ADHD Management: The Necessity of Psychotherapy: Clinical Paper

A group of kids playing in the mud as the tide comes in

attention deficit hyperactivity disorder (ADHD) is generally treated by medication in the United States. Medication treats the acute symptoms of the disease, but does little to affect the long-term prognosis if the medication in stopped. Non-pharmacological methods of treating ADHD take longer to work, but effect long-term changes in behavior. Thus, a multimodal treatment of ADHD is the best choice, especially in light of the fact the many children who take medication stop their medications within 1 year.

Prevalence

Attention Deficit Hyperactivity Disorder is a disorder that affects approximately 3-5% of the children in the United States (American Psychiatric Association, 1994). Contrary to popular thought, however, the disorder is not limited to childhood. It is a lifetime illness, with the disease progressing into the teen years and adulthood.

Of the children diagnosed with ADHD, 70-80% will continue to meet the criteria when they reach their teenage years, and 50-70% will meet the criteria when they reach adulthood (Guervemont & Dumas, 1994; Barkley & Murphy, 1998; Shaughnesy & Martin, 1998). This lifetime span of the illness is indicative of the need for lifetime solutions to the problems that it brings.

Definition

ADHD has been defined by Barkley (1991) as a disorder of response inhibition and executive dysfunction leading to deficits in self-regulation, impairment in the ability to organize behavior toward present and future goals, and difficulty adapting socially and behaviorally to environmental demands. Additionally, it is classified in the Diagnostic and Statistical Manual of psychiatric disorders, Fourth Edition (DSM-IV) as a disruptive disorder due to its impact on those around the person with the disorder. However, unlike the other two disruptive disorders, oppositional defiant disorder and conduct disorder, ADHD is the only “non-voluntary” disruptive disorder. Instead, it is the result of limited behavior due to incompetent and developmental impairments (Schaughency & Rothlind, 1991).

Symptoms

Not all ADHD is created equal. There are three different types of ADHD according to the DSM-IV (1994, p 85). The first is ADHD predominately inattentive type; the second is ADHD predominately hyperactive-impulsive type; the third is ADHD combined type; and the fourth is ADHD not otherwise specified.

The appropriate subtype is important in the treatment of the person with ADHD. While medication may treat the symptoms for either subtype, the dichotomous symptoms, as described by Hutchins (1994), are important in the psychotherapeutic treatment:

Main SymptomsImpulsivityInattention
BehaviorOveractiveSluggish
ModelImpulse InhibitionOrganization
OccurrenceBoys more than GirlsBoys more or equal to Girls
Languagelanguage disorderSubtle Deficits
PeersPeer RejectionSocial Withdrawal
ComorbidityAggression, conduct disorderAnxiety, Depression
PresentationBehavior, early referralLearning, late referral
Family TypeDiscord/angerstress/Frustration
OutcomePersistenceAdjustment

And by Zgonc’s Study (as cited in Price, 1999)

TraitADHD / ImpulsivityADHD / Inattention
Decision MakingImpulsiveSluggish
BoundariesIntrusive, RebelliousHonors Boundaries, Polite, Obedient
AssertionBossy, IrritatingUnderassertive, Docile,Overly Polite
Attention SeekingShow-off, Egotistical, Best at WorstModest, Shy, Socially Withdrawn
PopularityAttracts but doesn’t BondBonds but doesn’t Attract

Social Problems

Competent social skills are essential to life success. Unfortunately, individually, children with ADHD manifest a multitude of social problems. According to Pelham and Milich (1984), they are less often chosen by peers to be best friends, partners in activities or seatmates. Teacher reports of social interactions of children with ADHD describe fighting, interrupting and being disliked or neglected (Pelham & Bender, 1982), while Barkley (1981) reported that parents in 80% of the cases felt their children had severe social problems. Waddell (1984) believes that this is a vicious circle, in which social problems worsen as the child grows older, with behavioral excesses leading to rejection and social skill deficits leading to low acceptance. Peer relationships have been found to be an important predictor of positive adult adjustment and behavior, and lowered self-esteem from decreased peer relationships in childhood carries on to adulthood (Glow & Glow, 1980).

Children with ADHD have been shown to have effects on their environments as well. Increased rates of negative teacher-child interactions among the classroom as a whole were reported in classrooms where there were children with attention problems (Campbell, Endman & Bernfield, 1977).

Psychopharmacological Treatments

Nearly 80% of the children with ADHD are treated with pharmacological treatments (Zito, Safer, dosReis, Magder, Gardner & Zarin, 1999; Wolraich, Lindgren, Stronquist, Milich, Davis & Watson, 1990). Additionally, children with a comorbid conduct disorder receive medication at a higher rate than children with ADHD alone.

The two major groups that see children with ADHD are primary care doctors and psychiatrists. While primary care physicians perform 75% of office visits, psychiatrists perform 25% of the visits. This is not to say that 25% of the children are seen by psychiatrists, as the primary care physician will see a child on average 3-4 times per year while a psychiatrist sees a child on average 1 or more times per month (Zito, Safer, dosReis, Magder, Gardner, Zarin, 1999).

