Russell A.

Barkley

Psychosocial Treatments for

Attention-Deficit/Hyperactivity Disorder in Children
Russell A. Barkley, Ph.D.

This article provides a brief overview of the major psychosocial treatments that have some efficacy
for the management of attention-deficit/hyperactivity disorder (ADHD) in children. Parent training
in effective child behavior management methods, classroom behavior modification methods and
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academic interventions, and special educational placement appear to have the greatest promise of
efficacy. Augmenting these, additional family therapy in problem-solving and communication skills
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and the coordination of multiple school resources across the day may be necessary. To be effective in
improving prognosis, treatments must be maintained over extended periods of time.
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(J Clin Psychiatry 2002;63[suppl 12]:36–43)

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A dvances in the treatment of attention-deficit/ The determination of eligibility for such programs is often
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hyperactivity disorder (ADHD) over the past 20 a major referral concern of parents or teachers, dictating
years have been relatively circumscribed and have oc- that clinicians be familiar with federal, state, and local
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curred mainly in the area of psychopharmacology rather regulations regarding placement in such programs.
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than psychosocial treatments. Research increasingly This article provides a brief overview of those
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points to ADHD as a development disorder of probable treatments; more detailed discussions can be found else-
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neurogenetic origins in which some unique environmental where.4,6,7 None of the treatments discussed here are cura-
factors play a role in its expression, though far less than tive of ADHD symptoms. Their value lies in the temporary
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do genetic ones. Treatment is actually management of the reduction of symptom levels or in the reduction of related
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chronic developmental condition and involves finding behavioral and emotional difficulties, such as defiance and
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means to cope with, compensate for, and accommodate to conduct problems, depression and low self-esteem, or aca-
the developmental deficiencies, as well as providing symp- demic underachievement. When such treatments are re-
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tomatic relief such as that obtained by various medications. moved, the level of ADHD symptoms appears to return to
Those major psychosocial treatments that have some pretreatment ranges of deviance. Their effectiveness in
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proven efficacy for the management of ADHD have been improving prognosis, then, rests on their being maintained
(1) parent training in contingency management methods,1
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over long periods of time (often years).

(2) classroom applications of contingency management
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techniques,2,3 and (3) assorted combinations of these ap- BEHAVIOR MODIFICATION

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proaches with psychopharmacology. Besides these inter-

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ventions, therapists should also be cognizant of the avail- One justification for using behavior modification
ability of special educational programs for ADHD children techniques for ADHD is the argument that, since referral
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now mandated under the Individuals With Disabilities in of children for ADHD in part rests on the social distress
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Education Act and Section 504 of the Civil Rights Act.4,5 they have created for their caregivers, an intervention that
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attempts to change the interaction between children and

their caregivers should be useful.8 With the recent trend
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From the Department of Psychiatry, University of

toward viewing ADHD as a potential problem in response
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Massachusetts Medical School, Worcester. inhibition and self-regulation in children that may cause
Presented in part at the roundtable “Novel Treatments secondary poor self-motivation to persist at assigned
for Attention-Deficit/Hyperactivity Disorder in Children and
Adults,” which was held November 15–17, 2001, in Boston, tasks,1 a persuasive theory-based rationale for employing
Mass., and was supported by an unrestricted educational behavioral interventions with ADHD may now exist.
grant from Eli Lilly and Company.
This article is an adaptation of an earlier chapter by the
If ADHD is in fact a developmental delay in the self-
author and has been substantially edited and revised. It is regulation of behavior by internal means of representing
printed here with permission. Barkley RA. Attention deficit information and motivating goal-directed behavior, then
hyperactivity disorder. In: Mash EJ, Barkley RA, eds. Treatment
of Childhood Disorders. New York, NY: Guilford Press; 1998. interventions that directly alter the nature of the stimuli
Corresponding author and reprints: Russell A. Barkley, controlling behavior as well as the pattern, timing, or sa-
Ph.D., Department of Psychiatry, University of Massachusetts
Medical Center, 55 Lake Ave. N., Worcester, MA 01655 lience of such consequences by socially arranged means
(e-mail: [email protected]). would be useful, at least for symptomatic reduction in

