Treatment Update for ADHD

The conventional wisdom is that a child or teen with attention deficit disorder should be started on ADHD medications (such as Ritalin or Adderall) right away. Sometimes some type of psychotherapy may be recommended, with a therapist trained in treating ADHD. A new debate outlined in Thursday’s Washington Post explains why drugs alone are not a good treatment option, in a followup study that looked at whether children diagnosed with ADHD do better when treated with drugs, with drugs and psychotherapy, with psychotherapy alone or with routine medical care alone:

In August 2007, the […] researchers reported the first follow-up data, which by then no longer showed differences in behavior between children who were medicated and those who were not. But the data did show that children who took the drugs for 36 months were about an inch shorter and six pounds lighter than those who did not.

In other words, the drugs appear to wear off over time. One of the original researchers in the study, psychologist William Pelham, is leading the charge for behavioral treatments over medication treatments — especially for long-term behavioral change in children. In a recent presentation, he outlined the following ADHD treatment recommendations for children:

• Behavioral Parent Training — Use always
• Behavioral School Intervention — Use always
• Intensive Behavioral Child Intervention — Use when needed
• Medication — Use when needed

In the same presentation, Pelham persuasively argues that dose and sequencing of treatments for ADHD are very important considerations, too often overlooked. When behavior modification techniques are used, they reduce the need for high doses of stimulant medications. What order treatments are provided — called sequencing — is also important. Providing behavioral treatment first reduces need for medication; providing medication first reduces parental desire to pursue behavioral treatments. According to Pelham, “Parents strongly prefer psychosocial or combined treatment approaches. Parental preference is important because it affects long term adherence.”

If behavioral treatments are started first and continued, Pelham suggests that 50 to 75 percent of children with attention deficit disorder will not need medication (fewer at school and more at home). For children who do need medication, doses will generally be lower. So Pelham argues that most children diagnosed with ADHD should very nearly always start with behavioral treatment first, and only add medication when impairment is not minimized and parents prefer medication or resources limit more intensive behavioral treatments.

When a combination treatment approach is used — behavioral modification and stimulant medications — it produces better outcomes in the short-term. A child with ADHD in a combination approach may also be on a lower dose of medication and, because of that, have fewer side effects. The combination approach also importantly produces last behavioral effects if the medication is withdrawn in the future. And the combination approach tends to be strongly preferred by parents and teachers to medication alone, and thus more likely to be utilized in the long run.

Since children who take ADHD medications long-term (e.g., 36 months) were about an inch shorter and six pounds lighter than those who did not, treatment providers and parents should reconsider what they think about ADHD treatments — especially the virtually automatic prescription of ADHD stimulant medications by primary care physicians and pediatricians.

The first treatment for attention deficit disorder in children that appears to be best is a behavioral modification treatment, with medication only added if needed later on.

Read the full article: Debate Over Drugs For ADHD Reignites.

Maggie Mahar’s 2007 post about the MTA study (worth a read)