درمان روانی اجتماعی مبتنی بر شواهد برای کودکان و نوجوانان با نقص توجه/بیش فعالی

Despite the vast literature supporting the efficacy of stimulant medication in the treatment of attention-deficit/hyperactivity disorder (ADHD), several limitations of pharmacological treatments highlight the clear need for effective psychosocial treatments to be identified. A large evidence base exists for behavioral interventions, including parent training and school interventions, which has resulted in their classification as “empirically validated treatments.” Additionally, social skills training with generalization components, intensive summer treatment programs, and educational interventions appear promising in the treatment of ADHD. Given the chronic impairment children with ADHD experience across multiple domains of functioning, multimodal treatments are typically necessary to normalize the behavior of these children. The state of the ADHD treatment literature is reviewed, important gaps are identified (e.g., treatment for adolescents), and directions for future research are outlined within a developmental psychopathology framework.

Attention-deficit/hyperactivity disorder (ADHD) is the primary reason for referral to mental health services among school-aged children (Barkley, 1998). Children with ADHD display chronic and pervasive difficulties with inattention, hyperactivity, and impulsivity that result in profound impairments in academic and social functioning across multiple settings (typically, at home, in school, and with peers). Effective treatments for ADHD consist of stimulant medication and behavior modification. Although the efficacy of stimulant medication in the treatment of ADHD is well established, purely pharmacological approaches to treatment fall short of optimal outcomes for a number of reasons, highlighting the need for effective psychosocial treatments to be identified. A large and convincing evidence base exists for behavioral parent training and behavioral school interventions, which has resulted in their classification as “empirically validated treatments” according to American Psychological Association (APA) Division 53 criteria (Lonigan et al., 1998 and Pelham et al., 1998). Behavioral interventions involve manipulating environmental factors that are antecedents to (e.g., setting, structure) or consequences of (e.g., adult attention) the maladaptive behavior. Given the chronic and pervasive nature of ADHD, behavioral treatments (like medication) must be implemented consistently over the long-term in each setting in which impairment is present (Chronis et al., 2001). Effective psychosocial treatments for ADHD will be reviewed herein, and will be presented within a developmental psychopathology framework (Holmbeck, Greenley, & Franks, 2003). 1. Developmental psychopathology framework The developmental psychopathology framework has as one of its initial considerations the developmental appropriateness of behavior. Developmental appropriateness is critical in arriving at a diagnosis of ADHD, setting appropriate goals for treatment, and appreciating environmental demands that are at play during any given developmental period. For example, many of the behaviors that characterize ADHD (e.g., difficulty sustaining attention, high activity level) are normative at certain stages of development, and may or may not be viewed as impairing depending on the environmental expectations at a particular developmental stage ( Lahey et al., 1998). Thus, prior to diagnosis the child's behavior must be compared to developmental norms, impairment in functioning must be assessed across multiple domains, and appropriate treatment goals must be based on normative functioning for the child's age. Treatments must also be developmentally sensitive, meaning that they must involve careful consideration of the child's level of cognitive development and his/her developmental needs and challenges ( Holmbeck et al., 2003). In this regard, behavioral treatments for younger children must include consequences that are tangible, offered frequently, and presented immediately following the behavior so that children comprehend the connection between their behavior and the consequence. Likewise, treatments for adolescents must consider their desire for autonomy, for example, by involving them more fully in the treatment process. Across all age groups, consequences must be chosen that are meaningful and motivating for the individual at that particular stage of development. For example, time out may be a less appropriate punishment for adolescents. Rather, loss of privileges or activities (e.g., talking on the telephone, going to the mall with friends, obtaining access to the car) may be much more effective punishments for adolescents. Similarly, treatments must be modified at developmental transitions using developmentally sensitive behavioral strategies to reflect the behaviors that are most impairing at the time (e.g., disorganization at the transition to middle school; Chronis et al., 2001). Finally, the developmental psychopathology perspective emphasizes that children exist within multiple contexts—most notably, home and school—that may include a multitude of risk and/or protective factors that must be modified or fostered in treatment in order to enhance developmental outcomes ( Mash, 1998). By definition, ADHD symptoms and impairment must exist in at least two settings ( APA, 1994). Treatments must therefore be implemented in each setting to bring about maximum benefit ( Pelham et al., 1998). Furthermore, effective psychosocial treatments for ADHD rely on parents and teachers as agents by which treatment is delivered directly to the children. A vast literature suggests that the behaviors of children with ADHD are stressful to parents, and the same is likely true for teachers ( Fischer, 1990 and Johnston and Mash, 2001). Furthermore, many parents of children with ADHD experience psychopathology themselves ( Chronis, Lahey et al., 2003), which is associated with suboptimal response to ADHD treatments (e.g., Sonuga-Barke, Daley, & Thompson, 2002). Therefore, comprehensive treatments rely upon a thorough assessment of the strengths and weaknesses of the child and his/her environment (e.g., the family, peer group, classroom setting) so that treatments can target child, parent, and other environmental contributors to the problem behavior across multiple settings. We will now turn to a discussion of effective treatments for children with ADHD, beginning with a discussion of the efficacy and limitations of pharmacological interventions and the rationale behind the need for psychosocial treatments. We will then review the literature on effective and promising psychosocial treatments for ADHD.

