintain or exacerbate the behavioral difficulties (Patterson, DeBaryshe, & Ramsey, 1989). Therefore, family-based interventions that focus on modifying antecedents and consequences of their child’s behavior by parents are the focus of behavioral parent training treatment for children with ADHD (Pelham, Wheeler, & Chronis, 1998). Behavioral parent training interventions are based on a foundation of social learning principles that teach the child more socially acceptable behavior by training primary caregivers in contingency management strategies, emphasizing behavior modification, cues, and consequences, reward systems, and discipline (Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004). Parents learn how to identify and manipulate the antecedents and consequences of a child’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 non-physical discipline techniques (Chronis et al., 2001). In essence, these approaches focus on reducing any positive reinforcement (e.g., parental attention) being unintentionally provided to the child for engaging in disruptive/defiant behavior, while simultaneously increasing the reinforcement parents provide for appropriate and compliant behavior. Punishment is contingent on the display of disruptive or unacceptable behavior, and parental use of consequences is predictable, contingent, and immediate to the behavior which precedes it (Barkley, 1997; Barkley, 2000). Many studies have employed interventions that focus on the above principles in 8 to 12 group or individual sessions. A typical parent training program will include educational sessions on the child’s disorder, social learning theory, and behavioral management techniques; training in specific

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techniques for giving commands, reinforcing adaptive and positive social behaviors of the child while ignoring minor inappropriate behaviors to reduce or eliminate them; training in techniques for establishing and enforcing rules and establishing time-out procedures; training on initiating a point system with reward and response cost, and how to enforce contingencies across settings; problem-solving techniques; and strategies for maintenance and relapse prevention (Chronis, Chacko et al., 2004; DeNisco, Tiago, & Kravitz, 2005). It also has been emphasized that behavioral treatments must be implemented consistently over the long-term, since ADHD is recognized as a chronic condition (Chronis et al., 2001). Behavioral parent training is one of the oldest and most substantiated treatment interventions in child mental health (Chronis, Chacko et al., 2004; Kazdin, 1997; Lundahl, Risser, & Lovejoy, 2006), particularly for children with aggression/conduct problems (Brestan & Eyberg, 1998). Family-based interventions also have been effectively employed in children with ADHD for improving behavior in the home setting (Huang, Chao, Tu, & Yang, 2003; Pelham et al., 1998). In addition, the vast majority of children with conduct problems or with a diagnosis of conduct disorder (CD) have comorbid ADHD, and the effect sizes for parent training are at least as large, if not larger, for comorbid ADHD/CD children than for children with CD alone (Bor, Sanders, & Markie-Dadds, 2002; Lundahl et al., 2006). Behavioral parent training also has been found to increase parental knowledge of ADHD and caregivers’ sense of competence in responding to their children, reduce parental and family stress and improve maladaptive parenting behavior (Anastopoulos, Shelton, DuPaul, & Guevremont, 1993; Chronis, Chacko et al., 2004; Pisterman et al., 1992a; Weinberg, 1999; Wells et al., 2000). For example, Weinberg (1999) examined 34 parents who participated in a 6-week parent training program for 25 children ranging in age from 4 to 13 years who also were being treated with stimulant medication (n = 23), nortriptyline (n = 1), or guanfacine (n = 1). Results revealed that parents who participated in the parent training program reported significant improvement in their knowledge and understanding of ADHD and behavior management skills, and they also experienced slight reductions in the stress of managing their child’s ADHD symptoms and behavior problems. Furthermore, Sonuga-Barke, Daley, Thompson, Laver-Bradbury, and Weeks (2001) compared two different parent-based therapies and a wait-list control group for children with ADHD in a community sample of three-year-olds and their mothers. One parent-based group utilized parent training, while the other group was a parent counseling and support group. Results showed a statistically and clinically significant effect of treatment on ADHD symptoms, as well as significant effects on maternal adjustment and well-being in the parent training group, but not for the other two groups (Sonuga-Barke et al., 2001). Springer

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However, there is a degree of variability in the effectiveness of behavioral treatments in the management of ADHD for individual children (Chronis et al., 2001; Chronis, Chacko et al., 2004; Lundahl et al., 2006). The effects of behavioral parent training are larger in specific domains, such as compliance with parental requests, rule-following, defiant/aggressive behavior, and parenting skills (Anastopoulos et al., 1993; Pisterman et al., 1992b), than on specific symptoms of ADHD as delineated by the DSM (MTA Cooperative Group, 1999a; 2004). Furthermore, the literature has revealed mixed results when examining the effectiveness of behavioral parent training on improving child functioning and reducing ADHD symptoms, which may be due, in part, to methodological differences across studies (Lundahl et al., 2006). For example, some studies obtained parent, teacher, and child or adolescents ratings of child behavior (Barkley, Guevremont, Anastopoulos, & Fletcher, 1992), while others employed a blinded, objective rater of the child’s behavior in the classroom (Wells et al., 2006). The studies that used parental ratings as dependent measures have yielded significant results; however, they may be influenced by rater bias and expectancy effects given that the raters themselves were involved in the treatments. In an attempt to address this methodological problem, Wells and colleagues (2006) designed a study that included baseline and post-treatment laboratory observations of parent-child interactions which were coded by trained observers that were blind to treatment condition. Results revealed that multimodal treatment (behavioral treatment in combination with medication management) resulted in significantly greater improvements in parents’ use of proactive parenting strategies than did a community-treated comparison group. It is noteworthy that ratings for the medication management or behavioral management alone did not reveal improvements as had been reported in a similar study that only employed parental ratings (Wells et al., 2000). The child’s age may also influence treatment outcome. For example, younger children are dependent on parents for fulfillment of basic needs and would therefore be expected to be most responsive to behavioral management skills taught in behavioral parent training programs (Kazdin & Weisz, 1998). Alternatively, adolescents are more advanced in their abstract thinking and reasoning abilities, and are not as reliant on their caregivers to fulfill their needs. Therefore, they may benefit from nonbehavioral programs that focus on improving parent-child communication. However, there is no consensus on how the child’s age influences parent training outcomes (Serketich & Dumas, 1996). It has been suggested that parent training may be fairly robust with regard to outcome without any influence of age effects (Lundahl et al., 2006). Most studies of behavioral parent training and ADHD have focused on children between 6 and 12 years of age, Springer