36 J Clin Psychiatry 2002;63 (suppl 12)

 Psychosocial Treatments for ADHD in Children

some settings and tasks. Such procedures for the manipu- breaks from the task could also achieve improved task per-
lation of antecedent and consequent events are precisely formance.
those provided by the behavior therapies. A logical exten- Another means of altering stimulus control parameters
sion of this argument holds, however, that such socially might be to increase the use of externally and concretely
arranged means of addressing this neurologically based represented time limits and rules that are often associated
dysregulation would not alter its underlying neurophysi- with particular tasks. The behavior of ADHD children
ologic basis. These techniques must be employed across seems to be poorly controlled by such internal perceptions
situations over extended intervals (months to years) much of time and self-statements or are inconsistently controlled
as prosthetic devices (e.g., hearing aides, mechanical limbs) by them.1 These children could be assisted by portable tim-
are employed to compensate for physically handicapping ers placed on their desks and set to reflect the elapsed time
conditions. Premature removal of the socially arranged available for task performance and by small “reminder”
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motivational programs would predictably result in an even- cards on their desks during individual desk work. A similar
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tual return to pretreatment levels of the behavioral symp- tactic to enhance stimulus control is to allow ADHD chil-
toms. Also, use of the behavioral techniques in only one dren to clip a small portable tape player to their belt with
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environment would be unlikely to affect rates of ADHD earphone attached to permit them to listen to tapes while
symptoms in other, untreated settings unless generalization performing desk assignments in class that remind them to
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had been intentionally programmed to occur across such stay on task, finish the work, and not daydream. Despite
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settings. The research reviewed below for the various be- clinical anecdotes supporting the value of these methods,
havioral techniques seems to support this interpretation. much research needs to be done to more rigorously test the
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efficacy of these stimulus control programs.

Direct Application of Paniagua13 used correspondence training to establish
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Behavior Therapy Methods in the Laboratory greater control over ADHD symptoms by commands and
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Early studies that evaluated the effects of reinforcement rules previously stated publicly by the children. Correspon-
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and punishment on the behavior and cognitive performance dence refers to the degree of concordance between public
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of ADHD children usually indicated that performance on statements by children as to what they will do and the
tasks measuring vigilance or impulse control can be imme- actual behavior they subsequently display in that setting—
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diately and significantly improved by contingent conse- in essence, the degree of agreement between “saying” and
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quences.9,10 In some cases, the behavior of ADHD children “doing.” In this paradigm, ADHD children are requested
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approximates that of normal control children. However, no to publicly state how they will behave in an immediately
study has examined the degree to which such changes gen- subsequent situation. Their behavior in that situation is
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eralized to the natural environments of the children, call- then observed after which they are reinforced or punished
ing into question the clinical efficacy of such an approach. for the degree of correspondence. Future research needs
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In a series of studies, Zentall and colleagues11 showed to show that the children’s own statements are serving as
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that increasing relevant intratask stimulation and novelty, the controlling stimuli in such paradigms rather than the
as well as reducing task complexity, reduced ADHD symp- presence of the examiner during the task.
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toms. In contrast, providing extratask stimulation, espe-

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cially during difficult or complex tasks, increased ADHD Training Parents in Child Behavior Management
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symptoms and proved more disruptive to the performance Despite the plethora of research on parent training in
of these children on academic tasks. Douglas and Parry12 child behavior modification,1 only a small number of
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further suggested that repeating task instructions fre- studies have examined the efficacy of this approach with
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quently throughout a task enhanced the performance of children specifically selected for hyperactive or ADHD
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ADHD children to within normal limits in laboratory stud- symptoms. What limited research exists can be interpreted
ies. Hence, an additional behavioral treatment of ADHD with cautious optimism as supporting the use of behavioral
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children besides altering response consequences would be parent training with ADHD children.14–16 One of the few
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to alter the stimulus properties of settings and especially studies to conduct a follow-up reevaluation 1 year after
tasks assigned to ADHD children. treatment, however, found that the families receiving
Making tasks more novel and stimulating through parent training were no longer different from the control
the use of added color, motor participation by the child, group, although the child’s school behavior was rated by
frequent shifts in the nature of the task, increased rate teachers as significantly better.16
of presentation of the material, frequent repetition of the Those treatment techniques used to date have primarily
task instructions, and greater enthusiasm and theatrics consisted of training parents in general contingency
by the instructor during teaching of the task may make management tactics, such as contingent application of
ADHD children more attentive, less active, and more pro- reinforcement or punishment following appropriate/
ductive in such tasks. Moreover, reducing the length of the inappropriate behaviors. Reinforcement procedures have
task by creating smaller task units and providing frequent typically relied on praise or tokens, while punishment

