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From Assessment to Treatment:
Developing a Comprehensive Plan to Help Your Child with ADHD
Sam Goldstein, Ph.D.
The primary goal of evaluation is not, as some believe, diagnosis but rather treatment. Parents are not so much concerned about the specific diagnosis but rather their focus lies in helping their child with the problems that bring them to the assessment. Our treatments are designed to influence symptoms and problems for the better not change diagnoses. Thus, as Dr. Anastopoulos and colleagues pointed out in a recent issue of ATTENTION, a comprehensive assessment is not only thorough but geared towards defining symptoms, problems and behaviors in such a way as to facilitate the choice and initiation of medical, educational, behavioral, and psychosocial treatments. As a parent you will ultimately act as your child's case manager and, in many cases, treatment provider (e.g., implementing parenting and educational strategies). It is important for you to be included in each step of the evaluative process, diagnosis and development of a treatment plan. Understanding a number of specific skill deficits causing varied and multiple problems in most if not all areas of your child's interaction with the environment, facilitates your ability to understand the need for specific and multiple interventions. The frequent lack of compliance with treatment recommendations in all areas of medicine and mental health is in part contributed to by a lack of understanding and involvement in the diagnosis and treatment planning phases. If parents perceive problems of ADHD as apart from them, as stable, internal and consistent within the their children, they stand little chance of doing very much about the problem or of acting as effective change agents. On the other hand, if they recognize that their attitudes, perception and knowledge of ADHD can facilitate change in their children, treatment will be more effective.
It is important to recognize that ADHD is a disorder that is managed, not cured. Thus, each of your child's problems, whether behavioral, cognitive or psychological, must be identified and treated. It is rare for an effective ADHD management or treatment plan to consist of only one intervention. At this time, the primary symptoms of ADHD are most effectively treated with medication. A combination of medication, behavior management and skill building may also be effective. The secondary by-products of living with ADHD (e.g., low self-esteem issues) can be addressed through psychotherapy and support. You and your child, as well as siblings, teachers and other professionals must be active participants in the treatment program. It is essential that all involved develop sensitivity to the complex and pervasive impact ADHD has upon daily functioning and how symptoms can compromise your child's ability to meet the expectations of his or her world. Treatment for ADHD must consist of a partnership between the child, family, school personnel, mental health practitioner and physician. Thus, the assessment process should not only provide accurate diagnoses and behaviors targeted for change but facilitate everyone's ability to see the world through the eyes of the child with ADHD.
Choosing the Right Clinician
The majority of clinicians and clinics offering diagnostic and assessment services for ADHD usually offer treatment planning, case consultation and direct treatment services. Thus, if you are satisfied with the assessment - if you can see the world through the eyes of your child - then this particular clinician is probably best suited to now assist you in making treatment choices. At our Center, when an assessment is completed, an hour is spent with parents discussing the data, reviewing a day in the life of their child with an emphasis on understanding the forces that affect the child's daily behavior, thoughts, feelings and achievement. This leads to a discussion of the implications this pattern of strengths and weaknesses holds for treatment choice and selection. We are also placing an increasing emphasis upon each child's strengths as it has been well recognized that a deficit based model focusing only on what's wrong with a child may lead to symptom relief but is not likely to lead to much in the way of positive long-term outcome. Thus, treatment planning must not only include identifying strategies to manage problematic symptoms and behaviors but also finding strategies to build on what's right, to facilitate self-esteem, self-confidence, resilience and a sense of self-efficacy. Thus, the discussion of treatment planning must equally focus on what is right with your child as upon what is wrong.
As you listen to the clinician describing your child and his or her problems, use your common sense. Is what you are hearing consistent with what you think and believe? Is the data being presented not only with authority, accuracy and sensitivity but empathy and the perception that this clinician likes your child and wants to work with him or her and your family?
In many cases, the clinician helping to develop a treatment plan will be a non-medical professional. As medication is an integral part of treatment for ADHD, you must also locate a physician to provide care for your child. Such a physician must be familiar with ADHD and the use of medications to manage ADHD symptoms. It has been my experience that at least half of children with properly diagnosed ADHD can be medically managed efficiently by their pediatrician or family practitioner. Approximately 30%, due to co-occurring problems, should seek psychiatric consultation to assist in the choice and titration of medication. These children can then be managed by their primary care physician. Finally, 20% of children with ADHD due to the combination of problems they experience, should be closely followed by a child psychiatrist. The treatment planning clinician will usually consult with your physician to determine the need for and make a referral to, a child psychiatrist if necessary.
