CENTER FOR THE PROFESSIONAL STUDY OF

ATTENTION DEFICIT HYPERACTIVITY DISORDER (AD/HD)

Dr. Robert R. Erk, Ed.D., is the Director of the Center for the Professional Study of Attention Deficit Hyperactivity Disorder. Dr. Erk is an Associate Professor of Counselor Education and Educational Psychology in the Department of Educational Studies at the University of Tennessee at Martin, TN 38238. Dr. Erk teaches graduate coursework in the school and mental health counseling tracks, is a past president of the Southern Association for Counselor Education and Supervision, serves as the American School Counselor Association Coordinator for Children With AD/HD Professional Interest Network, is a Licensed Professional Counselor and Marital and Family Therapist in Tennessee, and is the parent of a child diagnosed with AD/HD.

The Center strives to provide resources or information on AD/HD for professional counselors, teachers, and parents, conducts inservices and workshops on AD/HD at the state, regional, and national levels, and maintains a research and publication agenda on the disorder.

A SYSTEMS ORIENTED APPROACH TO AD/HD:

FAMILIES, SCHOOLS, AND COMMUNITIES WORKING TOGETHER

The Center is dedicated to advocating and promoting a Systems Oriented Approach To AD/HD: Families, Schools, and Communities Working Together. A systems oriented approach to AD/HD can be broadly defined as--the development of the child with AD/HD and their ability to function more effectively in their home, in their school, and in their community--can often be related to the education and training on AD/HD that has been conducted or occurred in the major systems that are connected to the affected child's life. The major systems considered here are the following:

THE FAMILY SYSTEM. For example, the parents and siblings comprise the family system; the family system may also be composed of extended or blended family members. It is important for parents (or all family members) to increase their knowledge and understanding of the AD/HD, realize that the disorder has often brought about high stress levels for its members, and that the problem behaviors can be managed more effectively. Importantly, the family needs to understand that the unity of the parents and siblings in fully accepting the child with AD/HD and working collaboratively to foster a supportive and healthy family environment is crucial. This includes the parents' taking responsibility for seeking and supporting appropriate treatment interventions or regimens for the AD/HD.

THE SCHOOL SYSTEM. For example, the school officials, teachers, classmates, and peers comprise the school system. In many instances, by not being educated or trained on the symptoms and problematic behaviors that are often connected to the disorder, school personnel or educators may inadvertently exacerbate the symptoms or problematic behaviors of the child with AD/HD. Unfortunately, classmates or peers at school often relentlessly tease, taunt, devalue, and socially shun many children with AD/HD. For children with AD/HD, these social-emotional experiences with classmates or peers can be indelible in theirmemories. Therefore, schools are the place of choice for also educating students about the AD/HD symptoms and the problem behaviors they may observe.

THE SCHOOL TO FAMILY SYSTEM. For example, the school personnel or educators, parents, and siblings comprise the school to family system. The school and family system need to become clinical allies or form a therapeutic alliance for the identification and behavioral management of the child with AD/HD. Moreover, school systems may be subject to complying with the provisions of the federal acts such as the Individuals With Disabilities Education Act (IDEA), Section 504 of the Vocational Rehabilitation Act, and the Americans With Disabilities Act (ADA). These federal acts can apply to students diagnosed with AD/HD from elementary school through the college years. Schools are becoming increasingly aware of their legal obligation to appropriately serve children and adolescents with AD/HD. For example, these federal acts have often served as an impetus and pointed out the need to increase the inservice education and training for educators on AD/HD children. School systems may need to increase their vigilance for identifying and supplying appropriate interventions, accommodations or variations in classroom instruction and testing practices for AD/HD children. At school, the counselor may consent to serve as a resource person or a case manager for appropriate services or treatment for the child with AD/HD. By forming a school to home partnership and coordinating together the interventions or treatment plan, the likelihood that the AD/HD child can perform more satisfactorily is optimized.

