Behavior Modification

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ADHD

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BEHAVIOR MODIFICATION William E. Pelham, Jr., PhD, and Gregory A. Fabiano, BA

Attention deficit hyperactivity disorder (ADHD) is the most common mental health disorder of childhood, affecting 3% to 5% of the population. It is a chronic disorder characterized by abnormally high levels of inattention, impulsivity, and overactivity. The symptoms of ADHD result in serious impairment in functioning for affected children, including in school, family, and peer domains. These dysfunctions highlight the seriousness of ADHD as a childhood problem and predict the development of the even more serious problems and poor outcomes that occur for individuals with ADHD in adolescence and adulthood. Thus, effective treatment for childhood ADHD is a major public mental health agenda. In the authors' previous article for this clinic,49 they reviewed what was known at the time about behavioral and combined (behavioral plus pharmacologic) approaches for treating ADHD. The following four conclusions were drawn: (1) there was clear evidence that behavioral approaches, as implemented with parents and teachers, were effective alternatives to pharmacologic treatments for ADHD; (2) there was little evidence that cognitive behavioral treatments for ADHD (typically implemented in individual sessions with children in clinics or schools) had any effect on ADHD; (3) there was increasing evidence that the combination of behavior modification and stimulant medication yielded a better outcome for most ADHD children than either treatment alone; and (4) there were promising novel approaches to intensive treatments for ADHD. In this article the authors update these conclusions, focusing primarily on the literature since 1990. Recently, a number of reviews have investigated the treatment litera-

From the Department of Psychology (WEP, GAF); and the ADHD Program (WEP), State University of New York at Buffalo, Buffalo, New York

CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA VOLUME 9 • NUMBER 3 • JULY 2000

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ture on ADHD. Pelham et al53 determined that behavioral parent training and behavioral classroom interventions (e.g., daily home notes, response cost procedures) but not cognitive-behavioral interventions met the criteria of the American Psychological Association task force on evidencebased treatments for childhood mental health disorder. 29 Similarly, DuPaul and Eckert12 recently reviewed school-based interventions used to treat ADHD, and they also concluded that contingency management strategies were effective treatments for ADHD in the schools. Pelham et al43 recently updated the 1998 report and added a review of the support for combined behavioral-pharmacologic treatments for ADHD. In total, more than 70 studies were reviewed with more than 2000 participants. Table 1 summarizes the behavioral and combined treatment studies for children with ADHD. Based on the evidence, behavior modification and combined behavioral-pharmacologic treatment for ADHD have demonstrated effectiveness for reducing impairment and symptoms in a number of studies, a conclusion also reached by representatives of the American Psychological Association, 53 the American Medical Association, 19 a National Institutes of Health consensus conference statement,33 and the American Academy of Child and Adolescent Psychiatry. 2 The short-term efficacy of CNS stimulants is also well documented in the treatment of ADHD. 60• 62 WHY USE BEHAVIOR MODIFICATION FOR TREATING ADHD?

Stimulant medications are used ubiquitously as a treatment for ADHD, and therefore any discussion of behavior modification must include a brief discussion of the limitations of pharmacologic treatment for ADHD. First, despite many studies documenting the short-term efficacy of stimulant treatment, no studies document long-term efficacy in improving any area of impairment or outcome.62 Second, because many children only receive medication during the school day, it is likely that many parents never directly benefit from improved behavior

Table 1. BEHAVIOR MODIFICATION AND COMBINED BEHAVIOR MODIFICATION AND STIMULANT TREATMENT FOR ADHD Type of Treatment

Behavior therapy Combination of behavior therapy and stimulant medication* Total

No. of Studies

No. of Subjectst

50 20

1180 860

70

2040

*Studies were classified as combined treatments if any condition or group received a combination of behavior therapy and stimulant treatment. tThese numbers include children in control or alternative treatment conditions in addition to total treated subiects.

' .

