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Adolescents with Attention-Deficit/Hyperactivity Disorder: An Overview of Empirically Based Treatments

BARKLEY, RUSSELL A. PhD

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Journal of Psychiatric Practice: January 2004 - Volume 10 - Issue 1 - p 39-56
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Abstract

Teens who are inattentive, impulsive, and restless and who possess these attributes to a degree that is markedly deviant for their age and sufficient to create impairments in major life activities are currently diagnosed as having attention-deficit/hyperactivity disorder (ADHD). 1 Their problematic behavior often arises early in childhood (before they are 12 years of age) and typically persists across developmental phases. 2 Some cases may arise secondary to brain injury at later stages of development, but this is uncommon. The disorder is among the most well studied psychiatric conditions in children, yet the public struggles to accept the idea that it may be largely a biologically based developmental disability. This article first presents a brief overview of ADHD as it presents in adolescents and then reviews treatments for teens with ADHD for which there is some empirical support in the scientific literature. Due to space constraints, issues pertaining to the assessment and diagnosis of teens with ADHD will not be covered in this article. Interested readers can find information on these topics in other, more extensive sources. 3,4

ADHD IN ADOLESCENCE

Differences in Presentation in Adolescent ADHD

Much of what is known about ADHD is drawn from studies in children. Far fewer studies, particular treatment studies, have been conducted in adolescents with ADHD. Research suggests, however, that the adolescent stage of the disorder may be sufficiently continuous with the childhood stage that much of what is known about ADHD in children can be extrapolated to adolescence. In fact, there is currently no compelling evidence that ADHD in teens is qualitatively different from the disorder in children, or in adults for that matter. This is not to argue that the disorder is identical across these major stages of development—but that there is some continuity in the disorder and its management. One difference across stages of development is that quantitative declines in symptom severity occur, 5,6 particularly in the domain of hyperactive behavior, 7 so that, for example, it is highly unlikely that teens with ADHD would be characterized as frequently climbing on things or unable to play quietly. At the same time, other symptoms, such as those reflecting poor persistence of effort, impaired self-control and organization, and deficient time management, may become more prominent. Changes in neurological and hormonal development are also likely to have an impact on the neuropsychology of the disorder and the way in which its symptoms are expressed in adolescence. Cognitive domains, such as verbal working memory, internalized speech, emotional self-control, and cross-temporal organization of behavior, become progressively more elaborate and better developed by this age and consequently may be more affected by the disorder than they were in childhood. 8 The risk of certain comorbid disorders (e.g., conduct disorder, substance use disorders, depression) may also change as the disorder progresses into adolescence. At the same time, new domains of potential impairments (e.g., dating, sexual risks, driving risks) become evident that were not relevant in childhood. While the constructs comprising the disorder (inattention, poor inhibition) do not appear to change qualitatively, their surface manifestations may change due to biological-developmental changes as well as changes in social expectations and responsibilities that occur at this developmental stage.

The clinical presentation of ADHD in adolescence appears to become more complex in its potential for impairments. It also becomes more complicated and difficult to manage owing to factors such as teens’ increasing independence from family influences and growing peer influence. Although few studies on the etiology of ADHD have sought to replicate results in teens with the disorder, there is little evidence from the fields of neuroanatomy, neuroimaging, and behavioral and molecular genetics to suggest that large qualitative shifts occur at this age. While quantitative changes in symptoms are likely to occur in this age group, such changes would not preclude extrapolation of childhood evidence to adolescent ADHD. In short, a wholly new disorder does not spring forth at puberty. However, a widening of social ecological effects, a shift in emphasis to some symptom constructs over others, the likely emergence of greater deficits in executive functioning, coupled with a progressive capacity for self-determination, add new layers of complexity to impairments and treatments in adolescence.

Longitudinal studies of hyperactive children published over the past two decades have done much to overturn the view of the disorder as a benign, transient condition, as it was believed to be in earlier decades. 6,9–11 It is now realized that ADHD persists in most children into their adolescence. At the same time, the growing recognition of adolescence as a separate stage of human psychological development has also contributed to the recognition and acceptance of an adolescent stage of ADHD. Even so, the scientific study of ADHD in teens (and adults) lags far behind research in children with the disorder. However, studies of clinically referred teens diagnosed with ADHD 12,13 as well as studies that have followed clinically diagnosed children into adolescence, 5,6,14 all suggest that the disorder exists in teens.

The Predominantly Inattentive Subtype

Controversy continues concerning the appropriate classification of a subtype composed primarily of inattention within the larger construct of ADHD (see the special issue of Clinical Psychology: Science and Practice15 for a debate on this subtype), and this controversy is also relevant to the adolescent stage of the disorder. Some scientists argue that the inattentive subtype is actually a new disorder, unique from ADHD, 15 while others argue that this distinction may be premature or is not especially important in treatment planning. However, one opinion is relatively consistent across viewpoints: that a subset of children who have only high levels of inattention associated with cognitive sluggishness and behavioral passivity probably represent a qualitatively different attention problem from that seen in ADHD (poor persistence, inhibition, and resistance to distraction). Nonetheless, there are no studies of this subtype in teens with ADHD.

Persistence of Symptoms into Adolescence

It is likely that 50%–80% of those who are clinically diagnosed with ADHD in childhood will continue to have the disorder in adolescence, with most studies supporting the higher figure. 5,16–19 Using the same parent rating scales at both childhood and adolescent evaluation points, Fischer et al. 20 were able to show that inattention, hyperactive-impulsive behavior, and home conflicts declined by adolescence. The hyperactive group showed far more marked declines than the control group, mainly because the former were so far from the mean of the normative group to begin with in childhood. Nevertheless, even in adolescence, the groups remained significantly different in each domain, with the mean for the hyperactive group remaining two standard deviations or more above the mean for the controls. The persistence of ADHD symptoms across childhood as well as into early adolescence appears to be associated with the initial degree of hyperactive-impulsive behavior in childhood, the coexistence of conduct problems or oppositional hostile behavior, and poor family relations—specifically conflict in parent-child interactions—as well as maternal depression and duration of mental health interventions. 21,22