J Clin Psychiatry 2002;63 (suppl 12) 37

Russell A. Barkley

methods have usually been loss of tokens or time-out from mands and rules are given. Such behavior appears to
reinforcement. Why these particular methods were chosen function primarily as escape/avoidance learning in which
and what specific target behaviors they were used with have oppositional behavior succeeds in the child’s escape from
often gone unreported. I1 have developed a parent-training aversive parent interactions and task demands, negatively
program in child-management skills, the methods of which reinforcing the child’s coercion. As in the first session,
have been borrowed from research indicating their efficacy this content is covered so as to correct potential misconcep-
in managing defiant and oppositional children. Results sug- tions that parents have about defiance (i.e., it is primarily
gest that up to 64% of families experience clinically signi- attention-getting in nature).
ficant change or recovery (normalization) of their child’s 3. Developing and enhancing parental attention.
disruptive behavior as a consequence of this program.17 Patterson et al.20 have suggested that the value of verbal
The rationale for the program is 2-fold. First, it is hypo- praise and social reinforcement to oppositional or hyperac-
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thesized that ADHD children may have a specific deficit tive children is greatly reduced, making it weak as a rein-
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in rule-governed behavior or the stimulus control of behav- forcer for compliance. In this session, parents are trained in
ior by commands, rules, and self-directed speech.1 This does more effective ways of attending to child behavior so as to
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not mean that the problem has arisen due to poor child enhance the value of that attention. The technique consists
management by parents but instead proposes a neurophysi- of verbal narration and occasional positive statements to the
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ologic deficiency underlying the problem with rules. Con- child with attention being strategically deployed only when
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sequently, parents need to use more explicit, systematic, appropriate behaviors are displayed. Parents are taught to
externalized, and compelling forms of presenting rules ignore inappropriate behaviors but to greatly increase their
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and instructions to ADHD children and providing conse- attention to ongoing prosocial and compliant behaviors.
quences for compliance than are likely to be needed with 4. Attending to child compliance and independent play.
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normal children. There also exists a considerable overlap of This session extends the techniques developed in Session 3
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oppositional/defiant behavior with clinic-referred ADHD to instances during which parents issue direct commands to
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children. The most useful vehicle for managing these behav- children. Parents are trained in methods of giving effective
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iors seems to be parent training in behavioral techniques.1 commands, such as reducing question-like commands (e.g.,
The program consists of 10 steps, with 1- to 2-hour Why don’t you pick-up your toys now?), increasing impera-
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weekly training sessions provided either to individual fami- tives, eliminating setting activities that compete with task
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lies or in groups. Each step is described in detail elsewhere,1 performance (e.g., television), reducing task complexity,
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but is briefly presented below: etc. They are then encouraged to begin using a more effec-
1. Review of information on ADHD. In the first session, tive commanding style and to pay immediate positive atten-
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the therapist provides a succinct overview of the nature, tion when compliance is initiated by the child. Parents are
developmental course, prognosis, and etiologies of ADHD. asked to increase the frequency with which they give brief
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Providing additional reading materials, such as a book for commands this week and to reinforce each command
parents,18 and professional videotapes can be useful. Such
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obeyed. Research suggests that these brief commands are