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exhibited by children while medicated, leaving the parent-child relationship untreated. Notably, medication is not active when a child wakes up in the morning, or right before bedtime, two times frequently noted as problematic for parents. Third, medication effects are not uniform across children (e.g., approximately 70% to 80% of children respond positively to a stimulant regimen) or within children. 52• 62 Fourth, children may intentionally or unintentionally neglect to take their medication, especially as they approach adolescence. 59 The vast majority of children with ADHD take stimulant medication for only a few months, and they stop taking medication in adolescence. Fifth, administering medication may reduce the likelihood that parents and teachers will continue or initiate psychosocial treatments. Relying solely on medication to treat children with ADHD may leave untreated significant areas of impairment not amenable to stimulant medication. A few examples common to ADHD children are reactive aggression, lack of proficiency in sports, academic skills such as notetaking, specific social skills, and family functioning, low self-esteem, and comorbid problems such as specific learning disabilities, anxiety, depression, and enuresis. In contrast to medication, behavioral treatments are flexible and potent enough to treat any impaired area of functioning. Based on these limitations, it is arguable that behavioral modification should be a first-line treatment tried for treating the impairing behaviors characteristic of ADHD, and its use presents many advantages over the sole reliance on stimulant medication. As is discussed in this article, medication often is a useful adjunctive treatment for the majority of ADHD children, but it can clearly be argued that all treatment plans for treating children with ADHD should include a behavior modification component. WHAT IS THE TARGET OF TREATMENT IN ADHD?

A major point regarding behavioral treatments for ADHD concerns the appropriate targets of treatment. Over the past 20 years, most researchers and clinicians in the psychiatric community have strongly emphasized the importance of making an accurate diagnosis for ADHD and using the Diagnostic and Statistical Manual of Mental Disorders (DSM) 3 definition to identify symptoms. These same DSM symptoms have frequently been the targets of treatment and measures of treatment outcome. These authors developed parent and teacher rating scales that enabled DSM symptomatology to be relatively easily measured (e.g., the Swanson, Nolan, and Pelham [SNAP] Rating Scales, 5 and the Disruptive Behavior Disorders Rating Scale44 ) . Only recently has a split between what is routinely practiced in behavior therapy and the emphasis on diagnoses and symptoms become apparent. The focus of behavioral treatments (as well as the evaluation of pharmacologic approaches) is not primarily on diagnostic symptoms, but on the child's problems in daily li-fe-fun~tiGning in-hGm@,-SchGG-1,-aml- pe@r--Settings. Th@Se problems in

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daily life functioning (e.g., peer relationships, adult relationships, academic achievement, self-esteem, family functioning) are codified in DSM-IV as impairment, and cross-situational impairment must be demonstrated for a diagnosis to be made.3• 28 For this reason, behavior modification practitioners focus their interventions on socially valid problems in daily life functioning, which typically are called target behaviors. The authors' clinical work always begins with a detailed, functional analysis of a child's referring problems. This is accomplished by obtaining information from parents, teachers, and other sources about the child's functioning in multiple domains (e.g., academic, peer) and contexts (home, school, and recreational settings). These problems rarely include the DSM symptoms of ADHD (e.g., "fidgeting" or "often does not seem to listen when spoken to directly"). Instead, referring problems typically include teasing peers, refusing to comply with commands, not completing school assignments accurately, and disruptive classroom behavior. Although the DSM system is useful for screening for ADHD and identifying if the symptoms of the disorder are present, its utility is limited because a DSM diagnosis does not provide any useful treatment information.57 The logical second step requires identifying socially relevant and individually meaningful target behaviors, and this may only be achieved through a comprehensive functional analysis (see Mash and Terdal3° for an expanded discussion of how to conduct a functional analysis in the initial stages of treatment planning). BEHAVIORAL MODIFICATION

