Private Pediatric Neuropsychology Practice Multimodal Treatment of ADHD: An Applied Approach

This article was downloaded by: [Memorial University of Newfoundland] On: 16 July 2014, At: 23:48 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Applied Neuropsychology: Child Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hapc20 Private Pediatric Neuropsychology Practice Multimodal Treatment of ADHD: An Applied Approach Paul Beljan a , Kathleen D. Bree a , Alison E. F. Reuter a , Scott D. Reuter a & Laura Wingers a a Beljan Psychological Services , Scottsdale , Arizona Published online: 10 Jul 2014. To cite this article: Paul Beljan , Kathleen D. Bree , Alison E. F. Reuter , Scott D. Reuter & Laura Wingers (2014) Private Pediatric Neuropsychology Practice Multimodal Treatment of ADHD: An Applied Approach, Applied Neuropsychology: Child, 3:3, 188-196, DOI: 10.1080/21622965.2013.875300 To link to this article: http://dx.doi.org/10.1080/21622965.2013.875300 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. 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Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions http://www.tandfonline.com/loi/hapc20 http://www.tandfonline.com/action/showCitFormats?doi=10.1080/21622965.2013.875300 http://dx.doi.org/10.1080/21622965.2013.875300 http://www.tandfonline.com/page/terms-and-conditions http://www.tandfonline.com/page/terms-and-conditions Private Pediatric Neuropsychology Practice Multimodal Treatment of ADHD: An Applied Approach Paul Beljan, Kathleen D. Bree, Alison E. F. Reuter, Scott D. Reuter, and Laura Wingers Beljan Psychological Services, Scottsdale, Arizona As neuropsychologists and psychologists specializing in the assessment and treatment of pediatric mental health concerns, one of the most prominent diagnoses we encounter is attention-deficit hyperactivity disorder (ADHD). Following a pediatric neuropsy- chological evaluation, parents often request recommendations for treatment. This article addresses our approach to the treatment of ADHD from the private practice per- spective. We will review our primary treatment methodology as well as integrative and alternative treatment approaches. Key words: ADHD, intervention, multimodal, private practice, treatment Many attention-deficit hyperactivity disorder (ADHD) treatment options exist. This article offers an applied multimodal approach for treatment of ADHD based on our clinical experience in a private practice that specializes in pediatric neuropsychology. We offer an overarching philosophical perspective that outlines our conceptualization of the disorder, as well as our collabo- rative approach to working with children, their families, and school personnel. This multimodal, collaborative treatment approach includes education about the dis- order, parent skills training, and behavior therapy. Other psychotherapeutic interventions discussed include mindfulness, educational recommendations and inter- ventions, consultation with allied health care providers, and consideration of integrative and alternative treat- ment approaches. We recognize that it is not possible to talk a child out of a brain-based disorder. Instead, we work to facilitate awareness and insight for children, their parents, and their educators. We provide guidance in developing new skills, as well as guidance in the home and school environments to provide structure, consistency, and routine to manage the symptoms of the disorder. We provide intervention, consultation, and collaboration aimed at management of symptoms to optimize long- term outcomes. In our experience, attention and inhibitory expression are ‘‘have=have not’’ abilities (Mirsky, Pascualvaca, Duncan, & French, 1999). They do not conform to the bell curve. When an individual is a ‘‘have’’ for attention and inhibition, he or she can execute the ability reliably and consistently for as long as he or she wants and whenever he or she wants. If the individual is in the ‘‘have not’’ domain, it does not mean the complete absence of inhibition and attention. Instead, it means the irregular or incomplete expression of inhibitory con- trol or allocation of attentional resources across time. Therefore, many children with ADHD express a ‘‘Swiss cheese’’ presentation of behavioral direction, problem solving, academics, and social adaptability. These chil- dren also may display rigidity, trouble adjusting to com- plex situations, and failure to use experience to amend behavior. Children with ADHD are often expected to behave and perform academics more consistently than they are able to, which in turn continually puts them into a position of failure—sometimes despite immense effort. ADHD, after all, is a disorder of good intent with bad outcomes. A further difficulty with attention and inhibition problems is that the individual in question is largely unaware of the problem as he or she expresses Address correspondence to Paul Beljan, Beljan