Which treatments are effective for ADHD?

Elementary school teachers in the Netherlands are increasingly experiencing burnout symptoms (DUO Onderwijsonderzoek, 2016). This makes it likely that the quality of education will suffer, with teachers mainly pointing out that having too many students in a classroom in need of additional assistance due to some form of psychopathology is increasing the workload (DUO Onderwijsonderzoek, 2016). One fairly common issue – at three to seven percent of the children in a classroom – is the presence of attention-deficit/hyperactivity disorder (ADHD), a neurodevelopmental disorder in which a child mainly presents with problems controlling impulses, remaining concentrated on the task at hand, and hyperactivity (Wilmhurst, 2015; Centers for Disease Control and Prevention, 2019). Next to making the already challenging task of an elementary teacher more straining, the disorder is associated with a range of negative outcomes, such as the presence of comorbid disorders, family problems and substance abuse (DUO Onderwijsonderzoek, 2016; Wilmhurst, 2015). To minimize these adverse effects and alleviate some of the workload of educators, it is essential to tackle this disorder (DUO Onderwijsonderzoek, 2016; Wilmhurst, 2015; Centers for Disease Control and Prevention, 2019).

ADHD is a persistent and heterogeneous disorder that consists of several subtypes (Wilmhurst, 2015). While it may be useful to tailor interventions to these subtypes (Barnard, Stevens, To, Lan, & Mulsow, 2009; Abikoff, 2001), the best results in treating ADHD may be obtained by targeting the theorized causes of ADHD as knowledge of the mechanisms of change allows for optimization of an intervention (Moldovan & Pintean, 2015; Kangaslampi & Peltonen, 2019). According to the dual pathway model of ADHD (Sonuga-Barke, 2002), the disorder consists of deficits in executive function and impairments in the motivational and reward system. The former pathway is reflected in both symptoms of hyperactivity/impulsivity (Franke et al., 2018; Dovis, van der Oord, Wiers, & Prins, 2012) and inattention (Franke et al., 2018) while the latter pathway is mainly associated with hyperactive and impulsive symptoms (Boyer, 2021). Following this model, it may be that interventions tailored to either of these pathways are useful in ameliorating ADHD symptoms.

Steiner, Frenette, Rene, Brennan, and Perin (2014) compared two interventions – both of which are aimed at reducing ADHD symptoms by improving executive functioning – with each other and a control group. The definition of executive function is controversial but most definitions include, among other things, working memory, shifting and inhibition (Zelazo, & Müller, 2011). The first treatment, cognitive feedback, uses feedback to reinforce correct responses on a task and this is believed to improve attention, impulsivity and working memory (Klingberg et al., 2005; Rabiner, Murray, Skinner, & Malone, 2009). While this mainly focuses on the response of the child, the second intervention, neurofeedback, focuses feedback on a person’s attention level. Direct auditory and visual feedback allows for better monitoring of one’s situation and this is believed to improve executive function through changing one’s brainwave patterns (Heinrich, Gevensleben, & Strehl, 2007). Both treatments showed significant improvements on measures of ADHD compared to the control and the results were maintained over six months. Surprisingly, the participants in the neurofeedback condition scored better than those in the cognitive feedback group, even though both treatments are believed to improve executive functions (Klingberg et al., 2005; Rabiner et al., 2009; Heinrich et al., 2007). Of particular interest is that the use of stimulant medication increased in the cognitive feedback and control group. While usage is understandable, as this is a common treatment for ADHD (Centers for Disease Control and Prevention, 2020; Daley et al., 2014), it may have confounded the results since medication is believed to have a direct effect on symptoms (Daley et al., 2014). Participants did not increase their stimulant medication use in the neurofeedback condition while showing the greatest improvements on measures of ADHD. This implies that medication may negatively impact the effectiveness of behavioural interventions. Alternatively, the interaction between medication and the treatment may be essential, meaning that the change in dose could have led to the change, rather than medication use itself. Indeed, research has shown that stimulant medication may enable treatments to become effective (Franke et al., 2018). While Steiner et al. (2014) demonstrated that ADHD symptoms can be reduced by improving executive function, it may be useful to scrutinize the second pathway of the dual pathway model (Sonuga-Barke, 2002), as the interaction between stimulant medication use and executive function improvement cannot be excluded.

