Cases of attention-deficit/hyperactivity disorder (ADHD) have been well-documented since the first official case was described in 1775 by German physician Melchior Adam Weikard (Mash & Wolfe, 2019). Today, we know that this chronic condition affects approximately five to nine percent of four to seventeen-year-old individuals within North America (Mash & Wolfe, 2019); worldwide, we know that ADHD “affects [approximately] 5% of school-aged children” (Raman et. al., 2015) with a higher prevalence rate found in boys than girls. As ADHD is characterized by persistent age-inappropriate symptoms of inattentiveness, impulsivity and hyperactivity, it often causes impairments to both daily and major life activities (Mash & Wolfe, 2019). In fact, research shows that ADHD is often “associated with academic difficulties, poor social relationships [with both family and peers], substance abuse, and psychiatric comorbidities in childhood and across the life span” (Raman et. al., 2015), as well as higher rates of accidents, risk taking behaviors, health-related problems (such as enuresis, encopresis, asthma, dental health problems, sleep disturbances, and eating problems/disorders, among others), speech and language impairments, distorted self-perceptions, and deficits in one or more executive functions (Mash & Wolfe, 2019). As the aforementioned list shows, ADHD can have a significant impact on several important developmental realms that can affect an individual throughout their lifetime. In order to improve the outcome for children diagnosed with ADHD, it is extremely important to identify and implement evidence-based interventions.
Pharmacological treatment is one such evidence-based treatment, although controversial, that has been used as a first-line defense, as recommended by the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry, against the symptoms of ADHD since their effectiveness was discovered by chance in the 1930s (Mash & Wolfe, 2019; Paul, 2014; Barbaresi et. al., 2014). In particular, stimulant medications, such as methylphenidate, d-amphetamine, and pemoline, are the most commonly used today (Mash & Wolfe, 2019; Anastopoulos, DuPaul & Barkley, 1991; Barbaresi et. al., 2014). In fact, statistics show that the prevalence of stimulant treatment is on the rise, with the majority (approximately 80%) of children diagnosed with ADHD given a prescription for a stimulant medication today (Barbaresi et. al., 2014). This significant prevalence rate is likely due to the fact that stimulant medications have been shown to be the most effective at managing the symptoms of ADHD in several controlled clinical trials (Mash & Wolfe, 2019; Anastopoulos et. al., 1991; Barbaresi et. al., 2014).
In fact, Anastopoulos, DuPaul and Barkley (1991) found that “over 70% of children with ADHD taking these medications exhibit behavioral, academic and attentional improvements, according to parent/teacher ratings, laboratory task performance, and/or direct observations.” This statistic has been re-affirmed by Barbaresi, Katusic, Colligan, Weaver, Leibson and Jacobsen (2014) in their retrospective population-based study where they found that nearly three fourths (specifically 71.3%) of the subjects diagnosed with ADHD had a favorable response while taking a stimulant medication, which is comparable to the accepted efficacy rate of 70% in short-term controlled clinical trials. The high efficacy rate of psychostimulants is likely due to the neurological impact that stimulant medications have on an individual’s brain. In fact, Mash and Wolfe (2019) explain that “these medications alter activity in the frontostriatal region of the brain [which is responsible for mediating motor, cognitive and behavioral functions within the brain] by affecting neurotransmitters (dopamine)” that aid in information processing within this region. In addition, research has shown that psychostimulants may also help to normalize various structural and functional abnormalities within the affected individual’s brain (Mash & Wolfe, 2019; Paul, 2014).
Although pharmacological treatments do have several benefits, it is also important to keep in mind that medications may not be the most appropriate form of treatment for every child who is diagnosed with ADHD due to various limitations associated with the treatment. To begin with, it is important to consider the circumstances of the family’s situation before prescribing a psychostimulant. This is due to the fact that the use of psychostimulants “must be closely prescribed, titrated, monitored, and withdrawn under a physician’s care” (Anastopoulos et. al., 1991), which can be problematic for a variety of reasons.