Psychological Services, LLC, 9835 E. Bell Rd., Suite 140, Scottsdale, AZ 85260. E-mail: [email protected] APPLIED NEUROPSYCHOLOGY: CHILD, 3: 188–196, 2014 Copyright # Taylor & Francis Group, LLC ISSN: 2162-2965 print=2162-2973 online DOI: 10.1080/21622965.2013.875300 D ow nl oa de d by [ M em or ia l U ni ve rs ity o f N ew fo un dl an d] a t 2 3: 49 1 6 Ju ly 2 01 4 it. If the child does not know when he or she is being inattentive or impulsive, he or she cannot be completely expected to change the behavior on his or her own or based on imposed consequences or repeated discussion or rewards. In our experience, change for children with these problems tends to be slower, causing them to appear environmentally insensitive and emotionally less mature than same-age peers. INITIAL STEPS TO INTERVENTION Following the completion of the child’s neuropsy- chological evaluation, parents are provided with detailed explanations about how attention, inhibition, and executive function systems work and how their child expresses them at home, at school, and in social situa- tions. This is one of the most significant interventions a neuropsychologist in private practice can provide because it causes immediate change in the family. When parents know how ADHD works, they more specifically understand how the disorder prevents their child from making good behavioral choices or amending behavior based on natural or imposed consequences. This knowl- edge helps parents shift their view from frustration, blaming, and reactivity to one of understanding and acceptance. When parents learn their child’s inappro- priate behavior is neither willful nor malicious, their interpretation of the child’s behavior improves, which subsequently helps shift their parenting approach to one that is better suited to supporting the child. That is, parents learn they cannot punish the ADHD out of their child, but they can provide the child with an environment and behavioral strategies conducive to minimizing the impact of the ADHD symptoms. Parents also are provided with information about available treatment options. Although we frequently include information about medication management and referrals to pediatricians and child psychiatrists, we also review nonmedication options. Although stimulant medication repeatedly demonstrates strong efficacy (American Academy of Pediatrics [AAP], 2011; Multimodal Treatment of ADHD [MTA] Cooperative Group, 1999, 2004) in reducing the expression of ADHD symptoms, stimulant medications do not teach children with ADHD ways to manage their symptoms or how to undo a lifetime of maladaptive interactions. Many parents are leery of medication of any kind and express interest in nonmedication treatment options. We encourage parents to consider adjunctive treatments that offer them and their child the opportunity to learn important coping mechanisms and compensatory strate- gies to manage symptoms of ADHD. It is essential to keep in mind the child will require prompting to utilize learned skills due to the nature of ADHD, which prevents them from reliably thinking to execute these skills on their own and at the right time. We find a criti- cal treatment error among professionals is that the child is often expected to initiate learned ADHD management skills on his or her own. Therein lies the inherent prob- lem with many ADHD treatments: The child is expected to act as if he or she does not have ADHD. Children recently diagnosed with ADHD must first learn about the disorder. Gaining awareness about the nature of their disorder helps children in a variety of ways. Making the child aware of the disorder is the first step toward developing insight, which helps the child develop a self-understanding. With a developed self-understanding (insight), the child can more readily accept parental and school interventions. Insight devel- opment is the initial step in teaching the child to take responsibility for the disorder, which is important because he or she will be held responsible for all of his or her actions during adulthood, regardless of the pres- ence of ADHD. Helping the child understand that at times, ADHD makes it more difficult for him or her to make appropriate behavioral decisions helps the child separate his or her identify and self-worth from poor behavioral outcomes; however, this does not mean the child can blame ADHD for all of his or her poor beha- vioral outcomes. The child is taught that he or she is an important participant in managing the disorder. PARENT–CHILD PARTNERSHIP The parent–child relationship is extremely important in regard to managing ADHD. One of the main goals for the parents of a child with ADHD is to raise an individ- ual who feels competent and has high self-esteem. In our experience, an important component to meet that goal is education about the disorder for both the parents and the child. Increasing parental involvement and parent–child interactions, as