Treatment Resistance in Youths With ADHD and Comorbid Conditions

Considering that ADHD has significant effects on cognitive, emotional, and behavioral domains of functioning, it is not surprising that medication treatment alone frequently does not induce remission, especially in patients with comorbidities. It is important to introduce psychosocial interventions in addition to pharmacotherapy to maximize outcomes. According to the American Academy of Child and Adolescent Psychiatry ADHD practice parameters, parent training in child behavior management techniques, family-oriented cognitive-behavioral therapy, social skills training, and school-based interventions are essential ingredients of a comprehensive multimodal treatment plan.¹³ Moreover, the parameters state that comorbid conditions must also be treated (Table 3).

Recently, Chronis and colleagues²⁸ published a comprehensive review of the evidence for psychosocial treatments of ADHD. A number of these studies show that manualized parent training resulted in reductions in parenting stress and improvements in child social behavior and acceptance. Behaviorally based classroom interventions (such as daily report cards and contingency management programs) were also shown to improve classroom deportment and academic performance.

Academic interventions, such as task and instructional modification, homework assistance, peer tutoring, computer-assisted instruction, and strategy training, seem to benefit children with ADHD; however, there is a paucity of studies from which to derive valid estimates of treatment effect sizes. Large behavioral effects on both core symptoms and functional measures (eg, following rules, sports skills, self-esteem) have been demonstrated by summer treatment programs such as those that were incorporated in the MTA study. Also, social skills training interventions, while less studied than other approaches, have shown promise, especially when combined with parent training.

With respect to interventions for adolescents with ADHD, far less is known than with children because there is nothing comparable to the MTA study. The absence of well-controlled studies combining medication and psychosocial treatment of adolescents with ADHD underscores the desperate need for more extensive research with this age group, especially in view of the serious health risks (eg, driving, sexual activity, substance abuse) faced by teenagers in the United States.

A study comparing behavior management training, problem solving, communication training, and structural family therapy found comparable improvements in various functional measures (eg, parent-child communication and conflict resolution, internalizing and externalizing symptoms, parent- reported school adjustment).²⁹ A later study of the first 2 interventions (alone and in combination) found similar results.³⁰ Group-based training for parents of adolescents with ADHD has also shown some promising results.³¹

A literature review of academic interventions³² reported that school-based interventions appear to have moderate to large effects on specific behavioral targets (eg, reduced off-task behaviors, classroom disturbance) and academic performance, but only minimal gains have been seen in social functioning. As Weiss and colleagues³³ have observed, there is dire need for more efficacy studies of outcomes in ADHD that can "tell us how our treatments meet the patient's expectation to be able to achieve a particular functional target."