Keys to Success in ADHD Treatment
The clinical understanding of attention-deficit/hyperactivity disorder (ADHD) and the evidence-based treatments available have greatly increased over past years; however, the amount of successful treatment outcomes has unfortunately remained the same. Therefore, clinicians who treat children with ADHD face a challenge, as there are high rates of treatment discontinuation, poor medication adherence, and lack of long-term improvements. Professor and Assistant Professor in the Department of Psychiatry at the University of Florida, Regina Bussing, M.D. and Ayesha Lall, M.D. believe that there is a missing ingredient that may improve ADHD treatment: sufficient partnering between families and treatment providers, which they review in their article “Keys to Success in ADHD Treatment: Strategies for Effective Partnering with Families.”1
According to Bussing and Lall, there are three concepts that will improve the understanding of an effective partnership with families: patient activation, patient empowerment, and patient-centered care.1 The Institute of Medicine of the National Academics has stated the importance of patient-centered care, based in respect and sensitivity to the patient’s preferences, needs, and values—including recognizing the family as an equal partner in the equation.
Engaging Family in ADHD Treatment
When engaging the patient and their family, setting the stage for partnership, it is important to establish who will be a part of the team.1 Bussing and Lall recommend expanding the focus from only parents/caregivers to entire families.1 Also, once a team is established, those family members who are unable to attend sessions should still be able to play a role in decision-making, as their influences should still be included in the planning process despite absence. However, it is important not to forget that the child or adolescent should have meaningful input into their treatment planning. While younger children require their caregivers to be the primary decision-makers, teenagers are old enough to be, and should be, actively engaged in the decision-making.1
Learning about the child and the family is also an important part of partnering, according to Bussing and Lall; therefore, clinicians should listen to their stories about living with ADHD. Practicing guidelines require the need for parent and teacher reports of ADHD symptoms; however, building upon those reports with personal stories from the child or adolescent only strengthens a clinician’s understanding. Also, while time constraints may tempt a clinician to cut the personal accounts and opt for standardized questionnaires, Bussing and Lall state that this could make the family feel as if they haven’t been heard or understood—feelings that do not create a strong partnership.1 Therefore, it is important for clinicians to understand the family’s explanatory model of their child or adolescent’s disorder.1 Kleinman coined the term in the 1970s, meaning to explore a patient’s understanding of their condition. Using six open-ended questions, a clinician may understand the parental beliefs about the cause, time course, severity, preferred treatment, and desirable treatment outcome.1 The model may be compared with the perspective of the clinician’s in order to provide the family with sensitivity to their preferences, needs, and values. It also assures that the family will be more willing to consider a wider variety of treatment options.1
Partnering Up to Treat ADHD
Bussing and Lall state that another important element of partnerships is education, as it aids future collaborative decision-making and increases treatment adherence.1 Through providing resources, such as the National Alliance on Mental Illness (NAMI) or Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD), the family can increase their understanding of ADHD and evidence-based treatment.1 However, it is important they steer clear of blogs or unaccredited sources. Also, as ADHD affects a youth’s academic and social functioning, regular communication exchanged with the child’s school is mandated and the child’s progress and areas of concern can be monitored.1 From this, the clinician is able to work with the child to develop positive attitudes towards school and provide the family with information about relevant education laws and school-based ADHD interventions, such as 504 Plans and Individualized Educational Plans (IEPs).
Next, a partnered treatment plan may be developed. Instead of simply recommending treatments, clinicians working in partnerships should increase the family’s understanding of research-based treatment concepts, and according to Bussing and Lall, the NAMI’s Choosing the Right Treatment: What Family Members Need to Know About Evidence-Based Practices is a great resource that can help educate them.1 The Multimodal Treatment Study of Children with ADHD (MTA) states that pharmacological treatments are more effective than behavioral treatments alone, and there are multiple pharmacotherapy choices.1 Stimulants are the first- and second-line treatments for ADHD; however, non-stimulant options do exist.1 There are also other alternative treatments, such as specialized diets, vitamins, and herbal therapy, but they have not shown reliable and effective results. After receiving all the information regarding treatment options, some families may still choose behavioral interventions over medicine, and in partnerships, Bussing and Lall state that clinicians should be open to their reasoning and recommend monitoring treatment goals to assess progress made.1
Agreeing on a Treatment Plan for ADHD
When an agreement regarding a treatment plan is reached, discussing how progress will be monitored is the next step. Considering what the family would like to see most as the outcome is important to consider, and monitoring progress with standardized rating scales may help to keep families engaged in the treatment process, as progress is given a value. 1 However, it is also important to monitor for adverse effects and adherence barriers; therefore, anticipating what those could be and addressing them promptly is important for the partnership.1
Bussing and Lall state that partnerships between families of youth with ADHD and clinicians is an important factor to symptom improvement and treatment success. Working through each stage of the treatment process, as well as providing education and a listening ear will all aid in the child’s success.
 Bussing, R. and Lall, A. (2012, Oct. 18). Keys to Success in ADHD Treatment: Strategies for Effective Partnering with Families. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/child-adolescent-psych/content/article/10168/1696493
 Zima BT, Hurlburt MS, Knapp P, et al. Quality of publicly-funded outpatient specialty mental health care for common childhood psychiatric disorders in California. J Am Acad Child Adolesc Psychiatry. 2005;44:130-144.
 Institute of Medicine of the National Academies. Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series. November 1, 2005. http://www.iom.edu/Reports/2005/Improving-the-Quality-of-Health-Care-for-Mental-and-Substance-Use-Conditions-Quality-Chasm-Series.aspx.
 Bussing R, Koro-Ljungberg ME, Gary F, et al. Exploring help-seeking for ADHD symptoms: a mixed-methods approach. Harv Rev Psychiatry. 2005;13:85-101.
 Williamson P, Koro-Ljungberg ME, Bussing R. Analysis of critical incidents and shifting perspectives: transitions in illness careers among adolescents with ADHD. Qual Health Res. 2009;19:352-365.
 Bell L, Kellison I, Garvan CW, Bussing R. Relationships between child-reported activity level and task orientation and parental attention-deficit/hyperactivity disorder symptom ratings. J Dev Behav Pediatr. 2010;31:233-237.
 Kleinman A. The Illness Narratives: Suffering, Healing, and the Human Condition. New York: Basic Books, Inc; 1988.
 Walter HJ, Berkovitz IH. Practice parameter for psychiatric consultation to schools. J Am Acad Child Adolesc Psychiatry. 2005;44:1068-1083.
 Weber W, Newmark S. Complementary and alternative medical therapies for attention-deficit/hyperactivity disorder and autism. Pediatr Clin North Am. 2007;54:983-1006; xii. ADHD.