Multimodal Treatment of the School-aged Child With Attention-Deficit/Hyperactivity Disorder

1. Multimodal Treatment of the School-aged Child
With Attention-Deficit/Hyperactivity Disorder
Attention-deficit/hyperactivity disorder (ADHD) is
the most common childhood neurobehavioral disor-
der, affecting approximately 8% of US children.1
Although ADHD is associated with substantial
impairment of family, school, and peer functioning,
effective treatments are available. In this Viewpoint,
we highlight the fundamentals of treatment, including
evidence-based pharmacologic and nonpharmaco-
logic approaches.
Successful Treatment Depends on Thorough
Initial Assessment and Sound Diagnosis
The initial assessment for ADHD involves determining
whetherachildmeetsDiagnosticandStatisticalManual
of Mental Disorders (Fifth Edition)2
criteria for ADHD
and ruling out other conditions. Notably, two-thirds of
children with ADHD are estimated to have a develop-
mental or behavioral comorbidity. Unfortunately,
nocurrentlyavailableobjectivemeasure(ie,computer-
based test of attention or response inhibition, electro-
encephalographictest,neuroimagingtest,orotherlabo-
ratory test) has adequate sensitivity and specificity to
beusedinisolationtodiagnoseorexcludeADHD.Rather,
the clinician must collect information about the child’s
symptoms and functioning in home and school set-
tings,whichcanbefacilitatedbyusingstandardizedcare-
giver- and teacher-completed rating scales (such as the
Vanderbilt or Conner ADHD Rating Scales).1
However,
theseratingscaleshelptodeterminewhetherthesymp-
tomsandimpairmentsarepresent,notwhethertheyare
due to ADHD. Thorough patient and family interviews
aswellasaphysicalexaminationareessentialfordeter-
mining whether mimicking or comorbid conditions or
both are present (see the American Academy of
Pediatrics [AAP] ADHD clinical practice guideline1
for
informationaboutimportantconditionstoexclude).The
AAP has also developed a toolkit to guide assessment
and treatment of the most common relevant develop-
mental and behavioral conditions to consider.3
Once the diagnosis of ADHD has been verified, the
clinicianmustpartnerwiththefamilytoestablishtreat-
mentgoalsandselectmodalities.Notreatmentplanwill
besuccessfulifthefamilycannotimplementitortheplan
does not address the family’s most pressing concerns,
includingincorporatinghowfamiliesweighthebalance
between amount of perceived benefit and potential
downsides, such as time, cost, and adverse effects.
Fortunately, interventions to promote shared decision
making in the family visit have led to caregivers that are
better informed and more involved without increasing
visit duration compared with usual care.4
One such
ADHD shared decision-making tool is available at the
Cincinnati Children’s Hospital Medical Center website.5
Effective ADHD Treatment Modalities Include
Pharmacologic and Nonpharmacologic Therapies
The AAP ADHD guideline recommends that
clinicians prescribe US Food and Drug Administration–
approved medications for ADHD, evidence-based
behavioral therapy for ADHD, or preferably both.1
Although stimulant medications alone have been
shown to produce significant improvements in
ADHD symptoms, for many important facets of a
child’s life, such as parent-child relations, academic
outcomes, social skills, anxiety symptoms, and
oppositional/aggressive symptoms, combined
medication and behavioral interventions achieve the
best results. Combination therapy may also allow for
better results at lower medication dosages.6
In
addition, behavioral treatment provides the family
with much-needed skills to manage behaviors when
medication is not “on board” and is not associated
with adverse effects.
Effective ADHD Medication Management
Requires Careful Titration and Monitoring
Among the US Food and Drug Administration–
approved ADHD medications, psychostimulants are
considered first-line therapy because they have the
highest response rate and effect size (amount of
change in symptoms). Second-line ADHD medications
include atomoxetine hydrochloride and α2-adrenergic
agonists (ie, extended-release guanfacine hydrochlo-
ride and clonidine hydrochloride). Because no factors
have been identified that are consistently associated
with ADHD medication response, gradual escalation
titration is recommended to achieve optimal dosing,
with titration and dosing fundamentals detailed in the
AAP ADHD guideline.1
The revised Texas Children’s
ADHD Medication Algorithm also provides guidance
on systematic medication treatment of ADHD both
with and without comorbid psychiatric disorders.7
Notably, heavily marketed shortcuts to titration, such
as pharmacogenetic and neuroimaging tools, lack
sufficient evidence to support their clinical utility in
predicting ADHD medication response. Rather, expe-
ditious first contact after the initial ADHD medication
prescription and the periodic collection of teacher rat-
ings appear to be especially relevant for maximizing
symptom improvement. Physicians do not need to
rely on office visits to monitor medication response
and adverse effects in the week(s) after initially pre-
scribing medication but can use telephone calls or
email correspondence to check in with families.8
Web-based tools have also been developed to facili-
tate monitoring of parent and teacher symptom
ratings.8
VIEWPOINT
Tanya E. Froehlich,
MD, MS
Cincinnati Children’s
Hospital Medical
Center, Cincinnati,
Ohio; and Department
of Pediatrics, University
of Cincinnati College of
Medicine, Cincinnati,
Ohio.