but some studies have shown similar positive changes for younger children (Bor et al., 2002; Pisterman et al., 1989; Pisterman et al., 1992b; Sonuga-Barke et al., 2001) and adolescents (Barkley, Edwards, Laneri, Fletcher, & Metevia, 2001; McCleary & Ridley, 1999). For example, Bor, Sanders, and Markie-Dadds (2002) compared a standard behavioral family intervention involving the education of parents on child management strategies and an activities routine applicable to a broad range of target behaviors to an enhanced behavioral family intervention that also included partner support and coping skills. Families (n = 87) of preschoolers with disruptive behavior and attentional/hyperactivity difficulties were assigned either to one of the intervention groups or to a wait-list control group. Their results showed that both intervention conditions were associated with positive outcomes in child behavior problems, parenting skills and competence, and parental conflict compared to the wait-list controls. However, the enhanced intervention program was not superior to the standard program on any of these major outcome measures. Further, the results were maintained at a one-year follow-up (Bor et al., 2002) attesting to the durability of the intervention. Barkley and colleagues (1992), however, compared behavior management training to problem-solving and communication training, as well as to structural family therapy in 12–18 year olds (n = 61) and their parents. Results revealed that all three treatment approaches yielded significant improvements during conflict discussions in parentadolescent communication, number of conflicts, and anger intensity at home as reported by the mother and adolescent. In addition, all three treatments resulted in significant improvements in school adjustment as reported by parents, and the dimensions of both internalizing and externalizing symptoms as reported by both parents and adolescents. In a meta-analysis of parent training programs to modify disruptive child behaviors, and parental behavior and perceptions (Lundahl et al., 2006), findings indicated that parent training designed to modify disruptive child behavior is a robust intervention producing effect sizes in the moderate range immediately following treatment. Although smaller in magnitude, parent training effects remained durable at one-year follow-up. In summary, a large evidence base exists for the use of parent behavioral interventions to reduce ADHD symptoms, to improve parenting skills and their sense of competence, and to diminish family distress. Given this compelling body of literature attesting to its effectiveness, behavioral parent training should be considered as a firstline treatment for ADHD by itself or in conjunction with medication. Classroom interventions Behavioral classroom interventions have been widely employed with children diagnosed with ADHD for more than


three decades (e.g., O’Leary, Pelham, Rosenbaum, & Price, 1976), and even longer with children described as disruptive, aggressive, or conduct-disordered at home or school (e.g., O’Leary & Becker, 1967). The results of these interventions are consistent with established criteria for an empiricallysupported treatment (Pelham et al., 1998). Research suggests that teachers widely implement behavioral classroom interventions that target ADHD symptoms and associated functional difficulties, such as complying with classroom rules, engaging in appropriate interactions with classmates, displaying disruptive behavior, and complying with teacher commands. Reid, Maag, Vasa, and Wright (1994) found that nearly three quarters of teachers surveyed reported the use of behavioral interventions with students classified with ADHD. In a recently completed survey, 81% of teachers reported the use of behavioral modification techniques in the classroom (Fabiano et al., 2001). Direct contingency management strategies employed in the classroom setting are more effective than traditional outpatient treatment for ADHD-related behaviors (Pelham et al., 1998). Classroom behavior management strategies are often managed by means of consultation with the teacher and are based on a functional analysis of the child’s problematic behavior. The consultant and teacher collaboratively develop specific individual, classroom-wide, or school-wide behavioral interventions such as verbal praise, effective commands, a point or token economy system, daily report cards, or time out (Chronis, Jones, & Raggi, 2006). Relatively intensive behavioral programs typically were studied in special classroom settings, whereas less intensive programs often were examined in traditional classroom settings. Intensive programs often included a token or point system that may be implemented for an entire classroom or school, rather than only for an individual child. O’Leary and Drabman (1971) suggested that these behavior modification systems, based on operant conditioning principles, have three basic characteristics: (a) behaviors to be reinforced are clearly stated (often in written format); (b) procedures are designed for administering reinforcing stimuli (tokens or points) when the target behavior occurs; and, (c) rules are devised to govern the exchange of tokens for reinforcing objects or events. Although children do not compete to earn tokens, social reinforcement such as visible records of achievement or verbal praise may increase the effectiveness of the token system (Blackman & Silberman, 1980; Mercer & Mercer, 1981). For example, Pelham, Burrows-MacLean and colleagues (2005) demonstrated that an intensive, comprehensive behavior modification system with both reward and cost components (e.g., token or point system, social reinforcement, daily report cards, effective commands) produced a significant reduction in ADHD symptoms among 27 children, aged 6 to 12, in a classroom-based summer treatment program. However, a combination of the behavior