Finally, the right clinician to assist you in the treatment process must be a good communicator. This individual must be willing to write letters, speak on the telephone and advocate for you and your child with your child's physician, school personnel and even when necessary, athletic coaches. This person must be willing to act as a consultant, providing you with guidance, support and assistance. He or she must be available to support your job as a case manager.
A Multiple Treatment Model
There is a growing acceptance in the use of a multi-treatment or multi-modal approach for ADHD. The multi-treatment approaches and combinations of interventions researched include:
Behavioral parent training combined with self-control therapy for the child.
Modifying the environment and using medication.
Medication and self-control training for the child.
Medication and behavioral management at home and school.
Medication and family therapy.
Medication, self-control training for the child.
Teacher and parent behavior management training.
The five year, multi-site, multi-modal ADHD treatment study underway at this time by the National Institute of Mental Health, aims to provide even better defined answers concerning the benefits of single and combined treatments, as well as the impact comorbid conditions, gender issues, family history, home environment and age variables hold for children with ADHD. This knowledge will impact diagnosis and treatment in the short and long term.
Choosing Treatments that Work
Research data gathered over thirty years finds that stimulant treatment accounts for by far the greatest percentage of behavioral improvement in children with ADHD. Non-medication treatments such as educational modification and behavior management for parents and teachers have been demonstrated as beneficial for most children with ADHD but to a significantly lesser degree. Child, parent and teacher self-perceptions, knowledge of the disorder and sense of efficacy in perceiving symptoms as capable of being changed may act catalytically to improve compliance with all interventions, including medication. The available research data strongly supports medication as a first-line treatment for all children and adolescents with ADHD as a primary diagnosis. Education about the disorder and modification of tasks making them more interesting and payoffs more valuable to the child with ADHD should be considered as integral parts of a multi-modal treatment program. Single treatment approaches - medication, behavior management, parent training, cognitive and educational techniques, and building social pro-social skills - may yield benefits but each in isolation has been considered inadequate to comprise a total treatment plan for children with ADHD. Again, although the available literature clearly reflects that the introduction of stimulant medication leads to the greatest percentage in symptom improvement, these data do not suggest that alternative or combined treatments are ineffective or should be discontinued. Although the benefits of medication alone may far outweigh those of other single treatments, treatments such as behavior management have demonstrated improvements in specific symptoms for children with ADHD. The dose or strength of each of these treatments must be varied in a systematic fashion for each child to obtain a comprehensive picture of response to treatment combinations.
The multi-treatment or multi-modal treatment model offers a combination of interventions providing the promise of effective management for a wide range of problems children with ADHD experience. It is clear that the combination does not provide a cure. It has not been demonstrated that any single treatment or combination of treatments leads to significantly better outcome as individuals with ADHD move into adulthood. It is my belief, however, that eventually such data will be generated, particularly when the myriad of additional life issues and factors that affect all children's outcome are better defined and understood. It has been my experience as a clinician that over the short term the suggested combination of treatments in this article offers significant symptom relief and the promise of greater progress than the use of any single treatment alone.
There has been a dramatic increase in interest in non-traditional treatments as potentially beneficial for ADHD. These have included various modifications of diet, alternative forms of therapy including: optometric vision training, sensory integration therapy, biofeedback, osteopathic treatment and neuro-organization techniques. An increasing number of dietary supplements have also been touted as beneficial for ADHD. Although some of these treatments deserve continued research attention, many are considered controversial. They are controversial because their proponents market them with overstated claims, single case testimonials and in some cases exorbitant fees and a general lack of any scientific support. They are not suggested.
The Components of an Effective Treatment Plan
As it is the rule rather than the exception for children with ADHD to experience co-occurring disorders, including learning disability, oppositionality, anxiety or depression, parents must be prepared to include additional components in their child's treatment plan to address these problems. Treatment for ADHD is not a panacea and is not likely to resolve many of the problems caused by these other childhood disorders.
An effective treatment plan for children with ADHD must recognize the pervasive nature of symptoms and the chronicity of the disorder. Thus, treatment must be focused on the long haul. The treatment plan must be feasible and manageable over a long period of time as it is likely that treatments for the child with ADHD will continue throughout the child's school career. Further, increasing research is suggesting that many of the ADHD treatments effective in childhood continue to be beneficial into the adult years. Developing a transition treatment plan for ADHD adolescents progressing into adulthood will be the subject of a future article.
An effective treatment plan for children with ADHD includes:
Education. To manage a problem that cannot be cured requires insight and understanding. To be an effective advocate requires knowledge. You should set out to gather as much information as you can about ADHD and effective treatments. The right clinician can provide such resources as well as suggestions for future reading. Parent support groups such as CH.A.D.D. often offer members lending libraries providing a myriad of resources. Education about the disorder and it's treatments is a parents' best ally.
