Wednesday, February 11, 2009

Brain & Behavior

ADHD Medication: Can Your Child Go Without?

Behavioral therapy for ADHD—and parent retraining, too—can be good alternatives to medication

Posted January 14, 2009

Attention deficit hyperactivity disorder can be a distressing diagnosis, but families have more treatment options than they might realize. Although Ritalin and other stimulant drugs are the most common prescription, ADHD treatments that don't involve medication have a proven track record. And here's a surprise: One of the most beneficial options treats the parents, not the child. For children, skills training programs and ADHD summer camps can help teach techniques to overcome everyday problems that often make life miserable, such as remembering to bring assignments home from school or to listen without interrupting.

Two kids playing on trampoline
Video: ADHD
Video: ADHD

How training parents helps the child. Parent skills training has been used for years to improve the behavior of children, and multiple clinical trials have validated its effectiveness. Those same programs improve the behavior of kids with ADHD. Although it may seem odd to be changing parents' behavior to treat what's considered a medical condition in children, research has found that for children with ADHD, having parents who use effective parenting techniques is one of the best predictors of success in adulthood. These programs teach parents to make clear, specific requests of children, for instance, and to use praise and rewards for good behavior far more often than punishment.

In fact, parent training for ADHD is considered so mainstream that last fall the British government mandated parent training as the first choice for treatment in many cases. "For milder cases, we recommend starting with behavioral therapy," says Eric Taylor, a professor of psychiatry at King's College Hospital and an ADHD authority who helped write the new standards for the National Institute for Health and Clinical Excellence. In England, parents of children with ADHD are offered free government-funded classes where they learn to set clear limits for the child, be consistent in enforcing those limits, and reward good behavior.

In a perfect world, all children with ADHD would get coordinated, "multimodal" treatment, which would include parent training; a tailored program at school; education about ADHD for kids, parents, and teachers; and medication if necessary. But all too often, kids get just the pills. Most children are treated by pediatricians, who may not be aware of the data on the benefits of behavioral treatments such as parent training, despite the fact that the American Academy of Pediatrics recommends both behavioral interventions and medication. The various professional societies favor their own strengths, not surprisingly, with the psychologists endorsing behavioral therapy and the psychiatrists big on medication as the first line of treatment. "The behavioral treatment had no side effects," says William Pelham, a research psychologist who directs the Center for Children and Families at the University at Buffalo-SUNY and who was a pioneer in the use of parent training as a behavioral intervention for ADHD. Side effects of medication include insomnia, loss of appetite, and stunted growth. That, he says, is reason enough to follow the British model.

Parents who want to give parent training a try may need to ask around for evidence-based classes. (The National Resource Center on AD/HD is a good place to start, as are community mental health clinics. Ask if the program offered has been validated in clinical trials.) Some popular parenting books are based on clinically validated behavioral treatment. Three good ones: Parenting the Strong-Willed Child by Rex Forehand and Nicholas Long, The Incredible Years by Carolyn Webster-Stratton, and The Kazdin Method for Parenting the Defiant Child by Alan Kazdin. (Here's in-depth information on evidence-based parenting programs.)

"There are some caveats," says Russell Barkley, a clinical psychologist specializing in ADHD treatment and coauthor of the evidence-based parenting manual Your Defiant Child. Parent skills training tends to work better for younger children than for teenagers, Barkley says, probably because parents have less influence on teens than they do on 6-year-olds. And in his own research on preschoolers, parent training didn't improve children's behavior at school unless the teacher was also on board. Finally, parent training takes time and effort, because it means not only learning new techniques but also abandoning old habits (adios, nagging).

"Parent training is much more work," Pelham agrees. "It's a pain. But being a parent is a pain."

Teaching kids life skills. It's time to start thinking about new ways to treat ADHD, says Howard Abikoff, director of the Institute for Attention Deficit Hyperactivity and Behavior Disorders at the New York University Child Study Center. "Do we have enough evidence-based treatments to say we know how to deal with the problems in these folks' lives?" he asks. "I don't think so."

Many children with ADHD struggle with social skills, such as waiting for their turn to talk instead of interrupting or keeping their temper instead of dissing teachers. Increasingly, programs are trying to solve that problem with behavioral treatments that offer rigorously tested skills training. Duke University Medical Center's ADHD program, for one, offers classes for third to fifth graders on listening and following directions, homework, organizational skills, effective communication, and problem-solving. ADHD therapeutic summer programs, including the Summer Treatment Programs founded by Pelham, as well as ADHD summer camps offer skills training at a level that might not be available closer to home. Mary Alvord, a clinical psychologist in Rockville, Md., offers weekly group sessions using cognitive behavioral therapy to help children with ADHD improve their social skills. "We also mix in kids with social anxiety," Alvord says. "They provide excellent modeling opportunities and support for one another."

Abikoff is halfway through a National Institute of Mental Health-funded clinical trial to test whether children with ADHD can be taught to become better at organizing, time management, and planning, three skills that many continue to struggle with as working adults. "If you've ever looked in the book bag of some of these children, it's quite remarkable," Abikoff says. "Even if the kids are doing everything in the classroom that we've worked on with them, it's still possible that they'll come home and they don't have it," Abikoff says. "We try to provide them with reminders at the point where it's critical to remember—something attached to the zipper of their book bag. It's the last thing they do before they walk out."

Finding the right help for your child. Scientists now know that ADHD takes different forms, and those differences are probably rooted in brain physiology. For instance, about 20 percent of children get no benefit from stimulant medications, but right now the only way to find out who does is by trying the drugs. Someday there may be a simple test that will tell parents just what form of ADHD their child has and what treatment will work best. For now, alas, finding the right fit is all too often lots of trial, too much error. Just one example: Doctors and therapists often recommend "talk" or "play" therapy for the child, even though there is no evidence that it helps with ADHD. Indeed, behavioral treatments that teach skills to parents or children are the only nonmedical form of ADHD therapy with solid scientific evidence that they work.

In the 1990s, the National Institute of Mental Health tried to weigh the relative benefits of the two most common treatments for ADHD: stimulant drugs and behavioral treatments, including parent training. The Multimodal Treatment Study of Children with ADHD followed 579 grade-schoolers for 14 months. Some got stimulants, and some got behavioral therapy that included parent training, teacher training, and a summer camp that taught the kids social skills. A third group got both medication and the behavioral intervention. A fourth group had treatments chosen by their parents in the community. At the end, the children in all four groups were doing better. Parents and teachers rated the medication-only group as having many fewer symptoms of inattention and hyperactivity/impulsivity. But they rated the children who got behavioral treatment as doing better on aggressive behavior, peer relations, parent-child relations, and academic achievement. Since the first results were published in 1999, researchers have been arguing strenuously over whether the study proves that medication or treatment without medication is best.

"What the MTA really showed is that it's not the medication per se but the intensive monitoring," says Benedetto Vitiello, chief of the child and adolescent treatment and preventive interventions branch for the National Institute of Mental Health. "Having a visit each month, putting together all the information for the school and the parent, tailoring the treatment." Indeed, when the study ended and the extra monitoring stopped, the benefits faded for all groups, medicated or not.

The take-home message for parents: There are other good treatments besides the pills, but no treatment's going to work without sustained effort from the whole family.



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