In the context of ADHD treatment, behavior modification is the application of the principles of social learning theory to modify children's behavior by training parents and teachers to manipulate environmental antecedents (e.g., commands), consequences (e.g., rewards, punishments), and contingencies (the relationship among target behaviors, antecedent events, and consequences).24 Behavioral treatments have been used for children specifically diagnosed with ADHD for more than 20 years37 and have been used for more than 30 years to treat children variously described as disruptive, aggressive, or conduct disordered.35 Recent epidemiologic studies and clinical studies of comorbidity have suggested that most children described as disruptive or aggressive in early studies would have been diagnosed with ADHD (with or without comorbid aggression, conduct disorder, or oppositional-defiant disorder) had DSM criteria been employed. 35• 39 Thus, there is an extensive literature on behavioral treatments for ADHD, covering hundreds of studies and thousands of children beyond those noted in Table 1.9• 53 Applications of traditional, outpatient-based behavior modification, also called clinical behavior therapy, have typically involved training either parents or teachers to implement contingency-management programs with children.4• 21• 50• 55 Typical clinical parent training programs include a series of 8 to 16 weekly sessions. Parents are given

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assigned readings and are tau ght standard behavioral techniques such as the following :7, 8, 11, 1s, 16, 17, 38, 39 Parent Training* 1. Overview of social learning and behavior management principles 2. Home I school daily report card 3. Giving effective commands and reprimands 4. Time out 5. Attending, rewarding and ignoring skills 6. Establishing and enforcing rules and when ... then contingencies 7. Home point system-reward and response cost 8. Planned activities and setting generalization outside of the home 9. Level systems and fading procedures 10. Maintenance of program after contact ends Teacher Consultation* 1. Introduction to ADHD, rationale for and overview of treatment; obtain teacher I school commitment to implement intervention, introduce social learning theory and behavioral classroom management procedures, assess teacher knowledge and use of behavioral procedures, and design content of subsequent sessions accordingly 2. Establish and post operationalized classroom rules 3, Home I school daily report card (always done) 4. Structure I instructional modifications for an individual child 5, Attending, praising, rewarding, skills 6, Giving effective commands and reprimands, enforcing rules and when . . . then contingencies 7, Classwide interventions 8. Group contingencies 9. Response cost I reward point or token system for the target child 10. Time out (classroom, office, systematic exclusion) These programs typically employ well documented approaches and teach the fundamentals of social learning theory, as well as basic information about ADHD. Parent training is usually accomplished in groups (although some programs include individual sessions), with homework assignments given for parents to track behavior and practice techniques with their children. Therapists using behavior modification techniques (or school psychologists or counselors) often work simultaneously with teachers in a consultation model to teach the same kinds of behavioral strategies that are taught to parents. Materials are available to facilitate such instruction to teachers. 12, 14, 41, 63 Behavioral strategies taught to teachers include the following: (1) daily report cards (DRCs) that target individualized problems for children, establish procedures for the teacher to monitor, *Every consultation contact includes a functional assessment of child's current progress toward treatment goals, and these goals/treatment strategies are continually added, deleted, and modified based on the effectiveness of current treatment and the child's current functional impairment.

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give feedback to the child for those problems, and provide feedback to parents on the children's school performance, for which parents provide a positive consequence at home; 25' 37 and (2) other classroom management strategies that can be implemented by the teacher with the target children, such as immediate feedback following target behaviors, reward or response cost point systems, and time out. 1, 6, rn, i 3, 14, 22, 25, 42, 56 Figure 1 depicts a typical DRC for a child with ADHD. The efficacy of clinical behavior therapy approaches has been evaluated in a number of studies. 26, 37, 5o, 51 In general, the behavior therapy techniques examined in these studies consistently revealed considerable improvement relative to control conditions, in both classroom and home

Child's Name:

Date:

Special

LA

Math

Reading

y

N

y

y

N

y

N

y

N

y

N

y

N

y

N

y

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y

N

Completes ass ignments at 80% accuracy.

y

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y

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y

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y

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y

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Complies with teacher requests.

y

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y

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y

N

y

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y

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y

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y

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y

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y

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y

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Follows lunch rules.

y

N

Follows recess rules.

y

N

Follows class rules with no more than

N

SS/Science

3 rule violations per period. Completes assignments within the designated time.