The existing literature clearly supports the efficacy of behavior modification, namely behavioral parent training and classroom behavioral interventions, in the treatment of childhood ADHD, both alone and in combination with stimulant medication. Due to the large evidence base consisting of rigorous experimental investigations, behavioral parent training and behavioral classroom interventions have been designated “empirically supported” psychosocial treatments for ADHD (Pelham et al., 1998). Social skills training, summer treatment programs, and academic modifications also have some support in the treatment of specific impairments and are therefore considered promising treatments at this time. Existing research, including the results of the MTA study, suggests that combined behavioral–pharmacological treatment is most effective in terms of addressing existing comorbid disorders and broad domains of impairment, as well as in normalizing child behavior (MTA Cooperative Group, 1999a). Given the chronic and pervasive nature of ADHD, it is not surprising that intensive, multi-component treatments are often necessary. These treatments must be implemented consistently over the long-term in all settings in which impairment is present in order to bring about maximum benefit. The developmental psychopathology perspective provides a critical framework by which these interventions are selected and implemented. There may be no area within the ADHD treatment literature that is lacking more than the treatment of adolescents. It follows from developmental psychology that modifications need to be made to the treatments that have been shown to work for children with the disorder. Adolescence is a time in which parents and teachers struggle to maintain adequate supervision, involvement, and control over the adolescent while adolescents strive for autonomy in decision-making and the peer group becomes increasingly influential (Holmbeck et al., 2003). At the same time, the adolescent is faced with increasing academic demands, peer pressure, and opportunities to engage in risky behavior. For all of these reasons, adolescents with ADHD are particularly vulnerable to negative outcomes during this stage, while being less equipped to make adaptive decisions on their own. Perhaps for any or all of these reasons, the evidence base for existing adolescent interventions is substantially weak. Treatments that have overwhelming evidence for younger children, such as interventions that rely largely on parents, have been found less effective during this stage of development. Moreover, efforts to enhance adolescent responsibility and prosocial behavior through the use of coping and problem solving skills appear to have only minimal benefit. School-based interventions, including self-monitoring, functional assessments, strategy training and behavioral management techniques, have shown some promise in improving academic performance and on-task behavior. Unfortunately, the relatively few studies conducted prevent any definitive conclusions regarding efficacy from being made. Future research must be directed at identifying developmentally appropriate interventions that integrate the involvement of adolescent, parents and teachers and effectively address a wide range of issues. Also, efforts need to be directed at developing ways to identify and intervene with children at earlier ages to maximize outcomes and circumvent many of the challenges present when treatment begins during adolescence. Once effective interventions are identified, the next step is to obtain a better understanding of factors that predict treatment response. The large and diverse sample of 7–9 year old children in the MTA study permitted more extensive analyses regarding factors that may moderate treatment outcomes. Despite significant limitations to this study (see Pelham, 1999 for a discussion of these limitations), these MTA findings shed light upon factors that may allow practitioners to better match treatments to children based on comorbidity, parental education, or occupational attainment. Also highlighted in these analyses is the importance of parental cognitions and psychopathology as potential barriers to parent-delivered interventions, pointing to the need for future research examining the effects of treatment components specifically aimed at improving parenting efficacy and decreasing parental symptomatology. These findings and many others still to come from the MTA study will likely generate increasingly sophisticated research examining the practical use of empirically supported treatments for children with ADHD and comorbid disorders. Future investigations of moderators of treatment response for adolescents with ADHD must also be pursued, as no existing studies have examined this issue. As discussed herein, effective psychosocial treatments for ADHD are rarely implemented directly with the children. Rather, all of the empirically supported treatments for the disorder rely on parents and teachers to implement on a consistent basis. We know from the child therapy literature that among children who begin treatment, 40% to 60% drop out prematurely against the therapist's advice (Kazdin, 1996). This same limitation exists for medication, which requires that parents regularly attend physician visits and refill their children's prescriptions. Although medication is often viewed as an “easier” solution, ongoing medication management is usually necessary over the long-term to bring about continued effects (Sherman & Hertzig, 1991); yet, the average number of prescriptions filled for stimulant medication is two (Sherman & Hertzig, 1991). Therefore, future research must be directed at understanding what can be done to improve the attainment of, adherence to, and outcomes following both behavioral and pharmacological treatments. This likely involves addressing contextual variables that may contribute to poor treatment compliance (e.g., parental stress and psychopathology), exporting evidence-based treatments beyond specialized academic clinic settings to community locations (e.g., schools, mental health centers, pediatrics offices), and presenting treatments in a manner that is both culturally sensitive and accessible regardless of education or income level. For ADHD, perhaps more so than any other childhood disorder, research has identified very effective therapies. That is, we now know what treatments work for ADHD under optimal conditions. The challenge now is to better understand how to maximize the effects of these treatments in real-world settings.