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Evaluating ADHD as an Intervention By Debra Clough Stokan, M.D.

It has been established that children with ADHD have high rates of comorbidity and dysfunction in many areas. Numerous studies have looked at the most effective treatment modalities. The stimulants certainly address attention and concentration, and have been shown to be equally effective in decreasing the aggressive behaviors frequently associated with ADHD children. Behavior therapy also continues to play an extremely important role in ADHD treatment for all subtypes. Studies have shown that it has an additive effect to medication treatment.

MULTIPLE DIMENSIONAL APPROACH
We have more choices than ever with stimulant medications. Using different formulations, we attempt to tailor the medications to fit the needs of individual patients. Doing this, we take into consideration all the possible areas that ADHD is causing dysfunction – school, family, social and even sports.

However, in developing and helping a patient and his family work a behavioral program, we get a crystal clear picture of the unique struggles the patient and his family face. Using the behavior program, it becomes clear whether difficulty following through on tasks is secondary to pure attention/concentration/follow-through issues or one of those comorbid conditions that often lurk under the cover of the ADHD diagnosis. Anxiety, learning disorders, depression or other mood disorders, and Post Traumatic Stress Disorder are all examples of the less obvious comorbid diagnosis. The disruptive behavior disorders typically present more obviously, particularly when exploring family dynamics.

INDIVIDUAL ASSESSMENT
Because of the high rate of comorbidity with ADHD children, as well as many different aspects of the child's life potentially affected by the disorder, it is critical to look at each child individually. After examining how ADHD affects this particular child, it is then necessary to understand how this child functions in the different worlds he must operate in, such as family, school, social, and chosen activities. Evaluating a child's functioning as influenced by multiple motivating factors assists in determining his personal strengths and weaknesses. An individualized behavior plan capitalizes on the strengths to reinforce self-esteem. Additionally, the behavior plan assists the evaluator and parents identify areas of weakness resulting from ADHD classic symptoms versus oppositionality or another comorbid diagnosis. In this regard, the behavioral treatment plan is the perfect complement to medication treatment. By following the concrete data reflected by the behavioral plan, the evaluator gains clear evidence of medication efficacy. Medication can then be adjusted more reliably without complete reliance on the subjective memories of parents and teachers. It also becomes more evident when medication alone will not be effective and more intense therapy is required.

PARENTAL INVOLVEMENT
Although building a child's self-esteem through positive reward can never be underestimated, I believe that simply the process of parents joining together to discuss a reasonable plan of behavior and consequences for their child is an invaluable intervention. Parents and researchers agree that raising an ADHD child is stressful, often leading to elevated levels of family dysfunction. The increased incidence of ADHD in children whose parents also have the disorder makes it unclear whether stress was always present as a result of the parent's symptomatology. A parent with ADHD that is untreated can have devastating effects on the ADHD child's development. Regardless, parenting an ADHD child remains challenging. By creating a family-agreed-upon tool to face the challenge, the behavior plan will likely alter negative family cycles in a dramatic fashion.

THE COMMITMENT
One of the primary reasons that behavior and family therapy are not undertaken more often is the constraint of time and family finances. When compared to the already hectic daily schedule the family faces, the additional "burden" of time and financial commitment required when initially seeking help may seem unnecessary. However, children with ADHD, and especially ADHD with comorbid diagnosis, are at increased risk for many problems. The behavioral plan is a tool to assist families in changing negative patterns, such as oppositional behavior. The behavioral plan builds structure and teaches the child, who has been living with disorganization, tools to become more organized. Once learned, these tools are carried for a lifetime. Behavioral plans highly reward patience and teach the value of delayed gratification.

COSTS OF NOT TREATING
In the absence of improved structure and the ability to delay gratification while still feeling successful, many of these children look for distraction from school, family and social struggles. The "distractions" are often extremely costly to the family – a cost often overlooked. Repeated studies have shown increased risk for substance abuse and performing below academic potential. The costs of substance abuse, resulting poor functioning, treatment and possible legal consequences are difficult to estimate. For example, years of college tuition may go wasted as the young adult struggles. The emotional costs resulting from the stress caused by years of conflict and dealing with negative behaviors is similarly difficult to quantity. What is the cost of poor self-esteem?

DISCUSSION OF OPTIONS
When an evaluator observes the negative patterns responsible for creating these risks, it is his/her responsibility to educate the family regarding treatment options. This education includes not only the risks and benefits of medication, but also the risks and benefits of behavior management. Discussions should include the potential negative consequences defined by studies when ADHD and its frequent comorbid diagnosis go untreated.

CONCLUSION
Certainly, some of the children and adolescents I evaluate do very well with medication alone. Many of the families I see have already found parenting tools that work well. However, without a thorough, objective evaluation, it cannot be determined whether full potential is being met and family dynamics are truly as presented. Completing this comprehensive evaluation at the onset of treatment may save precious time, creating the positive intervention we all hope to achieve.

The Medication Corner, provided by the Tarnow Center for Self-Managementsm, is a featured article in each of the ADDA Newsletters. The article will provide you with the latest information and research about the medications that are being used to treat Attention Deficit Disorder. Debra C. Stokan, M.D., and Jay Tarnow, M.D. will keep you abreast of all the latest happenings in the medical community. In order for us to address your needs, we would like to encourage you to "ask the professionals" your questions. Write the Tarnow Center for Self-Managementsm with your questions and we will see that they are answered in each edition of the newsletter. You may contact us at: Tarnow Center for Self-Managementsm: The Medication Corner, 1001 West Loop South #215, Houston, Texas 77027, or fax: (713) 621-7015, or call: (713) 621-9515, or visit www.tarnowcenter.com.