well as improving positive behavior sup- port (e.g., prompting and reinforcing child behavior) and proactive parenting (e.g., communicating clearly and providing the child with forced choices) fosters sustained improvements in the overall parenting app- roach and results in improved child behavior (Dishion et al., 2008; Patterson, Forgatch, & DeGarmo, 2010). Together, parent and child education can facilitate a stronger parent–child bond, which research indicates is key in improving overall family functioning (Gottman, Katz, & Hooven, 1996). While emphasizing ADHD as a ‘‘way of being’’ (Rogers, 1980) is the primary focus of our child inter- ventions, we also provide specific interventions for the parents and child, as well recommendations for educa- tors. Several approaches are described in this article, MULTIMODAL TREATMENT OF ADHD 189 D ow nl oa de d by [ M em or ia l U ni ve rs ity o f N ew fo un dl an d] a t 2 3: 49 1 6 Ju ly 2 01 4 such as organizational skills for the child, behavior therapy and management, mindfulness, and school recommendations. We consider the neuropsychological assessment pro- cess a collaborative experience that can lead parents and their child with ADHD to powerful insight and motivation for change. The concept of collaborative neuropsychological assessment is relatively new (Gorske & Smith, 2009) and has important implications. In our outpatient practice setting, we find that active engage- ment throughout the assessment process creates an environment in which parents are more likely to remain invested in the difficult but necessary work to support change and pursue appropriate interventions for their child. In many settings, the recommendations that result from the assessment process only target the child or the school environment. Much could be done to support the family, which can reduce the strain of parenting and remove blame from the child as being the sole source of family conflict or concern. The goal of our assessment is not only to determine or rule out diagnoses, but also to provide appropriate parent education, support, and con- sultation as the family begins to implement our recom- mendations. Ongoing parent support and consultation is an important component of the treatment plan in many cases. Organizational Skills Our approach to the improvement of organizational skills in children with ADHD requires intervention tar- geting the child’s home and school environments as well as the child’s skills and abilities. This may involve con- sultation with parents, teachers, or other care providers regarding changes in the physical environment, modifi- cation of task demands, provision of cues and support for the child, and ways to improve communication with the child regarding organizational demands. Our work with the child involves teaching specific skills and rou- tines, modeling, and motivating the child to use newly learned skills. Skills taught are based on specific infor- mation gleaned from the comprehensive evaluation, which always guides treatment planning. Specific skills may include routines aimed at improving task initiation, planning, organization, time management, response inhibition, and emotional control. Scenarios covered may include managing beginning-of-the-day and end-of- the-day routines, managing homework, organizing materials, preparing for tests, and planning for com- pletion of long-term projects. A variety of methods are used to teach skills, including developing specific routines, modeling and practicing skills, enlisting the support of parents and teachers in the practice of new skills, monitoring and evaluating progress, and modifying the approach as needed. It is always kept in mind and taught to parents and educators that these skills, once taught to the child, must be prompted and facilitated by immediate caregivers. Behavior Therapy and Management The AAP (2001, 2011) and the MTA Cooperative Group (1999, 2004) recommend behavior therapy as an adjunctive treatment to the prescription of stimulant medications for the treatment of childhood ADHD. The AAP (2001, 2011) also recommends behavior therapy as a standalone treatment for ADHD and notes that it represents a broad group of treatment methods designed to reduce a child’s expression of problematic behaviors related to ADHD by increasing structure and direction and by limiting distractions in the child’s environment. Specific strategies can include, but are not limited to: positive reinforcement, timeout, response cost contin- gency, and a token economy system. Implementation requires that a parent, caregiver, and=or teacher receive training in behavior management. Per the clinical prac- tice guidelines recommended by the AAP (2001), parents and teachers are taught to provide the child with struc- ture (e.g., explicit behavioral expectations and rules), a routine (e.g., a predictable schedule), consistent rewards for desirable behaviors (e.g., positive reinforcement), and consistent consequences for inappropriate behavi- ors (e.g., discipline). One must be sure to refrain from setting expectations beyond what a child with this brain- based disorder can logically be expected to execute. The AAP (2001) asserts that consistently and repeat- edly applying these methods will gradually shape and improve the child’s behavior. The AAP (2001) reports implementation of behavior modification through par- ent and teacher training has ‘‘successfully changed the behavior of children with ADHD’’ (p. 1039); however, they also note that the environmental modifications involved in behavior therapy ‘‘have not undergone care- ful efficacy assessment’’ (p. 1039). Further, the AAP (2001, 2011) and Rajwan, Chacko, and Moeller (2012) report behavior management strategies only demon- strate efficacy while they are being implemented. That is, consistent behavioral improvement requires consist- ent and continuous implementation of behavioral man- agement techniques. If the parent, caregiver, or teacher does not provide consistent behavior management stra- tegies or if they stop implementing them, the child will frequently revert to prior behavioral problems. Results of a literature review (Rajwan et al., 2012) indicate improvements in child behavior (i.e., reduction in oppositional, noncompliant, aggressive, and disruptive behavior; reduction in inattention and hyperactivity) are maintained from 2 months to 12 months following treatment. Ultimately, the AAP (2001) reported that 190 BELJAN ET AL. D ow nl oa de d by [ M em or ia l U ni ve rs ity o f N ew fo un dl an d] a t 2 3: 49 1 6 Ju ly 2 01 4 behavioral therapy ‘‘improves the child’s functioning and decreases disruptive behavior but (as with stimulant medications) does not necessarily bring the behavior of a child with ADHD into the normal range on parent [or teacher] rating scales’’ (p. 1039). We also note that child development is dynamic, meaning that as the brain develops and the child matures, old behaviors can nat- urally extinguish as new behaviors emerge. The emerg- ence of new and problematic behaviors is a growth into deficit. The child’s environment naturally allows them more opportunity to self-direct behavioral decision making and thus make more and new errors. Despite the lack of evidence that behavior therapy for ADHD generalizes improvement across differing activi- ties and environments or demonstrates long-term beha- vioral improvement, it appears to provide adequate short-term management of problematic behaviors (AAP, 2001, 2011; Rajwan et al., 2012). Additionally, a review of literature and research on behavioral parent training indicates improvement in parenting skills and competen- cies, as well as improved parental mental health (Rajwan et al., 2012). In our opinion, behavior therapy for children with ADHD ultimately demonstrates worth. Although research on behavior therapy, as implemented through parent, caregiver, and=or teacher behavior management, does not indicate robust long-term efficacy outcomes, it appears to offer short-term benefits. Further, behavior therapy techniques can easily be taught through psy- chology and neuropsychology practices. The AAP (2001) asserts that a wide range of health and education professionals can implement behavior therapy, as well as teach behavior management techniques to parents and teachers. In our experience, providing parents with psy- choeducation regarding behavioral theory and behavior management strategies is beneficial. The most consist- ently implemented, individually tailored behavioral management program will not cure a child of his or her brain-based ADHD symptoms. Nevertheless, man- agement is the key word in behavior management, and it can reduce the child’s opportunity to make ADHD- based mistakes by providing external structure and feedback when the child’s executive function and inhi- bition systems fail. Mindful Parenting Parenting a child with ADHD requires much thoughtful planning and organization. Unfortunately, many parents of children with ADHD have ADHD them- selves, which can make parenting more difficult (Galili- Weisstub & Segman, 2003). Research suggests parents who are stressed exhibit less positive affect, respond less consistently and positively to their child, are often more critical or irritable in their interactions with their child, and engage in more coercive parenting (Davis et al., 2009; Gottman et al., 1996; Shin & Crittenden, 2003). Mindfulness is an experience-based practice whereby the practitioner gives full attention to, and is fully aware of, the internal and external sensory and cognitive experience of the present moment. In addition, mind- fulness stresses the importance of acknowledging such experiences without judgment (Bishop et al., 2004). ‘‘Mindful parenting’’ refers to an approach that empha- sizes proactive, rather than reactive, parenting (Kabat- Zinn & Kabat-Zinn, 