MULTIMODAL TREATMENT ACROSS THE LIFESPAN

Treating ADHD requires a compressive approach, or multimodal treatment plan (NICE, 2009). ADHD is an extremely treatable and manageable condition, and with the right supports an individual can develop to their potential (Brown, 2006).

Psycho-education is strongly recommended for the individual and their family. In children the strongest evidence bases is for a combination of medication, behavioural therapy, and parent management training (MTA, 1999). Treating adolescents and adult’s differs significantly for a number of reasons, in particular because cognitive development and increased demands for self-managementof symptoms, whereas in children parents and teachers often facilitate this.

By the end of this paper you should understand multimodal treatment plan, which tend to be made up of psycho-education, medication, behavioural therapy, and/or other psychosocial approaches.

MULTIMODAL TREATMENT

Attention Deficit Hyperactivity Disorder (ADHD)is not a single entity, it is an extremely complex and multifaceted condition, which varies both across and within individuals (see #1 &#6). In addition, depending on the severity and type of the ADHD, along with any comorbid conditions or difficulties (see #5), many if not all aspects of the person’s life is likely to be affected. Thus, the individual often requires a number of different types of treatment from a few different specialists.

Multi-modal literally means many different types of treatments (Carr-Fanning, 2011). Having all of one’s needs supported and building on strengths is likely going to take more than one professional. According to best practice guidelines (e.g., NICE, 2008) these specialists should work together, or collaboratively, as a multi-disciplinary team. In addition, since ADHD affects everyone differently, and all people who have ADHD are different from one another, treatment needs to be tailored to meet the unique needs of the individual, their lives (e.g., school or work), and their family.

At ADHD-Europe we are well aware of the lack of adequate services and support available in our member countries, and as such, while this discussion is based on best practice guidelines and an idealized version of how we wish the situation was, and how we hope the not too distant future will be.

EDUCATION

A comprehensive account of the in’s and out’s of educating yourself, others around you, and modifying your life style and environment is beyond the scope of discussion here, so this represents a very brief overview of some of the key issues in the area.

It is undeniably true that there is a lack of services, supports and understanding around Europe, with regards to ADHD. This is an obstacle which you will invariably be faced with at some point.According to best-practice guidelines, teachers and other educators should have training and be knowledgeable in the area. However, as our survey highlighted in 2011 knowledgemay be low and negative attitudes high, so advocating for your child and preparing older adolescents to advocate for themselves in an educational setting is important.

Another issue is that there is no universally applicable treatment or plan which will work for everyone who has ADHD. ADHD affects everyone differently, and individuals with ADHD are all very different from one another; possessing a diverse range of strengths, experiences, and personal goals. As such, what works well with one individual, family, or organization will not necessarily transfer to another context.

While no two people with ADHD will be exactly alike, there will also be a great deal of overlapping in shared experiences and difficulties. As such, learning about the conditions and engaging with others who understand the condition and/or are affected by ADHD is central to effective management of your condition and your life.

Receiving a diagnosis, if often met with a short period of relief followed by feelings of despair, hopeless, anger, shame, confusion, or some mixture thereof. However, a diagnosis can be a very helpful signpost on the map of your life. We are all self-determining, which means we are the primary causal agents in our own lives, and with that right comes the responsibility to live up to it. It is imperative that one remembers knowledge is power and self-awareness keya diagnosis has started you down this path, however, a great deal of what is to come depend upon you.

So, you need to be proactive, creative and resourceful, solution-focused, and above all be positive about yourself and your capabilities.

First, find out everything you can about ADHD, and figure out how it affects you / someone you know. There’s a huge storehouse of information on ADHD, but you need to be careful, ADHD is often misunderstood and some sources are not only unhelpful, but potentially damaging.

Then you need to educate others.If you’re a parent, this means telling your child, they usually are aware something’s not right, and their invented explanation may be worse. Being open with your child’s school is also advisable, to reduce stigma and create a good partnership to supporting your child’s needs across contexts. As an adult, this means letting your partner and/or family know.

You will also probably need to re-educate yourself/your child about how you/they think about yourself/themselves. Prior to receiving a diagnosis people with ADHD usually have a long history of negative experiences, failure, frustration, and rejection. This will invariably have impacted upon how they view themselves, especially with regards to their self-esteem (i.e., self-liking or self-worth) and self-efficacy (i.e., self-confidence and self-belief).

Having ADHD means you are a member of the neuro-diversity club. As such, living in a world structured for the neuro-typical majority will pose certain challenges, however, other less ordinary things will come easily and you may have in abundance. Individuals with ADHD tend to be very creative abstract thinkers, with insight and compassion not found in most people. In addition, while there are certain people who view hyperactivity in a dim light, one may chose to celebrate passion, drive, and enthusiasm, for the simple reason that those who think they can are generally the ones who do.

