James H. Johnson, Ph.D., ABPP University of Florida

James H. Johnson, Ph.D., ABPPUniversity of Florida

Treatment of ADHD: Basic Assumptions

ADHD is a chronic disorder and should be managed as such!

Elements of Chronic-condition care: Educating parents and child regarding the

condition Developing individual treatment plans Helping coordinate multiple services Encouraging parents to have contact with

parents of other children with chronic conditions.

American Academy of Pediatrics (2005)


Treatment of ADHD will be based on a comprehensive assessment of the child’s core symptoms comorbid conditions. areas of impairment

Assessment to rule out “mimics”. Physical exam Evidence-based assessment measures

(See Pelham, et al, 2005)

Treatment of ADHD: Basic Assumptions Treatments should take into account

core symptoms: hyperactive/impulsive behavior attention difficulties

The choice of treatment for core symptoms should be evidence-based (Pelham, et al 2008).

In choosing treatments - consideration should be given to treatment effectiveness and potential for side effects, considered within a risk/benefit framework.

Treatment of ADHD: Basic Assumptions Treatment should address areas of

impairment. These areas can include:

academic impairment social impairment Impairments in adaptive behavior impairments in family functioning.

DSM IV places a relatively greater emphasis on core symptoms compared to impairment

This may be a misplaced emphasis (Pelham, et al. 2005)

Treatment of ADHD: Basic Assumptions DSM IV symptoms are not especially good

predictors of long-term outcome Symptoms are not usually the major reason

for referral for treatment In contrast, areas of impairment that are

commonly seen in children with ADHD (academic, social, and family functioning are: predictive of negative long-term outcomes are common reasons for referral and can be thought of as target behaviors to be

modified to improve current and long term functioning

Pelham, et al (2005)


Treatment plans should address relevant diagnosed comorbid conditions and co-occurring difficulties In some instances comorbid conditions may be more

closely related to long term negative outcomes than ADHD itself (e.g. Conduct Disorder)

Comorbid conditions may contribute to various types of impairment over and beyond ADHD core symptoms.

Multimodal treatments addressing core symptoms and comorbidities may be required to address the full range of factors that contributing to impairment.

Evidence-base for Treatments of ADHD

The assumption that treatments of children with ADHD should be evidence-based raises the question of what treatments, for what difficulties are supported by empirical research?

These questions have been addressed by a summary of evidence-based treatments for ADHD undertaken by the American Academy of Pediatrics (2006).

This review was based on information provided by three major sources.

Evidence-base for Treatments of ADHD – McMaster Review

The first source was a review by the McMaster University Evidence-based practice Center.

Focused on studies of grade school children treated for > 12 weeks. Emphasis was on the efficacy (and safety) of

pharmacological interventions with ADHD The efficacy of single versus combined treatments of

children with ADHD. Stimulant drugs examined included methylphenidate

(MPH), dexadrine (DEX) and pemoline (PEM - Cylert) as well as trycyclic antidepressants.

Evidence-base for Treatments of ADHD – McMaster Review Review included 92 empirical articles

reflecting 78 investigations from a pool of 2,405 citations compiled from traditional databases.

Two reviewers independently rated articles to determine the quality of the methodology.

Studies were included in the evidence-based review if they were randomized controlled trial studies involved human subjects published as a full report which included

participants with ADHD.

Evidence-base for Treatments of ADHD – McMaster Findings Drug-to-Drug Comparisons

Stimulant drug comparisons documented few, if any, overall differences between MPH, DEX, and PEM (Cylert)

Studies comparing different formulations of the same drugs found no significant effects.

Combined Interventions: MPH + dexadrine, caffeine, desipramine (a TCA) or

haloperidol and a single medication; behavior or cognitive therapy + stimulant medication

compared to single treatment No evidence that non-pharmacological

interventions alone (behavioral intervention) performed as well as the non-pharmacological intervention plus stimulant medication.

Evidence-base for Treatments of ADHD – McMaster Findings

Adverse Effects Across studies the most frequent examples

of adverse effects were appetite suppression, sleep disturbances, headaches, motor tics, abdominal pain, irritability , nausea, and fatigue.

Many of thee effects were mild, of short duration, and responsive to dosing or timing adjustments.

There were few if any differences in adverse effects across stimulants (MPH, DEX, PEM).