Children with ADHD may underperform tasks due to executive function deficits but they often also appear to be unmotivated (Sonuga-Barke, 2002; Dovis et al., 2011) and rarely show task persistence (Dovis et al., 2011). Nonetheless, parents report that this is not the case for some activities (Boyer, 2021), such as videogames (Carlson, Booth, Shin, & Canu, 2002; Boyer, 2021). This implies that interventions aimed at enhancing motivation may be successful in improving task performance and decreasing ADHD symptoms. To further analyze this matter, Dovis et al. (2011) investigated the role of reinforcement on task performance. They differentiated between four types of reinforcement; feedback, low reward, high reward, and computer-based reward. While – for children with ADHD– every form of incentive improved performance compared to only receiving feedback, performance did not reach the level of controls. Computer-based rewards and higher monetary rewards did not differ,  and both outperformed smaller incentives. It is unrealistic to continuously provide the child with financial incentives, thus video games may be a useful method of improving task performance and persistence. The effectiveness of using technology-based rewards may be explained by the reinforcement pattern. Given that a child with ADHD is very sensitive to rewards (Dovis et al., 2011; Sonuga-Barke, 2002; Boyer, 2021) and the reward pattern, as is the case with videogames, is continuous and immediate (Sault, 2015), this may have explained the improved task performance. Similarly, task persistence may be enhanced by employing a comparable pattern as the child with ADHD is easily distracted (Wilmhurst, 2015) and invariably looking for new rewards (Dovis et al., 2011; Boyer, 2021). Indeed, Dovis et al. (2011) found that by utilizing this method, task persistence improved and normalized with the highest incentives and the computer-based intervention. While the relationship between reinforcement and stimulant medication has not fully been explored yet (Dovis et al., 2011), it may have an additive effect on interventions aimed at the motivation and reward system since stimulant medication increases dopamine levels in the brain (Zuvekas & Vitiello, 2012; Heal, Smith, Gosden, & Nutt, 2013) and the reward system is a dopaminergic system (Arrias-Carrión, Stamelou, Murillo-Rodríguez, Menédz-Gonzáles, & Pöppel, 2010; Volkow et al., 2010). Although providing reinforcement may not directly treat ADHD, as the symptoms may recur when incentives are removed (Dovis et al., 2011), motivation may be an essential aspect of interventions aimed at ADHD. Enhancing motivation may optimize treatments and could allow for better management of the disorder.

By aiming treatment at improving executive functioning, it is possible to obtain both a reduction in ADHD symptoms and achieve a lasting change (Steiner et al., 2014). Furthermore, treatment aimed at increasing motivation allows for improving task performance and persistence (Dovis et al., 2011). Thus, by tackling the theorized underlying mechanisms of ADHD, it is possible to alleviate some of the adverse effects of the disorder (Sonagu-Barke, 2002; Steiner et al., 2014; Dovis et al., 2011). In addition to this, it can allow for optimalization of present and future treatments (Moldovan & Pintean, 2015; Kangaslampi & Peltonen, 2019) such as by making interventions more engaging through the use of videogames (Dovis et al., 2011; Boyer, 2021; Sault, 2015). Albeit the relationship between behavioural interventions aimed at improving the hypothesized causal mechanisms of ADHD with stimulant medication has not been fully explored, it is an effective method of decreasing symptoms (Franke et al., 2018; Daley et al., 2014; Arnold et al., 2003; Dovis et al., 2011). The best outcomes are obtained when the child is able to choose the treatment of preference from the vast number of treatments targeting different developmental pathways of ADHD (Boyer et al., 2016; Dovis et al., 2011; Frenette et al., 2014). This may be due to the heterogeneity of the disorder (Wilmhurst, 2015; Boyer et al., 2016). To conclude, there is no ‘perfect’ treatment for a heterogeneous disorder such as ADHD (Wilmhurst, 2015; Dovis et al., 2011; Frenette et al., 2014). It is important to personalize treatment (Abikoff, 2011) and, importantly, listen to the one who it is all about; the child with ADHD (Boyer et al., 2016). By doing this, the negative outcomes of ADHD can be reduced and some of the workload of elementary school teachers can be alleviated, leading to higher quality education.