Comorbidity in Adolescent ADHD

Teens diagnosed with ADHD often have a number of other disorders besides ADHD. Our knowledge of ADHD comorbidity is largely confined to individuals with the combined subtype of ADHD. In community derived samples, up to 44% of children and teens with ADHD have been found to have at least one other disorder, and 43% had two or more additional disorders. 23 The figure is higher, of course, in samples drawn from clinic populations. As many as 87% of children who have been clinically diagnosed with ADHD may have at least one other disorder and 67% at least two other disorders. 24

The most common comorbid disorders found in adolescents with the combined subtype of ADHD are oppositional defiant disorder (ODD) and, to a lesser extent, conduct disorder (CD). General population studies have found that the presence of ADHD increases the odds of ODD/CD by 10.7 fold (95% confidence interval [CI] = 7.7–14.8). 25 Studies of children and teens with ADHD who were referred to clinics have found that 54%–67% meet criteria for a diagnosis of ODD by 7–15 years of age. ODD is a frequent precursor of CD, a more severe and often (though not always) later stage of ODD. 26 Having both CD and ADHD is the strongest predictor of risk for substance use and abuse disorders (SUDs) in ADHD children when they reach adolescence and adulthood. 27–29 While an elevated risk for alcohol abuse has not been consistently documented in follow-up studies into adulthood, the risk for other SUDs among hyperactive children followed to adulthood ranges from 12%–24%. 18,19,30

Anxiety disorders have been found to co-occur with ADHD in 10%–40% of clinic-referred children, averaging about 25%. 31–33 However, in longitudinal studies of children with ADHD, the risk of anxiety disorders was found to be no greater than in control groups in either adolescence or young adulthood. 11,19,30 General population studies of children, however, do suggest an elevated odds ratio of 3.0 (95% CI = 2.1–4.3) of having an anxiety disorder in the presence of ADHD, with this relationship significant even after controlling for comorbid ODD/CD. 25

The evidence for the co-occurrence of mood disorders, such as major depression or dysthymia, with ADHD is now fairly substantial. 34–36 Of those with ADHD, 15%–75% may have a mood disorder, although most studies place the rate between 20% and 30%. 30,37,38 The link between ADHD and depression seems to be mediated entirely by the linkage of both disorders to CD. 25 In the absence of CD, ADHD is not more likely to be associated with depression.

The comorbidity of ADHD with bipolar disorder is controversial. 39 Some studies of children and teens with ADHD indicate that 10%–20% may have bipolar disorder, 40–42 a figure that is substantially higher than the 1% risk found in the general population. 43 Follow-up studies of hyperactive children, however, have not documented any significant increase in the risk of bipolar disorder by adulthood. 11,19,30 A 4-year follow-up study of children with ADHD reported that 12% met criteria for bipolar disorder in adolescence, 44 but this association with bipolar disorder has not been found in other follow-up studies and remains to be replicated. In any case, the overlap of ADHD with bipolar disorder appears, for now at least, to be unidirectional—a diagnosis of ADHD does not appear to cause much increase in the risk for bipolar disorder, whereas a diagnosis of childhood bipolar disorder seems to dramatically elevate the risk of a having a prior or concurrent diagnosis of ADHD. 36

TREATING THE ADOLESCENT WITH ADHD

The vast majority of ADHD treatment research has also been conducted in children, while strikingly less attention has been given to studies of treatment efficacy in teens with the disorder. 45 For instance, fewer than 5% of studies on medication management of ADHD have been done with teens; and only a handful of family training studies have focused on this age group. In addition, only a few studies on educational management strategies for ADHD have looked at teens. This does not mean that no recommendations can be made for teens with ADHD—but it does mean that many of these recommendations will be based largely, if not entirely, on extrapolating (with caution!) from research in children as well as what little research has been done in teens. Clinicians must keep in mind that, due to adolescents’ psychological and physical stages of maturity, their developing sense of autonomy, and their emergence into the larger community, adjustments must be made to even the most effective treatments for childhood ADHD. Teens are also far less likely than children to receive mental health services of any kind. 35 This may due to their increased autonomy and capacity to counteract their parents’ efforts to obtain treatment for them, but may also reflect the greater costs of the more extensive treatment that teens with ADHD and their families are likely to need. 45

This section briefly describes the major interventions that are likely to benefit teens with ADHD and discusses issues clinicians need to address in treating this age group. It must be said at the outset, however, that no intervention has been found to cure this disorder. Treatment is therefore focused on symptom management and the reduction of secondary problems that may arise if the disorder is left unmanaged. In this sense, treating ADHD is comparable to treating diabetes. A combination of medication and psychosocial accommodations may work very well to contain the disorder and preclude the occurrence of secondary problems and even some comorbid disorders—but treatment only works when it is used and often does not produce any enduring benefits if removed.

Advances in the treatment of ADHD over the past 20 years have been relatively circumscribed and have mainly occurred in psychopharmacology rather than psychosocial treatment. This is not to say that we have not learned more about the psychosocial treatment of ADHD, but no significant breakthroughs in this area have been forthcoming. Most research has clarified the efficacy (or lack of it) of already available treatment approaches or combinations of those approaches. Findings concerning multi-modality treatments have been especially sobering 46,47 although all of these studies have been conducted in children, not teens. Before discussing the efficacy of specific treatments for teens with ADHD, it is helpful to re-examine some traditional assumptions about the treatment of ADHD. These assumptions are being called into question not only by newer theoretical models 8 but also as a result of research on the etiologies of the disorder (behavioral genetics and neuroimaging) and on the efficacy of particular treatments. 3