a session is essential to dispel a number of misconceptions more likely to be obeyed, thereby providing excellent train-
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parents often have about ADHD in children. A recent study ing opportunities for attending to compliance. In this ses-
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suggests that just this provision of information can result sion, parents are also trained to provide more positive at-
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not only in improved knowledge of parents about ADHD tention frequently and systematically when their children
but also in improved parental perceptions of the degree of are engaged in nondisruptive activities while parents must
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deviance of their child’s behavioral difficulties.19 be occupied with some other work or activity. Essentially,
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2. The causes of oppositional/defiant behavior. Next, this method amounts to a shaping procedure in which par-
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parents are provided with an in-depth discussion of those ents provide frequent praise and attention for progressively
factors identified as contributing to the development of longer periods of child nondisruptive activities.
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defiant behavior in children (see references 1 and 20 for 5. Establishing a home token economy. Children with
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reviews). Essentially, 4 major contributors are discussed: ADHD may require more frequent, immediate, and salient
(1) child characteristics, such as health, developmental consequences for appropriate behavior and compliance in
disabilities, and temperament; (2) parent characteristics order to maintain it. Instituting a home token economy is
similar to those described for the child; (3) situational critical to addressing difficulties with intrinsically generated
consequences for oppositional and coercive behavior; and represented motivation by bringing more salient exter-
and (4) stressful family events. Parents are taught that nal consequences, more immediately and more frequently,
problems in (1), (2), and (4) increase the probability that to bear on child compliance than is typically the case.
children will display bouts of coercive, defiant behavior. In establishing this program, the parents list most of the
However, the consequences for such defiance, (3) above, children’s home responsibilities and privileges and assign
seem to determine whether that behavior will be maintained values of points or chips to each. Parents are encouraged
or even increased in subsequent situations in which com- to have 12 to 15 reinforcers on the menu to maintain the

38 J Clin Psychiatry 2002;63 (suppl 12)

 Psychosocial Treatments for ADHD in Children

motivating properties of the program. Generally, plastic ents. Instead, any problems with previously implementing
chips are used with children 8 or younger as they seem to time-out are reviewed and corrected. Parents may then ex-
value the tangible features of the token. For 9-year-olds and tend their use of time-out to 1 or 2 additional noncompliant
older, points recorded in a notebook seem sufficient. behaviors with which the child may still have trouble.
During the first week of this program, the parents are 8. Managing noncompliance in public places. Parents
not to fine the child or remove points for misconduct. The are now taught to extrapolate their home management
program rewards good behavior only. Parents are also asked methods to troublesome public places. Using a “think
to be liberal in awarding chips to children for even minor aloud–think ahead” paradigm, parents are taught to stop
instances of appropriate conduct. However, chips are given just before entering a public place, review 2 or 3 rules with
only for obeying first requests. If a command must be re- the child that the child may previously have defied, explain
peated, it must still be obeyed but the opportunity to earn to the child what reinforcers are available for obedience in
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chips has been forfeited. Parents are also encouraged to give the place, explain what punishment may occur for disobe-
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bonus chips for good attitude or emotional regulation in dience, and finally assign the child an activity to perform
their children. For instance, if a command is obeyed during the outing. Parents then enter the public place and
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quickly, without complaint, and with a positive attitude, par- immediately begin attending to and reinforcing ongoing
ents may give the child additional chips beyond those typi- child compliance with the previously stated rules. Time-out
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cally given for that job. When this is used, parents are to or response cost is used immediately for disobedience.
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expressly note that the awarding of the additional chips is Whenever time-out is used in a public place, it need not
for a positive attitude. be for as long an interval as at home. Half of the usual time-
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6. Implementing time-out for noncompliance. Parents out interval may be sufficient for public misbehavior, given
are now trained to use response cost (removal of points or the richly reinforcing activities in public places from which
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chips) contingent on noncompliance. In addition, they are the child has just been removed. Parents can also be trained
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trained in an effective time-out-from-reinforcement tech- to use a delayed punishment contingency. In this case, the
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nique for use with 2 serious forms of defiance that may con- parent carries a small spiral notebook to the public place
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tinue to be problematic despite the use of the home token and, before entering the building, indicates that rule viola-
economy. These 2 misbehaviors are selected in consultation tions will be recorded in the book and the child will serve
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with the parents and typically involve a type of command time-out for them upon return home from this trip.
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or household rule that the child continues to defy despite 9. Improving child school behavior from home: the
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parental use of previous treatment strategies. Time-out is Daily School Behavior Report Card. This session is a re-
limited to these 2 forms of misconduct so as to keep it from cent addition1 to the original parent training program and
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being used excessively during the next week. was designed to help parents assist their child’s teacher
The time-out is to be implemented shortly after noncom- with the management of classroom behavior problems. The
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pliance by a child begins. Parents issue a command, wait 5 session focuses on training parents in the use of a home-
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seconds, issue a warning, wait another 5 seconds, and then based reward program in which children are evaluated on a
take the child to time-out immediately should compliance daily school behavior report card by their teachers. This
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not have begun. Parents are taught to tell the child not to card serves as the means by which consequences will be
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leave the time-out chair until the parent tells them to. Three dispensed at home for classroom conduct. The card can be
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conditions must be met by the child before time-out ends, designed to address class behavior, recess or free time be-
and these are in a hierarchy: (1) The child must serve a mini- havior, or more specific behavioral targets for any given
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mum sentence in time-out, usually 1 to 2 minutes for each child.