(no more than 3 instances of noncompliance per period) No more than 3 instances of teasing per period. OTHER

Total Number of Yeses Teacher's Initials Comments:

Figure 1. Sample daily report card (DRC).

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settings, results similar to those reported in numerous studies of behavioral treatments of aggressive (e.g., conduct disorder or oppositional defiant disorder) children,9 many of whom also have comorbid ADHD. Additionally, some studies examined a broad array of measures of parental functioning and reported improvement in those domains, although they were not specifically targeted. 4• 54 Interestingly, some single-subject design studies using more potent behavior modification procedures22• 23• 34• 56 show equivalent or superior effects of behavior modification compared with medication in classroom and play settings, demonstrating a "dosage" effect of behavior modification. These studies suggest a viable alternative treatment for parents who desire it or children who do not respond to stimulant medication. For these individuals, relatively more time- and energy-intensive interventions, such as response cost procedures or time out, may be equivalent treatment alternatives for stimulant medication. School-based behavioral interventions for children with ADHD received increased attention in 1991, when the federal government issued a policy memorandum declaring that children with ADHD could be classified as "other health impaired" under the Individuals with Disabilities Education Act (IDEA). This policy change, and its 1997 reauthorization, meant that children with ADHD should receive federally mandated behavioral interventions to assist with their academic progress. Parents have the right to request special education services (it is often necessary for teachers, physicians, and mental health professionals to inform parents of this right) based on the child's educational impairment, and classification as "other health impaired" increases the accountability of school systems to comply with behavioral treatment recommendations. Even children in regular education classrooms should have behavioral programs under section 504 of the 1973 Rehabilitation Act. It is these authors' view that the IDEA may serve as the impetus to initiate behavior modification programs for children with ADHD in the school, and the naturally reinforcing results of a behavioral intervention (e.g., improved child behavior, increased academic productivity) may serve to maintain the procedures. In summary, many studies have shown that behavior modification of the sort that can easily be implemented by therapists and counselors in community mental health, primary care, or private practice settings, and by staff in school settings (e.g., 8 to 12 weekly sessions with parents and teachers conducted over periods between 2 and 5 months) results in reliable, substantial, and clinically important improvement on multiple measures for most children who receive treatment. The components of comprehensive, combined treatment are as follows: Parent Training 1. Behavioral approach; therapist teaches parents contingency management techniques to use with the child and the parent implements the treatment

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2. Focus on specific target behaviors that reflect impairment in multiple domains of functioning (e.g., peer and adult relationships, sibling relationships, academic progress, classroom and family functioning, self-esteem) 3. Typical model is group-based, weekly sessions with therapist initially, then contact faded 4. Adherence to treatment components regularly checked, and treatment goals are continually added, deleted, or modified based on an ongoing functional analysis of behavior 5. Continued support and contact as long as necessary (e.g., 2 or 3 years after the initial sessions) 6. Program for maintenance and relapse prevention (e.g., develop plans for dealing with backsliding/ concurrent cyclic parental problems, such as maternal depression, parental substance abuse, and divorce) 7. Reestablish contact for major developmental transitions (e.g., adolescence) School Intervention 1. Behavioral approach; therapist teaches teacher contingency management techniques to use with the child and the teacher implements the treatment 2. Focus on specific target behaviors that reflect impairment in multiple domains of functioning (e.g., peer and adult relationships, academic progress, classroom functioning, self-esteem) 3. Consultant works with teacher: initial weekly face-to-face or telephone sessions, then contact decreased 4. Adherence to treatment components regularly checked, and treatment goals are continually added, deleted, or modified based on an ongoing functional analysis of behavior 5. Continued support and contact for multiple years after initial consultation (as long as necessary) 6. Program for maintenance and relapse prevention (e.g., school-wide programs, inservice training for all school staft including administrators; eventually train parent to work with the teacher and monitor or modify behavior) 7. Reestablish contact for major developmental transitions (e.g., move from elementary school to middle school) Child Intervention 1. Behavioral and developmental approach involving direct work in natural or analog settings, not clinic settings 2. Focus on specific target behaviors that reflect impairment in multiple domains of functioning (e.g., friendships, adult relationships, sibling relationships, academic progress, classroom and family functioning, self-esteem) 3. Paraprofessional implemented 4. Intensive treatments such as summer treatment programs (9 hours daily for 8 weeks) and school-year, after-school, and Saturday (6hour) sessions