Re-examining Treatment Assumptions

Advances in research on the etiologies of ADHD and new theoretical models of the disorder may explain why there have been few treatment breakthroughs, especially in the psychosocial arena. Information from these sources increasingly points to ADHD being a developmental disorder that is probably of neurogenetic origin, in the expression of which some unique environmental factors (including biological hazards affecting brain development) play a role, though far less than genetic factors. 3 Common family environment factors, once thought to have a major effect on the disorder, now appear to have a minor and often insignificant role in determining individual variation in the traits that make up ADHD. 48 Yet such shared environmental factors may play an important role in risk for comorbid conditions, such as ODD, CD, or depression. Thus, it is unlikely that new family-focused treatments will be discovered that would result in the amelioration or even containment of the disorder, since such treatments are unlikely to correct the underlying neurological substrates or genetic mechanisms that contribute so strongly to it. They may, however, have a greater impact on associated comorbidity. Contrary to the social learning models on which family interventions for ADHD were originally based, children with ADHD are not tabulae rasae on which socialization makes the major contribution to psychological development. The disorder is not learned through imitation of poor role models, and it does not arise from exposure to faulty contingencies, such as poor or disrupted parenting. As with learning disabilities and mental retardation, which appear to have relatively analogous etiologies, treatment is symptomatic management or containment of a chronic developmental condition and involves finding the means to cope with, compensate for, and accommodate to developmental deficiencies. These means include provision of symptomatic relief, such as that obtained through the use of various medications. The goal of treatment, then, is the containment of the disorder (symptomatic reduction) and the prevention of or reduction in risk for secondary harms (e.g., school failure, auto accidents, peer rejection, antisocial activities), not the cure or amelioration of the disorder. Given the greater relative contribution of genotype compared with environment in explaining individual differences in ADHD symptoms, it is highly likely that treatments for the disorder, while improving symptoms, do little to change the rank ordering of such individuals relative to each other in their post-treatment levels of ADHD. This is not to say that environmental or psychosocial therapies may not result in clinical benefits to individuals, since the effects of many genetically based disorders can be altered by environmental treatments, but that such therapies do not strike at the cause of the disorder and will have limitations as a consequence. It is also likely that treatments, particularly in the psychosocial realm, will prove to be specific to the treatment setting and will show minimal generalization unless specific strategies are implemented to promote such generalization.

The theoretical model of ADHD proposed by Barkley 8 suggests other reasons why treatment effects may be so limited. According to this model, ADHD is not the result of a lack of skill, knowledge, or information. Therefore, it will not respond well to interventions that emphasize the transfer of knowledge or skills, as might occur in psychotherapy, social skills training, cognitive therapies, or academic tutoring. All of these interventions involve a tacit assumption that the client with ADHD is naïve about or ignorant of these skills; yet no research has actually examined this issue in detail. Instead, ADHD can be viewed as a disorder of performance—of doing what one knows rather than knowing what to do. It is more a question of “when” behavior should be performed rather than “how” to perform it. As in patients with injuries to the frontal lobes, in individuals with ADHD, the disorder appears to have partially cleaved or dissociated intellect from action, or knowledge from performance. Thus, individuals with ADHD may know how to act but may not act that way when placed in social settings in which such action would be beneficial to them. In ADHD, it is the timing and timeliness of behavior that is being disrupted more than basic knowledge or skill about that behavior.

From this vantage point, treatments for ADHD will be most helpful when they assist with the performance of a particular behavior at the point (place and time) of performance in the natural environments where and when such behavior should be performed. A corollary of this is that the further away in space and time a treatment is from this point of performance, the less likely it is to be effective in assisting with the management of ADHD. Consequently, it is important not just to train the person in the behavior but to provide assistance with the time, timing, and timeliness of behavior at the actual “point of performance.” Nor will there necessarily be any lasting value or maintenance of treatment effects from such assistance if it is summarily removed within a short period of time once the individual is performing the desired behavior. The value of such treatments lies not only in eliciting behavior, which is likely already in the individual’s repertoire, at the point of performance where its display is critical, but in maintaining the performance of that behavior over time in that natural setting. Disorders of performance like ADHD pose great challenges for mental health care and educational services, since the core of the problem is how to get people to behave in ways that they know are good for them yet which they seem unlikely, unable, or unwilling to do. It has been found that altering the motivational parameters associated with the performance of the behavior at its appropriate point of performance is more helpful than just conveying more information to the person. However, it is important to realize that such changes in behavior are maintained only so long as those environmental adjustments or accommodations are also maintained. To expect otherwise would be to approach the treatment of ADHD with outdated or misguided assumptions about its essential nature.

This conceptual model of ADHD as a disorder of performance (executive functioning) has numerous other implications for management that can only be briefly touched on here:

  • If the process of regulating behavior by internally represented forms of information (the internalization of behavior) is delayed in those with ADHD, it is helpful to “externalize” those forms of information by providing external, physical representations of that information in the setting at the point of performance. Since covert or private information is a weak source of stimulus control in these individuals, making the information overt and public may help strengthen control of behavior.
  • Difficulty organizing behavior across time is one of the ultimate disabilities associated with ADHD. ADHD is to time what nearsightedness is to spatial vision: it creates a temporal myopia in which the individual’s behavior is governed even more than normal by events close to or within the temporal now and the immediate context, rather than by internal information that pertains to longer term, future events. It should therefore be helpful to provide a physical external representation of time, such as by using a timer or clock placed in the work setting. It will also be of benefit to reduce or eliminate gaps in time among the components of a behavioral contingency (i.e., event, response, outcome), for example, by having the teen do small amounts of reading now and write several sentences now, for which they receive 50 points now, instead of assigning a book report for them to do on their own over the next month.
  • The performance model of ADHD hypothesizes a deficit in internally generated and represented forms of motivation that are needed to support goal-directed behavior; consequently, those with ADHD will need to be provided with externalized sources of motivation. For instance, one may need to provide artificial rewards, such as tokens, throughout the performance of a task or goal-directed behavior when there are few or no immediate consequences associated with that performance. For the teen with ADHD, such artificial reward programs become like prosthetic devices or mechanical limbs for the physically disabled, allowing them to perform more effectively in some tasks and settings where they otherwise would have considerable difficulty. The motivational disability created by ADHD makes such motivational prostheses nearly essential for most individuals with ADHD. Yet difficulties arise in providing such prosthetic motivational devices to teens, because of their greater autonomy from parents and teachers, the fact that they are interacting with many more adults, and the increasing time they spend with peers and in unsupervised community settings. For instance, when a teen is driving home from a high school dance late on Saturday night, no one else is in the car to provide externalized information and prosthetic motivation, such as tokens, for the use of safe driving behavior. Many other similar scenarios—in which the delivery of psychosocial interventions is difficult if not impossible—arise in the lives of teens with ADHD. Medication is often needed in such settings and during such activities to insure control of ADHD symptoms and minimize their impact on functioning.