Evidence-base for Treatments of ADHD – McMaster Findings

Conclusions from this review: Stimulant medication significantly out

performs non-pharmacologic interventions in controlling the core symptoms of ADHD.

There was insufficient information to conclude whether drug combinations outperform

stimulant medications alone, or that non-pharmacologic interventions adds

to drug treatment effects.

Evidence-base for Treatments of ADHD Canadian Coordinating

Office for Health Technology Assessment (1998)

A second source of evidence-based research was reviewed by the Canadian Coordinating Office for Health Technology Assessment (1998) Reviewed empirical evidence from 195 treatment

studies of ADHD published after 1980; Studies were RCT’s involving parallel group

designs or within-subject crossover designs with participants randomly assigned, and involving children 18 or younger.

The review provided findings regarding: the efficacy of MPH in treating symptoms of ADHD

and the efficacy of combined interventions.

Evidence-base for Treatments of ADHD Canadian Coordinating

Office for Health Technology Assessment (1998)

Review concluded that: Evidence consistently supports the efficacy of

drug therapy in managing core symptoms of ADHD

No clear differences between MPH, DEX, and PEM. Psychological/behavioral treatments without

medication treatment were not efficacious in managing core symptoms of ADHD.

Combined therapy did not out perform medication alone, at least with core symptoms.

Finding were inconsistent with regard to the value of combining psychological/behavioral therapies with medications - as compared to drug therapies alone.

The Multimodal Treatment Study: Background

Until fairly recently there were no well controlled long-term treatment studies in the area of ADHD. There were many double-blind/placebo

controlled studies, designed to assess the effects of various stimulant medications.

Results of these studies most often supported the use of these medications.

However, these studies were typically short duration studies.

The Multimodal Treatment Study: Background While such studies often provided support for

the effectiveness of stimulant medications in treating ADHD, they provided little information regarding their long term effectiveness.

Likewise, there were few well-controlled studies on the relative effectiveness of different approaches to treatment of children with ADHD.

Little information was available regarding the long-term effectiveness of combined treatment approaches (e.g., stimulants and psychosocial interventions) in ADHD treatment.

The Multimodal Treatment Study: Background

Late 1990’s, NIMH sponsored a large multi-site, 14 - month, investigation of the treatment of ADHD.

Multimodal Treatment Study of Children with ADHD – ("MTA“)

18 nationally recognized authorities in ADHD. At different university medical centers and

hospitals Goal: To evaluate the effectiveness of leading

treatments for ADHD – notably stimulant drug and behavioral treatment.

Multimodal Treatment Study: Background Research sites included:

New York State Psychiatric Institute at Columbia University, New York, N.Y.

Mount Sinai Medical Center, New York, N.Y. Duke University Medical Center, Durham, N.C. University of Pittsburgh, Pittsburgh, PA. Long Island Jewish Medical Center, New Hyde

Park, N.Y. Montreal Children's Hospital, Montreal, Canada University of California at Berkeley, CA. University of California at Irvine, CA.

Multimodal Treatment Study: Subject Recruitment Only children determined to have Combined

Type ADHD were included in the MTA study. Children diagnosed with the

hyperactive/impulsive subtype and inattentive subtype were excluded

This decision was made because the combined type is the most frequently diagnosed type of ADHD.

All in all, the study included 579 children ages 7 to 9.9 years

Approximately 20% were female and approximately the same percentage was African American.

The Multimodal Treatment Study: Overview After participants were identified, were

determined to have meet study criteria, & pre-treatment assessment measures were obtained, they were assigned at random to 1 of 4 treatment conditions. medication alone; psychosocial/behavioral treatment alone; Combined treatment; or routine community care.

Fourteen months later, the participants were again assessed so that the impact of the different treatments could be evaluated.

The Multimodal Treatment Study: Assessment Measures Primary ADHD symptoms - ratings provided by

parents and teachers; Aggressive and oppositional behavior - ratings

provided by parents, teachers, and classroom observers;

Internalizing symptoms (e.g. anxiety and sadness) -

ratings provided by parents, teachers, and children; Social skills - ratings provided by parents, teachers,

and children; Parent-child relations - rated by parent; Academic achievement - assessed by standardized

tests

The Multimodal Treatment Study: Overview

The MTA Study was designed to answer three basic questions regarding the treatment of ADHD; How do long-term treatments with medication

and psychosocial (behavioral) interventions compare with one another?

Are there additional benefits of combining these two treatments in treating individual children?