For example, if a family lives in a rural area where medical care is limited, it may not be appropriate to prescribe a psychostimulant, as the careful monitoring mentioned previously may not be readily available. In this regard, physicians should also consider a family’s ability to administer and safely store medications (Paul, 2012), as some family environments or schedules may prohibit proper administration and storage. In addition, “psychostimulants may be ineffective or inappropriate in treating certain subgroups of children with ADHD (e.g., those with anxiety symptoms), some behavioral classes (e.g., aggression), or behavior in certain settings” (Anastopoulos et. al., 1991). Once a psychostimulant has been administered, it is also important to keep a watchful eye out for side effects of the medications, as these can also be a drawback to the use of psychostimulants. In fact, Barbaresi, Katusic, Colligan, Weaver, Leibson and Jacobsen (2014) found that approximately one fourth of all individuals using a psychostimulant will experience at least one side effect at some point during their treatment. This is important to note as side effects can range from relatively minor (e.g., headaches, stomach aches, decreased appetite, and insomnia) to more severe (e.g., symptoms of Tourette’s syndrome; Mash & Wolfe, 2019; Anastopoulos et. al., 1991).
In addition to the use of psychostimulants and other medications, it is often recommended that parents participate in the evidence-based intervention known as Parent Management Training (PMT). This is due to the fact that the parents of children who have been diagnosed with ADHD “tend to regard themselves as less competent, to have more relationship problems and use more negative parenting strategies, compared with parents of non-afflicted children” (Ostberg & Rydell, 2012). With this in mind, several PMTs have been built upon various learning theories, including the attachment theory, the social learning theory, and other developmental theories of parenting, in order to provide parents with effective parenting practices and coping strategies to deal with the challenges that accompany parenting a child with ADHD (Ostberg & Rydell, 2012; Paul, 2014; Mash & Wolfe, 2019).
Of the programs created, the programs with the most empirical evidence base seem to be “Strategies in Everyday Life” (based in Switzerland), Parent-Child Interaction Therapy, the Incredible Years Parent program, and the Positive Parent Program (Ostberg & Rydell, 2012; Paul, 2014). In each of these PMT programs, the focus is on providing “training in reinforcement and problem-solving strategies, promotion of positive parent-child interactions and of emotional communication” (Ostberg &Rydell, 2012), as well as tailored instruction in the family’s particular areas of need (Paul, 2012), consistency, and relaxation, meditation and exercise techniques to help the parents reduce their own levels of stress and arousal (Mash & Wolfe, 2019).
Training sessions are often offered in individual and small group settings, depending on the area’s availability and the preferences of the participants, over the course of an average of 6-12 therapy sessions (Ostberg & Rydell, 2012; Anastopoulos et. al., 1991). In general, PMT programs typically show a reduction in problematic behaviors and ADHD-related symptoms (Ostberg & Rydell, 2012). It is important, however, to keep in mind that a PMT program may not be appropriate for all families. For example, some families may not be able to complete the entire PMT program due to various life events, such as an unexpected illness, scheduling changes, family crises, transportation difficulties, and the like (Anastopoulos et. al., 1991; Ostberg & Rydell, 2012). Whereas, other families may need to overcome other difficulties, such are marriage problems and time commitments, along with others, before they can begin participating in a PMT program.
Although pharmacological interventions and parent management training (one type of behavior modification intervention) do result in a reduction of ADHD-related behavior and symptoms, typically within the home, research has shown that “changes that occur in one setting do not generalize to another setting without intervention” (Miranda, Jargue & Tarraga, 2006); therefore, there is a distinct need to provide education interventions to children diagnosed with ADHD. This is especially demonstrated when one considers the fact that “globally, around 70% of children with ADHD present some type of learning difficulty… and they are 3 to 7 times more likely than other children to receive special education, be expelled or suspended, and repeat a grade” (Miranda et. al., 2006). In general, educational interventions center around the idea of managing a student’s inattentive and hyperactive-impulsive behaviors, while providing a classroom environment that can build upon the strengths of each individual child (Mash & Wolfe, 2019).
Often, this is completed through the implementation of contingency management techniques in which the teacher and student work together to set realistic goals, establish an agreed upon reward (e.g., an extra break, a tangible object, computer time), monitor progress, and reward the child for the successful completion of the pre-established goals, as well as establish and follow through with behavioral consequences when disruptive behaviors are displayed (Mash & Wolfe, 2019; Miranda et. al., 2006). In addition, many school-based interventions provide students with training in self-regulation/self-management strategies. This can include “self-instructions, cognitive modeling, problem-solving strategies, self-monitoring, self-evaluation, and self-reinforcement” (Miranda et. al., 2006), which is often provided in conjunction with or immediately after the use of contingency management techniques. Many school-based interventions also provide students with social-skills training, as well as training in study skills (e.g., taking notes, organizational skills, written language skills; Miranda et. al., 2006; Evans, Axelrod & Langberg, 2004).
