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Article Excerpt
The purpose of this article is to discuss evidenced-based treatment for 7- to 1O-year-old children experiencing ADHD (combined type) with the goal of potentially informing "real-world" mental health counselor practice. This article first discusses the results of the landmark Multimodal Treatment Study of Children with ADHD (MTA; MTA Cooperative Group, 1999a). Then, clinical implications of this well controlled study for outpatient practice are addressed. Specifically, a family-based, behaviorally oriented, multimodal, and multisystemic approach is suggested by the study. The comprehensive treatment approach includes parent management training, school interventions, and medication. Common treatment considerations relevant to working with child ADHD are discussed.
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Attention-deficit/hyperactivity disorder (ADHD) is a complex and chronic mental health disorder involving problems with inattention and hyperactivity-impulsivity developmentally inconsistent with the age of the child. Behavioral disinhibition appears to be a central feature of child ADHD (Barkley, 1997a). Child ADHD seems to be a disorder of performance rather than a skills and/or knowledge problem. As Barkley (1998a) notes, child ADHD involves a problem "of doing what one knows, rather than knowing what to do" (p. 69). It is estimated that 3% to 7% of school-age children (most frequently males) experience ADHD disorder (American Psychiatric Association, 2000). Moreover, child ADHD referrals constitute a significant proportion of child referrals for mental health services (Goldman, Genel, Bezman, & Slanetz, 1998; Popper, 1988). ADHD significantly impacts the child's emotional, family, school, and social functioning (Barkley, 1998b). Furthermore, comorbid disorders are common including oppositional defiant disorder, conduct disorder, and learning disorders (Barkley, 1996).
Due to the complexity, chronicity, prevalence, and multisystem impact of child ADHD, mental health counselors' knowledge and use of effective outpatient treatment for children experiencing ADHD is imperative. Yet, how can counselors find out about effective treatment such that they can use it in their day-to-day practice? The most accurate resource for counselors is the treatment outcome literature, which is primarily published in professional journals. However, there are many good reasons why counselors do not access the outcome research concerning child ADHD. First, counselors might not know how to conduct literature searches to locate relevant journal articles. Second, treatment outcome articles can be "boring" and not one's first choice for reading material. Third, the articles can be difficult to understand and possibly not relevant to daily practice. Fourth, counselors in full-time outpatient practice often have little time to read in the context of seeing many clients, keeping up with written documentation requirements (e.g., progress notes), and case management responsibilities (e.g., returning phone calls).
The purpose of this article is to discuss the clinical implications of recent treatment efficacy research concerning child ADHD with the goal of informing mental health counselor outpatient practice in a potentially useful manner. This article is written in an attempt to "translate" the results such that they are clinically meaningful to practitioners. In essence, I am attempting to address the following challenge: "What can mental health counselors `take' from the evidenced-based ADHD outcome research that will inform their practice in the next hour with a child experiencing ADHD?" Although this is not a how-to article, it is hoped that mental health counselors can utilize the information in their clinical settings. I first discuss a recent landmark National Institute of Mental Health sponsored study (MTA Cooperative Group, 1999a) and follow-up report (Conners et al., 2001). Then I discuss clinical implications to potentially inform "real-world" practice.
THE MTA STUDY
The Multimodal Treatment Study of Children with ADHD (MTA; MTA Cooperative Group, 1999a) is the largest and most well-controlled study in child mental health. The details of this study are discussed in many articles (e.g., MTA Cooperative Group, 1999a; MTA Cooperative Group, 1999b). Hence, I only briefly address the study here. The overall purpose of the study concerned what is the most efficacious treatment for child ADHD (combined type) over a 14-month period of time: medication (MED), behavioral treatment (BEH), combined treatment (COMB; medication and behavioral treatment), and routine community care (CC; "treatment-as-usual" which turned out to be medication for approximately 67% of the children). In essence, "Cadillac" versions of intensive state-of-the-art treatment approaches (MED, BEH, and COMB) were compared with each other and with "treatment-as-usual" (CC). There were 19 measures of six dependent variables: (a) ADHD symptoms, (b) aggression-oppositional defiant disorder, (c) internalizing symptoms, (d) social skills, (e) parent-child relations, and (f) academic achievement.
Characteristics of the Children
The study participants were 579 children (80% males), 7 to 9.9 years of age, who were randomly assigned to the aforementioned four treatment groups at each of six sites in the United States and in Canada. All the children were diagnosed as experiencing ADHD, combined type. The three most common comorbid disorders were oppositional defiant disorder (39.9%), anxiety disorders (33.5%), and conduct disorder (14.3%). Approximately 61% of the children were White, 20% African-American, and 8% Hispanic. The educational levels of mothers and fathers were 94% and 90% high school educated respectively. Approximate income levels of the families were: 21% in the $0 to $20,000 range, 41% in the $20,000 to $50,000 range, and 36% greater than $50,000. Household family composition was 69% two-parent households and 30% one-parent households. The relative heterogeneity of the participant sample has broad applicability to the outpatient practice of many mental health counselors.
Description of Treatment Groups
The BEH...
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