THE FAMILY TO COMMUNITY SYSTEM. For example, the parents and siblings along with the individuals in their community comprise the family to community system. Locale and its prevailing attitudes and sentiments are often the principal components of the community system. However, for the family with an AD/HD child, the community system can refer moreappropriately to the development of social interaction, social cohesion, moral support, and contains the potential for fostering a therapeutic resource or alliance. For example, it is crucial that our communities become better informed or educated on children with AD/HD and their problematic behaviors, rather than focusing on and labeling the dysfunctional elements or parts of the child with AD/HD. The family to community system is the place where the family lives, attends school, engages in recreational activities, has intimate ties, and it is the community that can act as a facilitator for fostering the development of positive mental health for many children with AD/HD. Finally, it is the community that can strongly affect the course of events or the outcomes for families with an AD/HD child.

CHANGING AND RECONSTITUTING SYSTEMS

From a systems oriented approach to AD/HD, all of these systems can be perceived of as changing and reconstituting themselves by becoming more open to scientific, medical, and behavioral explanations for the disorder. For example, many persons who come into contact with an AD/HD child do not know that the child's behavior is not willfully or deliberately planned to confront, undermine, or provoke their parents, teachers, or peers. Instead, becoming educated and understanding how this complex disorder can have life-long effects (e. g., academic, social-emotional, occupational) on the child with AD/HD, and that the actions taken (e. g., positive or negative) in any one system can have reciprocal or circular effects. For example, the AD/HD child's problematic behaviors or actions in any one system can in-turn influence the family, school, and community's reactions to the child. It should be remembered that these reciprocal actions and their consequences can often be imprinted into the life of the child or adolescent with AD/HD.

CLOSING REMARKS

These systems can be viewed as forces working for either the good or to the detriment of the child with AD/HD. There is an interconnectedness among the systems, the actions in one system or any part of it can affect the health or dysfunctionality of the child. The child with AD/HD is an interacting and interactive member of these systems. They are powerful parts of the child's life and they frequently exert a strong influence over not only the child's behaviors, but certainly how their feelings, values, and attitudes evolve towards themselves and others.

A note of caution is probably in order, change in how these systems view and interact with AD/HD children and adolescents will likely be gradual or long-term. By necessity there will need to be a heavy investment in education and training on the disorder.

MULTIDIMENSIONAL TREATMENT FOR AD/HD

Through a systems oriented approach to AD/HD and a multidimensional treatment plan the development of children and adolescents with AD/HD can be enhanced. Perhaps the most important point of information to emerge from the last several years of research on AD/HD is that no single intervention alone is probably going to be successful. The multidimensional treatment approach, moreover, needs to be long-term so as to optimize the child's development. The goal of multidimensional treatment should not be to find a cure. The goal is to provide interventions or strategies that can be important for managing this often chronic and disabling condition. The multidimensional treatment plan enables the professionals and parents to attack the AD/HD from as many avenues as are feasible. Interventions or treatment typically includes some combination of the following:

PARENT EDUCATION. Education for parents and siblings on the AD/HD symptoms and problem behaviors that are associated with the disorder is the necessary first-step. Parent education can be the benchmark upon which further progress for the family may be measured. For example, parent education can explain how the AD/HD symptoms can frequently create in the home and at school, the myriad of problematic behaviors that are often considered disruptive or maladaptive to parents and teachers. Parent education can normally be accomplished in four to six well-planned one-hour sessions from a professional (or a parent support group) that is well-informed and experienced with the disorder. From parent education on AD/HD, parents can be relieved of the guilt that they were somehow the cause of the disorder, they can acquire a better understanding of the disorder, and they can focus their efforts towards improving the quality of life for their AD/HD child.

TEACHER EDUCATION. Educating teachers and school officials on the academic, behavioral, and personal-social problems that students with AD/HD often exhibit provides them the information that they need to work more effectively with these children. As teachers and school officials become better educated about AD/HD students, they can work collaboratively to maximize the interventions or strategies that are targeted at improving the academic, behavioral, and social functioning of these children. Through teacher education on the AD/HD, issues such as educational negligence or malpractice with AD/HD children can then be taken out of the equation. Increasingly, many state departments of education are urging local educational agencies or school districts to come into compliance with federal acts or statutes that can address the need for the identification and treatment of children with AD/HD.