Overall, each of these school-based interventions have shown to reduce the number of ADHD-related problems within the school environment according to parent and teacher rating scales (mash & Wolfe, 2019, Miranda et. al., 2006). However, it is important to keep in mind that school-based interventions do not have evidence of long-term effectiveness, which means that this type of intervention will likely have to maintained over a long period of time (Miranda et. al., 2006). In addition, most research conducted on the effectiveness of school-based interventions is conducted with primary school children, meaning the effectiveness of school-based interventions with adolescents is unclear.
Additionally, the Summer Treatment Program (STP) is an intensive, cost-effective (in the long-term), and evidence-based intervention that is used to treat children who have been diagnosed with ADHD since the 1980s (Fabiano, Schaltz, Pelham, 2014). Within STP, “campers” (participating five to 16-year-old individuals diagnosed with ADHD) are engaged in classroom and recreational activities for six to nine weeks (of continuous treatment) in age-matched groups (Mash & Wolfe, 2019; Fabiano, et. al., 2014). Treatments consists of contingency management (e.g., reward and response cost token economy similar to that used in educational interventions, individualized daily report cards, time out from positive reinforcement following negative behaviors, and social reinforcement), peer interventions (e.g., social skills training and development of sports skills and related competencies), and academic accommodations and interventions (e.g., point systems, response-cost, behavioral management system within a classroom setting, and academic enablers), as well as parent involvement (e.g., behavioral parent training provided through the Community Parent Education program in formal, weekly meetings, daily contact with SPT staff during pick-up and drop-off, and shared exercises with their children using vivo training; Fabiano et. al., 2014). In addition, the SPT program will provide a child with a controlled evaluation of stimulant medications when it is desired by the parents and the child has not responded sufficiently to the behavioral modification programs (Fabiano et. al., 2014).
A major component of these intensive interventions within the STP program is that they are provided within the child’s typical context (e.g., home, school/classroom, and sports field), rather than within a clinical setting (Mash & Wolfe, 2019; Fabiano et. al., 2014). However, it is important to keep in mind that the SPT program has not yet been widely used with females, and the program is still being adapted for use in after-school and community settings (Fabiano et. al., 2014; Mash & Wolfe, 2019).
In addition to evidence-based treatments, several complementary and alternative medical treatments have been proposed and claim to have a positive effect on reducing ADHD-related behaviors. Such treatments include “allergy treatments, homeopathic treatments, medication to correct inner ear problems, vestibular stimulation, walks in the park, treatment for yeast infection, megavitamins, sensory integration training, chiropractic adjustment, eye training, special colored glasses, metronome therapy, and applied kinesiology (realigning bones in the skull)” (Mash & Wolfe, 2019), as well as neurofeedback, massage therapy, melatonin supplementation, micronutrient supplementation, acupuncture, yoga, meditation, and the use of herbs, among others (Paul, 2014). However, it is important to remember each of these treatments are not scientifically based (Mash & Wolfe, 2019). In fact, complementary and alternative medical treatments are not rigorously studied, as “less than 1% of studies [involve] randomized controlled trials” (Paul, 2014). Therefore, the use of such treatments can often offer a false hope for a speedy cure, add to the expense of ADHD treatment, and prolong the implementation of evidence-based interventions (Mash & Wolfe, 2019). In some cases, complementary and alterative medical treatments can even be harmful (Mash & Wolfe, 2019).
After a careful review of current evidence-based treatments for ADHD, it is clear that it is critical to continue researching the efficacy and effectiveness of ADHD treatments. With this in mind, there are several important implications for future research. To begin with, future research should evaluate the long-term effectiveness of current evidence-based ADHD interventions (e.g., pharmacological interventions, parent management training, educational interventions and the SPT program), as the current long-term findings are either non-existent or inconclusive. In addition, further research should evaluate the effectiveness of complementary and alternative medical treatments (e.g., individual/family counseling, biofeedback, special diets, support groups) in a randomized, controlled trial format, as the professional consensus on these treatments is varied, despite limited to no research base. In order to best support children who have been diagnosed with ADHD, it would be critical to provide a multimodal approach to treatment. This was shown in the Multimodal Treatment Study of Children with ADHD (commonly referred to as the MTA Study), which after careful review found that the highest percentage of improvement occurred in those who received the combined treatment (68%), which is important, considering these individuals received a lower dosage of medication compared to those assigned to the medical management group (Miranda et. al., 2006), as well as that a multimodal approach provides improvements in multiple contexts (e.g., home, school, community) of the child’s environment, allowing the child to maximize their potential.