What is the effectiveness of systematic, carefully delivered treatments vs. the way these treatments are usually applied in routine community care?

MTA: Medication Alone Group

Children assigned to the Medication Management condition received drug treatment only. Treatment: 28-day, double-blind placebo-

controlled trial in which the effects of 4 different doses of short-acting methylphenidate were evaluated.

The doses tested were 5, 10, 15, and 20 mg. Children received a full dose at breakfast and

lunch, and a half-dose in the afternoon. Parent and teacher ratings of children's

behavior on each dose were compared by a team of experienced clinicians, and the best dose for each child was selected by consensus.


In this double-blind placebo-controlled trial, the child was administered actual medication on some days and a placebo during other days.

Neither the child, the teacher, nor the parent knew when the real medication was being received and when placebo was being given.

This was designed to insure that parent and teacher ratings of the child's behavior were not biased by the knowledge that the child was on medication.


If children did not show a response to methylphenidate in the initial trial, alternate

medications were tested (non-double-blind procedures) in the following order until a satisfactory medication/dose was found: dextroamphetamine (the generic version of

dexedrine), pemoline (the generic version of Cylert), and imipramine (a tricyclic antidepressant).

MTA: Medication Alone Group A total of 289 participants were initially

assigned to receive medication in either the medication only condition or the combined condition.

A total of 256 (88.6%) successfully completed this initial titration period used to select an effective medication.

In the case of the remaining children, parents either refused to try their child on medication, there were intolerable side effects, or parents could not cooperate with the careful

titration procedures.


An adequate response with at least one of the doses of methylphenidate was obtained for about 69% of the children completing the initial medication trial - they began treatment on this dose.

Twenty-six children who did not respond to methylphenidate were found to do well on dextroamphetamine and began on this medication.

A final 32 did not begin on any medication because they had such a strong placebo response that no clear benefits of medication could be demonstrated.


Monthly visits were scheduled during which time the provider for the child reviewed information about the child's behavior over the past month that had been provided by parent and teacher.

After reviewing this information, any needed dosage adjustments were made using predetermined guidelines.

Adjustments that involved increases or decreases of more than 10 mg/dose needed to be approved by a cross-site panel of experts.


At the end of the study, some 14 months later, approximately 74% of participants in the medication or combined treatment groups were being successfully maintained on methylphenidate.

10% were being successfully maintained on dextroamphetamine.

1% were being successfully maintained on Cylert.

Only two children were on any other type of medication.


Side effects were monitored monthly for all children who were on medication.

Over 85% of the sample reported either no or mild side effects.


It is important to note how different this approach to pharmacological treatment was from what often occurs in community treatment.

The primary differences are the use of a double-blind trial to establish the

best initial dose and type of medication for each child; and,

regular follow-up visits to evaluate ongoing medication effectiveness based on parent and teacher reports

systematic adjustments made as needed.


Almost all children were effectively managed on one of the standard stimulants.

None required a combination of medications to effectively manage their ADHD symptoms.

This suggests that combination of mediations is rarely needed to treat ADHD, if a careful procedure is used to test out the different types of stimulants that are available.

MTA: Behavioral Treatment

Behavioral treatment included 1) parent training, 2) child-focused treatment, and a 3)school-based intervention program.

Parent training involved a total of 27 group sessions and 8 individual sessions per family.

The focus was on teaching parents specific behavioral strategies to deal with the challenges that children with ADHD often present.

MTA: Behavioral Treatment

The Child-focused Treatment was a summer treatment program that children attended for 8 weeks, 5 days a week, during the summer.

This program employed intensive behavioral interventions that were administered by counselors/aides who were supervised by the therapists conducting the parent training.

The basic model was one in which children were able to earn various rewards based on their ability to follow well-defined rules and meet certain behavioral expectations.

Social skills training and specialized academic instruction was also provided.

MTA: Behavioral Treatment The School-based Treatment had 2 components:

10 to 16 sessions of biweekly teacher consultation focused on classroom behavior management strategies, and 12 weeks of a part-time aide who worked directly in the classroom with the child.

During the school year, a Daily Report Card was used to link the child's behavior at school to consequences at home. The Daily Report Card was a 1-page teacher-completed

rating of the child's success on specific behaviors. This was brought home daily by the child to be

reviewed by parents with rewards for a successful day provided as indicated.