INDIVIDUAL COUNSELING. Professional counselors who work with AD/HD children and adolescents should acknowledge at the onset that many of these children can be a formidable challenge. Often children with AD/HD tend to be in a state of denial about their disorder and their problems. Moreover, many of these children can be oppositional in their attitudes, distrustful of authority figures, have low self-esteem, and see most of their difficulties or problems as being caused by others such as teachers, parents, and peers. Counselors who are remarkably patient and understanding, who can endure more relapses than progress in the beginning sessions or phases of counseling, and who can remain a positive force in the lives of these children often have the most success in forging a therapeutic relationship. Professional counselors should be aware that many children with AD/HD can have coexisting conditions such as learning disabilities, oppositional defiant behavior, excessive anxiety, language usage problems, anger control problems, and can experience depression.

BEHAVIORAL MANAGEMENT TECHNIQUES. Educators and parents should consider that behavioral management techniques or strategies such as time-out, negative reinforcement, cost response measures for inappropriate behavior, contracting, earning rewards and special privileges for appropriate behavior, and cognitive behavioral training (e. g., self-instructional training) coupled with appropriate medical treatment seems to be the most effective treatment for many children with AD/HD. In collaboration with the parents and the school, professionals, parents, and teachers can develop priorities for employing behavioral management techniques that target or address the child's problematic behaviors at school and in the home. It needs to be remembered that behavioral techniques or strategies often need to be varied, adjusted, or changed to meet the problematic behaviors or situations that AD/HD children typically exhibit. It should also be remembered that there is a neurobiological basis for the AD/HD. This suggests that AD/HD children will often need more behavioral structure, more time to come into compliance, and more varied or unique reward systems to effectively promote change in their lives. Furthermore, in June, 1997 changes in IDEA were signed intolaw by President Clinton. One of the key changes, for example, that could be pertinent to schools and parents is the provision dealing with discipline. It is not usual for a child with AD/HD to become involved at some point in their school career, in a disciplinary process thatinvolves their behavior. In determining whether suspension or expulsion from school is allowable, the school or committee must consider: (a) the child's ability to understand or comprehend accurately what he or she did, and (b) their ability to control the behavior involved in the event or problem. The control part of this change can have important factorssuch as did the child have the opportunity to receive appropriate medication and interventions or treatment for the disorder.

SELF-ESTEEM EDUCATION. The major goal of parents, teachers, and counselors for many children with AD/HD needs to be the restoration of their self-esteem. Without realizing it, many parents, teachers, and peers have often been excessively critical of the child, repeatedly complained about their misbehaviors, and unfortunately demeaned or belittled many of their efforts or struggles to improve themselves. For persons who come into contact with AD/HD children, it should be remembered that they have endured many more frustrations and failure experiences in their young lives than other children. At every opportunity, parents and teachers should seek to create or take advantage of opportunities that can foster self-esteem and accomplishment in AD/HD children.

SOCIAL SKILLS EDUCATION. There usually needs to be a strong instructional and training program on social skills education. Unfortunately due to their disorder, many AD/HD children often have a limited or inadequate repertoire of social skills available to them. From the standpoint of many teachers and peers, poor or deficient personal-social skills stand-out almost immediately as the area most in need of improvement. For example, almost everything the child with AD/HD does is viewed as socially different or inappropriate, they often feel that they are being excluded from active participation in their classrooms, and they often feel that their peers further exclude them from many social activities or games at recess. In many instances, the child with AD/HD can also be disinvited by classmates or peers from attempting to play with them after school or on weekends. Instruction and real-life practice in acquiring an improved repertoire of social skills across settings (e. g., school, home) often needs to be a priority for many AD/HD children.

FAMILY COUNSELING. Family counseling is frequently recommended because the AD/HD typically disables the family's communication patterns, is a root cause of family disagreements or arguments, and can lead to marital dysfunction, sibling dissension, and the social shunning of the family by others in their community. Many families need to come to the realization that the child cannot be separated from their disorder. Accepting and nurturing the child with AD/HD from childhood, to adolescence, to adulthood despite the multiple frustrations can be the best form of therapy. For children with AD/HD, the unity of the parents can be crucial to the future direction of their young lives.