Medication. The judicious, reasoned and reasonable use of medication to alleviate ADHD symptoms is an essential treatment component for most children with ADHD. You should monitor three to five behaviors on an ongoing basis, allowing you to consistently monitor the benefits medication provides.
Parent training. A behaviorally based management system that increases motivation by making tasks more interesting and/or payoffs more valuable in a consistent, structured, planned way is also essential. Expectations must also be adjusted to recognize that these strategies form an effective and needed prosthetic environment for children with ADHD. Particularly in the short run they will not change ADHD symptoms, but act to modify behavioral problems ADHD symptoms cause. The behavior of children with ADHD quickly regresses in the absence of these management strategies.
School. An increasing volume of research literature is being generated to define the types of educational strategies and environments best for children and teens with ADHD. Creating the best educational climate for your child requires first creating a working alliance with your child's educational team. Fortunately, educators are increasingly aware of ADHD and have an increasing number of resources available to them. In some circumstances, given the co-occurrence of specific learning disabilities, as well as the fact that children with ADHD often fall behind in academic subjects requiring practice for proficiency (e.g., spelling, written language, math facts, etc.), identifying a community based educational specialist well-versed in ADHD is recommended. Such an individual might work with your child on an regular basis or be consulted as needed.
The family climate. The success of treatments for ADHD depends upon consistent and appropriate utilization over long periods of time. Thus, successful treatment requires a stable, consistent environment. As you are your child's case manager and treatment provider, it is important that your mental health be stable and that other family issues and problems be attended to as well. It has been repeatedly demonstrated that even the best of ADHD treatments fail when placed within chaotic or unsupportive home and educational settings.
Building self-esteem. I frequently remind parents and their children that it is more often the case that our strengths and assets best predict what happens to us in life, rather than our weaknesses and liabilities. Thus, in a balanced, strength based model, it is equally important to identify and build upon your child's intellectual, artistic, athletic and other strengths. As Dr. Bob Brooks so eloquently reminds us, if one has a bigger sea of dysfunction to swim through then one must possess larger islands of competence to rest upon.
Summertime. It is best to plan the summer activities of children and teens with ADHD. A number of summer treatment programs have been developed and actually researched with ADHD children and teens. Many communities are now offering such programs. Make certain, however, that prior to enrolling your child you understand the philosophy of the program, staff involved, and the daily schedule of activities. The majority of children with ADHD, however, may not require a specialized summer program but, at the very least, should be kept busy in organized activities.
The topic of ADHD likely will continue to be the most widely researched and argued area in child development and psychopathology. New ground is broken daily. We are increasingly coming to recognize the multiple forces that shape the lives of all children, including those with ADHD. Our emphasis on the best interests of children, their rights and their dignity, represents a bright star in our passage into the twenty-first century. For in the end, no matter how effective and efficient our treatments are for ADHD, it is the course of society and the outcome for all children that will best predict and contribute to the successful life outcome for children with ADHD.
For indepth information concerning developing and implementing effective treatment for children with ADHD, interested readers are referred to the following trade and professional texts:
Barkley, R. (1995). Taking Charge of ADHD: The Complete, Authoritative Guide for Parents. New York, NY: Guilford.
Barkley, R. (1997). Attention Deficit Hyperactivity Disorder, 3rd Edition. New York, NY: Guilford.
Garber, S.W. (1997). Beyond Ritalin. New York, NY: Villard Books.
Goldstein, S. (1992). Why Won't My Child Pay Attention? New York, NY: Wiley.
Goldstein, S. & Goldstein, M. (1998). Attention Deficit Hyperactivity Disorder, 2nd Edition. New York, NY: Wiley.
Ingersoll, B. (1998). Daredevils and Daydreamers. New York, NY: Doubleday.
Mather, N. & Goldstein, S. (1998). Overcoming Underachieving: An Action Guide to Helping Your Child in School. New York, NY: Wiley.
Sam Goldstein, Ph.D. Dr. Goldstein is a member of the faculty at the University of Utah and in practice at the Neurology, Learning and Behavior Center. He has authored twelve texts, book chapters, articles and training videos dealing with a range of child development topics.
Correspondence to Dr. Goldstein can be addressed c/o the Neurology, Learning and Behavior Center, 230 South 500 East, Suite 100, Salt Lake City, Utah 84102, (801) 532-1484, FAX (801) 532-1486, e-mail: firstname.lastname@example.org
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