The prescribing patterns between the primary care doctor and psychiatrist are vastly different, as well. The primary care physician generally prescribes a single stimulant medication. The psychiatrist may prescribe a single stimulant medication, but is much more likely to prescribe a combination of medications, up to 50% of the time (Zarin, Suarez, Pincus, Kupersanin, & Zito, 1998). This is likely due to referrals from primary care physicians who were unable to manage the children through monotherapy or comorbid disorders. There is an approximate 80% success rate for pharmacological ADHD management (Smucker & Hedayat, 2001).

The use of multiple medications in children has not been well studied, however, and some researchers have questioned it. While there has been undoubtedly positive effects for some children,

Children with concurrent attentional, affective and tic disorders may be prescribed various drugs, including stimulants, antidepressants, clonidine and mood stabilizers. Almost no data, however, exists about the efficacy and safety of these combinations, and the rationale for their use is not always sound. (Vitiello & Hoagwood, 1997)

In the MTA study, Pelham (1999) found that children treated under strict medication regimens by psychiatrists did better than children treated by community physicians who treated children with medication. However, the psychiatrists utilized medications that were at dosages 65% higher than the community physicians (per study protocol), along with an attendant increase in side-effects. These side-effects include insomnia, decreased appetite, stomach pain, headache, emergence or worsening of tics, decreased growth velocity, tachycardia, blood pressure elevation, rebound or deterioration of ADHD behaviors when the medication wears off, emotional lability, irritability, social withdrawal and flattened affect ( Smucker and Hedayat, 2001).

In some studies, stimulants which have been optimally titrated have been given twice per day, morning and afternoon. This has resulted in positive effects on behavior at school, but parental reports show that the symptoms are still apparent in the home. Additionally, the some side effects are acute, but others may not be evident at the beginning of the medication regime. This partially may be a contributing factor to the lack of adherence to the medication programs, and why families frequently abandon the medication route of treatment, as discussed later. In one 4-month study, 10% of participants withdrew due to side-effects (Schachar, Tannock, Cuningham & Corkum, 1997).

Psychosocial Treatments

Ness & Price (1990) believe that “the best non-medical interventions (for ADHD) are practical, commonsense adjustments to an impulsive and disorganized style.” They also go on to state that those suffering from ADHD will be more frustrated, apathetic and pessimistic than others about psychosocial treatments, decreasing the probability of success.

Thus, the important first step in treatment of a person with a learning disability is the gaining of their participation, and helping them to becoming active participants in their treatment. Two of the first obstacles that must be overcome initially in order to do this are the common feelings of denial and underconfidence (Ness & Price, 1990).

The four problems that are brought into the therapeutic setting by the ADHD client, according to Barton and Fuhrman (1994) are stress and anxiety resulting from struggles to meet life’s demands, low self-esteem and feelings of incompetence, grief over lack of accomplishments, and helplessness. To this, I add social skills.

Up to 20% of children and adults with ADHD will not respond to medications, and many more will experience only partial remission of their symptoms. Additionally, a significant portion of the impairment from ADHD comes for its secondary impact on self-esteem and social skills deficits. These are the targets of psychotherapeutic interventions (Clinical Practice Guideline, 2001; Weiss, Hechtman, & Weiss, 1999, p. 190). In their study of adults with ADHD, when asked what had helped them the most in growing up, they report that the responses were very congruent: a particular person who had believed in them and helped them turn the tide of failure, which is a good metaphor for the work of psychotherapy (Weiss & Hechtman, 1993).

The most common form of therapy with children with ADHD is behavior therapy. This is a set of interventions that have a common goal modifying the environment to change the child’s behavior. This is often done in both the home and school, and includes more structure, closer attention, and limitations of distractions (Clinical practice guidelines, 2001). The child is given a set of desired behaviors, and is rewarded positively for performing the desired behaviors, and given consequences for failing to meet the desired behaviors. This serves to shape the behaviors over time.

In studies, children who were treated with both behavioral and medication therapies showed more improvement than those who were treated with medication alone or with behavioral therapies alone, and had greater parental satisfaction (Jensen, Arnold, Richers, 1999).

In the National Institutes of mental health 14-month study of treatment options for children with ADHD, those children who received combined treatment with medication (administered by psychiatrists) and behavioral therapy were shown to have a higher level of functioning than children treated community practitioners, and parents preferred the results of the two groups in which the children participated in behavioral treatments (behavioral alone or combined with medication) over medication by psychiatrist or treatment by a community practitioner (Pelham, 1999).

