by Brittany M. Merrill, MS, Amy R. Altszuler, MS, & William E. Pelham, PhD
Children with ADHD experience problems in daily life functioning in school, with their family, and with peers. Rather than focusing on symptoms of ADHD, treatment providers should focus on these impairments in daily life functioning when making recommendations, as these problems are the reason parents and teachers are concerned about the child. For example, the fact that a child with ADHD moves around too much isn’t the functional problem that his parents worry about or spend time fixing. This child’s parents are likely much more concerned that moving around too much is making it difficult for this child to complete homework or get along with other kids. Which treatments improve these difficulties in daily life functioning? Our lab has been studying how behavioral treatments, medication, and their combination work for improving difficulties in daily life across settings and how treatments should be sequenced (Fabiano et al., 2007; Pelham et al., 2014, 2016). Here, we are going to focus on recent findings on two understudied domains of childhood functioning in ADHD: homework problems and sports skills deficits. We conducted these studies in the context of an NIMH-funded clinical trial of stimulant medication for ADHD children (R01-MH099030).
The evidence is clear that medication, behavioral therapy, and their combination lead to improved classroom behavior and class work completion among children with ADHD (Evans, Owens, & Bunford, 2014; Pelham & Fabiano, 2008). However, there is surprisingly less research on the impact of these treatments on homework problems among children with ADHD, despite research showing that homework performance predicts long-term academic success among children with ADHD (Langberg et al., 2011). Available studies show that behavioral treatment produces clear effects on homework performance among children with ADHD (Langberg et al., 2010). Specifically, behavioral parent training (BPT) programs focused on homework problems have resulted in improved parent-reported homework problems (Power et al., 2012), but the effects of medication had not been studied.
Based on this research, we conducted a randomized clinical trial comparing how long-acting stimulant medication, BPT (based on Power et al., 2012), and their combination improve actual homework performance and parent rated homework problems among children with ADHD (Merrill et al., 2017). Children in this study (n=75) were also attending a Summer Treatment Program (STP; Pelham et al., 2010), an evidence-based program for children with ADHD. Half of the families were assigned to the homework-focused BPT program, which included 6, two-hour, large group sessions within the first two weeks of the STP and one individual booster session. Families were concurrently enrolled in a medication study. Beginning in the third week of the STP, children were randomly assigned to receive their lowest-effective dose of medication for three weeks followed by placebo for three weeks or the opposite order.
Homework-focused BPT led children with ADHD to complete 10-14% more homework with 8% higher accuracy, on average. This would be the difference between earning a ‘C’ and earning an ‘F’ (in other words, the difference between passing and failing). Long-acting stimulant medication, on the other hand, produced little to no benefit for homework completion or accuracy, especially when behavioral treatment was offered. These results are critical in informing practice. Our highly controlled, randomized clinical trial shows that BPT should be the recommended treatment to improve homework functioning for children with ADHD. Despite years of pharmaceutical companies claiming such benefits, long-acting stimulant medications do not improve the homework functioning of children with ADHD. There are limitations to this study as there are to any research study. One limitation is that the medication may not have been in effect by the time children completed homework (an average of 11 hours post-ingestion). However, the time lag isn’t atypical for when families are starting homework after a long day of school.
We also examined peer relationship functioning within the context of youth sports activities (Altszuler et al., 2017). In childhood, many peer relationships are formed and maintained during sports activities. Decades ago, our group published a study showing that medication improved children’s ability to pay attention while playing baseball, but that medication did not lead to improvements in actual sports skills (Pelham et al., 1990), a crucial component of successful sports participation. To evaluate whether behavioral intervention could improve the sports performance of children with ADHD, we conducted a 2 (medication, placebo) x 2 (sports training, recreational play) between-groups study over three weeks in the STP. In addition to the behavioral point system present in the STP (Pelham et al., 2010), the sports training included instruction in sports rules, structured skills periods, and specific coaching and feedback.
The main finding was that, relative to medication, brief sports training led to the largest benefits on the greatest number of sports-related outcomes, including sports skills and knowledge, attention to game play, effort, frustration, and enjoyment. Most youth sports activities take place in the evenings and on weekends – which are important times for children to take breaks from stimulant medications to reduce side effects like weight loss and sleep difficulties. These results suggest that behavioral skills training, rather than medication alone, will lead to successful participation in sports activities for children with ADHD. Adding a low dose of medication to a child’s treatment did produce incremental benefit on behavior during game play, suggesting that children with high rates of disruptive behavior may benefit from combining behavioral intervention with medication during sports activities.
These studies show that combined treatment is not always needed for children with ADHD, and for many children unimodal behavioral therapy or specific skills training leads to substantial and sufficient improvement. This appears to be especially true for functional, daily life impairment associated with childhood ADHD. We’ve explored just two impairments here, homework problems and sports skills deficits, and there are likely a myriad more to be examined. That behavioral treatments are better-suited than medication alone to address functional impairments relevant to long-term outcome is not a new idea. The most important indicators of long-term outcome are peer functioning, family relationships, and academic success. These critical domains are rarely significantly improved when using medication alone. Notably, when group-based treatment is provided, rather than individual, behavioral treatment may also be more cost-effective than medication as a treatment for ADHD (Page et al., 2016).
Discussion Questions
- Within clinical practice, how can these types of treatment recommendations for problems in daily life functioning among children with ADHD be integrated?
- This homework study shows the versatility of behavioral parent training programs in targeting a variety of presenting problems. How can parent training be delivered flexibly to address these presenting problems?
- The study focusing on teaching sports skills to children with ADHD showed that behavioral sports training leads to the largest improvements in sports-related outcomes. How can behavioral programming (e.g., structured rules, consequences for following/violating rules) be more widely incorporated into youth sports and recreational activities?
Brittany M. Merrill, MS. Brittany is a doctoral student in the Clinical Science in Child and Adolescent Psychology program at Florida International University. Her research focuses on evaluating the effects of evidence-based behavioral treatments, medication, and combined treatment on functioning among children with ADHD, specifically as it relates to improving academic functioning.
Amy R. Altszuler, MS. Amy is a doctoral student in the Clinical Science in Child and Adolescent Psychology program at Florida International University. Amy has worked with children with ADHD and disruptive behavior disorders for over 7 years. Her research focuses on examining long-term outcomes of these youth and how behavioral interventions, stimulant medication, and their combination can be used to improve long-term outcomes.
William E. Pelham, Jr. PhD. Dr. William E. Pelham, Jr. is Distinguished Professor of Psychology and Psychiatry at Florida International University and Director at the Center for Children and Families. Dr. Pelham has focused his research on ADHD in children and adolescents, and has authored and co-authored more than 400 professional publications. His interests include treatment, development and evaluation, including behavioral treatments, pharmacotherapy, and the combination of the two. He has also received numerous awards and recognitions, and has held more than 80 research grants from federal agencies (NIMH, NIAAA, NIDA, NINDS, NICHD, and IES), foundations, and pharmaceutical companies.
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