1997; Siegel & Hartzell, 2003). Mindful parenting provides a framework whereby par- ents conscientiously and intentionally respond to their child with a focus on being ‘‘in sync’’ with the child. While many parenting techniques teach what, when, and how to use specific discipline techniques, mindful parenting encourages parents to understand why they use specific techniques in a given situation (Kabat-Zinn & Kabat-Zinn, 1997). For example, the parent replaces reactivity (e.g., yelling) with a more thoughtful and intentional response (e.g., soothing the child and then helping the child express his or her needs in a more appropriate manner). In this way, parents respond more effectively to their child’s needs without causing undue harm to the child’s self-esteem. After all, ‘‘A nurturing home environment can maximize a child’s capabilities and minimize the impact of impairment’’ (Davis et al., 2009, p. 63). Mindful parenting research suggests mind- fulness may improve the child’s behavior, enhance the parent–child relationship, and increase parenting satis- faction (Singh et al., 2010; Thompson & Gauntlett- Gilbert, 2008). Hence, mindfulness practice can enhance a child’s self-awareness. Research on mindfulness (Singh et al., 2010; Thompson & Gauntlett-Gilbert, 2008) shows benefits to parenting and the parent–child rela- tionship, and there is an increasing amount of research supporting the practice of mindfulness meditation to enhance attention and executive functions (Flook et al., 2008). Child Mindfulness Mindfulness approaches exist for children and adoles- cents. Research on many of these approaches has shown efficacy in reducing symptoms of ADHD (van der Oord, Bogels, & Peijnenburg, 2012;Weijer-Bergsma, Formsma, Bruin, & Bogels, 2012; Zylowska et al., 2008). Van de Wiejer-Bergsma et al. (2012) provided an 8-week mind- fulness training for adolescents (aged 11–15 years old) who were diagnosed with ADHD while their parents concurrently received mindful parenting training. At 8-week follow-up, adolescents reported fewer attention, behavior, and executive function problems. Adolescents also showed improved performance on attention tests. Mothers reported reduced parenting stress. A similar MULTIMODAL TREATMENT OF ADHD 191 D ow nl oa de d by [ M em or ia l U ni ve rs ity o f N ew fo un dl an d] a t 2 3: 49 1 6 Ju ly 2 01 4 study was conducted with children (aged 8–12 years old) by van der Oord et al. (2012) also showing significant improvements in observed ADHD symptoms and redu- ced parental stress. Zylowska et al. (2008) conducted an 8-week study of mindfulness training with a small group of adolescents diagnosed with ADHD. Not only did participants perform significantly better on standardized tests of attention and inhibition, but they also self-reported decreased symptoms of ADHD, depression, and anxi- ety. Similar outcomes were observed in adult study part- icipants. The Mindful Awareness Research Center at University of California-Los Angeles conducted two studies with preschool and elementary school students that indicated improvements in self-regulatory abilities. Those with the poorest self-regulation abilities prior to the study showed the greatest gains (Flook et al., 2008, 2010). School Recommendations School-age children with ADHD may qualify for an Individualized Education Plan through the Individuals with Disabilities Education Improvement Act (U.S. Department of Education, Office of Special Education Programs, 2006) or a 504 Plan through the Americans with Disabilities Act (U.S. Department of Education, Office for Civil Rights, 2010). Incidentally, there are no specifications about what accommodations should be made for children with ADHD. In our experience, education plans for ADHD typically include accommo- dations such as preferential seating, extra test-taking time, and behavior charts with rewards for consistently expressed appropriate behavior. Although these inter- ventions are helpful in some contexts, they are not necessarily rooted in understanding ADHD as a brain- based disorder. Using reward charts, in particular, gives the child the impression that he or she has a choice in expressing ADHD-related behaviors. When children fail to make good ‘‘choices,’’ they lose a reward. In addition, their self-esteem likely decreases as their frustration increases. Parents in our practice often complain that schools do not consistently follow the child’s educational plan, which in point of fact is a contract under federal law. The way we have dealt with this problem is by attending multidisciplinary education team meetings to explain our assessment findings in detail and to teach educators about this brain-based disorder. In our experience, this collaborative approach can help improve educators’ compliance with specific academic accommodations. Children with ADHD, particularly those with the hyperactive type, are repeatedly punished for behaviors