The child’s perceptions (and potential anxieties) about his or her difficulties also must be understood, validated, and addressed. Children are more likely to engage in a treatment if they participate in the decision to adopt it.
Anxiety can heighten vigilance in the child or the parents to treatment-emergent side effects, which you may exacerbate by providing exhaustive lists of potential ad-verse events. Limit discussion to serious side effects—with emphasis on their rarity—and those that are common.
ADHD traits in families can affect treatment success. Because of their own distractibility and organizational difficulties, parents with ADHD traits may have difficulty ensuring the child’s medication adherence and treatment participation.16
Behavior modification can require a high degree of consistency in parents’ behavior toward the child. This may be difficult to achieve in families where:
- 1 or both parents are inattentive because of ADHD
- a high degree of conflict exists between parents.
To help these families, provide reminder calls about appointments and schedule sessions at a consistent time. To improve consistency of medication use:
- combine medication administration with an essential daily activity
- check adherence with pill counts or other means.
If the child participates in CBT, provide separate notebooks for in-session and homework exercises—anticipating some loss of homework notebooks.
Individualizing care
Individualized care is important to return each child to his or her best possible level of functioning. The child’s symptom profile, environment, and developmental level can affect treatment.
For example, in a child whose ADHD-related impairment is substantial but whose anxiety-related impairment is mild, pharmacotherapy for ADHD and some pa-rental guidance may be adequate to manage remaining anxiety symptoms.17 As mentioned, some children show decreased anxiety as their ADHD is better controlled.4 Conversely, if ADHD-related impairment is mild but the child is highly anxious, consider CBT alone—preferably on an individual basis—provided the child can manage the cognitive aspects of therapy.
School personnel can monitor change in relation to various interventions, as many of these children’s symptoms manifest in the classroom. Behavioral interventions are more likely to succeed if they are administered consistently across home and school environments8 and teachers participate in behavior modification.
To elicit cooperation from school personnel, listen to their concerns and observations and help them understand the child’s difficulties and the rationale for various treatments. This approach often reduces negative feedback toward the child, a benefit that may further improve outcomes.
Attention to peer relationships and social stressors is often needed. Because of their multiple difficulties, these children may lack social skills and be shunned by their peers.1 You may need to help them develop social skills and reconnect with their peers after symptoms are well-controlled.
Poverty or lack of social support can affect treatment. Children with ADHD and anxiety usually need multiple interventions, and it is difficult for families to at-tend to these consistently when struggling with social stressors.
Behavioral interventions used in the MTA study
The 14-month intensive behavioral intervention used in the National Institute of Mental Health’s Multimodal Treatment Study (MTA) of 579 children age 7 to 9 with ADHD included:
- weekly parent training initially, decreasing to monthly by the end
- biweekly teacher consultations in behavior management
- 8-week full-day therapeutic summer program for children, focusing on behavioral and cognitive behavioral intervention
- 12-week half-time behaviorally trained paraprofessional aide in the classroom to generalize gains from summer program
- parent coaching on collaborating with teacher long-term so therapeutic consultation could be faded.
ADHD: attention-deficit/hyperactivity disorder
Adolescent adjustments. ADHD and anxiety often are diagnosed in the early school years, so anticipate developmental effects on treatment as the child enters adolescence. Adolescents value autonomy and may need to be more involved in treatment decisions than younger children.
Ask about and address family disagreements about treatment options, which may reduce adherence. You may need to talk about peer pressure to “not take drugs” by clearly differentiating the reasons some people take street drugs and the reasons for taking prescribed medication. Also discuss in a frank, nonjudgmental manner the risks of experimenting with street drugs (especially with prescribed medication) or of “sharing” one’s medications with friends.
Increased cognitive sophistication in adolescence may increase the potential benefit of CBT, so explore this option with the teen, especially if it was not attempted in the past.
Related resources
- American Academy of Child and Adolescent Psychiatry. “ADHD—a guide for families,” under the Resources for Families tab. www.aacap.org.
- Watkins C. Stimulant medication and ADHD. www.ncpamd.com/Stimulants.htm.
- Manassis K. Keys to parenting your anxious child. 2nd ed. Hauppauge, NY: Barron’s Educational Series, Inc.; 2008.