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year of their age, (2) the child must then become quiet for a 10. Managing future misconduct. By now, parents
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brief period of time so as not to have disruption associated should have acquired an effective repertoire of child man-
with the parents approaching the time-out chair and talking agement techniques. The goal of this session is to get par-
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to the child, and (3) the child must then agree to obey the ents to think about how they might be implemented in the
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command. Failure of the child to remain in time-out until future if some other forms of noncompliance developed.
all 3 conditions are met is dealt with by additional punish- The therapist challenges the parents with misbehaviors they
ment. The consequence is tailored to meet parental wishes have not seen yet and asks them to explain how they might
but may consist of a fine within the home token system, ex- use their recently acquired skills to manage these problems.
tension of the time-out interval by an additional 5 or 10 min- One-month review/booster session. In what is typically
utes, or placement of the child in his or her bedroom. In the the final session, the concepts taught in earlier sessions are
latter case, toys or other entertaining activities are removed reviewed, problems that have arisen in the last month are
from the bedroom, and the door to the room may be closed discussed, and plans made for their correction. Other ses-
and locked to preclude further escape from the punishment. sions may be needed to deal with issues that persist, but for
7. Extending time-out to additional noncompliant be- most families, the previous 10 sessions appear adequate for
haviors. In this session, no new material is taught to par- improving rates of compliant behavior in ADHD children.

J Clin Psychiatry 2002;63 (suppl 12) 39

Russell A. Barkley

For teenagers with ADHD and oppositional behavior, I a task may improve attention and performance. The use of
have often recommended a family training program that in- written, displayed rules and timers for setting task time
cludes Problem Solving Communication Training Program limits, as already described, may further benefit ADHD
(PSCT) developed by Robin and Foster.21 children in the classroom.
A number of studies have also shown that the contingent
Training Teachers in Classroom Management application of reinforcers for reduced activity level or in-
Somewhat more research has occurred on the application creased sustained attention can rapidly alter the levels of
of behavior management methods in the classroom with these ADHD symptoms.2,25 Usually, these programs incor-
ADHD children than with parent training. A voluminous porate token rewards as some research suggests that praise
literature on the application of classroom management may be insufficient to increase or maintain normal levels
methods to disruptive child behaviors clearly indicates the of on-task behavior in hyperactive children.3 Several stud-
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effectiveness of behavioral techniques in the short-term ies have shown that group-administered rewards, where all
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treatment of academic performance problems in ADHD children in class receive a reward contingent on the perfor-
children. mance of one child, are as effective as individually admin-
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A recent meta-analysis of the research literature on istered rewards. One problem that arose in such research,
school interventions for ADHD comprised 70 separate however, was the demonstration that simply reinforcing
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experiments of various within- and between-subjects de- greater on-task behavior and decreased activity level did
signs as well as single-case designs.2 This review found an
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not necessarily translate into increased work productivity