MTA: Behavioral Treatment Consistent with what occurs in actual clinical

practice, the family and child's involvement in behavioral treatment was gradually tapered over the 14 month period (Note: BT stopped but meds not – implications for findings??)

In most cases, contact had been reduced to once monthly or stopped altogether by the end of this period.

It can be noted that the behavioral treatment received here, reflects state-of-the-art practice that would be difficult for most children to get.

Thus, one would assume that the benefits of behavioral treatment seen here would likely be much greater than which would typically be obtained.

MTA: Combined Treatment Children in the combined treatment group

received all of the treatments received by children in the Medication and Behavioral Treatment conditions.

Consistent with prior studies, by the end of the study, children in the combined group were being maintained on lower daily doses of methylphenidate than children who received medication alone.

Here, average doses were 31.2 mg/day for the Combined group and 37.7 mg/day for the Medication Only group.

MTA: Community Treatment

As it would clearly be unethical to assign children with ADHD to a no-treatment control group for 14 months, some children were randomly assigned to a group that received "community care".

In this condition, following the child's diagnosis of ADHD, parents were provided with a list of community mental health resources and made whatever treatment arrangements they preferred for their child.

MTA: Community Treatment Most of the 97 children in this group (over 2/3)

received medication from their own provider sometime during the 14 months.

Several things are interesting about the medication these children received compared to children who received medication as part of the study. Community care children received less medication. For those treated with methylphenidate, the average

daily dose was 22.6 mg/day compared to the average daily doses of 31.2 mg and 37.7 mg for children in the other groups receiving medication.

Community care children received an average of 2.3 doses per day compared to 3 times/day dosing for children in the study groups.

MTA: Community Treatment None of the children receiving medication in the

study groups were maintained on clonidine or a combination of medications

4 children seen by community physicians were treated with clonidine and 10 children received more than one medication.

Thus, physicians in the community were in some ways more conservative in their use of medication, using lower doses of methylphenidate.

But less conservative, being more likely to use medications other than the stimulants for treating ADHD.

MTA: Research Questions As noted earlier, the MTA study was

designed to address 3 fundamental questions about ADHD treatment: How do long-term medication and behavioral

treatments compare with one another in treatment effectiveness in children with ADHD?

Are there additional benefits when these two treatments are used together?

What is the effectiveness of systematic, carefully delivered treatments vs. routine community care in the management of ADHD?

MTA: Overall Findings Children in all groups (i.e. medication only,

behavioral treatment only, combined treatment, and treatment in the community) showed significant reductions in their level of symptoms over time in most areas.

Even though some treatments were superior to others in certain domains, even children receiving the "least effective" treatment showed improvements.

Thus, these data should not be interpreted in a framework of "what worked" and "what did not work".

Rather, it is a matter of what was the most effective among treatments that showed positive effects.

Long-term Medication vs Behavioral Treatment

For both parent and teacher ratings of ADHDcore symptoms, medication management alone was clearly superior to behavioral treatment alone.

Medication management and behavioral treatment did not typically differ significantly on other outcome measures.

While medication was found to be superior to

behavioral treatment in managing core symptoms, these findings did not hold for other problems such as oppositional behavior, peer relations, internalizing behavior and academic achievement.

Combined vs Single Treatments

Combined Treatment & Medication Management treatment did not differ significantly on any of the 6 domains assessed in this study.

This suggests that for most children with ADHD, adding behavioral intervention on top of well-conducted medication management is not likely to yield substantial incremental gains.

Combined vs Single Treatments However, when one looks at the rank ordering

on different outcomes for children in the different groups, children in the combined treatment group did best on 12 of 19 outcome measures.

Those in the Medication Management group were best on only 4.

In addition, when the individual outcome measures were combined into composite measures, or when children's outcomes were grouped into “Excellent Response” vs. “Less Dramatic Response” categories, children receiving combined treatment did modestly, but significantly, better.

Combined vs Single Treatments Compared to Behavioral Treatment alone,

Combined Treatment was found to be superior; on parent and teacher ratings of ADHD core

symptoms, on parent ratings of aggressive/oppositional

behavior, on parent ratings of children's internalizing

symptoms, and on results of the standardized reading

assessment. Thus, adding medication to the treatment of a

child already receiving behavioral intervention is likely to yield additional benefits for most children.

MTA Treatments vs Community Care Both Combined Treatment and Medication

Treatment were superior to community care for parent and teacher reports of ADHD core symptoms,

Behavioral treatment was not. In general, parents and teachers tended to report

a decline of approximately 50% in inattentive and hyperactive/impulsive symptoms for children in the medication and combined treatment groups.