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modification system with stimulant medication (methylphenidate) yielded a stronger treatment effect than either treatments alone. These findings were consistent with previous empirical investigations of the efficacy of behaviormodification in special classroom settings (Abramowitz, Eckstrand, & O’Leary, 1992; Chronis, Fabiano et al., 2004; Pelham et al., 1993). Although more intensive programs in special education classes tend to show a more salient effect, less intensive programs such as daily report cards or teacher consultation in traditional classroom settings also demonstrate significant effects (DuPaul & Eckert, 1997; Pelham et al., 1998). For example, a daily report card for an individual child typically contains 3 to 8 clearly defined positive behavioral goals, chosen collaboratively by the teacher and parent. These goals may target academic work, behavior, peer relationships, or other areas of difficulty. The teacher monitors and records the student’s success in meeting the behavioral goals, and provides feedback to the parent and child via the written daily report card. When the child meets a predetermined level of success, a reward is provided at home. The behavior required to earn a reward is modified to require increasingly desirable behavior as the child becomes better able to meet the specified behavioral goals (O’Leary et al., 1976). Employing a daily report card was found to be consistently effective in reducing core symptoms associated with ADHD for children in traditional classroom settings (e.g., Chronis et al., 2001; O’Leary & Pelham, 1978; Owens et al., 2005) and is a commonly employed classroom intervention (Chafouleas, Riley-Tillman, & Sassu, 2006). The majority of the empirical evidence supporting behavioral classroom interventions has been based on singlesubject ABAB designs or group designs with a wait-list or notreatment control group. Treatment outcomes are frequently measured by teacher and observer report (Barkley, 2002). In a meta-analysis, DuPaul and Eckert (1997) found that behavioral classroom interventions showed a very large effect size (ES = 1.44) on measures of treatment outcome, with a larger effect on child behavior than academic or clinic performance. These findings demonstrated strong support for the efficacy of behavioral classroom interventions for children with ADHD and associated symptoms. Given the high frequency with which teachers report use of behavioral modification techniques in the classroom (Fabiano et al., 2001; Reid et al., 1994), collaboration between behavior modification specialists and teachers provides an excellent opportunity for empirically sound intervention for ADHD-related behavior in the classroom. Academic interventions In contrast to classroom interventions that primarily focus on disruptive behavior and task engagement, academic Springer

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interventions target the academic performance of children with ADHD by focusing on the academic instruction, materials, or the environment (DuPaul & Eckert, 1998). Children with ADHD frequently evidence difficulties in academic achievement (Barkley, 1998; DuPaul & Stoner, 2003; Weiss & Hechtman, 1993), high risk of comorbid learning disabilities (Silver, 1992), and high rates of expulsion, dropout, and grade retention (Barkley et al., 1990). For this reason, emphasis on academic interventions is vital to the comprehensive treatment of ADHD. Preliminary evidence suggests that a variety of interventions may enhance on-task behavior in the classroom and, in some cases, academic achievement. DuPaul, Ervin, Hook, & McGoey (1998) examined the effects of peer tutoring on classroom conduct and academic performance of children with ADHD (n = 18) and peer comparison students (n = 10) in traditional classroom settings. Target children were paired with children perceived by the classroom teacher to exhibit a high frequency of appropriate behavior and to be on grade level in all academic subjects. Students were observed while engaged in tasks related to spelling or math, in an ABAB design. As a function of peer tutoring, target children (both ADHD and peer comparison students) demonstrated increased active engaged time and decreased disruptive off-task behavior, as well as increased scores on weekly academic tests. Of the children for whom weekly subject test data were available, 50% of the children with ADHD showed greater success with peer tutoring than during baseline. It is noteworthy that children for whom the intervention was effective were more likely to practice challenging material during peer tutoring. While these data are consistent with other studies of peer tutoring (Greenwood,Maheady, & Carta, 1991; Locke & Fuchs, 1995), these data would likely be strengthened by a larger sample design, thereby providing greater statistical power, and a more objective means of choosing target and peer tutors. Computer-assisted instruction (CAI) provides a highly stimulating instruction format with frequent, immediate feedback and reinforcement, and steady opportunities to actively respond to the instruction (Xu, Reid, & Steckelberg, 2002), all of which have been shown to improve the academic performance of children with ADHD (Barkley, 1998). Although the literature examining the efficacy of computerassisted instruction is small, there is preliminary support for the use of CAI in increasing academic achievement across multiple areas of performance such as mathematics (e.g., Mautone, DuPaul, & Jitendra, 2005), science (Shaw & Lewis, 2005), oral reading fluency (Clarfield & Stoner, 2005), and attention and concentration (Navarro et al., 2003). Methodological limitations such as small sample sizes and limited follow-up data limit firm conclusions that might be gleaned from these studies, but the findings to date suggest that computer-assisted instruction may be a particularly promising method of intervention. Springer