that are out of their control. Again, the child is diag- nosed with ADHD but is treated as if they can manage the disorder. We recommend the child’s school environ- ment be modified to minimize the child’s opportunity to make an ADHD-like failure. For example, developing and consistently executing serial environmental routines develops habituated behaviors, thus reducing ADHD expression. Educators are encouraged to make beha- vioral expectations clear and consistent. When consequ- ences are necessary, they should be short, predictable, and applied without anger or shame. Consequences should be designed to teach appropriate behavior, and not to simply punish. Just as education about ADHD helps parents to understand the brain basis of the disorder, so too this information is beneficial for educators. For educators, insight into the nature of this disorder helps them to more congruently craft an educational plan specific to each child’s strengths, needs, and weaknesses. Neurop- sychologists should provide the child’s educational team with intervention recommendations similar to those sug- gested in other sections of this article, such as learning about ADHD. INTEGRATED CARE Integrative medicine is the combination of alternative, complementary, and allopathic medical care and remains anchored in the efficacy of evidence-based scientific research (Maizes, Rakel, & Niemiec, 2009; Weil, 2011). Integrated behavioral health care applies medical and behavioral health interventions to treat any acute or chronic physical condition and acknowledges that the management of a physical condition is impacted by the overall lifestyle of a patient (Hunter, Goodie, Oordt, & Dobmeyer, 2009; O’Donohue, Cummings, Cucciare, Runyan, & Cummings, 2006). In other words, behaviors help create, mediate, and exacerbate life-challenging physical conditions such as ADHD. We review four domains that relate to our ADHD integrated care approach, because supporting a healthy, mindful, and behaviorally wise lifestyle is an integral part of our interventions. The first two domains are nutrition and physical activity (Ransdell, Dinger, Huberty, & Miller, 2009); these terms expand our concept of diet and exercise, remove stereotype, and facilitate a long-term shift toward understanding and practicing lifelong nutrition and physical activity that promotes health. We discuss and evaluate with parents nutritional choices and eating patterns within the family, and we look for levels of parental control over the child’s food intake. We understand that as children’s food prefer- ences develop, they begin making independent and sometimes unfortunate choices for snacks or meals. The challenge with assessing nutrition is that parents 192 BELJAN ET AL. D ow nl oa de d by [ M em or ia l U ni ve rs ity o f N ew fo un dl an d] a t 2 3: 49 1 6 Ju ly 2 01 4 may demonstrate patterns of food choice and portion control that may negatively impact health and behavior. The level of agreement and motivation with an assessed recommendation will help outline what the early nutritional goals will look like. The U.S. Department of Agriculture ‘‘My Plate’’ (http://www.choosemypla- te.gov) and Harvard Medical School’s ‘‘Healthy Eating Plate’’ (http://www.hsph.harvard.edu/nutritionsource) are Web sites that can help families learn about nutrition and plan meals accordingly. We educate par- ents about how a child’s diet impacts not only physical growth and development, but also cognition, executive functioning, emotion, and behavior (Hallowell & Ratey, 2005; Howard et al., 2011; Millichap & Yee, 2012). We encourage parents to explore different evidence-based nutritional approaches linked to ADHD, such as diet (Howard et al., 2011; Lam, 2013), as well as potential food sensitivities and nutritional deficiencies (Millichap & Yee, 2012). Parents are also encouraged to consult with their child’s pediatrician and nutrition experts in our area. The second domain, physical activity, is considered one of the most potent mood enhancements available (Emmerson, 2010; Kanning & Schlicht, 2010). We unfortunately find that urbanization and electronic lei- sure have led many parents and children into sedentary lifestyles. Physical activity increases the brain’s pro- duction of mood and reinforcement-enhancing neuro- transmitters (Weil, 2011). Research indicates exercise can improve behavioral, neurocognitive, and scholastic performance in children with ADHD (Pontifex, Saliba, Raine, Picchietti, & Hillman, 2012), likely secondary to increasing the availability of dopamine within the frontal lobes and neostriate. This does not mean that physical activity will cure ADHD; however, ADHD’s expression may be positively modified through physical activity. The third domain is the family social network. The parent–child partnership we discussed earlier is a subset of this and brings in, from a systems perspective, all family members. Research shows that