Ineffective or Unproved Therapies

A variety of treatments for children with ADHD, which are far too numerous to review here, have been tried over the past century. 49 Vestibular stimulation, 50 oral-motor chewing, 51 EMG biofeedback and relaxation training, 52 sensory integration training, 53 and EEG biofeedback or neuro-feedback, 54 among others, have been described as potentially effective in uncontrolled case reports, small series of case studies, or in some treatment versus no-treatment comparisons, yet well-controlled experimental replications of their efficacy are lacking. Many dietary treatments, such as removal of additives, colorings, or sugar or addition of high doses of vitamins, minerals, or other “health food” supplements, have proven very popular despite minimal or no scientific support. 49,55 Traditional psychotherapy and play therapy have not proven very effective for ADHD or other externalizing disorders. 56

It was previously believed that cognitive-behavioral treatment (CBT), or cognitive therapy, held some promise for children with ADHD, and a few small-scale studies did suggest some benefits for this form of treatment in children with ADHD. 57 However, cognitive treatment has been challenged as being seriously flawed from the conceptual (Vygotskian) point of view on which it was initially founded. 58 In addition, the rather poor or limited results of empirical research with CBT have repeatedly called into question its efficacy for impulsive children or those with ADHD. 59 In the most ambitious CBT program ever undertaken in ADHD, which involved training of parents, teachers, and children, researchers found no significant treatment-specific effects on any of a variety of dependent measures, with the exception of class observations of off-task/disruptive behavior, 60 and even this treatment effect was not maintained at 6-week follow-up. Meta-analyses of the literature on CBT and cognitive therapy have typically found that the effect sizes are only about a third of a standard deviation and, in many studies, even less than that. 61,62 While such treatment effects may at times rise to the level of statistical significance, they are of only modest clinical importance and are usually found mainly on relatively circumscribed lab measures rather than on more clinically important measures of functioning in natural settings.

Similarly, reviews of the use of social skills training (SST) as applied specifically to children with ADHD have reported quite discouraging findings. 63,64 A recent study of SST in children with different subtypes of ADHD found some improvement on parent and child ratings of assertion skills but no benefits on other domains of social competence. 65 Children with comorbid ODD appeared to derive little benefit from the program, while those with the inattentive subtype of ADHD improved more than those with the combined type in assertion skills (but not on other domains of social competence). However, at follow-up, these few gains in the inattentive type were not sustained. It is also a cause of concern that a small subset of children with the inattentive subtype were rated by their parents as significantly worse following SST, perhaps due to the social contagion effect of being in training with more aggressive peers. 66 Consistent with findings from other studies, 67,68 the authors concluded that SST had little efficacy in addressing the social problems of ADHD children.

The treatments with some proven efficacy for assisting teens with ADHD and their families are:

  1. medications
  2. parent training in contingency management methods 69
  3. parent-teen training in problem-solving and communication skills 4
  4. classroom applications of contingency management techniques 67
  5. various combinations of these psychosocial approaches with psychopharmacology.

Therapists should also be aware of the availability of special educational programs for children with ADHD that are now mandated under the Individuals with Disabilities in Education Act and Section 504 of the Civil Rights Act. 70 Since parents and teachers who make referrals are often very concerned about determination of eligibility for such programs, it is important that clinicians be familiar with federal, state, and local regulations regarding placement in such programs.

Medications for Managing ADHD

Four classes of psychotropic drugs have proven useful in the management of ADHD symptoms. Most of this evidence comes from children with ADHD, with far fewer studies of adolescents. The four classes are stimulants, noradrenergic reuptake inhibitors, tricyclic antidepressants, and antihypertensive agents. All have been shown to be significantly more effective than placebo in reducing ADHD symptoms in randomized, controlled trials, mostly involving children.

Stimulant medication (dopamine agonists).

Since Bradley first accidentally discovered the successful use of stimulants in children with behavior problems in 1937, 71 an enormous amount of research has been done with these agents, far more than for any known treatment for any childhood psychiatric disorder. The results overwhelmingly indicate that stimulant medications are quite effective in managing ADHD symptoms in most children older than 5 years of age. 72,73 The response rate is probably much lower in children between 4 and 5 years of age, and the drugs are not recommended for use in children under 3 years of age. The effectiveness of these medications has led to their widespread use in children with ADHD. National figures for the prevalence of such treatment are not available but review of large scale regional databases suggests that approximately 2.8% of the school-age population are likely being treated with stimulants for ADHD symptoms. 74 These medications may be nearly as useful for adolescents with ADHD, 45 although fewer than 10 studies have been done with this age group.

The most commonly prescribed stimulants are methlyphenidate (MPH) (Ritalin, Concerta, Medadate CD, Focalin), d-amphetamine (AMP) (Dexedrine or Dextrostat), a d- and l-AMP combination (Adderall, Adderall XR), and pemoline (Cylert). MPH appears to work by slowing down dopamine reuptake from the extracellular space. The amphetamines appear to work primarily by increasing dopamine release but may also have some effect on reuptake. It is not known how pemoline achieves its therapeutic effect. Because of the potential for liver complications, 75 pemoline is no longer recommended for use with patients unless frequent monitoring of liver functioning is done. Pemoline is not discussed further here since it is so rarely used in treating children. Adderall is a stimulant compound that was recently approved for the management of ADHD. It is a combination of different forms of AMP salts that is effective in treating ADHD symptoms in children 76,77 and adults. 78

MPH (in various forms) and AMP are the most commonly prescribed medications for ADHD. In their original forms, they are rapidly acting stimulants that produce effects on behavior within 30–45 minutes after oral ingestion of the standard preparations, with their behavioral effects peaking within 2–4 hours. 72 Their utility in managing behavior quickly dissipates within 3–7 hours, although minuscule amounts of the medication may remain in the blood for up to 24 hours. 73,79 Because of their short half-life, they were often prescribed two to three times per day, causing great inconvenience and requiring that at least one dose (at noon) be administered at school. Although these agents were once used predominantly on school days, there is an increasing clinical trend toward using them throughout the week as well as during school vacations. This is the result of recent discoveries that the growth of children with ADHD who are taking stimulants is not as seriously affected as was once believed, 80 so that the rationale for universal drug holidays is no longer justifiable. Focalin, or dex-MPH, was recently approved for use in ADHD. It is simply the right turning MPH molecule, which some research suggests may be the effective form of this medication as opposed to the left turning molecule (levo-MPH). It is otherwise identical in effects and side effects to MPH but requires only half the typical dose.