overall mean effect size for contingency management pro- or accuracy.26 Since the latter are the ultimate goals of be-
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cedures of 0.60 for between-subject designs, nearly 1.00 for havioral intervention in the classroom, these results were
within-subject designs, and approximately 1.40 for single- somewhat dismaying. Research now suggests that reinforc-
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case experimental designs. Interventions aimed at improv- ing the products of classroom behavior (i.e., number and
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ing academic performance through the manipulation of the accuracy of problems completed) not only results in in-
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curriculum, antecedent conditions, or peer-tutoring pro- creased productivity and accuracy but also indirectly re-
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duced approximately equal or greater effect sizes. In con- sults in declines in off-task and hyperactive behavior.26,27
trast, cognitive-behavioral treatments when used in the A serious limitation to these promising results has been
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school setting were significantly less effective than these the lack of follow-up on the maintenance of treatment
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other 2 forms of interventions. Thus, despite some initial gains over time. In addition, none of the studies examined
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findings of rather limited impact of classroom behavior whether behavioral control generalized to other school
management on children with ADHD,22 more recent stud- settings where no treatment procedures were in effect.
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ies, such as those by Pelham et al.,23 Carlson et al.,24 and the Other studies employing a mixture of cognitive-behavioral
totality of the extant literature reviewed by DuPaul and and contingency management techniques have failed to
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Eckert,2 suggest that behavioral and academic interventions find such generalization with ADHD children,28 suggesting
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in the classroom can be effective in improving behavioral that improvements derived from classroom management
problems and academic performance in children with methods are situation-specific and may not generalize or
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ADHD. The behavior of these children, however, may not be maintained once treatment has been terminated.
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be fully normalized by these interventions. The role of punishment in the management of classroom
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Research suggests some promise in the use of stimulus behavior in ADHD children has been less well studied.
control procedures with ADHD children, many of which Pfiffner et al.29 evaluated the effects of continuous and in-
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can be readily adapted to the classroom. Reducing task termittent verbal reprimands and response cost on off-task
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length, “chunking” tasks into smaller units to fit more classroom behaviors. They found that while each of these
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within the child’s attention span, and setting quotas for the treatments significantly reduced disruptive and off-task be-
child to achieve within shorter time intervals may increase havior, the continuous use of response cost (loss of recess
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the success of the ADHD child with academic work.3 As time) was most effective. Allyon and Rosenbaum30 also
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Zentall11 has already documented, the use of increased report on the initial success of adding response cost con-
stimulation within the task (e.g., color, shape, texture, rate tingencies to an ongoing classroom token economy. How-
of stimulus presentation) may enhance attention to aca- ever, after less than 1 week, disruptive behavior returned
demic tasks in ADHD children. Teaching styles may play to baseline levels despite the punishment contingency.
an important role in how well ADHD children attend to Pfiffner and O’Leary31 determined that the sole use of
lectures by a teacher. More vibrant, enthusiastic teachers positive reinforcement for controlling ADHD behaviors in
who move about more, engage children frequently while the classroom was not sufficient to maintain improved be-
teaching, and allow greater participation of the children in havior in these children unless punishment in the form of
the teaching activity may increase sustained attention to the response cost was added to the program. The addition of
task at hand. Zentall has also shown that permitting ADHD response cost further increased rates of on-task behavior
children to move or participate motorically while learning and academic accuracy. These gains in behavior could then

40 J Clin Psychiatry 2002;63 (suppl 12)

 Psychosocial Treatments for ADHD in Children

be maintained by an all-positive program once the response contingency management training of parents or teachers
cost procedure was gradually withdrawn. However, abrupt with stimulant drug therapies is generally little better than
withdrawal of the punishment contingency resulted in de- either treatment alone for the management of ADHD
clines in on-task behavior and accuracy suggesting that the symptoms.39–41 One study22 found that classroom behav-
manner in which response cost techniques are implemented ioral interventions may have mildly improved the deviant
and then faded out of classroom management programs behavior of ADHD children but did not bring levels of be-
is important in the maintenance of initial treatment gains. havior within the normal range. Medication, in contrast,
In general, the efficacy of response cost procedures with rendered most children normal in classroom behavior.
ADHD children has been well-documented.32–35 Others have found more impressive results for classroom
What can be drawn from this literature to date? First, behavior management methods,2,23,24 but also found that
contingency management methods can produce immedi- the addition of medication provides added improvements
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ate, significant, short-term improvement in the behavior, beyond that achieved by behavior management alone.
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productivity, and accuracy of ADHD children in the class- Moreover, the combination may result in the need for less
room. Second, secondary or tangible reinforcers are more intense behavioral interventions or lower doses of medica-
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effective in reducing disruptive behavior and increasing tion than might be the case if either intervention were used
performance than are attention or other social reinforcers. alone. Where an advantage to behavioral interventions ex-
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The use of positive reinforcement programs alone does not ists, it appears to be in reliably increasing rates of academic
productivity and accuracy.39 Yet, here too, stimulant medi-
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seem to result in as much improvement nor does it main-