Remember that small changes to your environment can impact how a person feels and behaves. Since the ADHD brain is an exciting, but disorganized place, it is important that their environment is calm and predictable, with routine and external structures and support (Carr-Fanning, 2011;Hallowell &Ratey, 2004).

Supporting someone with ADHD mean that you need to empower them, not enable them. So, you need to identify and remove the obstacles and barriers, but keep the challenges. Since life is not always easy for someone with ADHD, you need to be understanding if they forget to pick up their room or they are late to meet you even though they promised they wouldn’t.

That said, ADHD should never be the excuse, everyone is always responsible for their behaviour.

MEDICATION FOR ADHD

This is one of the most common forms of treatment for ADHD; it is also one of the most vehemently debated. This discussion represents a very brief overview of the key issues in the area. However, whether you chose to include medication in your treatment plan is a decision you must make yourself. But if you do make sure it is only one aspect of a multi-method approach.

Discussion regarding ‘medication’ typically refers to the Central Nervous System (CNS) stimulant methylphenidate (e.g., RitalinConcerta,Equasym, Medikinet, &Rubifen). According to Russell Barkley (2006) medication is the ‘only intervention’ which ‘reliably’ targets and treats cognitive deficits in those with ADHD.

More recently a non-methylphenidate drug ‘atomoxitine’ (e.g., Straterra) has been introduced. However, it is less well understood (NICE, 2008), and findings vary between successful results (), reports of less efficacy and more risky (Paneli, 2011), through to it not being recommended for adults (Janssen-Cilag, 2011).

The Multisite Multimodal Treatment Study of Children with ADHD, abbreviated to the MTA (1999), is often considered to be the gold standard in research for treatment of ADHD in children and young people. This collaborative 14month randomized clinical trial included 579 children, and found that medication was superior to behavioural therapy or community care. They did find that a combination of medication and behaviour therapy was most effective; but they attributed this to its treatment of coexisting difficulties (e.g., aggression, anxiety, or learning issues), rather than the ADHD.

The efficacy of stimulants for the vast majority of individuals with ADHD is often reported as undisputed (Barkley, 2006; Brown, 2009; Fitzgerald et al., 2007; Myttas, 2010; Taylor, 2011). It has been suggested that it is effective in treating cognitive deficits, mood, and externalizing behaviours (Semrud-Clikeman, Pliska, &Liotti, 2008), and it is also one of the cornerstones to best-practice in treating ADHD (NICE, 2008).

Those who advocate medication, suggest that it is not only proven but also benign. Dr Thomas Brown (2009) stated that that methylphenidate had in excess of 200 successful clinical trials, when only three are required for distribution. In addition, they suggests it regulate the neurotransmitterd (e.g., dopamine) often implicated in the causes of the disorder (Fitzgerald et al., 2007).

PROBLEMS WITH THE RESEARCH

The European Medical Agency (EMA) (2009) have reviewed and approved methylphenidate for use in those over six years old. However, they noted a significant issue with the research. There are very little known about the long-term effects of medication, or the effects of prolonged usage. This is both surprising and concerning, since it has been used consistently since the 1950’s.

It is important to note that any medication comes with a risk of side-effects. The same is true of any herbal remedy or dietary supplement, synthetic or natural. If you come across a product claiming to be all ‘natural’ without any side-effects, you need to proceed with extreme caution, because it is just not possible. The side-effects associated with the drug Ritalin include dry mouth, headaches, weight loss, and nervous ticks (Shire, 2011). Although not listed as an official side-effect, Swanson et al. (2007) provided evidence supporting earlier findings that medication stunts growth.

In addition, in a follow-up study to the MTA (1999) discussed above, no long term benefits were found in either medication or behaviour therapy. The fact that medication suppresses symptoms on a short term basis providing no long term benefits is problematic (Loe& Feldman, 2007; MTA, 2007; Swanson et al., 2007). As such, if and when they are used additional psychosocial interventions are required to develop skills and capacities.

That said, some might wish to use medication long-term, and if so then that is their choice to make. Everyone must make their own decisions, forge their own life path, and live with their ADHD in ways that work for them.

SOME THINGS TO REMEMBER:

• These are not magic beans, and if you chose to use them, they should represent only one part of a multi-modal treatment plan.
• Medication will affect everyone differently, and finding the right type and dose is important, and it will take time under the supervision of an experienced professional.
• A medical examination and full case history may be necessary to ensure there are no underlying conditions (e.g., heart problems).

