Talking to Parents About Behavioral Treatment for ADHD

Hi. I'm Jennifer Mautone, a psychologist in the Center for Management of ADHD at The Children's Hospital of Philadelphia (CHOP). I'm also a psychologist in the Healthy Minds, Healthy Kids Program, which is our integrated behavioral health in primary care program at CHOP.

I'm here to talk about attention-deficit/hyperactivity disorder (ADHD) and how primary care providers can help facilitate the management of ADHD through their work with families. ADHD is a common mental health condition among children, and primary care providers encounter ADHD quite frequently. Families often feel extremely comfortable talking with their primary care providers about their concerns about their children at school, and behavior concerns they may be having at home or in the community.

Initiating Behavioral Interventions

The evidence-based interventions for ADHD include medication and behavioral parent training or behavioral interventions at school delivered by teachers and other school staff. The American Academy of Pediatrics^[1] recommends that we consider behavioral interventions to be our first-line approach when we are working with preschool-aged or very young children who have ADHD. We take a more combined approach when considering older kids and adolescents, which may include behavioral parent training, behavioral interventions at school, and medication. Pediatricians are often involved in the prescription of medication treatments for kids at adolescence who have ADHD.

Recent research suggests that beginning with behavioral interventions can actually be more effective for children and adolescents who have ADHD. More children tend to respond well if we start with behavioral intervention and add medication later if necessary. We also see that treatment engagement improves among children and families who start with behavioral interventions.

These are really important variables to consider. We are not just thinking about treatment outcomes in terms of symptom reduction and impairment but also how our recommendations, the order in which we present things, and how we deliver recommendations might positively affect family engagement. Again, we tend to see higher rates of engagement when we recommend behavioral intervention first rather than when medication is started first and behavioral intervention is offered later. Those families tend not to follow through on behavioral intervention.

Shared Decision-Making

The reality is, though, that even when we consider all of these variables, families struggle to follow through on treatment recommendations. We really need to think about how to deliver the recommendations to families once we have made the diagnosis of ADHD. I find that a shared decision-making perspective is the most effective way of meeting the family where they are and understanding their goals for their child and their preferences for treatment.

Once you have that solid understanding, you can really move forward to make treatment plan recommendations that will be most acceptable to the patient and to the family. This is also a nice opportunity for providers to [assess] the family's understanding of the treatment recommendations. There are many myths and concerns about treatment delivery and medication safety. Once providers really understand how the family thinks about treatment, they can help dispel myths and set the stage for good, solid treatment engagement moving forward.

Behavioral Parent Training

Pediatricians are often comfortable describing and discussing medication treatments with families. They do a great job of dispelling myths about side effects, talking about expected duration of action, and [describing] how to know whether the medication is working effectively at home or at school. But discussion about behavioral intervention may become a little bit more ambiguous. I often get questions from my physician colleagues: How do we describe behavioral parent training? How can I support a family's engagement in behavioral parent training?

One of the ways that I approach this when I work with families is to think about the primary goals of each treatment option. A medication does a really great job at symptom reduction, but medication does not teach the child the skills that he or she would need to cope with the symptoms of ADHD. Behavioral intervention can teach the child how to engage in appropriate behavior at home, at school, and with peers. Explaining that medication is useful for symptom reduction, and behavioral intervention teaches skills that a child might need, usually helps families really understand our treatment perspective.

Parent/child relationships are often disrupted, highly conflictual, and very stressful for parents of children who have ADHD. Once we acknowledge this and the high level of parenting stress that they experience, behavioral interventions often become very acceptable for parents, in hopes of ultimately reducing the stress they experience and fostering a strong parent/child relationship.

When I feel like parents are not quite buying what I'm selling, the other approach that I often take is explaining that kids are kind of like flowers. Orchids need a particular environment to flourish. That is true of children who have ADHD. If we can put kids in the right circumstances, and set up the environmental contingencies in just the right way, we can help them really flourish. Behavioral intervention strategies are designed to do just that. We are altering the environment so that we can set it up just the right way for the kid to build strength, build skills, and overcome symptoms of ADHD. Using these types of analogies can be really helpful for parents.

Setting Up Appropriate Expectations

It is also really important to set up appropriate expectations. Parents learn very quickly that medication can have a pretty quick impact. If we find one that works well, we will see improvement relatively quickly. That is not usually the case with behavioral intervention. We need parents to understand that even though they may need to attend multiple sessions and put in a good deal of work on the front end, they do not necessarily see change immediately. That does not mean that the intervention is not working. Changing behavior is a slow process. It's kind of like turning a cruise ship in the Suez Canal.

We need parents to understand that we are not turning a race car on a dime, but that we are turning a cruise ship slowly and eventually do see change. We need to encourage parents to look for small changes in their children's behavior and in their family's functioning to recognize that behavioral interventions are indeed having a nice positive effect on the child or on the teen. These are ways to talk directly with parents.

Finding the Right Provider

An important issue in terms of access and follow-through is that it is hard for families to find the right provider for delivery of behavioral interventions. Even with primary care pediatricians doing a phenomenal job of engaging parents in the discussion; using shared decision-making strategies; and getting parents to think, "Yes, this is really something I want to do," families still encounter barriers when finding a community-based mental health provider who delivers evidence-based behavioral intervention. This is a very real challenge. Families are getting sent out into the community without a lot of information or direct planning about where to go next, or who to see.

Oftentimes, I find that with primary care practices that have a solid referral resource base, providers feel more comfortable and more able to engage in these discussions with families. I find it can be really helpful if practices can build up a referral resource or even, in an ideal world, have a care manager who can help with that. Whenever that is feasible, that is also really helpful.