Strategy training involves training children in procedures to meet the requirements of a specific academic situation (DuPaul & Eckert, 1998). Chase and Clement (1985) trained six boys to self-monitor and self-reinforce in relation to a daily academic or behavioral goal. Although strategy training was superior to medication alone, the combination of the two interventions was the most efficacious. Strategy training that focuses on note-taking skills has demonstrated some preliminary efficacy with adolescents (Evans, Pelham, & Grudberg, 1995). Specifically, students who received strategy training improved their note-taking skills (e.g., increased detail, increased independence) and on-task behavior. In addition, students who took high-quality notes reduced their disruptive behavior while increasing their comprehension of material. Although these findings suggest that strategy training may be potentially effective, small sample sizes, non-traditional classroom settings, and other methodological limitations do not yet support stronger conclusions and generalization to other settings. The goal of task and instructional modification involves revising the curriculum in order to reduce undesirable classroom behavior while promoting prosocial behaviors (DuPaul & Eckert, 1998). Task and instructional modification may involve changes such as shortening task length and increasing opportunities for students to make choices between appropriate alternatives (Dunlap et al., 1994), increasing specificity or visual stimulation in instruction (Zentall, 1989; Zentall & Leib, 1985), or allowing children to respond orally rather than in written format (Dubey & O’Leary, 1975). However, empirical studies of task and instructional modification also are typified by methodological limitations such as small sample size, non-traditional classroom settings, and limited follow-up data. Peer related interventions The literature has documented extensively that most children with ADHD experience difficulties in developing and sustaining peer relationships (Milch & Landau, 1982; Nangle & Erdley, 2001), and that impaired social functioning is considered one of the most debilitating aspects of their disorder (Greene, Biederman, Faraone, Sienna, & Garcia-Jetton, 1997; Greene et al., 1999). Specifically, children with ADHD evidence a number of impairments in peer relationships due to symptoms associated with their disorder, including hyperactivity and impulsivity (e.g., annoying, bossy, immature, boastful, intrusive, overbearing, and physically and verbally aggressive behaviors) (Pelham, Fabiano, & Massetti, 2005). Peers are often critical of the behavior of children with ADHD because they consider these behaviors to be impolite or offensive. In a recent investigation, Hoza and colleagues (2005) examined peer ratings of children with ADHD relative to their same-sex typically developing counterparts.


Findings indicate that peers rated children with ADHD as lower on social preference, higher on social impact, less well liked, and more often in the rejected social status category. Children with ADHD had fewer dyadic friendships. Children with ADHD tend to be more impulsive, argumentative, and aggressive than their typically developing peers, and are often rejected by their peers (Hodgens, Cole, & Boldizar, 2000; Hoza et al., 2005; Moser & Bober, 2002). It is noteworthy that deficits in peer relationships and social functioning continue well into adolescence and even adulthood (e.g., Barkley, Fischer, Smallish, & Fletcher, 2004). In fact, poor social relationships with peers are considered to be some of the strongest predictors and mediators of negative adult outcomes (Coie & Dodge, 1998; Huesmann, Lagerspetz, & Eron, 1984), leading to maladjustment, mental health problems, criminal offenses, school dropout, and academic problems (for reviews see Parker, Rubin, Price, & Derosier, 1995; Rubin, Bukowski, & Parker, 1998). The finding that peer rejection of children with ADHD is not only commonplace, but may lead to serious long-term consequences, led to the design of psychosocial interventions that specifically target peer relationships. Implementing effective psychosocial interventions is important because research demonstrates that children with ADHD who overcome their social problems do better in the long term than those children who continue to experience problems with peers (Woodward & Fergusson, 2000). These interventions include instruction in social skills, social problem-solving, and behavioral competencies. In addition, the interventions attempt to enhance social competence by encouraging close friendships, and decreasing undesirable and antisocial behaviors. The psychosocial interventions remain especially viable treatments for peer relationships particularly because treatment with stimulant medication, while effective in reducing negative social behavior, has not been proven to increase positive behavior or normalize the peer status of children diagnosed with ADHD (Landau & Moore, 1991; Pfiffner et al., 2000; Whalen, Henker, Hinshaw, & Granger, 1989). Although children with ADHD are less socially effective than their peers, they do not perceive themselves as such (Hoza et al., 2000). Thus, the primary goal of social skills training is to promote prosocial behaviors that include cooperation, communication, participation, and validation (Kavale, Forness, & Walker, 1999). Social skills training represents the most common approach to treating social problems in children, with groups typically being conducted at a clinic, summer treatment program, or in school-based settings and often including parent and teacher participation. Surprisingly, interventions that employ social skills training as a stand-alone treatment for children with ADHD have not demonstrated significant effects on the children’s social status or on their overall social behavior (Kavale & Forness, 1996; Landau, Milich, & Diener, 1998; Pelham et al., 1988).

