Multi-modal management of ADHD - Key learning points
- Psychoeducation e.g. written information for parents/ school
- Family support e.g. parenting groups, Sure Start etc
- Local parent support groups
- Liaison with school re- classroom strategies
- Groups for children
- Individual work with children
- Consider the role of medication
The principles of a multi-modal treatment package for ADHD
Following assessment of a child with ADHD, a treatment/management plan should be developed in consultation with the parent or carer and other agencies involved. Treatment should reflect the diversity of presenting symptoms. ADHD is a chronic condition requiring access to long-term treatment and support, sometimes over many years. However, the level and type of support needed can vary. The principal aims of treatment are to promote the child's development and to reduce secondary difficulties or disabilities.
The American Academy of Child and Adolescent Psychiatry have published a practice parameter for the assessment and treatment of children and adolescents with Attention-Deficit/Hyperactivity Disorder (2007) which gives up to date recommendations on the treatment of ADHD. Additional information relevant to UK practitioners is now available from the National Institute for Health and Clinical Excellence who have produced guidance for the assessment and management of ADHD (see www.nice.org.uk/CG072).
Conventional treatment options tend to be either behavioural and/or pharmacological and essentially aim to reduce the core symptoms of inattention, hyperactivity and impulsivity as well as targeting the associated effects of these on psychosocial and educational functioning.
General principles of ADHD management
In many milder cases, careful management of behaviour and advice both to parents and teachers working with the child to control impulsiveness and maintain concentration may be sufficient to manage the problems. The National Institute for Health and Clinical Excellence guidelines on diagnosis and management of ADHD in children, young people and adults (2008, p17, www.nice.org.uk/CG072) state that children and young people with behavioural problems suggestive of ADHD can be referred by their school or primary care/practitioner for parent-training/education programmes without a formal diagnosis of ADHD.
Behavioural and psychoeducational interventions should be seen as the initial treatment of choice for most children.
Where these are not deemed to be sufficient, or where the child or young person has severe ADHD, however, medication may also be required to assist the process. This is a matter to be decided by the clinical judgement of the child psychiatrist or paediatrician who is managing the child in consultation with those who have day to day care of the child. It has been shown that the symptoms of ADHD can, in a large proportion of cases (~70-85%), be moderated by the use of one or other of 2 stimulant medications in common use in the UK (methylphenidate and dexamphetamine) (Joughin and Zwi 1999; Greenhill et al. 1999; Lord and Paisley, 2000; Jadad et al. 1999; Swanson et al. 1998).
Multi-modal management approaches to ADHD- specific elements to consider:
1. Following diagnosis of ADHD, written information should be given to the parents/ carers and the child's school regarding diagnosis and assessment, support and self-help, psychological treatment and the use and possible side effects of drug treatment. The value of exercise and a good diet should be stressed. Psychoeducation can also take the form of specific face to face sessions which can be offered individually to parents and young people or in a small group setting. See downloads and also list of useful websites from which information sheets about ADHD can be downloaded:
- (http://www.austinchildguidance.org ) click on parents, then click on articles
- (http://www.dshs.state.tx.us/) By entering 'ADHD' into the search box at the top of the home page, this will lead the viewer to a number of information sheets on aspects related to ADHD which can be printed out.
- Alternatively there is a useful website for parents which can be accessed at www.parent-plus.org
2. Family support should aim to improve relationships within the family, promote parental empowerment and develop strategies to manage behaviour, e.g. through a parenting group. In addition, families should be advised of ADHD parent support groups existing in their area;
3. Liaison with the SENCo or a teacher who has received training about ADHD and it’s management at the child's school should help inform behaviour management strategies within the classroom to address different learning styles and needs (see downloads). Further support from behaviour specialist teachers employed by the Local Education Authority should be sought where necessary;
4. Individual counselling or group work based on CBT and/ or social skills training may be offered to the child to address issues of low self-esteem as well as to promote social skills and peer relationships and offer skills in the area of problem solving, self control, listening skills and dealing with and expressing feelings;
5. Time should be spent with the child/young person to help them understand what ADHD is and if medication is to be used, how it works and what its side effects may be;
6. For children under five, other behavioural support advice for parents can be accessed via health visitors, Sure Start (not available in all areas at present) and nursery nurses. It is extremely unusual in the UK to prescribe stimulant medication to children below the age of six years. For pre-school children, the first line of treatment will be a referral to a parent training/education programme;
7. In the more severe cases, or where there is persisting significant impairment despite behavioural interventions in the home and classroom setting, a trial of stimulant medication may be considered. Where medication has been prescribed it is important that there is clarity regarding who holds medical responsibility;
8. In stimulant responsive young (aged 7 - 9.9 years) children with ADHD without learning disorders and conduct disorders (CD), a recent large study did not support the use of additional intensive academic assistance and psychotherapy to enhance academic achievement or emotional adjustment (Hechtman et al, 2004);
9. In stimulant responsive young children (aged 7-9.9 years) with ADHD, a recent large study did not support additional clinic based social skills training as part of a long term psychosocial intervention to improve social behaviour (Abikoff et al, 2004). It was noted that the benefits of stimulant treatment on social function did not diminish over time;
10. If a child presents with ADHD with co-morbid anxiety, both behavioural and /or medication interventions are likely to be equally effective (Jensen et al, 2001);
11. If a child presents with ADHD-only or with ADHD + ODD/Conduct disorder, treatments with medication appear especially indicated and behaviour alone strategies may be contra-indicated (Jensen et al, 2001);
12. If a child presents with ADHD plus anxiety plus ODD/ conduct disorder, combination treatments offering both medication plus a behavioural intervention offer the best option (Jensen et al, 2001).
Useful web based sources of information on multi-modal treatment of children with ADHD
- A summary of treatment options consistent with clinical practice in the UK is presented in the Auditable protocol for treating attention deficit/hyperactivity disorder. P. Hill and E.Taylor. Archives of Disease in Childhood, 84, P 407-408. (Available in full text form on line via http://adc.bmjjournals.com/ .This web address takes you to the home page. Enter Hill in the author box and ADHD in the keywords box and this will lead you to the article).
- SIGN guidelines for Attention Deficit and Hyperkinetic Disorders in Children and Young People (2001) (see http://www.sign.ac.uk/guidelines/fulltext/52/index.html).
- The American Academy of Pediatrics (2001) have published a clinical practice guideline for treatment of the school-aged child with attention-deficit/hyperactivity disorder (see. http://www.aap.org/policy/s0120.html)
- National Institute for Health and Clinical Excellence (www.nice.org.uk/CG072)