Both MPH and AMP later became available in slow-release preparations (Ritalin SR; Dexedrine spansules) that reduced the number of daily doses children required for management of their ADHD. 72 However, control of behavior was less than ideal with these formulations because of sub-optimal blood levels during the sustained release of the medication. New and more effective delivery systems have been invented over the past 5 years that make these earlier slow-release formulations nearly outdated. These include Concerta, Medadate CD, and Ritalin LA for MPH delivery and Adderall XR for mixed AMP delivery. Concerta is a miniature osmotic pump resembling a capsule that oozes liquid MPH while transversing the gut for an interval of 10–12 hours. 81 Medadate CD and Ritalin LA are tiny MPH pellets to which various time-release coatings have been applied so that they dissolve at increasingly longer time intervals as they course through the gut; they last for roughly 8–12 hours. Medadate CD has the advantage that it can be opened and sprinkled on soft food for easier oral ingestion in patients who have difficulties swallowing tablets or capsules without affecting its pharmacokinetic properties. 82 It is likely that Ritalin LA, given its similar composition, has this same advantage.

The behavioral improvements produced by MPH and AMP occur in sustained attention, impulse control, and reduction of task-irrelevant activity, especially in settings demanding restraint of behavior. 72,73 Generally, noisy and disruptive behavior also diminishes with medication. As a consequence of stimulant treatment, children with ADHD may become more compliant with parental and teacher instructions, be better able to sustain such compliance, and often increase cooperative behavior toward others with whom they may have to accomplish a task. ADHD children can perceive the benefit of the medication in reducing ADHD symptoms and even describe improvements in their self-esteem, though they may report somewhat more side effects than do their parents and teachers.

Drug-related improvements also occur in other domains of behavior, including aggression, handwriting, academic productivity and accuracy, persistence of effort, working memory, peer relations, emotional control, and participation in sports. 72,73,79 The effects of medication are idiosyncratic, with some children showing maximal improvement at lower doses, while others show the most improvement at higher doses. Stimulants appear to remain useful in managing ADHD over extended periods of time 47 and can be used successfully into adulthood.

Side effects include mild insomnia and appetite reduction, particular at the noon meal. 72 Temporary suppression of weight gain may initially accompany stimulant treatment, but is not generally severe or especially common, may rebound in the second year of treatment, and can be managed by insuring that adequate caloric and nutritional intake is maintained by shifting the distribution of food intake to other times of the day when the child is more amenable to eating. A small percentage of children with ADHD complain of stomachaches and headaches when treated with stimulants, but these tend to dissipate within a few weeks of beginning medication or can be managed by reducing the dose. Motor or vocal tics may occur in approximately 1%–2% of children with ADHD who are treated with stimulants. 73 In individuals who already have tics, stimulants can mildly exacerbate the tics in some cases, but may improve them in others. It now appears to be relatively safe to use stimulant medications in children with ADHD and comorbid tic disorders; however, clinicians should be prepared to reduce the dose or discontinue medication should children experience drug-related exacerbations of their tic symptoms.

The stimulant medications are the most studied treatment for the symptomatic management of ADHD and its secondary consequences and there is little doubt that they are also the most effective. Their side effects are relatively benign, particularly in comparison with other psychiatric drugs. For many children with moderate to severe levels of ADHD, this may be the first treatment employed in their clinical management. Other treatments may then be added as adjuncts for domains of impairment that are unaffected by the stimulant medication or when medication-free periods are required.

Norepinephrine reuptake inhibitors.

Several medications that slow reuptake of norepinephrine have some therapeutic benefit for the management of ADHD. The noradrenergic reuptake inhibitors are bupropion (Wellbutrin) and atomoxetine (Strattera), which was introduced in January 2003. Bupropion appears to affect both the noradrenergic and dopaminergic systems. Several studies in children with ADHD and one more recent study in adults have shown that bupropion produces significant improvement in ADHD symptoms compared with placebo. 83 However, the beneficial effects are not as substantial or dramatic as those achieved by the stimulants. Potential side effects include edema, rashes, irritability, loss of appetite, seizures (rare), and insomnia. One study that examined bupropion in a sample that included teens with ADHD found a significant effect relative to placebo, with bupropion nearly as effective as MPH, 84 while a second study involving an open trial format found some efficacy in teens with ADHD and comorbid substance use and conduct disorders. 85

Atomoxetine is the first new molecule for the treatment of ADHD approved by the FDA since 1975. Indications for children, teens, and adults with ADHD have been approved. Over the past 7 years, various studies have compared atomoxetine to placebo and, in some cases, to MPH. Research continues to examine the effect of the drug on specific domains of functioning in children (family functioning) and adults (occupational functioning, driving) with ADHD. Unlike bupropion, atomoxetine works selectively on noradrenergic reuptake, thereby making more norepinephrine available in the extra neuronal space. Atomoxetine has been studied in six acute, large, randomized, double-blind, placebo-controlled studies (two studies in children, 86,87 two in children and adolescents, 88,89 and two in adults 90). One trial in children was conducted using once-a-day dosing for a period of 6 weeks. The other three studies in children employed twice-daily dosing for 8–9 weeks. All doses were determined on a weight-adjusted basis. In the two studies in adults, dosing was twice daily for 10 weeks with dose escalation within a fixed range. In all studies, atomoxetine was superior to placebo in reducing mean symptom ratings on the primary outcome measure. The effect size for once-daily treatment was similar to that of twice-daily treatment. No serious safety concerns were observed and tolerability was good, with discontinuation rates for adverse events under 5% in the pediatric studies. The long-term safety of atomoxetine was assessed using data from clinical trials in children and adolescents treated for at least 1 year. Tolerability and safety were assessed by evaluating discontinuations, adverse events, weight, and height. Over 4000 patients have been exposed to atomoxetine in these and other clinical trials, with over 400 treated for at least 1 year. Discontinuations due to adverse events were uncommon (< 5%). Reports of decreased appetite and weight loss, which were reported statistically significantly more often than with placebo in acute trials, continued to decline during long-term treatment, as did other adverse events. After at least 1 year of treatment, atomoxetine increased mean heart rate 6.4 beats per minute and increased mean diastolic blood pressure 2.8 mmHg. When patients lost weight, this tended to occur early in treatment (mean weight loss of 0.5 kg in acute studies). However, over longer treatment periods, weight increased (mean 4.0 kg after 1 year). Because 1 year is a relatively short period in the growth of many children, analyses of height increases are inconclusive and require data from longer treatment periods. Atomoxetine appears to be safe and efficacious for the treatment of ADHD in children, adolescents, and adults and to produce a comparable proportion of clinical responders to MPH for the reduction of ADHD symptoms. Examination of effect sizes suggests that they may be somewhat lower than those achieved by MPH. Effect sizes also appear to be somewhat lower in teens and adults than in children with ADHD but these differences from MPH were not statistically significant in studies done to date and no direct comparisons of effects between children, teens, and adults have been undertaken in the same study.