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5. Adherence to treatment components regularly checked, and treatment goals are continually added, deleted, or modified based on a current functional analysis of behavior 6. Provided as long as necessary (e.g., 2 or 3 years after initial contact) 7. Program for generalization and relapse prevention (e.g., integrate with school and parent treatments) 8. Reestablish contact for major developmental transitions (e.g., move from elementary to middle school) INTENSIVE BEHAVIOR MODIFICATION APPROACHES

One area that has developed significantly during the 1990s is the area of intensive behavioral treatments for ADHD. The Children's Summer Treatment Program (STP)47 is a prototypic example, and it is an aggregation of home-, school-, and child-based behavioral modification techniques that delivers a powerful, concentrated dose of behavior therapy with built-in maintenance treatment. The STP combines an intensive summer treatment program with a school year, outpatient follow-up program to provide a maximally effective psychosocial interventions. 47 The behavioral modification component of the STP is a program of empirically supported techniques interwoven into an intensive treatment package. Components include evidence-based behavioral treatment, peer interventions, weekly parent training meetings, school consultations, and individualized behavioral programs tailored to the child's most salient areas of impaired functioning. Detailed descriptions of the program components, as well procedures for ensuring and evaluating treatment adherence and fidelity, are available. 46 Pelham and Hoza47 reported pre and post measures of functioning for a sample of 258 highly comorbid, ethnically and socioeconomically diverse boys with ADHD who attended STPs from 1987 through 1992. Very large effects of treatment were obtained on many behavioral measures. For example, 96% of the parents rated the children as improved and 93% said that they would recommend the program to other parents. Although there is a very large literature on behavioral treatment for ADHD and the other disruptive behavior disorders, there has until recently been no large clinical trial that investigated the effectiveness of behavior modification for ADHD. Indeed, no large clinical trial documents the effects of any treatment, psychosocial, pharmacologic, or otherwise for any childhood disorder. A National Institutes of Healthfunded trial, the Multimodal Treatment Study for ADHD (MTA), has recently been completed, however. 31• 32 The MTA is an investigation that compared four treatments for ADHD-Behavioral Treatment (Beh), Medication Management (Med), Combined Beh and Med (Comb), and a control group (CC; community comparison)-in seven collaborating sites across North America. Seven to 9-year-old ADHD children were recruited from a variety of community resources (e.g., schools, physicians, clinics, newspapers, parent referral) and randomly assigned to