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As one example, Antshel and Remer (2003) conducted a randomized controlled trial that evaluated a social skills intervention for children with either ADHD-Inattentive type or ADHD-Combined Type. Although children who were randomized to the social skills group demonstrated improvements in both parent- and child-perceived assertion skills, they did not evidence improvements across all other social skills and domains of social competence, regardless of diagnostic subtype. There is evidence that combining social skills interventions with behavior management programs and parent training does improve ADHD children’s behavior toward their peers (Frankel, Myatt, Cantwell, & Feinberg, 1997; Pelham, 1982; Pfiffner & McBurnett, 1997; Sheridan, Dee, Morgan, McCormick, & Walker, 1996). One example of combining intervention components is the Summer Treatment Program developed by Pelham and colleagues (Pelham et al., 2005), which is an intensive 8-week behavioral treatment intervention for children with ADHD that includes social skills training, a reward and response cost system, group practice and instruction in sports skills and team membership. Two wellcontrolled crossover studies have demonstrated positive effects of the Summer Treatment Program and enhanced social functioning of participants (Chronis, Fabiano, et al., 2004; Pelham, Burrows-McLean, et al., 2005). Mrug, Hoza, and Gerdes (2001) argue that in order to improve the effectiveness of social skills interventions it is necessary to move beyond solely focusing on improving the prosocial behavior of children with ADHD by also targeting the peers’ cognition and behavior toward the rejected child. Houck, King, Tomlinson, Vrabel, and Wecks (2002) examined the effectiveness of group interventions with schoolage children with ADHD for enhancing social behavior. The intervention employed group experiences that addressed four domains of communication, friendship, self-control, and social problem-solving. All participants were being treated with medication at the time of the intervention. Findings indicated enhanced social behavior and decreased disruptive behavior at the end of the group sessions. Several investigators have argued that it is important to assist children with ADHD to build and maintain close friendships in order to improve their long-term social outcomes (Bagwell, Schmidt, Newcomb, & Bukowski, 2001). Following this premise, Hoza, Mrug, Pelham, Greiner, and Gnagy (2003) designed a friendship intervention, which was implemented within the context of an intensive behavioral treatment program for children with ADHD. In the friendship intervention, children were paired with a “buddy” based on their preferences and other considerations. Special privileges were accorded to the “buddy pairs” in order to increase the frequency of their interactions and sharing. In addition, parents were asked to organize play dates for their child and his or her buddy in an environment outside the behavioral Springer

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treatment program. Findings revealed that children paired with less antisocial buddies demonstrated improved academic performance, were rated as having higher quality friendships, and were viewed as more normalized. These effects also were found for children whose parents had higher levels of compliance with the friendship intervention.

Strength of evidence for behavioral interventions Objective, data-driven demonstration of the efficacy and cost-effectiveness of psychological treatments needs to be established in order to emphasize clinical psychology’s strengths to the public, managed care, and other mental health care professionals, (Chambless, 1996; Hunsley & Johnston, 2000). The Task Force on the Promotion and Dissemination of Psychological Procedures (1995) developed criteria and a classification system for evaluating the empirical support for various treatments. The criteria initially established two categories of empirical support as either “wellestablished” or “probably efficacious” (Chambless, 1996). Two years later the criteria were updated such that evaluation of the efficacy of a treatment required a treatment manual for a specified population and targeted problem, reliable and valid outcome measures, and appropriate data analyses (Chambless & Hollon, 1998). Designation as a “well established” treatment requires demonstration that the treatment is: (1) statistically significantly superior to no treatment, placebo, or alternative treatments; or, (2) equivalent to a treatment already established in efficacy in a randomized controlled trial, controlled single case experiment, or equivalent time-series design. The superiority of this treatment must be demonstrated in at least two independent research settings. To merit designation as “probably efficacious,” one study meeting the above criteria is sufficient if there is no conflicting evidence. Additionally, each practice division of the American Psychological Association (APA) established a task force to examine the evidence concerning the efficacy of psychosocial interventions (Lonigan, Elbert, & Johnson, 1998). According to the APA Division of the Society of Clinical Child Psychology Task Force criteria, behavioral parent training and behavioral school interventions are classified as well-established empirically supported treatments. Although preliminary evidence provides some support for academic interventions, there is currently insufficient support for their efficacy to earn an empirically-supported treatment classification. A large number of studies examined the efficacy of parent training programs in treating ADHD, including randomizedcontrolled trials using manualized interventions for children and adolescents. In fact, several recent reviews and a metaanalysis summarize this large body of literature (Chronis, Chacko et al., 2004; Chronis et al., 2006; Lundahl et al., Springer

2006; Pelham et al., 1998). Overall, it is concluded that parent training results in improvements for children and their families in several areas, such as parent ratings of problem behavior, observed negative parent and child behaviors and interactions, parental reports of stress, and parental reports of increased knowledge and competence (Anastopoulos et al., 1993; Chronis, Chacko et al., 2004; Pisterman et al., 1992a; Sonuga-Barke et al., 2001; Weinberg, 1999; Wells et al., 2000). Further investigations indicate that parent training for disruptive child behavior is robust, with generally moderate effect sizes reported (Chronis et al., 2006; Lundahl et al., 2006). Despite the large number of studies finding parent training to be an efficacious treatment, the results should be interpreted with caution with regard to generalizability. As discussed previously, there is a great deal of variability as to which children improve with behavioral interventions, likely the result of individualized and/or familial factors (Chronis et al., 2006). Several mediators and moderators of ADHD treatment effects are suggested, such as chronological age, the presence of comorbidity, parental psychopathology, parental cognitions regarding children and treatments, socioeconomic status, race or ethnicity, family make-up and social supports (Chronis, Chacko et al., 2004; Lundahl et al., 2006). Further research examining treatment effectiveness needs to be pursued in order to clarify the generalizability of parent training for children and adolescents with ADHD. School-based interventions also have been widely studied for children with ADHD. Behavioral interventions for ADHD in the classroom were investigated in both single subject (e.g., Abramowitz et al., 1992) and between-group design (e.g., Gittelman et al., 1980) studies, commonly focusing on task engagement, disruptive behavior, and other treatment outcomes as measured by direct behavioral observation, parent ratings, and teacher ratings. Behavioral classroom interventions have shown very large effect sizes on these measures (e.g., in the range of 1.44), with larger effect sizes typically demonstrated on measures of classroom performance (Chronis et al., 2006; DuPaul & Eckert, 1997). In contrast to behavioral interventions, academic interventions in which the instruction or materials are modified to improve behavioral or academic outcomes have garnered preliminary support for their efficacy but have not yet met the criteria for an empirically supported treatment. Peer tutoring (DuPaul et al., 1998; Greenwood et al., 1991; Locke & Fuchs, 1995), computer assisted instruction (Clarfield & Stoner, 2005; Mautone et al., 2005; Navarro et al., 2003; Shaw & Lewis, 2005), strategy training (Chase & Clement, 1985; Evans et al., 1995), and task and instructional modification (Dubey & O’Leary, 1975; Dunlap et al., 1994; Zentall, 1989; Zentall & Leib, 1985) each has shown preliminary evidence of efficacy for increasing on-task behavior and,