Reference list

Abikoff, H. (2001). Tailored psychosocial treatments for ADHD: The search for a good fit. Journal of Clinical Child & Adolescent Psychology, 30(1), 122–125. https://doi.org/10.1207/s15374424jccp3001_14

Arias-Carrión, O., Stamelou, M., Murillo-Rodríguez, E., Menédez-Gonzáles, M., & Pöppel, E. (2010). Dopaminergic reward system: A short integrative review. Int Arch Med, 3–24. https://doi.org/10.1186/1755-7682-3-24

Arnold, L. E., Elliott, M., Sachs, L., Bird, H., Kraemer, H. C., Wells, K. C., … Wigal, T. (2003). Effects of ethnicity on treatment attendance, stimulant response/dose, and 14-month outcome in ADHD. Journal of Consulting and Clinical Psychology, 71(4), 713–727. https://doi.org/10.1037/0022-006x.71.4.713

Barnard, L., Stevens, T., To, Y. M., Lan, W. Y., & Mulsow, M. (2009). The importance of ADHD subtype classification for educational applications of DSM-V. Journal of Attention Disorders, 13(6), 573–583. https://doi.org/10.1177/1087054708326433

Boyer, B. (2021, February 17). ADHD and behavioral problems [Slides]. Retrieved from https://canvas.uva.nl/courses/21056/pages/lecture-3-adhd-and-behavioral-problems-slides-and-audio?module_item_id=846889

Boyer, B. E., Doove, L. L., Geurts, H. M., Prins, P. J. M., Van Mechelen, I., & Van der Oord, S. (2016). Qualitative treatment-subgroup interactions in a randomized clinical trial of treatments for adolescents with ADHD: Exploring what cognitive-behavioral treatment works for whom. PLOS ONE, 11(3), 1–23. https://doi.org/10.1371/journal.pone.0150698

Carlson, C. L., Booth, J. E., Shin, M., & Canu, W. H. (2002). Parent-, teacher-, and self-rated motivational styles in ADHD subtypes. Journal of Learning Disabilities, 35(2), 104–113. https://doi.org/10.1177/002221940203500202

Centers for Disease Control and Prevention. (2019, November 7). ADHD in the classroom | CDC. Retrieved 24 February 2021, from https://www.cdc.gov/ncbddd/adhd/school-success.html

Centers for Disease Control and Prevention. (2020, September 21). Treatment of ADHD | CDC. Retrieved 26 February 2021, from https://www.cdc.gov/ncbddd/adhd/treatment.html

Daley, D., van der Oord, S., Ferrin, M., Danckaerts, M., Doepfner, M., Cortese, S., & Sonuga-Barke, E. J. S. (2014). Behavioral interventions in attention-deficit/hyperactivity disorder: A meta-analysis of randomized controlled trials across multiple outcome domains. Journal of the American Academy of Child & Adolescent Psychiatry, 53(8), 835–847. https://doi.org/10.1016/j.jaac.2014.05.013

Dekkers, T. (2020, September 11). Development of ADHD [Slides]. Retrieved from https://canvas.uva.nl/courses/18583/pages/september-11-development-of-adhd?module_item_id=635199

Dovis, S., Van der Oord, S., Wiers, R. W., & Prins, P. J. M. (2011). Can motivation normalize working memory and task persistence in children with Attention-Deficit/Hyperactivity disorder? The effects of money and Computer-Gaming. Journal of Abnormal Child Psychology, 40(5), 669–681. https://doi.org/10.1007/s10802-011-9601-8

