Treatments for ADHD - and the forgotten role of motivation
Research on the treatments for ADHD suggest that even the most effective treatments may not be sufficient for improving outcomes for children with ADHD diagnoses. Current treatments have a predominately person-biased approach to conceptualizing and treating the disorder. For example, the largest study conducted to assess the efficacy of ADHD interventions pitted medication and psychosocial treatment against one another, as well as their combination, along with “treatment as usual” (Multimodal Treatment Study of ADHD [MTA], Jensen et al., 2001). All of these options treat the individual, rather than the context in which they live. The two outlined efficacious treatments of ADHD are 1) stimulant medication, and 2) behavioral management. The intent of the stimulant medication is to change the individual, and in part implies that the individual was the sole source of the problem if medication alone is used. Behavioral management strategies and psychotherapy are also person-level interventions. The fact that the MTA study only used person-level interventions provides evidence of the bias in seeing ADHD as a problem with the person. Incorporating the environment into these person-level interventions may be especially effective in reducing negative behaviors and increasing on-task and prosocial behavior. Some examples include implementing social programs to facilitate peer-relations and providing tutoring outside of class and student aids in the classroom. Current interventions that may complement treatments in classroom, such as parent training, does work to alter environmental context by teaching parents strategies like active ignoring. Yet even here the emphasis is overwhelmingly placed on seeing the problem as coming from the child.
In particular, non-medication person-centered treatments are not highly effective in alleviating difficulties associated with inattention and hyperactivity. In the MTA, those children who received behavioral management treatment did not differ from the “treatment as usual” group on outcome measures of symptom improvement (Jensen et al, 2001).
After interventions with a similar program, Shelton et al. (2000) found that at a two-year follow-up of a school-based intervention for disruptive behavior problems did not generalize to new classrooms. Behavioral management relies on extrinsic rewards and punishments. Without consistent use across time and contexts the efficacy of such practices may be greatly diminished. In fact, some argue that the use of external rewards can undermine the natural process of the desire to learn and master new material (Niemiec & Ryan, 2009). It is unclear whether the innate curiosity, love of learning, and volitional self-motivation processes outlined by Niemiec and Ryan (2009) apply to all individuals. However, their review outlines the role of choice in learning, and the importance that students believe what they are learning is of value. Rather than emphasizing control in the classroom, akin to behavioral management techniques, the authors argue that research shows this may be harmful for learning and motivation, and rather warmth and respect should be a focus of teacher-student interactions.