in some cases, achievement. However, firm conclusions about the efficacy of academic interventions are premature, given the limitations in the literature. In addition, there is a dearth of research using measures of treatment outcome related to academic performance, including female or adolescent participants, assessing generalizability over time or setting, or evaluating treatment integrity (DuPaul & Eckert, 1997). Systematic study of academic interventions within a manual-based, randomized clinical trial with sufficient power would greatly bolster confidence in the related findings.

Limitations of behavioral treatments The limitations associated with behavioral treatments for ADHD are similar to those reported for stimulant drug therapy. Specifically, employing behavior therapy as a single treatment typically will not result in normalized behavioral function for children with ADHD compared to their typically developing peers. As with stimulant drug therapy, most children will demonstrate psychosocial gains primarily in the circumscribed period of time in which the intervention is applied. That is, few studies (e.g., MTA Cooperative Group, 1999) have demonstrated maintenance of treatment gains following cessation of the behavioral intervention. In addition, some children do not demonstrate improvement following a course of behavior modification (Pelham et al., 2000). It also is noteworthy that effect sizes for acute stimulant medication effects tend to be higher for the core symptoms of ADHD when compared to behavioral treatments (e.g., Pelham et al., 1993). Finally, employing behavior therapy may be difficult due to the need for continued intervention, the complexity of the therapy, dependence on cooperation between parents and teachers, and the relatively high cost of implementing behavioral interventions (Barabasz & Barabasz, 2000) relative to pharmacological interventions.

Combined interventions As a result of the aforementioned limitations associated with employing either stimulant therapy or behavior modification as a stand-alone treatment, combined or multimodal interventions often are viewed as the gold standard for ADHD treatment. However, depending on the treatment outcome variable, some studies have not provided convincing data to suggest the benefits of combined treatments of pharmacotherapy and psychotherapy relative to medication alone. A study sponsored by the National Institute of Mental Health (NIMH), entitled the “Multimodal Treatment Study of Children with ADHD,” presents comprehensive data regarding

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the efficacy of combined treatments for ADHD (MTA Cooperative Group, 1999a, 1999b). This study investigated longitudinal data on 579 children aged 7 to 10 years who were diagnosed with ADHD, combined type, at six university medical centers in the United States and Canada. The effects of four interventions were compared: (1) behavioral intervention alone, including intensive treatment of parent training and education, classroom behavioral management training for teachers, social skills training, computer assisted instruction, and a summer treatment program; (2) state-ofthe-art medication management; (3) a combination of medication and behavioral intervention; and, (4) a control condition of routine community care without an intervention. This clinical trial showed that children in all 4 treatment groups demonstrated reductions in core ADHD symptoms over time. The combined treatment group and the medication management group alone were equally effective and superior to the community control condition methods for addressing ADHD symptoms, with no additional benefit noted for behavioral approaches alone or the typical community care condition (MTA Cooperative Group, 1999a). However, the MTA study demonstrated some measurable benefits of multimodal psychosocial treatment component over and above the medication management group (e.g., Pelham et al., 2000). Specifically, the combined intervention was most effective in mitigating related areas of functional impairments including troubled family relationships, social skills deficits, defiant and oppositional behavior, and poor academic achievement (Hinshaw et al., 2000). Moreover, these data indicated that combined treatment was superior to medication alone for children with comorbid conditions (e.g., anxiety disorder) and in the normalization of behavior (Connors et al., 2001; Jensen et al., 2001; Swanson et al., 2001). There also was evidence that the combined treatment allowed for lower doses of stimulant medication and that parents were most satisfied with the behavior and combined treatment approach for management of their child’s ADHD (MTA Cooperative Group, 1999a). Notably, the combined treatment group continued to demonstrate superior effects when compared to behavioral treatment alone at 10-month follow-up, but only on symptoms associated with ADHD and Oppositional Defiant Disorder. The McMaster University Evidence-Based Practice Center Group (1999) reviewed 20 studies to determine the effectiveness of combined interventions versus single interventions. This review found that 19 of the 20 studies provided evidence that combined interventions were modestly superior to non-pharmacologic intervention alone. However, other investigations of the effects of combined contingency management training of parents or teachers along with stimulant drug treatment were of little incremental benefit over single-treatment approaches (Gadow, 1985; Pollard, Ward, & Barkley, 1983). Another study found no additive Springer

