Multimodal Treatment of Attention-Deficit/Hyperactivity Disorder in Children

BARBARA T. FELT, MD; JULIE LUMENG, MD; and JENNIFER CHRISTNER, MD, University of Michigan Medical School, Ann Arbor, Michigan

Am Fam Physician. 2009 Apr 15;79(8):640-641.

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Attention-deficit/hyperactivity disorder (ADHD) is a brain-based, chronic condition that is often inherited.1,2 Primary care physicians should feel comfortable guiding families in an ongoing, multimodal treatment approach for ADHD, as discussed in an article by Rader and colleagues in this issue of American Family Physician.3 Treatment should include education with accurate, up-to-date information about ADHD; behavioral interventions; school-based support; social skills training; and, for many, medication.1,2,4–6 Although medication is commonly used to treat children with ADHD, behavioral therapy may be helpful as a first-line treatment when the diagnosis is uncertain, symptoms are mild, or the use of medication is not acceptable.1,2 Behavioral therapy, support, and a developmental approach are also useful adjuncts to medication.

It is important for children with ADHD and their families to learn about the medical basis of the condition, associated risks (e.g., comorbid mental health conditions, poor self-esteem, increased injuries and accidents), and the best management strategies. This education should be an ongoing learning process. A patient's strengths and needs change with age, as does the impact of ADHD symptoms on functioning in the family and community. The overall goal of this comprehensive approach is for patients with ADHD to develop a good understanding of their personal profile and to increasingly become self-advocates.

Behavioral recommendations have been developed for implementation at home and at school. Parents and other caregivers should be reassured that there is no evidence that poor parenting causes ADHD; however, effective behavioral strategies that are initiated early can reduce ADHD symptoms.1,2,4–7 Parent training programs are beneficial for childhood disruptive behavioral disorders, including ADHD.5,7 Parenting concepts include use of clear expectations and limits; consistent routines and discipline across caregivers; “time in” that includes attention to positive behaviors; ignoring minor negative behaviors; “time out” or other consequences for targeted negative behaviors; and building child competence and supporting success. Such training is available through books, lectures, and parent groups. Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) provides an online parent-to-parent training program and links to local parent groups. The Technical Assistance Alliance for Parent Centers also provides support for parents of children with disabilities, including ADHD.

Parents or caregivers are a child's best advocates for success. To play this important role, parents should know the laws that guarantee educational rights and assure optimal progress in the least restrictive learning environment. Many children with ADHD benefit from a 504 plan under the Rehabilitation Act, which outlines accommodations, such as preferred seating in the classroom, extra work time, or reduced workload.8 Those with more significant functional impairments may need further evaluation (e.g., academic and achievement testing) to determine eligibility for special education support under the Individuals with Disabilities Education Act.9

A child's need for special education support is detailed in an Individualized Education Plan (IEP) that includes targeted, measurable outcomes and, possibly, a classroom behavioral intervention plan. Whether a 504 plan or an IEP is sought, learning about educational rights and submitting a written request for an evaluation are the first steps. Additional advocacy assistance is available through the U.S. Office of Special Education and Rehabilitative Services, state departments of education, and local advocacy groups. Information about educational rights is available from the National Resource Center on ADHD.

An inclusive behavioral approach also focuses on building relationships. Children with ADHD may benefit from social skills training in clinics, schools, summer camps, or an individual counseling setting. This training focuses on initiating, building, and maintaining successful relationships with peers. Methods include role-play, modeling, practice, and positive feedback. Social skills groups seem to be most effective when used with other intervention programs (parenting and school-based).5,6 Caregivers should inquire about these programs at the child's school or physician's office.

Primary care physicians can help families obtain the information and support needed to institute and maintain a multimodal treatment strategy for ADHD. Table 1 includes resources for parental education, advocacy, and educational rights of children with disabilities.