Antidepressant medication.

Clinicians have also used tricyclic antidepressants (TCAs), such as imipramine and desipramine, for the management of ADHD symptoms. 83 This has been partly due to the occasional negative (and often undeserved) publicity in the popular media focusing on the stimulants, especially Ritalin. However, the rise in antidepressant use for ADHD may also have resulted from cases in which stimulants were contraindicated or were not especially effective or which involved significant comorbid mood disturbance. Less is known about the pharmacokinetics and behavioral effects of antidepressants in children with ADHD compared with stimulants. However, research on these compounds, particularly desipramine, increased in the early 1990s and generally supports their efficacy in the management of ADHD. These medications, which are often given twice daily (morning and evening), are longer acting than the stimulants. As a result, it takes longer to evaluate the therapeutic value of any given dose. Some research suggests that low doses of the TCAs may mimic stimulants in producing increased vigilance and sustained attention and decreased impulsivity. As a result, disruptive and aggressive behavior may also be reduced. Improvements in mood may also occur, particularly in children who had significant pretreatment levels of depression and anxiety. Treatment effects may diminish over time, however, so that the TCAs, unlike the stimulants, may not be useful in some cases as long-term therapy for ADHD.

The most common side effects of the TCAs are drowsiness during the first few days of treatment, dry mouth and constipation, and flushing. Less common but more important are cardiotoxic effects, such as possible tachycardia or arrhythmia, and in cases of overdose, coma or death. Some children may develop sluggish reactions in focusing the optic lens which may mimic nearsightedness. This reaction is not permanent and dissipates when treatment is withdrawn. Skin rash is occasionally reported and usually warrants discontinuation of the drug.

In general, it is probably preferable to use atomoxetine first as an alternative to the TCAs, since more information and safety data are available concerning this medication. The TCAs may be useful in the short-term treatment of children with ADHD when the stimulants or atomoxetine are not effective. However, clinicians need to properly evaluate the cardiac functioning of children before initiating treatment and then periodically monitor such functioning throughout the course of treatment, given the apparent risks of the TCAs for impairing cardiac functioning (see Wilens et al. 91 for a review and guidelines for monitoring children who are receiving TCAs).

There has been minimal research on the effectiveness of selective serotonin reuptake inhibitors (SSRIs) for management of ADHD, largely owing to the lack of any neurochemical rationale for doing so in view of the dearth of evidence that serotonin may be involved in this disorder. One very small open study suggested that fluoxetine may be beneficial, but it was the consensus opinion of the expert panel at the NIMH conference on ADHD that these compounds were not useful for this disorder. 83

Antihypertensive medication.

In the late 1980s, a small number of research papers appeared suggesting that the antihypertensive drug, clonidine (Catapres) may be beneficial in the management of ADHD symptoms, particularly in reducing hyperactivity and overarousal. 92 Another antihypertensive drug, guanfacine (Tenex) may also have some utility in managing ADHD. 92 These drugs are believed to act as alpha-2 adrenergic agonists that ultimately inhibit the release of norepinephrine, increasing dopamine turnover and reducing blood serotonin levels. 93 Although some changes in behavior may be the result of the general sedation produced by the medication, others appear to be related to improvements in activity regulation and attention. The limited research to date suggests that clonidine is much less effective than the stimulants in improving inattention and school productivity but may be equally efficacious in reducing hyperactivity and moodiness. The drug may also be useful in managing the sleep disturbances some children with ADHD experience. Side effects include drowsiness, dizziness, weakness, and occasional sleep disturbance. Rarer side effects include nausea, vomiting, cardiac arrhythmia, irritability, and orthostatic hypotension. Werry and Aman 93 have recommended that clonidine be used in the treatment of ADHD only as a last line of medical management when stimulants have proven ineffective or are contraindicated. Given the availability and greater safety of atomoxetine, it would certainly be used ahead of the antihypertensives in the management of ADHD.

Direct Applications of Contingency Management

A number of early studies evaluated the effects of reinforcement and punishment, usually response cost, on the behavior and cognitive performance of children with ADHD. These studies usually indicated that the performance of children with ADHD on tasks measuring vigilance or impulse control or on academic tasks can be immediately and significantly improved by the use of stimulus control techniques or by the contingent application of consequences. 3 In some cases, the behavior of children with ADHD who are treated with these techniques approximates that of normal control children. However, none of these studies examined the degree to which such changes endured after treatment was withdrawn or, more importantly, generalized to the natural environments of the children, calling into question the clinical efficacy of such an approach. Given the findings of highly limited generalization and maintenance of treatment effects for the classroom interventions described below, it is unlikely that behavioral techniques implemented only in the clinic or laboratory would carry over into the home or school settings of these children without formal programming for such generalization and maintenance. Consequently, they will not be discussed here further.

It is important to note that virtually no research has focused on the effectiveness of such behavioral treatments in teens with ADHD. Given the limited success and particularly limited generalization and maintenance of such approaches, it is unlikely that such studies will be done in the future. The overall treatment limiting features of these approaches, and of the other psychosocial approaches discussed below, indicate why they are likely to be of limited utility with teens:

  1. They rely on the compassion and willingness of others to employ them with teenagers with ADHD, when those others may have little time or inclination to do so.
  2. Teens spend progressively greater amounts of time away from caregivers, often with peers, who are frequently not part of the treatment team.
  3. Teens are likely to take classes with a larger number of educators than are children, increasing the likelihood that these educators will not comply with recommendations or will do so only half-heartedly.
  4. Teens have increasing opportunities to spend time with others in places (e.g., employment settings, driving, shopping at the mall, playing sports) that are largely out of reach of psychosocial treatments.
  5. Teens have an increasing capacity and desire for self-determination and freedom from coercion by others.