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one of the four treatments. Children and their families were followed intensively with major assessments at baseline and after 14 months of treatment. For the purposes of this article, the authors shall focus on the Beh and Comb treatments in the study, mentioning the Med and CC groups for the purposes of comparison. The Beh condition in the MTA study included all of the treatment components listed previously (parent training, school intervention, and summer treatment program), and the Comb group in addition received stimulant medication (primarily methylphenidate three times daily, 7 days per week) with monthly medication visits. Behavior modification contact was decreased gradually over the course of the study, with minimal contact occurring for the last 6 months of intervention, whereas medication was continued in its most intensive phase throughout the study, and children were actively medicated at endpoint. Seventy percent of the CC group received stimulant medication- usually MPH- from their community physicians, including at endpoint. The mean daily doses of medication received in the three groups were 38 mg/day (Med), 31 mg/day (Comb), and 23 mg/day (CC). In brief, the major findings at endpoint were as follows: (1) all four treatment groups showed dramatic improvement from baseline to 14 months, with changes from baseline on parent and teacher symptom ratings (in terms of baseline standard deviations) ranging from 0.9 to 1.3 for Beh and CC groups, and from 1.5 to 1.8 for Comb and Med groups; (2) Med was superior to Beh on parent and teacher ratings of inattention and teacher ratings of hyperactivity but not on any of the other 16 measures, including classroom observed behavior, parent- and teacherrated social skills, parent-rated parent-child relationships, peer sociometric ratings, and academic achievement; (3) Beh was equivalent to the CC group (as a whole, as well as the subset who were medicated) on most measures and superior on several; (4) Comb treatment was generally superior to Beh and Med, with superiority relative to Med occurring primarily in functional impairment across home, school, academic, and peer domains; (5) comorbidity and factors such as socio-economic status (SES) interacted only rarely with these findings, indicating that the Beh and Comb treatments were effective across the wide range of comorbidities and SES in the study; and (6) parents strongly preferred the Beh treatment to the Med treatment (by a factor of 2:1) and Comb treatment to the Med treatment by an even greater factor. 31• 32• 40 This study, therefore, demonstrated that a behavior modification approach as outlined herein produces effects comparable to those produced by stimulant medication. Further, the addition of behavior modification to the Med condition in the study produced consistent incremental benefit in multiple domains of impairment and enabled a 20% reduction in dosage, as well as a dramatic reduction in the rate of dosage increase over the study. This is one of the first studies to investigate the maintenance of behavioral treatments after therapeutic contact had been terminated, and it showed clear maintenance of treatment effects. Unfortunately, medication was not withdrawn from children in the Comb

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group, so the issue of whether effects of behavioral treatments maintain when medication is withdrawn cannot be addressed from this study.

COMBINED PHARMACOLOGIC AND BEHAVIORAL INTERVENTIONS

Since the authors' earlier article in this clinic, evidence for combined treatments (CT) has accumulated, 10• 27• 31 • 32• 34• 42 with most studies indicating an incremental benefit of the CT over and above a pharmacologic or behavioral treatment alone. For example, in CT studies, effect sizes of the CT usually are greater than either treatment alone by an effect size of 0.3 to 0.4. There are many advantages to combining behavioral and pharmacologic treatments. 48 For example, there are several reasons to speculate that long-term maintenance of treatment effects might be improved with a combined intervention. First, children with ADHD exhibit impaired academic and social adjustment. To the extent that these skills are necessary for successful long-term outcome, medication alone, which does not teach a child alternative behaviors for coping with problematic situations, would not be expected to be a sufficient treatment. The addition of a behavioral intervention that focused in part on building competencies in academic and social domains should improve the longterm outcome that would not be achieved with medication alone. Similarly, to facilitate maintenance of behavioral treatment effects, the intervention should be able to be continued by the child's parents or teachers for a protracted time or maintained by naturally occurring contingencies following therapy termination. Because the addition of a low dose of stimulant medication enables relatively greater effects to be achieved with less restrictive and more natural behavioral programs, a CT may be more likely to be maintained by parents and teachers following termination of therapeutic contact, 31• 51 and the comprehensiveness of CT ensures that a child is treated in all settings and times throughout the day. Several single-subject and within-subject studies and laboratory studies have shown that low (e.g., 0.3 mg/kg) doses of MPH and behavioral treatments have roughly additive effects, 43 yielding a larger treatment effect than either medication or behavioral intervention alone. Together, these studies provide convincing evidence for the efficacy of CT for ADHD. For a treatment to be deemed useful, however, it must be efficacious and effective. One way to determine the effectiveness of treatment is by assessing its social validity. Social validity is a construct comprised of the goals of treatment, the treatment procedures themselves, and the outcomes of treatment. Typically, social validity is demonstrated if a child exhibits clinically significant improvement in impaired domains and normalization of behavior, and consumer satisfaction ratings of the treatment are positive. 18 Many combined treatment studies have assessed the social validity of the treatment, and these studies indicate that CT is effective in obtaining clinically significant