In summary, a systems oriented approach to AD/HD and multidimensional treatment for the disorder can compliment and reinforce each other. They share the priority of providing and sharing education on the disorder and fostering a safer psychological environment for providing treatment or services for AD/HD children. It is within the family, school, and community systems that children with AD/HD can learn how to live more successfully and have more fulfilling lives.

THE COLLABORATIVE MULTIMODAL TREATMENT STUDY OF CHILDREN WITH ATTENTION DEFICIT/HYPERACTIVITY DISORDER (AD/HD)(MTA STUDY)

The MTA Study constitutes a landmark in the history of treatment research in child psychopathology; it is the largest single study of its kind ever undertaken for one disorder (AD/HD)(Barkley, 2000). Because the answers to such questions can only be pursued through large scale efforts that generate sufficient sample sizes for powerful tests of treatment effectiveness (e. g., so treatment outcomes can be more properly compared and evaluated), the National Institute of Mental Health (NIMH) launched a collaborative multisite (N=6) clinical trial of Multimodal Treatment of children diagnosed with AD/HD. The NIMH-MTA Study has been in the field since 1992; between 1992 and 1994, 579 children (aged 7-9 years, 11 months) were recruited at participating sites in the United States and one in Canada (Montreal). All the children had primary diagnoses of AD/HD, Combined Type, using Diagnostic and Statistical Manual for Mental Disorders (DSM-IV; American Psychiatric Association, 1994) criteria. In addition to the AD/HD, comorbid or co-occurring aggressive spectrum disorders (e. g., oppositional defiant disorder [ODD], conduct disorder [CD]), anxiety disorders, and affective disorders occurred in the MTA sample at these respective prevalence rates 54%, 34%, and 4%. The subjects in the sample were 61% Caucasian, 20% African-Americans, and 8% Hispanic; males constituted 80% and females 20% of the sample. Children were randomly assigned to one of four experimental groups: (1) an intensive, multifaceted behavior therapy program (BEH) comprised of three integrated components (Parent Training, School Intervention, Child Treatment anchored in a Summer Treatment Program): this program can be referred to as "psychosocial treatment" because of its largely behavioral procedures; (2) a carefully dose-adjusted and monitored medication management program consisting of methylphenidate and other stimulants (MED-MGT); (3) a careful and well integrated combination of the previous two (COMB); and (4) a community comparison group (CC). The CC comparison group allowed for a comparison of the three intensive manual-based treatments to the treatment delivered in the community (e. g., local community care resources). Treatment occurred over 14 months, and assessments were taken at baselines of 3, 9, and 14 months.
After this comprehensive assessment, the global effects of the treatment for the MTA Study of BEH, MED, COMB, and CC groups are summarized below. It should be kept in mind that the MTA Study was indeed large; many of the variables contained in the study are yet to be fully scrutinized for their specific roles. Nonetheless, here are some of the essential findings that I have gained from the study.
First, there were generally superior effects for COMB and MED-MGT compared to BEH or CC on the primary characteristics of AD/HD, including some comorbid conditions. This should not be unexpected: an array of interventions or a multidimensional approach to treatment has long been advocated in the management of this disorder (Barkley, 1990, 1995; Erk, 199, 1997, 2000).
Second, the BEH or psychosocial treatment approach "alone" did produce some effects despite being limited. The amount of gain here probably should have occurred because the study seemed heavily weighted toward the BEH or psychosocial treatment approach. However, Barkley (2000) questioned if such an extensive BEH program could be justified (e. g., now or ever) in homes and schools (e. g., due to its extensive scale). Relevant to the gains made in this approach, Barkley (2000) speculated that the modest differences found between the BEH and CC groups in the MTA Study might be more due to information and therapist attention; these could have accounted for the small differences (e. g., in favor of the HEB group). For example, numerous parent education and behavioral training programs for parents with children diagnosed with AD/HD are already in existence and might obtain much the same results when properly employed. The BEH approach to treatment "means" parents are willingly becoming involved in parent education and training on the AD/HD, and they are learning and actively practicing a range of behavioral interventions designed to benefit the family and the child.