This last feature means that teens can exert effective counter-control against attempts by others to alter their behavior. In this case, intervening with teens becomes more akin to treating adults with mental disorders, so that one must place far greater reliance on the willingness of the teen to cooperate with treatment recommendations. As in all other areas of adolescent medicine and clinical psychology, compliance with treatment becomes a, if not the, paramount issue in the management of ADHD in teens—and it is fair to say that most teens do not necessarily want the help or will not fully invest themselves in the treatments their parents may seek for them.

Training Parents in Behavior Management Methods

Despite the plethora of research on parent training in child behavior modification, 69 only a small number of studies have examined the efficacy of this approach in children specifically selected for hyperactive or ADHD symptoms. Only two studies have examined the efficacy of such approaches specifically in teens with ADHD. 94,95 However, the limited available research can be interpreted with cautious optimism as supporting the use of behavioral parent training with ADHD children. 69 The results for teens are less impressive but still suggest some benefits for a minority of families.

The parent training treatment techniques used to date for children with ADHD have primarily consisted of training parents in general contingency management tactics, such as contingent application of reinforcement or punishment following appropriate/inappropriate behaviors. Reinforcement procedures have typically relied on praise or tokens, while punishment methods have usually been loss of tokens or time out from reinforcement. Why these particular methods were chosen or what specific target behaviors they were used with have often gone unreported.

I have developed a parent-training program for children with ADHD. This program borrows methods that have been shown to be efficacious in studies of defiant and oppositional children. 69 The program has been modified somewhat for families of teens with ADHD 4 and has been tested in combination with training of both parents and teens in problem-solving and communication skills. 94,95 Such treatments appear to be more relevant for the oppositional/defiant behaviors associated with ADHD rather than being likely to change the symptoms of ADHD or their underlying causes. The contingency management portion of the program consists of 8 steps, with 1–2 hour weekly training sessions provided either in groups or to individual families. Each step is described in detail elsewhere. 95 The program focuses on teaching parents about ADHD and ODD, how to implement greater use of positive attention, praise, and tangible reinforcers, improving commands and instructions, setting up a home point system, home punishment tactics, managing children in public places, and implementing a daily school behavior report card. The program includes several booster sessions.

Research suggests that up to 64% of families experience clinically significant change or recovery (normalization) of their child’s disruptive behavior as a consequence of this program. 96 However, improvements in behavior may be more concentrated in the realm of aggressive and defiant child behavior than in inattentive-hyperactive symptoms. All of these studies have relied on clinic-referred families, most of whom sought out the assistance of mental health professionals for their children. In two studies of this program slightly modified for teens, my colleagues and I found significant improvement at the group level of analysis—that is, all treatment groups improved from pre- to post-treatment. However, at the individual level of analysis, a mixed picture emerged. While 31%–70% of families were brought to within the normal range (75th percentile or lower), only 23%–30% of treated families actually showed what could be considered reliable changes (unlikely to be due to unreliability of measurement alone) on measures of parent-teen conflict. These results did not differ from those with the problem-solving approach discussed next. 94,95

We have also examined a family training program that includes Problem Solving Communication Training Program (PSCT) procedures developed by Robin and Foster. 4,95 This treatment program contains three major components for changing parent-adolescent conflict:

  1. Problem-solving: training parents and teens in a 5-step problem solving approach (i.e., problem definition, brainstorming of possible solutions, negotiation, decision making about a solution, implementation of the solution)
  2. Communication training: helping parents and teens develop more effective communication skills while discussing family conflicts, such as speaking in an even tone of voice, paraphrasing others’ concerns before speaking one’s own, providing approval to others for positive communication, and avoiding insults, put-downs, ultimatums, and other poor communication skills
  3. Cognitive restructuring: helping families detect, confront, and restructure irrational, extreme, or rigid belief systems held by parents or teens about their own or others’ conduct.

These skills are practiced with the therapist during each session using direct instruction, modeling, behavior rehearsal, role-playing, and feedback. Homework assignments are also given that involve the family using PSCT skills during a conflict discussion at home and audio taping these discussions for later review by the therapist.

This procedure has been studied both separately and in combination with the behavioral parent training procedure described above. The combination of the two approaches was superior to PSCT alone in just one respect, though it was an important one. Significantly more families in the combined group, who received behavioral management training (BMT) first, stayed in treatment than did those receiving just PSCT. 95 Otherwise, the groups did not differ, either in improvements on the group level or in rates of normalization and reliable change. At most, 23% showed reliable change while 31%–70% showed normalization. We believe the former is a better indicator of true change occurring as a function of treatment over and above the expected unreliability of the measures used to assess treatment effects. It is of some concern that up to 17% of families showed significant worsening of family conflicts as a function of treatment, especially with PSCT, perhaps because treatment forces them to confront issues of conflict that they may otherwise have avoided directly discussing at home.

In sum, family treatments do not appear to be useful for the management of ADHD symptoms, but they may be useful in addressing the parent-teen conflicts that often arise in such families, especially when comorbid ODD is present. Family training may be maximally effective for elementary-age children with ADHD. Its utility may decline in adolescents, where only a minority of families (< 30%) derive clinically reliable change due to treatment. The combination of BMT with PSCT seems to be the most useful approach, if only in reducing rates of dropouts from treatment. Yet some families may actually show a worsening of conflicts as a function of treatment, apparently more so with PSCT.

Training Teachers in Classroom Management

More research has been done on the application of behavior management methods for children with ADHD in the classroom than with parent training. There is a voluminous literature on the application of classroom management methods to disruptive child behaviors, many of which include the typical symptoms of ADHD. This research clearly indicates the effectiveness of behavioral techniques in the short-term treatment of academic performance problems in children with ADHD. However, I am not aware of any studies that have tested these procedures directly with teens with ADHD in school settings.