William B. Brinkman,
MD, MEd, MSc
Cincinnati Children’s
Hospital Medical
Center, Cincinnati,
Ohio; and Department
of Pediatrics, University
of Cincinnati College of
Medicine, Cincinnati,
Ohio.
Corresponding
Author: Tanya E.
Froehlich, MD, MS,
Cincinnati Children’s
Hospital Medical
Center, 3333 Burnet
Ave, MLC 4002,
Cincinnati, OH 45229
(tanya.froehlich
@cchmc.org).
Opinion
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2. Generic “Behavioral Therapy” Recommendation
Is Insufficient to Ensure Evidence-Based ADHD Treatment
Caregivers often think that the goal of ADHD behavioral therapy is
to “fix” the child and may engage a behavioral therapist to work
primarily one-on-one with the child. However, there is no evi-
dence that individual psychotherapy or play therapy improves
children’s ability to pay attention or reduces impulsiveness.1
Rather, clinicians should educate families that the ADHD behav-
ioral therapy with the strongest evidence base is behavioral parent
training (BPT).9
The goal of BPT is not to change the child’s funda-
mental nature, but to train caregivers to improve the child’s envi-
ronment and set the stage for success. Behavioral parent training,
which is often delivered in small groups, teaches caregivers how to
provide positive reinforcement for appropriate behaviors, set lim-
its, and minimize emotionally destructive responses. One hallmark
of BPT—which clinicians should ask about in patient visits—is that
families are given “homework” in the form of behavioral manage-
ment plans to implement at home between sessions. For commu-
nities in which evidence-based BPT is not available, a national
organization dedicated to providing support for individuals with
ADHD (Children and Adults with Attention-Deficit/Hyperactivity
Disorder; http://www.chadd.org) offers in-person as well as web-
based training, including the Parent to Parent behavior training
program, which can be remotely accessed.
Caregiversofteninquireaboutarangeofadditionalnonpharma-
cologic treatments. However, there is currently insufficient evi-
dence to support a generalized recommendation for computer-
based cognitive training or neurofeedback to address ADHD
symptoms and impairments.9
Benefits of vision training, interactive
metronome training, occupational therapy, and sensory processing
therapies are also unsubstantiated for the treatment of ADHD.
Clinicians Must Educate Families About School
Communication and Accommodations
Appropriate classroom accommodations are key to success in
school for children with ADHD. Teacher-implemented strategies,
such as posted classroom rules, positive reinforcement for appro-
priate behavior and work completion/accuracy, and appropriate
consequences for rule violations, help decrease the contribution
of ADHD to impaired school functioning. There are also demon-
strated benefits of using the teacher-implemented Daily Report
Card intervention, which establishes goals for the child as well as a
system of evaluating and providing feedback daily to the family.9
Children with ADHD often need a Section 504 Plan at school to
ensure consistent implementation of these accommodations, and
some may meet criteria for an Individualized Education Program.
The National Institute for Children’s Health Quality ADHD toolkit10
(edition 1 available free) provides excellent handouts for care-
givers that explain how to work with the school, obtain appropri-
ate accommodations, and establish a Daily Report Card.
Conclusions
SuccessfulADHDmanagementbeginswithathoroughinitialassess-
ment that evaluates for mimicking or comorbid conditions as well as
the family’s goals and preferences. Optimal outcomes across a
broad range of functional domains can be obtained by combining
medication and behavioral interventions. Medication management
requires careful titration and monitoring. Clinicians also
have an important role in providing appropriate referrals for ADHD
behavior parent training and in linking families to school services.
If response to these multimodal treatments is unsatisfactory or the
diagnosisisambiguous,referraltoaspecialist,suchasadevelopmen-
tal and behavioral pediatrician or child psychiatrist, is indicated.
ARTICLE INFORMATION
Published Online: December 11, 2017.
doi:10.1001/jamapediatrics.2017.4023
Conflict of Interest Disclosures: Dr Froehlich is a
paid consultant for The American Board of
Pediatrics and the American Academy of Pediatrics,
serves on the board of directors for the American
Professional Society for ADHD and Related
Disorders, and receives research funding from the
National Institute of Mental Health. No other
disclosures were reported.
REFERENCES
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3. American Academy of Pediatrics. Addressing
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10. Caring for children with ADHD: a resource
toolkit for clinicians. National Institute for Children’s
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/caring-children-adhd-resource-toolkit-clinicians.
Accessed October 31, 2017.
Opinion Viewpoint
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