Third, the MED component, which entails no skill training for parents or teachers, achieved equal or superior effects to BEH across nearly all of the outcome domains (e. g., parent-child relations, familial and school functioning) examined in the study (Barkley, 2000). The MTA Study coupled with the incoming lines of scientific and medical information from medical imaging studies (e. g., PET scans, Human Genome Project) should further serve to prompt parents and practitioners to be increasingly receptive to MED-MGT as one of the key players for obtaining improved therapeutic results (e. g., especially where the AD/HD is moderate to severe).
Fourth, only in COMB treatment, not in BEH alone, were there the greatest reductions in negative-ineffective discipline. This finding should be considered among the most vital when treatment options are being planned. For example, success for COMB treatment was evident for important school-related outcomes (e. g., reduction in teacher reported disruptive behavior). Moreover, this finding would appear to be related to reductions in negative and ineffective parenting practices in the home (e. g., reduction in teacher reported disruptive behavior). Moreover, this finding would appear to be related to reductions in negative and ineffective parenting practices in the home (e. g., reciprocal or parent-child interactions; Erk, 1997). Therefore, the home and school environments benefited reciprocally from the COMB treatment.
Fifth, when comorbid symptomatology (e. g., ODD, CD) and functional skills (e. g., academic and social skills) were considered, the group differences among all the treatment groups were smaller. For example, only the COMB treatment was consistently superior to CC when the comorbid conditions were identified. It should be remembered that comorbid symptomatology can be a major disrupter to any treatment that is being utilized; what this finding from the study reinforces is the need for careful assessment of comorbid conditions and that these conditions deserve as much attention (e. g., treatment) as the AD/HD itself. Unfortunately for the child, if the comorbid conditions remain undiagnosed and untreated, the comorbid conditions will often be mistakenly identified as the primary problems. This can lead to the AD/HD remaining at the "core" of the person's difficulties while the disorder can continue as undiagnosed and untreated (Erk, 1997, 2000).
Sixth, COMB significantly outperformed MED-MGT with a small-to-moderate effect size (Hinshaw et al., 2000). This should not be entirely a surprising result; MED-MGT alone is not considered a prudent approach when it is to be used in isolation. Barkley (1990, 1995) recommended that parents should not invest in a MED-MGT only treatment plan. This is because with a MED-MGT only plan, the child is obviously deprived of opportunities to learn or acquire an improved behavioral repertoire (e. g., social and academic skills, enhanced and self-esteem).
Seventh, and last, although overall findings were consistent for boys versus girls, for children with and without prior medication treatment, and subjects with and without disruptive comorbidity, two baseline variables (e. g., comorbidity with anxiety disorder and socioeconomic status) had the effect of moderating some treatment outcomes.
A major limitation of the MTA Study may be the exclusive use of the AD/HD Combined Subtype; it was presumed that hyperactivity, impulsivity and inattention components are incorporated into the Combined Subtype. However, for example, in the Inattentive Subtype there may be different findings and implications for treatment identified for children who are diagnosed with this specific subtype (e. g., see Erk, 2000). Future studies will need to address issues such as this one (e. g., specific subtypes) and the comorbidities that most often co-occur.
The MTA Study and its employment of a multimodal treatment model paves the way for further research and treatment appropriate for children with AD/HD. For example, earlier clinical research (e. g., using parent behavioral training with medication management) for AD/HD children has yielded positive results; this is reinforced by findings contained in the MTA Study (Barkley, 2000). For professionals and practitioners, there is certainly much that is positive and informative from the MTA Study. Undoubtedly, more clinical results will emanate from this research for years to come; the MTA Study should be clinically, scientifically, and educationally examined for every drop of information it can yield on AD/HD and its management. The MTA Study was mammoth and unparalleled in the field of child treatment; for this reason it can be expected to take years, if not decades, to tease out all data that is has to offer researchers and professional practitioners (e. g., teachers, school and mental health counselors, psychologists, physicians).