positive, support- ive, and frequent social interaction significantly con- tributes to life satisfaction and personal well-being (Gottman et al., 1996; Holmbeck & Devine, 2010; Siddall, Huebner, & Jiang, 2013). Stressors, like caring for a child with ADHD, can expose preexisting prob- lems in families (Davis et al., 2009; Holmbeck & Devine, 2010). In some cases, we have found family therapy may be beneficial. The fourth domain we review is sleep. Restful sleep is vital to learning and memory consolidation, building and repair of the body, and stable moods and energy for daily living (Pastorino & Doyle-Portillo, 2013). We find that many children diagnosed with ADHD have difficulty getting to sleep, staying asleep, or both. We also have made numerous referrals for sleep studies only to find the child has sleep apnea. Once treated, the child’s cognition and ADHD symptoms often improve. OTHER INTERVENTIONS When parents ask for additional and nonpharmacol- ogical interventions, we provide information about interventions available through our office and elsewhere, which some neuropsychology practices may include. Research into the efficacy of proposed treatments indi- cates several nonpharmacological treatment methods that may be beneficial in treating ADHD, including: neuro=biofeedback, working-memory training, and alternative medical and physical treatments (AAP, 2011; Arns, de Ridder, Strehl, Breteler, & Coenen, 2009; Melby-Lervåg & Hulme, 2013; Rajwan et al., 2012). An additional treatment method we have developed, which requires more research, is a combined motor-cognitive approach (MC2), in part based on the independent work and writing of Elkhonon Goldberg (Goldberg, 2001) and Leonard Koziol (Koziol, Budding, & Chidekel, 2012; Koziol & Lutz, 2013). Each treatment method offers benefits and limitations with regard to their demonstrated efficacy and the feasibility of implement- ing them within a neuropsychology private practice. Neurofeedback Neurofeedback is a form of biofeedback that incorpo- rates electroencephalography and operant conditioning to manage the intensity and abundance of specific brainwaves. It has been proposed that certain forms of ADHD are associated with an overabundance of slow brainwaves and a reduced quantity of fast brainwaves (Arns et al., 2009). In theory, individuals can be trained to recognize and regulate their brainwave activity, which in turn can lead to a reduction in impulsivity and hyperactivity and can improve attention. Arns et al. (2009) described several neurofeedback approaches that are designed to enhance beta waves while inhibiting theta waves, enhance sensorimotor rhythm while inhi- biting beta waves, and=or incorporate reward with monitoring of slow cortical potential. A full description of each format is beyond the scope of this article; how- ever, interested readers are referred to Monastra et al. (2005), who provide an in-depth description of the use of neurofeedback in the treatment of ADHD. The efficacy of neurofeedback treatment for ADHD has been variably documented. Few scientifically rigor- ous studies have been completed, making it difficult for the efficacy of neurofeedback to be accurately mea- sured (Arns et al., 2009). Loo and Barkley (2005) and Holtmann and Stadler (2006) note that neurofeedback MULTIMODAL TREATMENT OF ADHD 193 D ow nl oa de d by [ M em or ia l U ni ve rs ity o f N ew fo un dl an d] a t 2 3: 49 1 6 Ju ly 2 01 4 currently cannot be considered a legitimate treatment for ADHD due to the lack of scientifically rigorous studies (e.g., randomized controlled trials), despite initial promising empirical results. More recently, Loo and Makeig (2012) reported that although the number and quality of scientific studies of neurofeed- back have increased in the past several years, current research evidence does not support the use of neuro- feedback as a standalone or primary treatment method for ADHD. Variable efficacy results notwithstanding, the major- ity of studies have failed to address several important factors. First, few studies have documented and assessed the impact of participants’ behavioral training prior to engaging in neurofeedback. Second, many of the studies Arns et al. (2009) included in their meta-analysis claimed efficacy based solely upon improvements in parent and teacher behavior ratings on subjective self-report scales, rather than documenting changes in brain waves, upon which neurofeedback theory is based. In fact, Arns et al. asserted the primary question should be, ‘‘Does it work?’’ rather than, ‘‘Why does it work?’’ If research- ers cannot explain why neurofeedback produces results, we wonder if they can truly be sure their promising findings are, in fact, the result of their neurofeedback intervention. Furthermore, studies included in the meta- analysis (Arns et al., 2009) that appear to demonstrate immediate improvement in ADHD behavior outcomes on parent and teacher rating scales do not provide data on the long-term maintenance of treatment gains, the transfer of treatment gains to other skill sets, or the gen- eralizability of treatment gains to other environments and tasks. Based upon these concerns and questions yet to be answered by empirical studies, we have chosen not to include neurofeedback in the interventions we offer through our practice at this time; however, we con- tinue to stay abreast of new literature and data as they become available. Working-Memory Training Working memory can be described as one’s ability ‘‘to maintain information in active memory while simulta- neously performing distracting or interfering activities’’ (Melby-Lervåg & Hulme, 2013, p. 270). Melby-Lervåg and Hulme (2013) note working-memory ability is syn- onymous with executive attention, as one must attend to pertinent information, sustain relevant information in mind, and inhibit attending and responding to irrel- evant information. Poor and inconsistently expressed working memory has been linked with difficulties in a variety of areas, including reading, mathematics, and sustained attention, as well as specific language impair- ments and difficulties associated with autism spectrum disorders (Melby-Lervåg & Hulme, 2013). Based upon this conceptualization of working- memory ability and its potential impact on one’s exp- ression of intellectual capacity, executive functioning, and academic achievement, researchers have developed working-memory training programs such as Cogmed (http://www.cogmed.com). These working-memory programs propose that improvements in working memory can be achieved through engaging in specific computerized verbal and visual working-memory activi- ties. Our question is: Can working memory be expanded or is attention being enhanced to support the reliable expression of working memory? Melby-Lervåg and Hulme (2013) further asserted that improvement in working memory will translate to immediate and long- term improvement in an individual’s performance on other tasks, such as arithmetic. Although the theory of working-memory programs appears sound, a meta- analysis assessing the efficacy of working-memory train- ing programs based upon published research reveals variable short-term results and poor long-term and transfer effects to other tasks (Melby-Lervåg & Hulme, 2013). Based upon the minimal transfer effects of computer- ized working-memory training programs, as demon- strated through the available efficacy research, we have chosen not to offer such a program through our prac- tice. We nevertheless provide parents with information about working-memory training programs available in our area, such as Cogmed; however, we encourage par- ents to consider other treatment options as well. MC2 MC2, orMotor-Cognition Squared, is a programwe have developed to address motor and cognitive aspects based upon cerebellar implications in ADHD (Goldberg, 2001; Koziol et al., 2012; Koziol & Lutz, 2013). A full descrip- tion of cerebellar interactions with executive functioning is beyond the scope of this article; however, interested readers are referred to works by Leonard Koziol, Psy.D., and Masao Ito, M.D. MC2 is in its infancy, and a full analysis of prepro- gram, postprogram, and follow-up data has yet to be conducted; however, individual patient data appear promising. When parents express interest in nonphar- macological treatment options, we often include a brief description of MC2 in addition to information about neurofeedback and working-memory training programs. If parents express additional interest in the MC2 pro- gram, we schedule an informational meeting with our MC2 program director; however, we emphasize that a formal evaluation of short-term and long-term out- comes has yet to be conducted, and we encourage par- ents to consider first-line interventions as well (i.e., education about the disorder, increasing structure and 194 BELJAN ET AL. D ow nl oa de d by [ M em or ia l U ni ve rs ity o f N ew fo un dl an d] a t 2 3: 49 1 6 Ju ly 2 01 4 routine at home and at school, mindful parenting, behavioral interventions, and medication). CONCLUSION Many treatment options are available for ADHD, including parent, child, and school-based interventions. In our experience, education for parents and children is a key component to successful intervention, followed by specific treatment options. By providing parents and children with education about the brain-based nature of this disorder, we provide parents and children with an alternative explanation of the child’s behavior. That is, the child’s behavior is not malicious or willful but is the outcome of a brain-based disorder. We encourage parents and children to collaborate when attempting to treat the symptoms of ADHD through environmental structure and routine, and through consistent behavioral expectations, rewards, and consequences. 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