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effect for combinations of medication, child self-control, and parent behavior management training (Ialongo et al., 1993). In contrast, Horn and colleagues (1991) found that gains were maintained on parents’ behavior ratings nine months after the medication had been withdrawn for families who had combined stimulant medication and parent training treatments. It was argued that to effectively increase prosocial behaviors in children with ADHD it may be necessary to combine stimulant use with adjunctive psychosocial therapies, such as social skills training or behavioral management (Bennett et al., 1999). In fact, in a systematic review of the extant literature in this area, Jensen (2001) found combined treatments that include stimulant medication and behavior therapy or social skills training offer some modest advantages over single treatment approaches. However, results from the MTA study provided disparate results regarding the effectiveness of combined treatment approaches on children’s social functioning. Specifically, no advantage was demonstrated on any measure of social functioning for the combined treatment group over methylphenidate alone or methylphenidate plus attention control. In an additional analysis of the MTA data, children with ADHD were rated by their classmates on several peer-assessed outcomes at the end of treatment. Results revealed little evidence of the superiority of any of the treatments for the peer-assessed outcomes studied, although the limited evidence that did emerge favored treatments involving medication management (Hoza et al., 2005). Post-hoc data analyses found that children from all four treatment groups failed to achieve normal peer relationships and actually remained significantly impaired in their peer relationships compared to randomly selected classmates (Hoza et al., 2005).

Strength of evidence for combined interventions Similar to behavior modification and stimulant medication management approaches, combined or multimodal treatments were shown to be evidence-based effective shortterm treatments for ADHD (Pelham & Waschbusch, 1999). The MTA study results indicated that the effect sizes for combined or multimodal interventions were nearly equivalent when compared to stimulant treatment alone (moderate to large) for their impact on the core ADHD symptoms (MTA Cooperative Group, 1999a). However, it was argued that combined treatment approaches produce stronger effects than stimulant treatment alone for specific functional impairments such as conduct problems, oppositional behavior, poor social skills, and disruptive behaviors (Connors et al., 2001; Jensen et al., 2001; MTA Cooperative Group, 1999b; Pelham, Burrows-McLean, et al., 2005; Swanson et al., 2001; Wells et al., 2000). Nonetheless, the evidence Springer

of the effectiveness of multimodal treatment in community practice is limited (dosReis, Owens, Puccia, & Leaf, 2004).

Limitations of multimodal treatment Evidence exists to suggest that a combination or multimodal treatment is less cost-effective than medication management alone for treating core ADHD symptoms (Jensen et al., 2005). However, combined treatment approaches may be more cost-effective for children with comorbid psychiatric disorders (e.g., anxiety, depression) (Jensen et al., 2005). Clearly, multimodal treatment is a time-intensive venture that often necessitates the involvement of multiple professionals in the care of children with ADHD and their families.

Alternative treatments Among the alternative treatments suggested for ADHD are electroencephalographic (EEG) biofeedback (neurofeedback or neurotherapy) and metacognitive therapy. EEG biofeedback attempts to treat ADHD by increasing the ratio of high-frequency ß-EEG activity to low-frequency θ EEG activity (Lubar, 1991). Despite some promising results, treatment effects may be due to nonspecific or placebo effects (Barkley, 1992). A literature review by Lee (1991) found biofeedback as a stand alone treatment program was not effectively evaluated, and methodological problems of the reviewed studies resulted in an inability to make generalizations to populations with ADHD. Ramirez, Desantis, and Opler (2001) also reviewed the literature on EEG biofeedback as a treatment for ADHD and concluded that methodological problems and a paucity of biofeedback research precluded definitive conclusions regarding efficacy of enhanced alpha and hemisphere-specific EEG biofeedback training. Similarly, a National Institutes of Health (1998) consensus report on ADHD treatment noted that the empirical evidence for treatments such as biofeedback was uneven and recommended more controlled studies were necessary before this treatment could be endorsed. Loo and Barkley (2005) reviewed three treatment outcome studies applying rigorous methodology that compared EEG biofeedback to either no-treatment or placebo control conditions, and concluded that two of the three studies failed to demonstrate an active treatment effect. Their review led the investigators to advise against the use of EEG biofeedback in a clinical setting based on the current lack of supportive empirical data (Loo & Barkley, 2005). Overall, despite anecdotal evidence for these alternative treatments, reviews of the applicability of neurofeedback for ADHD generally conclude that more controlled clinical trials are needed before it can be endorsed as an effective, reliable treatment.