REFERENCES/SUGGESTED READINGS ON AD/HD

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.), Washington, DC: Author.

Barkley, R. A. (1990). Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. New York: Guilford Press.

Barkley, R. A. (1995). Taking Charge of AD/HD: The Complete Authoritative Guide for Parents. New York: Guilford Press.

Barkley, R. A. (2000). Commentary on the multimodal treatment study of children with AD/HD. Journal of Abnormal Child Psychology, 28, 595-598.

Copeland, E. D., & Love, V. L. (1991). Attention, Please!: A Comprehensive Guide to Parenting Children With Attention Disorders and Hyperactivity. Atlanta, GA: Southeastern Psychological Institute Press.

Erk, R. R. (1995). The Conundrum of Attention Deficit Disorder. Journal of Mental Health Counseling, 17, 131-145.

Erk, R. R. (1995). A Diagnosis of Attention Deficit Disorder: What Does It Mean For School Counselors? The School Counselor , 42, 292-299.

Erk, R. R. (1995). The Evolution of Attention Deficit Terminology. Elementary School Guidance and Counseling, 29, 243-248.

Erk, R. R. (1997). Multidimensional Treatment of Attention Deficit Disorder: A Family Oriented Approach, Journal of Mental Health Counseling, 19, 3-22.

Erk, R. R. (1999). Attention deficit hyperactivity disorders: Counselors, laws, and implications for practice. Professional School Counseling, 2, 318-326.

Erk, R. R. (2000). Five frameworks for increasing understanding and effective treatment of attention-deficit/hyperactivity disorder: Predominantely inattentive type. Journal of Counseling and Development, 78, 389-399.

Friedman, R. J., & Doyal, G. T. (1992). Management of Children and Adolescents With Attention Deficit Hyperactivity Disorder. Austin, TX: Pro-Ed.

Hallowell, E. M., & Ratey, J. J. (1994). Driven to Distraction: Recognizing and Coping With Attention Deficit Disorder from Childhood through Adulthood. New York: Touchstone.

Hinshaw, S. P. et al., (2000). Family processes and treatment outcome in the MTA: Negative/ineffective parenting practices in relation to multimodal treatment. Journal of Abnormal Child Psychology, 28, 555-564.

Hosie, T. W., & Erk, R. R. (1993, January). American Counseling Association Reading Program: Attention Deficit Disorder. American Counseling Association Guidepost, 35, 15-18.

Learner, J. W., Lowenthal, B. & Learner, S. R. (1995). Attention Deficit Disorders: Assessment and Teaching. Pacific Grove, CA: Brooks/Cole.

Nadeau, K. G. (1995). A Comprehensive Guide to Attention Deficit Disorder in Adults: Research, Diagnosis, and Treatment. New York: Brunner/Mazel.

Reif, S. F. (1993). How To Reach And Teach ADD Children. West Nyack, NY: Center for Applied Research In Education

Shaywitz, S. E., & Shaywitz, B. A. (1992). Attention Deficit Disorder Comes of Age: Toward the Twenty-First Century. Austin, TX: Pro-Ed.

Disclaimer: The information contained on this web page is intended to be for informational purposes only. It is not intended as psychological or medical advice. Individuals who are diagnosed with AD/HD should secure information and recommendations on AD/HD from their treating professional. A systems oriented approach to AD/HD with families, schools, and communities working together and multidimensional treatment for AD/HD are the focus of this web page and its contents. The University of Tennessee at Martin is not responsible for the information or views expressed herein. Last updated April, 2001. Copyright 1997. All rights reserved. Email: rerk@utm.edu

INTERESTING LINKS FOR MORE INFORMATION ON AD/HD

  • Children and Adults With Attention Deficit Disorders (CHADD)
  • School Psychology Resources Online
  • Internet Mental Health
  • American Counseling Association
  • American School Counselor Association
  • American Mental Health Counselors Association
  • American Psychological Association
  • American Psychiatric Assocation
  • Attention-Deficit Disorder Archives-Legal
  • National Institute of Mental Health
    This is the time this file has been accessed.

    Email: rerk@utm.edu