PSYCHOSOCIAL THERAPY ACROSS THE LIFE SPAN

Interventions aimed at alleviating psychological distress, reducing maladaptive behaviour and increasing adaptive ones is referred to collectively here as ‘psychosocial therapy’ (Weis &Gray, 2008). However, these interventions are diverse and varied in approach and efficacy, and include behavioural management, psychotherapy, ADHD Coaching, and others. Some have a strong evidence-base with individuals with ADHD, while others lack research or target issues which may co-occur with ADHD but are not specific to the disorder. Before discussing the specific there are a few points which need to be addressed.

Pelham, Wheeler and Chronis (1998) reviewed the literature on ADHD treatments and concluded that behavioural classroom management, and to a lesser extent parent training met the criteria for evidence-based practice. However, social skills training, group therapy, and cognitive therapy did not meet the criteria. A decade later Pelham and Fabiano (2008) again reviewed the literature, and reiterated their earlier position.

A strong word of caution regarding how this is interpreted is necessary. The vast majority of research uses samples of school-aged children, and we know very little about ADHD or its treatment in adolescents and beyond (e.g., Smith et al., 2000), where cognitive therapy, skills training, coaching, and group work would be most appropriate and likely more beneficial.

Indeed, building on the work of Pelham and others, Young and Amarasinghe (2010) review suggests that treatment differs significantly across the life span, with more cognitive and skills development approaches being introduced in adolescents and adult treatment plans. They urge professionals not to assume that adolescents should receive similar treatment to school-aged children. Indeed, the prefrontal cortex, executive functions, and cognition all develop dramatically during adolescents which have obvious implications for treatment.

Barkley (2006) alluded to this point about therapy in older adolescents and adults. The Nice Guidelines (2009) also suggested that behavioural treatment represented the best researched psychosocial approach. That said, they strongly supported the use of psychological and community based supports beyond behavioural management. Suggesting that parent training is more beneficial when it is supplemented by cognitive therapy and social skills training groups even in school-aged children. They also recommend that cognitive behavioural therapy and social skills training may be considered for adolescents.

Therefore, when it comes to treating ADHD it is important that the underlying issues or problems (e.g., executive dysfunctions), are targeted and treated, and not only the disruptive behaviour. While medication and behaviour therapy has shown to be very effective in treating disruptive behaviour in the short term (MTA, 1999, 2007),they don’t necessarily teach skills, nor does it affectively address academic and other functional deficits(DuPaul et al., 2004; Raggi& Chronis, 2006).

Therefore, it is strongly recommended (indeed implored) that when considering treatment plans you include the development of capacities, build on strengths, teach skills, and prepare young people for a future where they must manage their ADHD themselves.

There is an urgent need for research into treatments in adolescents and adults. For those interested in diagnosis and treatment in adults, Sandra Kooji’s (2010) book on ‘Adult ADHD’ is strongly recommended.

BEHAVIOURAL MODIFICATION & PARENT TRAINING

This psychosocial therapy has the most robust evidence base when used with ADHD children (NICE, 2008).

According to Hinshaw(2002), the three best predictors of success in adulthood for those with ADHD were (1) effective parenting skills, (2) peer relationships, and (3) success at school. Behavioural treatment can directly teach skills to the parent and teacher, and also the child or young person, which might help to overcome their impairments.

Caution is recommended on two points. First, behavioural modification was reported by the MTA (1999) study as effective in treating coexisting difficulties not the ADHD, and more importantly, it was not found to have long-term effects or generalize into adult life (MTA, 2007). Second, there is no universal plan or intervention to treat all people with ADHD, your selection and implementation of interventions has to be based on assessment of unique strengths and needs of the individual and their situation, and requires systemic evaluations of outcomes.

WHAT IS BEHAVIOURAL THERAPY?

This type of therapy is a broad area, and the basic principles behind behaviour treatment is to reward good behaviour, with attention and praise, while attempting to eliminate problem behaviour with consequences such as the removal of rewards.

It is based on a technology of behaviour, based on accurate assessment of the problem behaviour in context. Essentially, one begins by identifying an objective target behaviour. For example, ‘impulsivity’ is too broad; it needs to be more specific and measurable. For example, leaving their seat during class time, could be the target behaviour. This behaviour is then measured; e.g., the amount of times the student leaves their seat in a 30min period.

The behaviour is then considered in terms of its antecedents (what comes before) and/or the consequences (what comes after). By manipulating the antecedents and/or consequences one can shape any behaviour from developing good study skills to eliminating aggressive behaviours (Pelham &Washnusch, 1999).