DUO Onderwijsonderzoek. (2016, January). Rapportage werkdruk leerkrachten in het basisonderwijs. Retrieved from https://www.duo-onderwijsonderzoek.nl/wp-content/uploads/2016/01/Rapportage-Werkdruk-Leerkrachten-PO-8-januari-2016-1.pdf

Franke, B., Michelini, G., Asherson, P., Banaschewski, T., Bilbow, A., Buitelaar, J. K., … Reif, A. (2018). Live fast, die young? A review on the developmental trajectories of ADHD across the lifespan. European Neuropsychopharmacology, 28(10), 1059–1088. https://doi.org/10.1016/j.euroneuro.2018.08.001

Heal, D. J., Smith, S. L., Gosden, J., & Nutt, D. J. (2013). Amphetamine, past and present – a pharmacological and clinical perspective. Journal of Psychopharmacology, 27(6), 479–496. https://doi.org/10.1177/0269881113482532

Heinrich, H., Gevensleben, H., & Strehl, U. (2007). Annotation: Neurofeedback - train your brain to train behaviour. Journal of Child Psychology and Psychiatry, 48(1), 3–16. https://doi.org/10.1111/j.1469-7610.2006.01665.x

Kangaslampi, S., & Peltonen, K. (2019). Mechanisms of change in psychological interventions for posttraumatic stress symptoms: A systematic review with recommendations. Current Psychology, 1–18. https://doi.org/10.1007/s12144-019-00478-5

Klingberg, T., Fernell, E., Olesen, P. J., Johnson, M., Gustafsson, P., Dahlström, K., … Westerberg, H. (2005). Computerized training of working memory in children with ADHD- a randomized, controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 44(2), 177–186. https://doi.org/10.1097/00004583-200502000-00010

Moldovan, R., & Pintea, S. (2015). Mechanisms of change in psychotherapy: Methodological and statistical considerations. Cognition, Brain, Behavior. An Interdisciplinary Journal, 4, 299–311. Retrieved from https://www.researchgate.net/publication/296431413_Mechanisms_of_change_in_psychotherapy_Methodological_and_statistical_considerations

Rabiner, D. L., Murray, D. W., Skinner, A. T., & Malone, P. S. (2009). A randomized trial of two promising computer-based interventions for students with attention difficulties. Journal of Abnormal Child Psychology, 38(1), 131–142. https://doi.org/10.1007/s10802-009-9353-x

Sault, D. M. (2015, October). The influence of videogame reinforcement schedules on game play duration. Retrieved from https://eprints.utas.edu.au/23558/1/Sault_whole_thesis.pdf

Sonuga-Barke, E. J. S. (2002). Psychological heterogeneity in AD/HD—a dual pathway model of behaviour and cognition. Behavioural Brain Research, 130(1–2), 29–36. https://doi.org/10.1016/s0166-4328(01)00432-6

Steiner, N. J., Frenette, E. C., Rene, K. M., Brennan, R. T., & Perrin, E. C. (2014). In-school neurofeedback training for ADHD: Sustained improvements from a randomized control trial. Pediatrics, 133(3), 483–492. https://doi.org/10.1542/peds.2013-2059

Volkow, N. D., Wang, G.-J., Newcorn, J. H., Kollins, S. H., Wigal, T. L., Telang, F., … Swanson, J. M. (2010). Motivation deficit in ADHD is associated with dysfunction of the dopamine reward pathway. Molecular Psychiatry, 16(11), 1147–1154. https://doi.org/10.1038/mp.2010.97

Wilmshurst, L. (2015). Essentials of child and adolescent psychopathology (Second edition). Hoboken, NJ, United States: Wiley.

Zelazo, P. D. (2011). Executive function in typical and atypical development. In U. Goswami (Ed.). The Wiley-Blackwell Handbook of Childhood Cognitive Development, Second Edition, 574–603. https://doi.org/10.1002/9781444325485

Zuvekas, S. H., & Vitiello, B. (2012). Stimulant medication use in children: A 12-year perspective. American Journal of Psychiatry, 169(2), 160–166. https://doi.org/10.1176/appi.ajp.2011.11030387