During the course of this study, in addition, the although the children in both the medication management only group and the medication management and behavioral therapy combined group were started on the same dose of medication, their ending doses of medication were significantly different. At each monthly visit, the children were assessed for the need to adjust medication, and doses were increased (never decreased) based upon reports and deterioration of symptoms as needed. The children in the groups receiving both types of therapy, on average, at the end of 14-months were on 20 to 50% lower doses of medication than their counterparts in medication only therapy groups (Pelham, 1999). Additionally, The children receiving behavioral therapy alone had as much success as the children who were receiving services from community providers only. And, this was achieved with the behavioral therapy being phased over the last 5 months of the study, which ran a total of 14 months.

The most successful group was the combined behavioral therapy and psychiatrist managed pharmacotherapy. According to Conners et al. (2001), when all 19 endpoints from the MTA study are combined and used as a single effect, the combined therapy group shows a statistically significant advantage over all other groups in the study.

The summary results of this study indicate that the behavioral treatment had an effect size improvement from baseline to endpoint of 0.9 to 1.3 on all measures, which is considered to be very large. It differed from psychiatrist managed medication only (which was 65% greater dosages than those provided in the community) on only 3 of 19 dependent measures, and was no different than the community treatment group on any of the treatment measures, despite the fading of the behavioral treatment after only 9 months. This is particularly significant when it the fact is considered that 50% of those that were treated in the behavioral subgroup were on medication prior to entry into the study, and were taken off of their medication to enter into the behavioral subgroup of the study (Pelham, 1999).

During the summer portion of the study, a comparison was made between the children in the behavior only and the behavior/medication groups. The children who were in the combination group were significantly better in five measures: rule following, good sportsmanship, peer negative nominations, and STP teacher posttreatment rating of inattention/overactivity. On the other 30 measures, there were no significant differences, which differs from the general MTA assumptions that the combination group would always outperform the behavior only group (Pelham et al., 2000).

Parents significantly preferred the behavioral only and behavioral and medication combined subgroups of the MTA treatment, which is important, due to the fact that parental involvement is influenced by parental preference and engagement. They found that many parents did not want their child medicated, and found that they preferred the behavioral treatments, and lacking that, the lowest possible doses of medication available (Pelham, 1999). Corkum, Rimer and Schachar (1999) also support this in their study, which found that parents of ADHD children viewed non-pharmacological treatments more favorably than pharmacological interventions, especially when they became more educated about the disease.

This preference has translated into the actual treatment of today’s children. There has been an increase in the number of children with ADHD receiving non-pharmacological therapy, either in conjunction with, or in place of medication. Between two studies, in 1989 less than 20% of children were receiving mental health services, mostly as an adjunct to medication while in 1999 approximately 33% were receiving services, with many of them being non-medicated (Jensen, Xenakis, Shervette & Bain, 1989; Jensen et al., 1999).

Conclusion

Psychopharmacological methods are effective in providing acute relief of many ADHD symptoms in many clients. Non-medication forms of treatment, however can produce effects in problem solving, anger/frustration management, and behavioral/social skills (Johnson, 1993). Unfortunately, a large number of people who take medication for ADHD discontinue it in less than 1 year (Sherman & Hertzig, 1991), or at the latest childhood or adolescence (Pelham, 1999). Firestone (1982) places the number of children who discontinue medication at 20% by four months and 45% by 10 months. Long-term maintenance and ability to adapt and generalize to new situations throughout their lives is best achieved through psychological and/or behavioral methods of treatment (Pelham, 1999). Studies by Klein and Abikoff (1997) and Pelham et al. (1988) have shown that the effects of psychotherapeutic gains while a person is concurrently taking medications remain when the medication is withdrawn. Firestone (1982) indicates that 51% of those engaged in behavioral interventions will not complete the behavioral intervention program. However, when compared to those who stop medication, the gains that have been made will remain with the person with ADHD, rather than vanishing when the medication does. Thus, psychotherapeutic methods are essential to the continued success of those diagnosed with ADHD. In fact, the American Academy of Child and Adolescent Psychiatry recommends a multimodal treatment plan with non-medical components (Smucker & Hedayat, 2001).

Finally, With parents viewing non-pharmacological interventions more favorably, it can only be assumed that a large percentage of children being treated in the community are not being given the option of non-pharmacological treatments, given that 80% of children are treated by stimulant medications, and less than a third having non-pharmacological supports.

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Derek Wood is a Nationally Board Certified Psychiatric/Mental Health Nurse, and holds a Master's degree in Psychology. His experience in the online arena of mental health can be traced back to 1997, when he was a host for Online Psych on AOL. He joined Get Mental Help, Inc. as Clinical Content Director for Mental Health Matters. Derek, with his wife Lisa, developed the original version of psychTracker (then called A Mood Journal), after his diagnosis with Schizo-Affective Bipolar, when they could not find a system available that was robust enough to help him effectively manage his symptoms and accurately interpret his charting. Derek has worked in the field of mental health since 2001, as a Unit Manager of an adult long-term treatment facility, a charge nurse in an adolescent short-term inpatient facility and long-term residential facility, and as a School Psychologist. He has also written several articles which are being used as CEU for nurses and educators.

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