Diversity issues Most research on children with ADHD has focused on Caucasian males from middle-to upper-middle-class families. Less attention was directed at females, children from low socioeconomic backgrounds, or children from diverse racial and ethnic backgrounds. For example, although there is a significant increase in the documented prevalence of ADHD among females (Hinshaw, Owens, Sami, & Fargeon, 2006), few investigations have addressed gender differences in response to behavioral treatment. The literature indicates comparable responsiveness to behavioral treatment and stimulant medication across genders (MTA Cooperative Group, 1999b; Pelham, Walker, Sturges, & Hoza, 1989). Socioeconomic status moderates behavioral treatment outcomes for those with ADHD (Brown, Borden, Wynne, & Clingerman, 1987; Firestone, 1982). Poorer behavioral treatment outcome is associated with such socioeconomic variables as single-parent status, low income, low education (Dumas & Wahler, 1983; Knapp & Deluty, 1989; WebsterStratton, 1985; Webster-Stratton & Hammond, 1990), poor adherence to treatment regimen, and higher attrition from treatment programs (Biederman, Newcorn, & Sprich, 1991; Firestone & Witt, 1982; Reid & Patterson, 1976). In addition, McMahon, Forehand, Griest, and Wells (1981) found low socioeconomic status associated with low compliance and poor outcomes following parent training for children with behavioral problems. The MTA study found behavior therapy resulted in some improvement over medication alone on core ADHD symptoms for more highly educated families (Rieppi et al., 2002). Although a majority of studies examining behavioral intervention effectiveness included primarily Caucasian children, some investigations included participants from various ethnic groups (Arnold et al., 2003; Pelham et al., 1997; Reid, Webster-Stratton, & Beauchaine, 2002). Comparable improvement is reported for children from various ethnic groups relative to their Caucasian peers.

Recommendations for future research Behavioral treatment appears to be a short-term evidencebased treatment modality applicable to children with ADHD. Behavioral techniques are useful to improve ADHD symptoms and they may have a larger impact than stimulant medication on associated impairments, while stimulants may have a larger impact on specific symptoms associated with ADHD. The inherent limitations of behavioral approaches and pharmacotherapy may be best addressed through a combination of pharmacotherapy and behavioral treatment, and combination therapy has received widespread research attention in recent years for ADHD and for other psychiatric disorders, including depression and anxiety. In general, behavioral

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approaches have no negative side effects. Although it was suggested that the rewards integral to behavioral management strategies may also have an iatrogenic effect and lessen intrinsic motivation for many children (Akin-Little, Eckert, Lovett, & Little, 2004), there have been no data for this potential adverse effect. Because a combination of behavioral treatment and stimulant medication have generally yielded greater effects with the use of lower doses of stimulant medication, the risk-benefit analysis of multimodal therapy is considered more favorable than use of higher doses of stimulant medication alone. There is strong evidence that behavior management and pharmacotherapy are each effective in the short-term, but there are few investigations of the durability of these approaches and their safety over the long-term. Only one study addressed the long-term use of behavioral treatment (MTA, 2004), and found that the acute benefits of behavioral treatment may be sustained for a period of nearly two years. However, there were no long-term studies (e.g., into adulthood) of behavioral approaches and such study remains an important subject for future investigators. Only one investigation has addressed the relative longterm effects of stimulant medication, i.e., over a period of two years. The MTA study data suggested that the beneficial effects of stimulant medication dissipate upon discontinuation of medication. Moreover, there was concern that growth suppression may be an adverse effect of stimulant medication and a particular risk with long-term stimulant use. For example, at the two-year follow-up of children receiving both stimulant medication and behavior therapy, these children had a similar outcome to those receiving behavior therapy alone, with the exception that the children in the combined condition also evidenced growth suppression but less than children in the medication only treatment arm. The children in the combined arm were treated with lower doses of stimulants. Thus, behavior therapy may make it possible for lower doses of stimulant medication to be used with these children (Pelham, Burrows-MacLean et al., 2006; Pelham, Gnagy et al., 2006). An important issue that remains to be addressed is the sequence in which specific interventions should be implemented in the management of ADHD (American Psychological Association, 2006). This is especially important in clinical practice where the clinician is faced with the dilemma as to whether medication or behavioral management should be employed as a first line treatment, or whether the two treatments should be implemented simultaneously. Related questions include whether behavior therapy or stimulant therapy should be employed first, how should the specific components of treatment (e.g., parent training, school intervention, peer intervention) be sequenced, and for how long should behavior modification be implemented and at which intensity prior to the initiation of medication? ADHD is a Springer

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chronic disorder that may require ongoing treatment, and a determination needs to be made about whether and when treatment may be terminated and whether specific components of either behavioral management or stimulant medication treatment may be time limited. The impact of development on treatment considerations also requires further clarification. In addressing efficacy of behavior management and its integration with medication treatment there also is a clear need to assess systems of care within which the intervention studies are evaluated (Stein, in press). Hinshaw (in press) observed that careful investigations must address specific subgroup effects, the mechanisms of action by which behavioral therapies or stimulant medication may be effective, and the important roles of mediators and moderators of outcomes of these various treatment approaches. Racially- and culturallydiverse families are generally underrepresented in clinical trials of behavior management or the integration studies that examine the efficacy of behavioral and medication treatments, or their combination. There is increasing recognition of the role of genetics as an etiology for ADHD, and it is important to appreciate the influence of genetic predisposition and its interaction with various treatment modalities, including medication (e.g., pharmacogenetics) and behavior management. Finally, a majority of studies focused on the short-term outcomes of various behavioral approaches for ADHD. Therefore, long-term outcome studies are needed and given the duration of symptomatology over time, investigators must focus on improvement for the long-term rather than simply short-term (Stein, in press). Important gains were made in the identification and treatment of children with ADHD over the past five decades. ADHD may be the most meticulously researched disorder in the mental health field. It is expected that important research will continue and there will be even greater focus on treatment options, combinations, and outcomes so as to improve the quality of life for these children and their families.

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