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The Variability of Treatment Response in Different Settings
This is a very important article that appeared in a recent issue of Behaviour Research and Therapy (1998, Vol. 36, 675-694). In this study, the authors examine the consistency and inconsistency of children's response to behavioral and medication treatment depending on the domain being assessed (i.e. classroom behavior, academic performance, getting along with adults, and getting along with peers), the setting in which treatment occurred (i.e. the child's regular school vs. an intensive summer treatment program), and treatment intensity (i.e. intensive behavioral treatment vs. more modest behavioral treatment). This is more of an extensive case study per se than a large scale research investigation, but it raises and emphasizes some very important points that are for parents to understand.
The purpose of this paper is to clearly demonstrate that children with ADHD can show either consistency or inconsistency in how they respond to treatment, depending on what outcome is being considered and what type of treatment is being implemented. For example, suppose one is examining how effective behavioral treatment alone - i.e. no medication - is for a particular child. One might find that for this child, a good behavioral plan is sufficient to help the child get along fine in several different domains (e.g. getting along with parents, teachers, and peers), but may be inadequate when it comes to the academic domain (i.e. the child is unable to complete assigned work and makes numerous careless mistakes).
For another child, the same type of treatment (e.g. behavioral treatment without medication) might result in adequate academic functioning but problems in the social domains (e.g. the child is unable to follow class rules or get along with peers). For still another child, all domains may be positively effected, or, the child may not function adequately in any domain. The same range of possibilities can occur with medication treatment alone, or even with the combination of medication and behavioral treatment.
In this excellent paper, the authors present fairly detailed case examples of three different children. All three children participated in treatment in both an intensive summer treatment program and in their regular classroom. All children were also receiving an appropriate dose of medication interspersed with a placebo, and in addition, received either intensive behavioral intervention (at the summer camp) and a more modest behavioral treatment program in their regular classroom. Through this design, the authors were able to establish whether medication improved children's functioning above and beyond the boost provided by behavioral treatment alone, and if so, what domains (e.g. academic vs. social) this was true for.
For one child, a consistent additive effect for medication was found across all domains (e.g. academics and social), settings (i.e. in the intensive summer treatment program and in the regular classroom), and treatment intensity (i.e. intensive vs. moderate behavioral intervention). That is, regardless of which domain was being assessed, which setting the child was in, or how intensive the behavioral treatment was, medication made a clear and important contribution to the child's functioning.
A second child also responded consistently to medication across different domains, but differed in his response to treatment depending on the setting or treatment intensity. That is, for this child, behavioral interventions alone were sufficient to produce a good response in academic and social domains during the intensive summer treatment program, but were not effective when the child returned to his regular classroom. In other words, even though this child functioned quite well without medication when at the summer treatment program, where more intensive behavioral treatment was readily available, he was unable to do well either academically or socially in his regular classroom without medication.
In the final case study presented, the child response consistently across the different settings (i.e. camp vs. school), but differed according to which domain was being assessed. Specifically, this child showed a positive response to behavioral alone in the social domain, and functioned adequately in this domain without medication in both the camp and classroom settings. Medication, however, provided a specific enhancement of this child's academic functioning in the classroom. In addition, during less structured classroom times, medication also had an incrementally positive effect on this child's behavior.
What this paper makes clear is that there is no simple answer to the question: "Is behavioral treatment effective for this child?" or "Is medication necessary for this child ?" The answer is that for many children with ADHD it depends - depends on what outcome is being considered (e.g. behavioral vs. academic), what setting is being considered (e.g. home vs. school) and what level of treatment intensity is being considered (e.g. highly structured behavioral treatment plan vs. more simplified behavioral contract).
This is really a critical point to pay attention to. In working to promote the healthy development of your child, it is often not sufficient to find an approach to treatment that works well in one setting or domain and assume that it will also be effective in other settings and domains. You need to carefully evaluate how your child is performing in the different settings and domains in their life that are important. Parents need to be aware that for their child to be as successful as possible in these different settings and/or domains, different treatments or combinations of treatments may well be necessary. Working with someone who understands this very important notion, and who can assist you in developing treatment strategies that may need to vary across domains and settings is a really helpful person to look for.
The other helpful point that follows from this discussion is that it can promote greater collaboration between the important adults in a child's life. Often times, I have seen parents and teachers get into an unnecessarily bad frame of mind about each other because they disagreed about what a particular child required to succeed. Parents may be successful with behavioral interventions alone at home and thus fail to understand why the child is not doing well at school. Often times, the assumption can be that the teacher must not be managing the child well. In actuality, however, the demands at school are quite different and behavioral methods by themselves may not be an adequate intervention at school, no matter how faithfully and skillfully they are implemented. Obviously, the reverse can also be true - teachers may not understand why the child is having such a hard time completing work at home when things at school seem to be going much better. When parents and teachers understand and appreciate that such discrepancies do not necessarily mean that one or the other is doing an inadequate job with the child, but instead may very well reflect the realities of how the child functions in different settings, a more helpful collaborative relationship can often take hold.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.