tain that improvement over time as well as does the combi- cation has shown positive effects.23 Despite some failures
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nation of token reinforcement systems with punishment, to obtain additive effects for these 2 treatments, their com-
such as response cost (i.e., removal of tokens or privi- bination may still be advantageous given that the stimu-
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leges). Third, what little evidence there is, however, sug- lants are not usually used in late afternoons or evenings
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gests that treatment gains are unlikely to be maintained in when parents may need effective behavior management
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these children once treatment has been withdrawn and that tactics to deal with the ADHD symptoms. Moreover, be-
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improvements in behavior probably do not generalize to tween 8% and 25% of ADHD children do not respond posi-
other settings where no treatment is in effect. tively to stimulant medications,6 making behavioral inter-
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Two additional classroom management techniques may ventions one of the few scientifically proven alternatives
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prove of value in treating ADHD children, but their effec- for these cases.
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tiveness remains to be more rigorously studied. One in- Several studies have examined the combined effects of
volves the use of a transmitter and receiver/counter for stimulant medication with cognitive-behavioral interven-
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implementing an in-class token system.34,35 Whenever the tions. Horn et al.42 examined the separate and combined ef-
teacher witnesses the child off-task or disrupting the class, fects of d-amphetamine and self-instructional training with
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she presses a button on the transmitter that activates a red a 9-year-old inpatient ADHD child. The combined program
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light on the receiver on the child’s desk to deduct a point was more effective in increasing on-task behavior during
from the face of the counter. The other method deserving class work and decreasing teacher ratings of ADHD symp-
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of further evaluation is the use of home-based contingen- toms. However, academic productivity was improved only
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cies for in-class behavior and performance based on daily by the use of direct reinforcement for correct responses. In
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school report cards, as mentioned earlier.23,36 contrast, using group comparison designs, Brown et al.43,44
Although little research has been done on the subject, it found no benefits of combined drug/cognitive behavioral
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is likely that certain aspects of the teacher’s personality, interventions over either alone on similar domains of func-
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presence of psychological difficulties, compatibility of tioning of ADHD children. Similarly, a later study by Horn
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teacher and student characteristics, and the teacher’s phi- et al.38 did not find the combination of treatments to be
losophy of child behavior management contribute to the superior to medication alone. Similarly negative results
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success or failure of any contingency management meth- were found by Cohen et al.45 for kindergarten-aged ADHD
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ods to be used in the classroom and the success of the children at a 1-year follow-up evaluation.
ADHD child in that classroom more generally.37 Some success for combined medication and self-
evaluation procedures has been reported46 when social
COMBINED INTERVENTIONS skills, such as cooperation, have been targets of inter-
vention. Yet, when these same investigators attempted
Psychopharmacologic and behavioral treatments are to teach anger-control strategies to ADHD children to en-
not, by themselves, typically nor completely adequate to hance self-control during peer interactions, no benefits of
address all of the difficulties likely to be presented by combined intervention were found beyond that achieved by
clinic-referred ADHD children. Optimal treatment is likely self-control training alone.47 The self-control techniques
to comprise a combination of many approaches for maxi- were the most successful in teaching these children specific
mal effectiveness.23,24,38 It appears that the combination of coping strategies to employ in provocative interactions

