BEHAVIORAL THERAPY

Behavioral therapy is a term commonly used to describe a type of psychosocial approach to treating childhood ADHD. One aspect of this therapy is parent training; a typical program of behavioral therapy involves 10 to 20 sessions for parents, including information about ADHD and advice on managing behavior, anticipating misconduct, using a token economy, and using a daily school report card [9]. Therapies for children may include teaching skills and adaptive behaviors, such as how to organize school materials or how to improve relationships with peers [73]. Parent training in behavior therapy (also known as behavior management training for parents, parent behavior therapy, and behavioral parent training) has been shown to strengthen the relationship between the parent and child and to decrease children’s negative or problem behaviors [74].

The Multimodal Treatment Study of Children with ADHD was a 14-month trial of specific medication management, intensive behavioral therapy (group and individual sessions, teacher consults, a classroom behavioral aide for 12 weeks, and a summer program), both medication and behavioral therapy, or ordinary community care [75]. This study revealed that combination treatment did not significantly differ from medication management alone on direct comparisons.

Combined treatment was found to be superior to intensive behavioral therapy and/or community care for oppositional and/or aggressive symptoms, internalizing symptoms, teacher-rated social skills, parent-child relations, and reading achievement. At follow-up three and eight years after intensive study treatments had concluded, all treatment groups were similar on measures of ADHD symptoms

A two-year trial compared the efficacy of methylphenidate alone; methylphenidate with psychosocial treatment (including parent training and counseling, social skills training, psychotherapy, and academic assistance); and methylphenidate plus a psychosocial control treatment [. Significant improvement was seen with all treatments; combination treatment did not provide an advantage.

A randomized clinical trial compared combined treatment (brief intensive multimodal behavior therapy and methylphenidate) to treatment with methylphenidate alone. The 45 children who participated were reassessed at adolescence in a naturalistic follow-up 4.5 to 7.5 years after treatment. A matched non-ADHD control group included 23 children. Of the adolescents who participated in the follow-up study, 50% still met the diagnostic criteria for ADHD . Adolescents in the combined treatment group used significantly less medication than those in the methylphenidate-alone group. Overall, the adolescents showed a significant decline in hyperactivity/impulsivity and oppositional and CD symptoms from post-test to follow-up. Adolescents originally diagnosed with ADHD fared significantly worse than the matched controls on all outcomes except CD and substance abuse symptoms.

As stated, for children younger than 5 years of age, the NICE recommends parent or caregiver participation in an ADHD-focused group training program as first-line treatment [31]. The NICE guideline also recommends training for parents and caregivers of school-aged children with ADHD [31]. Parent training and group-based ADHD-focused support is recommended for parents of school-aged children who display symptoms of oppositional defiant disorder (ODD) or CD [31]. This guideline also recommends that CBT be considered in children who have benefited from medication but whose symptoms continue to cause significant impairment in social skills with peers, problem-solving, self-control, active listening skills, and dealing with and expressing feelings

Evidence regarding psychosocial treatments in adults is very limited. However, there may be a role for CBT . A few small studies support the use of CBT programs, and CBT is often used in practice. The NICE guideline recommends either elements of or a full program of CBT for adults with ADHD in whom nonpharmacologic treatment is indicated [31].

The focus of CBT for ADHD in adults includes both the patient’s thought process and his or her coping behaviors. Cognitive therapy addresses beliefs that reinforce problematic behaviors, such as feelings of failure; the goal is to diminish the power of such beliefs and to help the patient cope efficiently with the symptoms that led to them. In addition, there are many specific skills and behaviors that patients can learn, such as ways to improve organization or reduce the chance of making an impulsive decision. These skills can be individualized, depending on what works best for each patient.

Other areas of patients’ lives may also be affected by ADHD. For adults, couples counseling, family therapy, and education about parenting may all be of use. Some patients will also benefit from therapy to improve their interpersonal skills.