Posting Date: 09/01/2004
Push to Medicate ADHD Children Ignores Successes of Behavioral Treatments
Teachers nationwide say about five percent of children in their classrooms have been diagnosed with attention deficit hyperactivity disorder (ADHD), and they estimate another 5 percent have ADHD but are undiagnosed, according to a survey conducted by University at Buffalo graduate student Gregory Fabiano and William Pelham, Jr., UB distinguished professor of psychology, pediatrics and psychiatry.
Many of these children likely will be placed on psychoactive medication by their family physician, often prompted by their child's school.
For parents of children who will be diagnosed with ADHD during the upcoming school year, Pelham, a national authority on ADHD treatment, has this important message: There is an effective alternative to medication for treating ADHD.
"Doctors and professionals in the ADHD field overemphasize the role that medication should play in the treatment of children," says Pelham, who has authored hundreds of studies on ADHD treatment and has conducted clinical trials of ADHD drugs Ritalin, Adderall and Concerta.
"Unfortunately, the end result is that many parents of ADHD children are not made aware that there is a well-established, evidence-based alternative to medication -- behavior therapy," Pelham adds.
Most physicians, he says, routinely prescribe medication to children without first discussing with parents the risks and benefits of drugs or discussing alternatives to drugs. Yet, research has shown that if you start ADHD children on behavioral therapy, half of the children don't ever need ADHD medication, Pelham says.
"Instead of immediately prescribing the drugs, physicians should be recommending to parents a sequential approach -- behavior therapy first and then add medication if needed."
One survey of parents indicated that 80 percent would choose behavior therapy over drug therapy as an initial treatment if they had been aware of the benefits of behavior therapy, Pelham points out.
"Medication for ADHD children is not bad, it just needs to be used in moderation," Pelham says. "Used in low doses, in combination with behavioral treatment when needed, medication is a very useful intervention for many ADHD children."
With behavioral therapy, children, parents and teachers learn techniques and skills to help improve children's behavior in daily life. The focus is on academic performance at school, relationships with parents, peers and siblings, failure to obey adult requests, and skill development in important areas.
"Behavior modification is the fabric of good parenting," Pelham explains. "Almost every parent uses rewards and consequence such as 'timeouts' when their children misbehave. And every teacher has a list of rules and a list of consequences for breaking the rules. Essentially behavior therapy involves parent and teacher consultation to tweaks those rules. It teaches parents and teachers how to better manage an ADHD child.
"How many parents of ADHD children would choose as a first-line of treatment putting a psychoactive drug into their child's brain as opposed to learning how to help their child by being a better parent?," he asks. "In my experience no parent chooses drugs if they know that they have a choice."
Pelham's award-winning Summer Treatment Program for ADHD Children held annually at UB since 1997 provides intensive behavioral therapy for children on medication and not. Two studies published in the current issue of Behavior Therapy document the effectiveness of this program. The summer program includes recreational and classroom components and focuses on teaching peer skills, sports and academic skills in a summer-camp context. According to Pelham, families like the program because children not only get better, but they also like the treatment. "For the first time, these kids are in a camp where they succeed, and they love it!" he says. Variations of the UB summer program are offered at many other sites around the country, including in New York City, Cleveland and Birmingham, as well as in numerous communities in western Pennsylvania.
One ongoing National Institute of Mental Health-funded study of children enrolled in the UB summer program found that children who received behavioral therapy in advance of drug treatment required much lower doses than children who were put on drugs without first undergoing behavioral therapy. Doses given to children while in school were halved, and most parents elected not to use medication at all at home.
"This is a significant finding because children who receive lower doses may be less susceptible to potential ADHD drug side effects, such as loss of appetite and stunting of growth," Pelham says.
Another very large NIMH study by Pelham and co-researchers found that ADHD children treated with medication alone grew a centimeter less per year on medication. Children who received behavior modification in this study, which included parent and teacher consultation and participation in Pelham's summer program, did not have any reduction in growth. Moreover, only about a third of behaviorally treated children were taking medication after two years, and among those who were, doses were reduced by almost half compared to the medicated groups.
According to Pelham, behavioral therapy, unlike drug therapy, also may produce long-term benefits for ADHD children, such as teaching them coping and behavior skills that carry into adulthood. When ADHD children treated with medication become teens, they typically refuse to continue taking their medication, he points out. "As a result the beneficial effects of the medicine go away," he says. "And it is much harder to implement behavioral treatments with adolescents than with younger children, so a window of opportunity for effective treatment in childhood may have been lost if parents relied solely on medication.
"Thirty years of research show that ADHD drugs used alone do not help children avoid long-term outcomes that are a hallmark of the disorder -- substance abuse, domestic problems, school dropout, delinquency and criminal behaviors," Pelham concludes. "More parents would opt out of using medication as the first line or sole treatment if they were provided with this information, and if physicians didn't opt for medication first."
Parents and teachers interested in behavior modification techniques for ADHD children can download information from the UB Summer Treatment Program Web site at http://www.wings.buffalo.edu/adhd (http://www.wings.buffalo.edu/adhd). Included is instruction on how parents and teachers can set up a very effective and no-cost behavioral treatment called the Daily Report Card. "Our group has tried to develop simple and effective programs for parents and teachers and make them available over the Internet for free," Pelham says.
"Every mental health professional in the country can do behavioral parent training, and parents and pediatricians need to push for it in their community if it doesn't appear to be available."