How do I assess the effects of therapy in Attention Deficit Hyperactivity Disorder (ADHD)?

Assessing the Effects of ADHD Therapy

Use standardized rating scales from multiple observers (parents, teachers, and when possible, the child) combined with direct observation of functional outcomes in home, school, and social settings to systematically assess treatment response. 1

Core Assessment Framework

Multi-Informant Rating Scales

• Obtain parent and teacher ratings of ADHD symptoms using validated tools like the ADHD Rating Scale (ADHDRS) to measure the 18 core symptoms of inattention, hyperactivity, and impulsivity across settings 1, 2
• Collect ratings from both home and school environments because medication effects may differ by setting—studies show stimulants improve classroom behavior both morning and afternoon, but parents may not report home behavior improvements with twice-daily dosing 3
• Include self-report measures for adolescents using tools like the Conners Adult ADHD Rating Scale (CAARS) adapted for teens, as adolescent insight becomes increasingly important 2

Functional Outcome Measures

Beyond symptom reduction, assess real-world functioning:

• Academic performance: Track grades, homework completion, test scores, and teacher reports of classroom participation and task completion 1, 4
• Social functioning: Evaluate peer relationships, family interactions, and ability to maintain friendships using structured measures like the Quality of Family and Social Functioning (QFS) 5
• Behavioral observations: Use direct classroom observation to measure rule violations, on-task behavior, and appropriate social interactions—this provides objective data beyond rating scales 4
• Quality of life indicators: Assess self-esteem, hopelessness, and overall life satisfaction using tools like WHOQOL-BREF 5

Medication-Specific Assessment

Stimulant Medications

• Evaluate core symptom reduction with effect sizes around 1.0, making stimulants the most robust treatment for ADHD's 18 core symptoms 1
• Monitor for common adverse effects: appetite loss, abdominal pain, headaches, sleep disturbance, and growth velocity (1-2 cm reduction over time) 1
• Track rare but serious effects: hallucinations, psychotic symptoms, and cardiac symptoms (though sudden death remains extremely rare) 1
• Assess timing of effects: Benefits should be evident after dose titration, though some side effects may have delayed onset 3

Non-Stimulant Medications (Atomoxetine, Extended-Release Guanfacine/Clonidine)

• Expect smaller effect sizes (approximately 0.7) compared to stimulants, requiring adjusted expectations for symptom improvement 1
• Monitor atomoxetine-specific effects: initial somnolence, gastrointestinal symptoms (especially with rapid titration), decreased appetite, and rarely suicidal ideation or hepatitis 1, 2
• Track α2-agonist effects: somnolence and dry mouth for extended-release guanfacine and clonidine 1

Behavioral Therapy Assessment

Parent and Teacher Satisfaction

• Measure treatment satisfaction separately because parents consistently report higher satisfaction with behavioral therapy than medication alone, even when symptom reduction is greater with medication 1
• Assess adherence to behavioral programs as ongoing implementation is critical—effects persist only with continued adherence, unlike medication which stops working when discontinued 1

Functional Domains Beyond Core Symptoms

Behavioral therapy addresses areas medication may not:

• Oppositional and conduct problems: Particularly important when ADHD coexists with anxiety or in lower socioeconomic environments 1
• Academic and organizational skills: Training interventions targeting disorganization of materials and time management show consistent benefits, especially for adolescents 1
• Family functioning: Evaluate parent-child conflict, communication quality, and problem-solving abilities 5

Combined Treatment Assessment

Additive Benefits

• Look for small but significant improvements in combined parent-teacher symptom ratings (effect size d=0.26-0.28) beyond medication alone 1
• Assess medication dosage reduction: Combined treatment allows lower stimulant doses while maintaining efficacy, potentially reducing adverse effects 1
• Evaluate comorbid conditions: Combined treatment shows superior outcomes for academic and conduct measures when ADHD coexists with anxiety 1

Age-Specific Considerations

Preschool Children (Ages 4-5)

• Prioritize behavioral therapy assessment first before considering medication, as behavioral interventions are first-line treatment 1
• Monitor for increased mood lability and dysphoria if medication becomes necessary 1

School-Age Children (Ages 6-12)

• Assess both home and school functioning using parent training in behavior management (PTBM) and classroom interventions 1
• Coordinate school-based supports: Evaluate effectiveness of 504 plans or IEPs, classroom adaptations (preferred seating, modified assignments), and behavioral plans 1

Adolescents (Ages 12-18)

• Include adolescent self-report and assess medication adherence, as discontinuation is common in this age group 1
• Monitor driving-related functioning: Ensure medication coverage during driving hours given increased crash and violation risks 1
• Evaluate training interventions: School functioning skills programs show the most consistent benefits for adolescents 1
• Assess for medication diversion: Monitor prescription refill patterns and consider non-stimulant options if diversion risk is high 1

Systematic Monitoring Schedule

Initial Titration Phase

• Assess weekly during dose adjustment to identify optimal medication dosage that maximizes benefits while minimizing adverse effects 1
• Use Clinical Global Impression-ADHD-Severity (CGI-ADHD-S) scores to track overall improvement 2

Maintenance Phase

• Schedule regular follow-up visits to monitor height, weight, heart rate, blood pressure, symptoms, mood, and treatment adherence 6
• Define treatment response: CGI-ADHD-S score ≤2 and at least 25% reduction from baseline in ADHD rating scale scores 2
• Watch for relapse indicators: CGI-ADHD-S increases of ≥2 points and symptom scores returning to ≥90% of baseline for two consecutive visits 2

Common Pitfalls to Avoid

• Don't rely solely on parent reports for medication effects—teachers may not report the same side effects parents observe, and medication benefits may be setting-specific 3
• Don't assume medication alone addresses all impairments—academic achievement, peer relationships, and family functioning often require behavioral interventions even when core symptoms improve 1
• Don't overlook coexisting conditions—anxiety, learning disorders, mood disorders, and sleep problems require separate assessment and may need additional treatment 1
• Don't expect immediate behavioral therapy results—unlike medication's rapid onset, behavioral interventions require consistent implementation over time to show benefits 1