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reports of improvement in impaired domains, and they are overwhelmingly endorsed by consumers (e.g., parents and teachers). Consider, for example, the Klein and Abikoff study.26 They reported global improvement rates for children in the CT group of 93%, 93%, and 97% for teachers, mothers, and psychiatrists, respectively, considerably higher than the 50% to 79% rates for the behavior therapy and medication groups. Children who received CT were considerably more likely to be normalized than those in the behavior therapy and medicationonly groups, which suggests that combined treatment is a socially valid intervention because it was effective in normalizing the behavior of the vast majority of children. In the MTA study, parents overwhelmingly rated behavior therapy and CT favorably, which further suggests that these treatments are improving functioning in impaired domains and meeting consumer expectations. In addition, children in the combined treatment exhibited normalized behavior at a greater rate than children in either of the unimodal treatments. 61 Further evidence for the social validity of CT is provided by Pelham et al, 42 who computed individual effect sizes (each child's treatment mean minus the no-treatment mean, divided by his or her standard deviation over no-treatment days) that were weighted according to children's baseline symptom severity and individual areas of impairment. Thus, the authors asked how many children showed incremental benefit from CT on their most impaired behaviors; 41 % of the boys showed incremental improvement with combined treatment over their medication only response, whereas 78% showed incremental improvement with CT over their behavior modification-only response. Thus, a substantial proportion of individuals clearly benefited from CT in the areas most in need of remediation, underscoring the power of CT to reduce a child's most impairing behaviors. A final key question regarding CT merits discussion: what effects maintain when either one or both treatments are withdrawn? This is a critical question regarding long-term outcome because only three studies have addressed this issue. 20• 26• 50 Ialongo and colleagues,20 reported that CT subjects who had received parent training maintained treatment gains on parent behavior ratings collected 9 months after medication withdrawal (as did subjects who received parent training without medication), whereas those in the medication groups did not. Klein and Abikoff26 and Pelham et al50 both reported the same result: CT subjects maintained the gains they had made from the behavior therapy, while losing the acute effects of medication on its withdrawal (Fig. 2). The MTA study withdrew psychosocial treatment but not medication, and found at posttreatment that CT was usually better than medication alone at a lower-dose level, but the effects were not as large as expected. Because medication continued, however, maintenance of psychosocial treatment effects without medication in the CT group could not be evaluated. These authors' prediction would be that medication withdrawal at the end of treatment in that study would have revealed substantial incremental benefit of the CT group over the medication alone group. 40

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Figure 2. The effect of withdrawing medication in a combined treatment. TRS = Conners' Teacher Rating Scale. Diamond = behavior therapy; squared = medication; triangle = combination. (Data from Klein RG, Abikoff H: Behavior therapy and methylphenidate in the treatment of children with ADHD. Arch Gen Psychiatry 2:89, 1997.)

In general then, after medication withdrawal, only the effects of behavioral treatment remain in CT studies. Although such a result could be viewed as a glass half empty, the fact that the behavioral treatment effects remained following medication is quite important. If medication is discontinued-and this appears not only likely for most children with ADHD at some point in time 58 but indeed may be a goal of treatmentthen a combination regimen of behavioral and low-dose pharmacologic treatments should yield better long-term functioning than a medicationonly regimen. Studies that evaluate CT effects without withdrawing medication to assess treatment maintenance are missing one of the major advantages of combined treatment. Somewhat surprisingly, all other existing studies of combined treatment regimens have focused on acute effects rather than maintenance. Whether a systematic medication withdrawal and maintenance program could effectively maintain all of the beneficial effects of CT (as opposed to just the behavioral treatment effects) over the long term has yet to be investigated. CONCLUSION

Since the authors' initial report in 1992, much progress has been made in the study of efficacious behavioral treatments for ADHD. The MIA study provides results from a very large, randomized, clinical trial, and it demonstrated equivalent effects and maintenance of a behavioral treatment protocol package relative to community medication administered by community physicians. The results reported herein align with a strong consensus from leading professional organizations that behavior