It sounds a little technical and complicated, but if you have ever praised a child for their good behaviour (i.e., positive reinforcement), or taken away an adolescents free time because they were late (i.e., punishment) then you were using these principles.

PARENT TRAINING

There are some excellent sources out there to help get you started, such as T. Phelan’s (2003) ‘1-2-3 Magic’ or R. Barkley’s (2000) ‘Taking Charge of ADHD’.

Self-education is an excellent place to start, but most parents require or benefit from a trained specialist who will assess behaviour, develop a management plan, and provide skills training for parents / teachers (Brown, 2006).

It will vary in your country as to where you can get help in this regard. Talk to your doctor, there are often specialized services, psychologists and educators will often have training in behaviour management. Another potential source is universities who have departments or clinics specializing in the area.

It has to be noted that findings regarding parent training is somewhat inconsistent (Barkley, 2006).But, one of the most significant obstacles to the process is consistency and follow-through. The behaviour can often get worse before it gets better which means that it may be abandoned too early, or it is implemented in some contexts and not in others (O’Leary, 2012). As such, skills training may be necessary.

In addition, parenting a child with ADHD is not an easy task, and some of the behaviours associated with ADHD can cause problems in the parent-child relationship. Parents may develop negative or maladaptive strategies to cope with problems, which further intensifies family conflict and stress (Young &Amarasinghe, 2010). Getting guidance, support, and training to respond appropriately can be invaluable for the whole family.

PUNISHMENT VS. POSITIVE REINFORCEMENT

As noted at the beginning, the downside is that the behaviour may not change long-term once the incentives are removed. There are certain measures which could facilitate long-term changes.

The use of punishment is common because if often results in immediate compliance. However, it is also associated with a range of psychosocial problems, such as increased aggression and decreased moral reasoning (Gershoff, 2002).

The use of positive rewards is always preferable. It encourages the growth of strengths and skills by teaching them what they should do, instead of what is wrong or bad (Skinner, 1970). It may also lead to more permanent changes than punishment or consequences, but it requires that one provide opportunities where the young person can be successful (Linley et al., 2009).

PARTICIPATION

The most important aspect in this process is an accurate and comprehensive assessment, and appropriate consistent implementation, which should include allow the young person to participate. It is important not to lose sight of the goal and the purpose of your efforts; by rigidly applying some technique and/or assuming you understand the reason for the behaviour.

As Greene’s (1994) observed in his book The Explosive Child, similar traits or characteristic will be exhibited by a certain cohort of young people, however, this does not mean these are all attributable to the same, or indeed, a single source. He advocates’ adopting a stance which is open and collaborative, and this is extremely important when one works with young people with ADHD. Any intervention in the home and/or school should represent a process of communication and feedback between all the stakeholders (i.e., the parent, teacher, and the child).

According to the United Nations Convention on the Rights of the Child (1989) young people have a right to have their voices not only heard but listened to. This is not to suggest that giving a child free rein over their treatment and self-management is appropriate, or advisable. However, to exclude them from the process entirely is not only unethical, it is illogical and impractical, and it is also one way to ensure no long-term effects to treatment.

PSYCHOTHERAPY & ADHD COACHING

These approaches have been grouped together, however, it is essential to not that they are not synonymous with one another.

The various forms of psychotherapy often delve into the past and consider early experiences, problematic emotions, and/or thought processes. By comparison, ADHD Coach is more practically based, emphasises collaborative problem solving, and is concerned with current and future functioning and performance. However, self-esteem, confidence, and motivation should always be a part of the process, in addition, some psychotherapeutic techniques and models are often used in coaching (Kooji, 2010).

ADHD Coaching is an newly emerging area, first introduced by Hallowell and Ratey’s (1994) book ‘Driven to Distraction’, and while the evidence base is currently small, findings are promising (Kubic, 2010).

Psychotherapy requires the individual(s) to speak openly about their feelings in a confidential, safe, and non-judgmental environment. This can occur on an individual basis, with the whole family, in a group, or couples counselling. The aim is to gain self-awareness, and insights into your relationships while developing inter- and intra- personal skills, in more general terms positive growth and emotional and psychological well-being is a part of the process here.

Speaking generally, everyone, with and without ADHD can benefit from therapy. However, for those with ADHD coming to terms with a diagnosis, or addressing past experiences of failure and rejection. Indeed, since ADHD can often negatively impact relationships, and create conflicts and stress, addressing the issues in therapy can be very beneficial, and facilitate positive relationships, and opening communication between family members can be very helpful.

