Benefits of a Multimodal Treatment Approach to ADHD

Rakesh Jain, MD, MPH: The classic treatment of ADHD [attention-deficit/hyperactivity disorder] has been pharmacotherapy. That’s appropriate, but it should never be offered in isolation. No matter how old the person is, no matter what subtype of ADHD they might have, it should never be recommended alone. Often, we offer school-based interventions if they’re appropriate, maybe even workplace setting adjustments. But I do think there’s 1 other emerging form of therapy worthy of our thought, and that is coaching. 

Coaching is different from psychotherapy. Coaching is very much goal setting, tracking progress, and encouraging. It doesn’t necessarily follow a CBT [cognitive behavioral therapy] model. It follows much more a model that often works well with individuals with ADHD, particularly those who are adolescents and older. Often, time management is such a big challenge. Coaching can address that. Very often, being late to pay bills or being present at appointments is a problem. Coaching can be very helpful. Shaming or blaming doesn’t go very far.

These are all executive function deficits. Of course, optimized treatment of ADHD does help, but it’s OK to offer additional treatment modalities like coaching to help our patients. I really do hope you will consider that as a valid option for appropriate patients.

The management of ADHD is always a combination of strategies. It could be 2 or more nonpharmacological techniques. It could be a pharmacological intervention with a nonpharmacological intervention. The combination doesn’t matter per se, as long as we never allow ourselves, as clinicians, to be monolithic in our approach, offering just 1 thing at a time. That is not logical. That is not supported by guidelines. That is not supported by the package insert for medications they’re unfamiliar with. They should be used in combination. But why? Because it’s politically correct, or is there evidence 1 plus 1 may actually equal 3 in some patients, metaphorically speaking? 

The evidence is for the full restoration of a person’s functioning and the restoration of their self-confidence. For the reinsertion of optimum functioning in a person’s life, rarely does 1 intervention do it all for most people. Therefore, I recommend a combination approach. It could be something as simple as physical exercise plus school-based interventions and academic adaptation to the child’s needs and a medication. If you remove even 1 of these 3 pillars, things come crashing down. Those 3 options end up supporting one another. It could be sleep hygiene. It could be cognitive behavioral therapy. It could even be family-centric psychotherapy, in which coaching is offered not to the patient—the patient may be too young—but to the parents.

The upshot of my recommendation is to resist the temptation to offer 1 intervention at a time. Resist it. It’s better to think of a multimodal approach for every single patient with ADHD.

Transcript Edited for Clarity