For children receiving community care, the declines reported were in the 25% range.

These were comparable to those reported for children receiving behavioral treatment.

MTA Treatments vs Community Care In the non-ADHD domains, with children

displaying oppositional behavior, internalizing symptoms, social skills deficits and reading problems, Combined Treatment was always superior to Community Based Treatment.

Here there were particularly dramatic differences in parent reports of oppositional and aggressive behavior.

MTA Treatments vs Community Care These data indicate that, although

children treated in the community made modest gains, those receiving medication treatment in the MTA study (either alone or in combination with behavioral treatment) did significantly better.

This was especially true for children receiving the combined treatments.

MTA: Follow Up Analyses The MTA research group also considered

whether the effects of the different treatments may have varied depending on child characteristics.

Thus, they also looked at whether similar results were obtained: for boys vs. girls for children with and without an additional

diagnosis of either Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD);

for children with and without a co-occurring Anxiety Disorder;

MTA: Follow Up Analyses In general, there were no substantial

differences in the effectiveness of the different treatments depending on these variables.

Similar treatment results were found for boys and girls and for children with and without a co-occurring behavior disorder.

There was some indication, however, that for children with a co-occurring anxiety disorder, behavioral intervention alone was as effective as both medication management and the combined treatment.

MTA: Follow Up Analyses It is also worth noting, however, that

children with anxiety disorders, who received medication only, did not have a poorer response to medication than other children with ADHD.

Thus, findings from previous studies suggesting that children with ADHD and an anxiety disorder do not do as well on stimulant medication are contradicted by these results.

Impact of Treatment Adherence In a final set of follow up analyses, the

researchers also analyzed the results according to how children and parents were able to adhere to the prescribed treatments.

Here, children assigned to the Medication Management condition were divided into 2 groups depending on whether or not medication treatment was implemented as recommended and

Whether the family attended at least 80% of the scheduled follow-up visits where the effects of the medication could be monitored.

Impact of Treatment Adherence

For behavioral treatment, children were divided into 2 groups depending on whether or not parents attended at least 75% of the

scheduled parent group meetings, the child attended at least 75% of the

summer treatment program, and whether the child and paraprofessional

working with the child in the classroom were both present for 75% of the intended days.

If any one of these 3 conditions were not met, the behavioral treatment was not considered to have been implemented as intended.

Impact of Treatment Adherence

For the Combined Treatment group, families had to adhere to the guidelines for both Medication Management and Behavioral Treatment to be placed in the "as intended" group.

Otherwise, they were placed in a group that was judged to not have adhered to treatment as recommended

Adherence to Treatment Recommendations One major item of interest is the percentage of

families in the 3 MTA treatment conditions that were able/willing to adhere to treatment recommendations.

Acceptance/attendance was higher for the Medication Management treatment (78% of families completing treatment as intended) than in Behavioral Treatment (63%) or Combined Treatment (61%) groups.

Here it is noteworthy that, even when state of the art behavioral treatment is provided to families FREE, almost 40% of families were unable and/or unwilling to fully take advantage of it.

Treatment Adherence and Outcome Regarding treatment adherence and child

outcome, significant effects were found only for the Medication Management group.

Outcomes were significantly better for children where the recommended medication management procedure was followed more closely.

For the Behavioral and Combined Treatment conditions, outcome was not found to be related to degree of adherence.

Treatment Adherence and Outcome Here, it has been suggested that the

absence of an effect of adherence for the Combined Treatment group was likely due to the fact that parents and children failed to comply with the Behavioral treatment procedure.

And, that these children likely did as well as the "adherers" because of the benefits they derived from the medication.

Treatment of ADHD

Stimulant Medications Other Medications Psychosocial Treatments Summer Treatment Programs Educational Accommodations

Commonly Used Stimulant Medications

Ritalin Concerta Dexadrine Adderall Cylert (no longer prescribed)

Between 70 and 80 % of children with ADHD respond positively to stimulant drugs.

Stimulant drugs represent an empirically supported treatment for core symptoms of ADHD.

New Approaches to ADHD Drug Delivery

The FDA has recently approved the Daytrana patch This is a skin patch for the treatment of ADHD

which was developed to help in the administration of ADHD drugs to children who find it hard to take pills or tablets.