A specific form of psychotherapy, Cognitive-Behavioural Therapy (CBT), addresses faulty cognitions, such as problem-solving, anger management, social skills, anxiety, self-esteem, etc. At first glance CBT appears to be a logical choice given our understanding of executive dysfunction. As was discussed earlier the research does not support it as an evidence-based treatment. However, that is likely attributable to the fact that the research base is primarily with school-aged children, where it may be inappropriate because cognition develops significantly during adolescents.

Kooji (2010) and Young and Braham (2007) discuss evidence supporting its use with adults, and modifications required for use with individuals with ADHD. Furthermore, the evidence-base for CBT in the treatment of anxiety, depression, compulsive behaviours, and a host of other psychological difficulties is extremely well supported.

OTHER SPECIFIC THERAPIES:

These are included, because they drop up in the literature, however, this review cannot include everything.

• Direct skills training (social, organization, study, etc.).
• Self-management and anger management therapies (often included under CBT).
• Solution Focused Brief Therapy and/or Motivational Interviewing.

ANGER MANAGEMENT

Anger is normal, but how it’s expressed can get people into trouble. People with ADHD can have problems suppression their thoughts and feelings, so they might need some help getting control of their emotions.

This process teaches someone new skills: that help them recognise the signs that they’re becoming angry, and how to deal with it in a positive way

PLAY THERAPY

Children with ADHD often have difficulties with social interaction, emotion, and behaviour regulation.

Some children benefit from treatment that involves them engaging in self-directed play as a means of working through their feelings and experiences. It’s a way for them to get to know themselves and develop positive social skills; and can help parents to interact positively with their child.

Whatever you chose and/or is available in your area, it is important that your coach or therapist has an understanding of ADHD (Hallowell &Ratey, 2004). That is not to suggest that your ADHD takes centre stage that would be a big mistake. You are not your ADHD it does not define who you are or what you can become. However, it exists and pretending it doesn’t is not helpful. For example, this is a bit like pretending someone is not visually impaired, and using story boards or other visual aids without providing glasses or verbal description. Essentially, what I am getting at here is that it takes ‘different strokes for different folks’. And that is neither good nor bad, it just is.

ACADEMIC & EDUCATIONAL SUPPORTS

A discussion about academic and educational issues is beyond the scope of this paper, however, for those interested in finding out more DuPaul and Stoner (2004) and Daley and Birchwood (2009) are recommended.

It is important to mention the area, because as Barkley (1998; 2006) observed almost all young people with ADHD are doing poorly at school, and underachievement represents one of the major risk factors for negative outcomes later in life.

There is a BIG difference between having the ability to succeed and having the skills to.

ADHD is often an issue with performance rather than ability. Where the individual is well able to learn but they will achieve below their potential because they lack basic performance skills, such as, planning, organization, time management, note taking, memory issues, etc.

SOME SUGGESTIONS FOR SPECIFIC SERVICES OR SUPPORTS:

Speech and Language Therapy may be helpful for individuals who have verbal deficits, which are commonly found in young people with ADHD (Cohen et al, 2000), and could be evident by (but not necessarily due to) problems taking notes in class, following instructions. This should be considered as part of the assessment process. Another one which is often recommended, but lacks an evidence-base is Occupational Therapists, which may be of assistance with issues such as writing, planning, organization skills, etc.

ADHD Coach can help with organization, motivation, goal setting, etc. Findings support its use with college students with academic and personal functioning (Swartz et al., 2005).

Teachers can help out by communicating clearly and effectively, using aids and breaking down complex subjects into more manageable pieces (Daley & Birchwood, 2009).One-to-one tutoring and support, provided by resource teachers, tutors, and others may also be beneficial. Parents can help with study at home and developing routine and good study habits (behaviour treatment helps here too) (Daley & Birchwood, 2010). In addition, peer mentoring could be helpful (DuPaul& Stoner, 2004).

Preliminary findings suggest that medication may help with concentration and task completion, but further research is needed to support this (Evans et al., 2001).

SUMMARY & CONCLUSION

ADHD requires a multimodal treatment approach, which will vary depending on the person but may include elements such as medication and a range of psychosocial interventions.

Psycho-education about the disorder and treatment options is a necessity for the individual with ADHD and those close to them. Managing ADHD requires an individualized plan based around the individuals strengths and unique needs of the person and their situation.

ADHD is an extremely pervasive condition, which is best viewed from a developmental perspective; meaning that it will affect the individual differently during different stages of their development. In school-aged children the most robust evidence base exists, and behavioural therapy and parent training has been found to be very effective. However, as cognition develops and environmental demands increase, in adolescents and into adulthood, cognitive and skills training needs to be considered.

Authors of the article: Kate Carr-Fanning and Conor Mc Guckin, the School of Education, Trinity College Dublin, 2012

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