Like all behavioural conditions, ADHD involves many variables which combine to push the child towards and over the threshold of the disorder, or protect from that threshold. These intrinsic traits and environmental factors must all be addressed in diagnosis and treatment. This is the rationale for multimodal management which will maximise strengths and minimise the most significant vulnerabilities within the limitations of available resources. Approaches may typically combine medication, behavioural and family support and developmental therapies such as language therapy. A specific multimodal plan should be individualised for each child, and treatment may vary from child to child. The individualised plan should take account of associated problems such as learning difficulties, peer relationships, low self-esteem, family dysfunction and co-morbid conditions.
Many agencies and professionals may be involved in multimodal management as discussed in Sections 8.1 and 8.2. Collaborative management is essential, involving individuals with ADHD, their families, teachers and professionals from health care and other agencies. The multimodal approach is endorsed by professional groups after thorough consultation over years (American Academy of Child and Adolescent Psychiatry 1991) and in professional and government reports following multidisciplinary discussions (NSW Department of School Education 1995; Technical Working Party on ADD in Western Australia 1996; Farrelly and Standish÷of the Australian Psychological Society÷1996).
Multimodal therapy is widely accepted as being a more effective mode of management than any individual form of management used in isolation. Evaluations of multimodal therapy were reported nearly two decades ago (Satterfield, Satterfield and Cantwell 1980). However, there is very little research comparing different treatments singly or in combination, as discussed in Section 4.1 on the rationale for medication, and for the existing evidence base, as detailed in Section 4.4 on the comparison of medication with other treatments. The large National Institute of Mental Health study is currently investigating the overall efficacy and effectiveness of component parts of multimodal therapy (Greenhill, Abikoff, Arnold et al 1996; Richters, Arnold, Jensen et al 1995).
With time, development and intervention, the relative importance of various intrinsic and environmental variables and available resources may change. Regular review is important to ensure that multimodal management remains appropriate and effective. In order to achieve optimum benefits and minimum side-effects, close monitoring is essential when medication is commenced or changed. Stimulant medications have pharmacokinetics such that most beneficial effects or side-effects are apparent within two weeks (as illustrated by the comparison trials which use treatment durations of two weeks, eg Efron, Jarman and Baker 1997). An essential component of all behavioural therapies is continuing review, reinforcement, modification and refinement of strategies and outcomes.
Frequency of review will depend on age, stage and complexity of treatment, educational and family factors, and will often involve three to six monthly review. However, at least once a year a review should occur covering medication, educational progress and behaviour in home and other settings. This review will take account of class change each year, in addition to assessment of strategies as outlined in Sections 5 and 6. Twice yearly review by a consultant in stable situations have been recommended by the Technical Working Party on Attention Deficit Disorder in Western Australia (1996).
- A specific and individualised management plan should be formulated for each child with ADHD and their family.
- Associated problems such as learning difficulties, peer relationships, low self-esteem, family dysfunction and co-morbid conditions should be specifically addressed in the individualised management plan.
- Treatment should be multimodal and involve consideration of simultaneous medication use, behaviour management, family counselling and support, educational management, and specific developmental issues.
- Treatment and management of ADHD should be reviewed regularly. At least once every year a review should be made using the same parameters as for the initial diagnosis. Such a review should collect information from multiple sources and specifically evaluate any deterioration following significant interruptions to the medication regimen.
- Further research should objectively evaluate methods of assessment and management of ADHD.
- Further research, including comparative studies, should be undertaken to establish the cost-effectiveness of the various components of management of ADHD.
- Appropriate, relevant and up-to-date information on ADHD should be available and accessible for children, families, and professionals.