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modification is an integral and necessary component of any treatment package for ADHD. 2• 19• 33• 53 In general, combined treatment studies indicate that the effective level of pharmacologic and psychosocial treatment intensity may be lower than when either treatment is used alone. In combined treatments, the daily dose, and therefore the child's lifetime intake of stimulant medication, can be reduced by 25% to 75%. 10• 3 1• 42 Because the combination of treatments reduces the need for intensive, costly treatments, parents and teachers might be more likely to maintain treatment programs and comply with treatment recommendations. Although a great deal of progress has been made in the identification and validation of treatments efficacious for treating children with ADHD, the next step is to increase the utilization of these treatments for ADHD in the community. Although most people have had experience with praise, rewards, removing privileges, and time out, both as a child or a parent, and most adults acknowledge commonly using these techniques successfully with their own children, barriers exist to implementing these treatments widely for children with ADHD. Some of the barriers are as follows: Barriers in Families Lack of financial resources for mental health services Lack of insurance coverage for mental health services Social stressors (e.g., single-parent family, parental psychopathology) Lack of parent knowledge about ADHD and effective behavioral treatment strategies Parent beliefs about treatment strategies (e.g., medication, nonevidence based treatments) Poor compliance with treatment and factors that negatively affect compliance Barriers in Schools Lack of financial resources for behavior modification treatments Lack of administrative or staff resources for behavior modification treatments District 504 and IDEA policies implemented inconsistently or inappropriately Lack of teacher knowledge about ADHD and effective behavioral treatment strategies Teacher beliefs about treatment strategies Poor compliance with treatment Barriers in Mental Health Settings Financial resources used inappropriately (e.g., money wasted on non- evidence based treatments) Lack of therapist knowledge about ADHD and effective behavioral treatment strategies Therapist training in non-evidence based treatment practices Therapist beliefs about treatment strategies

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Traditional, clinic-based approach to treatment with children (i.e., therapy does not take place in natural environment where impairment occurs) Barriers in Primary Care Settings Financial resources (e.g., managed care limits treatment length, does not cover intensive treatments) Availability of community resources for referrals in effective behavioral treatments Physician or nurse knowledge about ADHD and effective treatment strategies Physician or nurse beliefs about treatment strategies Barriers in Community Settings Financial resources of the community Absence of advocacy groups and community coalitions (e.g., schools, physicians, parents, mental health professionals) Lack of availability of effective behavioral treatments for ADHD (e.g., summer treatment programs) Community leader knowledge and beliefs about ADHD and treatments One reason for these barriers may be that our mental health, school, and medical infrastructures generally are not amenable to dealing with chronic disorders such as ADHD that do not lend themselves easily to office-based treatment, because of factors such as financial restrictions, lack of resources, and lack of training or knowledge. These problems may be avoided, however, through school-wide discipline programs, teacher, physician, and mental health professional inservices, reimbursing practitioners only for employing treatments that work, and educating people in the community about effective treatments. Future directions include disseminating these findings to those who implement and need treatment for ADHD and finding ways to integrate behavioral programs into the present treatment provider infrastructure. In conclusion, ADHD is a chronic and substantially impairing disorder. This means that treatment must also be chronic and substantial. Behavior modification, and in many cases the combination of behavior modification and stimulant medication, is a valid, useful treatment for reducing the pervasive impairment experienced by these children. Based on the evidence presented, the authors believe that behavior modification should be the first line of treatment for children with ADHD. Many, if not most, children might also benefit from an adjunctive, low dose of stimulant medication, with the expectation that long-term treatment focusing on continued maintenance of treatment gains is necessary. References l. Abramowitz AJ, Eckstrand D, O'Leary SG, et al: ADHD children's responses to

stimulant medication and two intensities of a behavioral intervention. Behav Modif 16:193-203, 1992

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Address reprint requests to William E. Pelham, Jr., PhD Department of Psychology, Park Hall SUNY at Buffalo Buffalo, NY 14260-4110 Email: [email protected]