J Clin Psychiatry 2002;63 (suppl 12) 41

Russell A. Barkley

with peers that usually lead to angry reactions from the combined therapy conditions did not differ from each
ADHD children. Medication, in contrast, served only to other in this regard. Combined therapy may have proven
lower the overall level of anger responses but did not superior to medication for management of some associated
enhance the application of specific anger control strategies. problems coexistent with ADHD.41
These studies suggest that each form of treatment may have
highly specific and unique effects on some aspects of so- Intensive, Multimodal Treatment Programs
cial behavior while not on others. Two of the most well-known and well-regarded multi-
Some investigators have evaluated the effects of behav- modality intervention programs are the summer treatment
ioral parent training in contingency management alone and programs developed by William Pelham and colleagues52
combined with self-control therapy48 on home and school and the University of California-Irvine/Orange County
behavioral problems. The results failed to find any signi- Department of Education.3 While the Pelham program
©

ficant advantage for the combined treatments. Both self- is conducted during the summer months in a residential
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control training and behavioral parent training alone im- “camp” style program, the UCI-OCDE program is a year
proved home behavior problems but neither resulted in round day-school–style program.
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generalization of treatment effects to the school, where no More recently, my colleagues and I have completed the
treatment had occurred. Since a no-treatment group was multimethod UMASS/WPS Early Intervention Project for
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not employed in this study, however, it is not possible to kindergarten children with significant problems with hy-
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conclude that these effects were due to treatment rather than peractivity and aggression, at least 70% of whom qualified
to nonspecific effects (e.g., maturation, therapist attention, for a clinical diagnosis of ADHD.53 These programs rely
20

regression effects). A later study by Horn et al.49 did find on 4 major components of treatment: (1) parent training in
such a treatment combination to be superior to either treat- child behavior management, (2) classroom implementation
02 ne p

ment used alone in producing a significantly larger number of behavior modification techniques, (3) social skills train-
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of treatment responders. Once again, no generalization of ing, and (4) stimulant medication, in some cases. Some of
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the results to the school setting occurred, however. the components of the day-treatment program, such as
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Satterfield and colleagues50 have attempted to evaluate classroom contingency management, have been found to
the effects of individualized multimodality intervention produce significant short-term improvements in children
ic op

provided over extensive time periods (up to several years) with ADHD, but the efficacy of other components, such as
ia y m

on the outcome of ADHD boys. Interventions included social skills training, is not so clear-cut. No data have been
ns ay

medication, behavioral parent training, individual counsel- published as yet on whether the gains made during the
ing, special education, family therapy, and other programs treatment programs are maintained in the normal school
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as needed by the individual. Results suggest that such an and home settings after the children terminate their partici-
individualized program of combined treatments continued pation in this program.
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over longer time intervals can produce improvements in

CONCLUSION
ra ted

social adjustment at home and school, rates of antisocial

behavior, substance abuse, and academic achievement.
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These results seem to be sustained across at least a 3-year The treatment of ADHD requires expertise in many
a

follow-up period.51 While such treatment suggests great different treatment modalities, no single one of which can
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promise for the possible efficacy of multimodality treat- address all of the difficulties likely to be experienced by
ment extended over years for children with ADHD, the lack such individuals. Among the available treatments, edu-
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of random assignment and more adequate control proce- cation of parents, family members, and teachers about
es

dures in this series of studies limits the ability to attribute the disorder, psychopharmacology (chiefly stimulant med-
s,

those improvements directly to the treatments employed. ications), parent training in effective child behavior man-
And these limitations certainly preclude establishing which agement methods, classroom behavior modification meth-
In

of the treatment components was most effective. Still, stud- ods and academic interventions, and special educational
c.

ies such as these and others23,24 have raised hopes that placement appear to have the greatest efficacy or promise
multimodality treatment can be effective for ADHD if of such for dealing with children who have ADHD. To
extended over long intervals of time. They have led to an these must often be added family therapy around problem-
historic venture by the National Institute of Mental Health solving and communication skills and the coordination of
to more systematically evaluate the effects of such treat- multiple teachers and school-staff across the school day. To
ment for ADHD in a multisite collaborative study.41 The be effective in altering eventual prognosis, treatments must
results of this study have only recently become available. be maintained over extended time periods (months to
They generally indicated that medication treatment and years) with periodic reintervention as needed across the life
combined therapy were superior to psychosocial treatment course of the child as well as the increasing enlistment of
or customary community treatment for the management the ADHD individual’s cooperation with and investment in
of ADHD symptoms, specifically. The medication and the long-term intervention program.

42 J Clin Psychiatry 2002;63 (suppl 12)

 Psychosocial Treatments for ADHD in Children

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