The patch is a once-daily treatment for children 6-12.

It delivers the active ingredient of Ritalin (methylphenidate) via the skin.

It is placed on the skin (hip) early in the morning and removed nine hours later.

It is applied, alternately, on the left and right sides of the hip (e.g. Monday - left, Tuesday - right, etc.)

The dosage comes in four strengths

NEW ADHD Medication: Designed to Last All Day Shire Pharmaceuticals has recently (2007)

released Vyvanse, a new stimulant drug formulated as a once-daily medication. Designed to last for up to 12 hours (after

school coverage). The medication has been shown to provide

consistent ADHD symptom control throughout the day based upon parent reports in the morning (approximately 10am), afternoon (approximately 2pm), and early evening (approximately 6pm).

Useful in controlling symptoms in the after school hours, to help child attend to homework and facilitate appropriate social behavior.

Side Effects of Stimulants Common side effects can include: loss of

appetite, weight loss, sleeping problems, irritability,

restlessness, stomachache, headache, rapid heart rate, elevated blood pressure, sudden deterioration of behavior

symptoms of depression with sadness, crying, and withdrawn behavior.

intensification of tics (muscle twitches of the face and other parts of the body), possible Tourette’s and growth suppression.

Side Effects (Cont.) While side effects are always a

possibility they are often Transient in nature The result of inappropriate medication levels

If one medication results in side effects, another might be used without side effects.

Sometimes other medications are used to minimize side effects.

Good clinical judgment by the clinician may help to minimize side effects.

Some Examples of Non-Stimulants in ADHD Treatment

Non Stimulant ADHD Medication Straterra - a norepinephrine reuptake

inhibitor- selectively blocks the reuptake of norepinephrine, which increases its availability

Other Non Stimulant Drugs Anti-depressants (e.g., Tofranil,

Wellbutrin) Anti-hypertensives (Clonidine)

Psychosocial Treatments

Parent Training Social Skills Training Cognitive Behavioral Treatments. Psychotherapy for comorbid

conditions Summer Treatment Program

Summer Treatment Program For 5-14 years old children's behavioral, emotional, and learning

problems. This program is composed of a set of evidence-based treatments

incorporated into an 8-week therapeutic summer day camp setting. Group and tailored individual treatment plans are implemented by

trained paraprofessionals under the supervision of experienced senior staff members.

Group sessions consist of 15 children paired with 4 clinical staff members for the duration of the day, encouraging development of group interaction and friendships.

Group activities include two hours in behavioral modification sessions conducted by developmental specialists.

Sessions focus on treatment of problem behaviors in a classroom context, and may include individualized and computer-assisted instruction, as well.

The remainder of each day consists of recreationally-based, age-appropriate games and group activities, with implementation of a variety of integrated treatment components.

Summer Treatment Programs Goals:

Development of the child's problem solving and social skills, and social awareness to enable him/her to get along better with other children

Improvement of the child's learning skills and academic performance

Development of the child's abilities to follow instructions, to complete tasks, and to comply with adults' requests

Improvement of the child's self-esteem by developing competencies such as in interpersonal, recreational, academic, and other task-related areas

Instruction of parents in how to develop, reinforce, and maintain these positive changes

If appropriate, evaluation of the effects of medication on the child's academic and social functioning in a natural setting

Summer Treatment Program Treatment Includes:

individually adapted reward and response-cost programs

training in group problem solving, social , and contracting skills

instruction in overcoming learning deficits strategies for improving concentration, task

completion, and self concept time out, and a daily feedback system Treatment plans and strategies are

continuously monitored and modified as necessary.

Summer Treatment Programs Research suggests that children who

participate in summer treatment programs typically make gains in a wide range of areas

Such treatment programs appear to - improve children's relationships with

peers, their interactions with adults, their academic functioning, and their level of self-esteem.

Educational Interventions

Special Education Services for existing learning disabilities.

Classroom accommodations (504 Plans).

Classroom behavior modification programs. School-Home Behavior Report Card

Treatment: Concluding Comments In treating ADHD it is essential to treat

the full range of difficulties that impact on child and family functioning.

Treatment of ADDH will often need to be “multimodal” in nature.

Findings from the Multimodal Treatment Study suggest that; Stimulant medication is effective in

reducing core symptoms Psychosocial treatments are of value in

addressing associated comorbidities.

That’s All Folks!

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James H. Johnson, Ph.D., ABPP University of Florida