A meta-analysis of the research literature on school interventions for children with ADHD examined 70 separate studies that used various within- and between-subjects designs as well as single-case designs. 67,70 This review found an overall mean effect size for contingency management procedures of 0.60 for between-subject designs, nearly 1.00 for within-subject designs, and approximately 1.40 for single-case experimental designs. Interventions aimed at improving academic performance through the manipulation of the curriculum or of surrounding task-related environmental conditions, or peer-tutoring produced approximately equal or greater effect sizes. In contrast, cognitive-behavioral treatments (e.g., self-instruction) when used in the school setting were significantly less effective than curriculum adjustments, in-class behavior modification, or peer-tutoring interventions. Thus, all the available literature suggests that behavioral and academic interventions in the classroom can be effective in improving behavioral problems and academic performance in children with ADHD. The behavior of these children, however, may not be fully normalized by these interventions. Although very encouraging, such results need to be directly tested with teens who have ADHD in their school environments. Given the large number of teachers teenagers must typically deal with each week (as many as 6 to 8 different teachers), the more limited time they spend with each, the greater periods of unsupervised time at school, and the larger school buildings where teens are likely to be taught, it is not clear that similar levels of success would be achieved by these approaches when used with teens as would be the case for children with ADHD. Only two studies have directly tested behavioral treatments with teens. Both studies primarily used note-taking training in combination with an intensive summer treatment program, with some success. 97,98

A serious limitation of these results has been the lack of follow-up on the maintenance of these treatment gains over time. In addition, none of these studies examined whether generalization of behavioral control occurred in other school settings where no treatment procedures were in effect. Other studies that have employed a mixture of cognitive-behavioral and contingency management techniques have failed to find such generalization in children with ADHD, suggesting that improvements derived from classroom management methods are quite situation specific and may not generalize or be maintained once treatment has been terminated.

The range of accommodations that can be suggested to help individuals with ADHD in the classroom is substantial. To illustrate the point, Table 1 provides a list of treatment recommendations that might be conveyed to school staff who deal with children or adolescents with ADHD. Such recommendations range from altering productivity requirements, classroom seating arrangements, and even teaching style, to instituting classroom token systems and daily school report cards linked to home-based token reward programs, to suggestions concerning classroom punishment methods. Some of the recommendations are based mainly on common sense and clinical wisdom while others are derived from the scientific literature on treatments used with children in the classroom. Not all of these recommendations will prove appropriate or effective in all cases, and any school intervention plan must be tailored to the situation of the specific individual with ADHD.

Table 1
Table 1:
A typical range of treatment suggestions for classroom behavior management of children and adolescents with ADHD

Combined Interventions

Optimal treatment is likely to involve a combination of psychosocial and medication approaches for maximal effectiveness. 47,98 Some research studies have examined the utility of such treatment packages with interesting results, although none was done with teens with ADHD. In many studies, it appears that the combination of contingency management training for parents or teachers with stimulant drug therapies is generally little better than either treatment alone for the management of ADHD symptoms. Classroom behavioral interventions may mildly improve the deviant behavior of children with ADHD but may not bring such levels of behavior within the normal range. In contrast, medication renders most children normal in classroom behavior. Others have found more impressive results for classroom behavior management methods 67 but have also found that the addition of medication provides additional improvement beyond that achieved by behavior management alone. 98 Moreover, the combination may result in the need for less intense behavioral interventions or lower doses of medication than might be the case if either intervention were used alone. Where behavioral interventions do appear to have an advantage is in reliably increasing rates of academic productivity and accuracy—yet here too stimulant medication has shown positive effects. Despite some failures to obtain additive effects for these two treatments, their combination may still be advantageous since stimulants are not usually used in late afternoons or evenings when parents may need effective behavior management tactics to deal with ADHD symptoms. Moreover, 8%–25% of children with ADHD do not respond positively to stimulant medications, 72 making behavioral intervention one of the few scientifically proven alternatives for these cases.

A historic collaboration across 7 sites spearheaded by the National Institute of Mental Health systematically evaluated the effects of intensive, multi-method behavioral intervention alone (for 14 months), rigorous psychopharmacological testing, titration, and monitoring (for 14 months), and their combination compared with a community treatment group (treatment as available in the children’s normal community setting). 47 The study involved 579 elementary age children (ages 7–9 years) with combined type ADHD. One- and 2-year post-treatment follow-up evaluations were also conducted. Results indicated that, for the management of ADHD, medication only and combination therapy were equally effective and were superior to the intensive behavioral and community control groups, which did not differ from one another. The results suggested that combined management may have been slightly superior to medication for certain subgroups of children or for other outcome domains. Over the 2 years the children have been followed since intensive treatment ended, only the medication management group has continued to benefit from ongoing treatment. The results of this study continue to reinforce the notion that medication continues to provide benefit for the management of ADHD symptoms specifically as long as it is sustained. Gains from behavioral interventions when combined with medication do occur for some subgroups and for some other outcome domains but can only be sustained if the interventions are continued.

Physical Exercise

One intervention that has received limited attention for the management of disruptive behavior is antecedent physical exercise, such as routine running, 101 other aerobic activities, weight training, or just simple movement. 102 Such exercise is not contingent on any particular behavior, such as aerobic exercise as punishment, but instead is conducted periodically and noncontingently. Few studies have focused specifically on children or teens with ADHD but a meta-analytic review of the available literature found significant results concerning reductions in disruptive behavior with mean effect sizes ranging from 0.33 (analysis of group studies) to 1.99 (analysis of single case designs) and evidence of greater effects in participants with hyperactivity. 102 Further and more rigorous study of this relatively harmless, socially acceptable form of treatment for teens with ADHD that has a benign profile of side effects seems in order.

CONCLUSION

The treatment of ADHD requires expertise in many different treatment modalities, no single one of which can address all of the difficulties likely to be experienced by individuals with this disorder. Among the available treatments, education of parents, family members, and teachers about the disorder, psychopharmacology (chiefly stimulant medications), parent training in effective behavior management methods, classroom behavior modification methods and academic interventions, and special educational placement appear to have the greatest efficacy or promise for dealing with children with ADHD. To these must often be added family therapy focused on problem-solving and communication skills, the coordination of multiple teachers and school-staff across the high school day, assisting the teen with ADHD with his or her expanded responsibilities, opportunities and privileges, and the preparation of the teen for eventual independent living and self-support. To be effective in altering eventual prognosis, treatments must be maintained over extended periods (months to years) with periodic re-intervention as needed across the life course. It is also important to increasingly enlist the individual’s cooperation with and investment in the long-term intervention program.

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      Keywords:

      attention-deficit/hyperactivity disorder; adolescents; comorbid disorders; oppositional defiant disorder; conduct disorder; stimulant medications; methylphenidate; d-amphetamine; bupropion; atomoxetine; tricyclic antidepressants; clonidine; contingency management; parent training; teacher training

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