According to a recent article, about 10.4 million U.S. children, mostly boys, were treated for Attention Deficit Hyperactivity Disorder in 2010. This number was the highest in the nation’s history, representing a 66% increase since the year 2000 and resulting in treatment costs totaling $6.85 billion. Given these statistics, it is no wonder that there has been a proliferation in the number and variety of ADHD treatments now available. What are they? And how well do they work?
The most prevalent form of treatment is medication, although it may be counter-intuitive, the majority of prescriptions are for stimulants such as Ritalin, Concerta, or Focalin. This class of drugs is designed to increase the brain’s production of the chemicals that help children sustain their attention and regulate their behavior. Although the government has designated these drugs as controlled substances, several decades of use suggest that when taken under the close supervision of a doctor, they are usually safe, non-addictive, and metabolized by the body in 3-5 hours (or about 8 hours for timed release versions). Some children may experience side effects such as headaches, loss of appetite, difficulty sleeping, dizziness, irritability, and the “jitters.” When these stimulants prove ineffective, some doctors may prescribe stronger ones including amphetamines such as Adderol or Vyvance, drugs that do have the potential to become addictive, may accumulate in the body, and require monitoring with greater care. In recent years, doctors have also begun to prescribe non-stimulant drugs originally developed to treat depression, including Wellbutrin and Strattera.
An equally common form of ADHD treatment, administered not by doctors but by schools and parents, is behavioral intervention – or what used to be called behavior modification. With this approach, teachers help children learn specific, concrete skills for sustaining their attention and regulating their motor activity. These may include deep breathing, meditation, awareness of body states, task planning, time management, and specific study skills. Clear academic or behavioral goals are set and children are rewarded for achieving them. Punishments are generally not used, something based on research showing that while positive responses will reinforce positive behaviors, negative responses will not prevent negative ones. Although some programs use “time outs,” they are explained not as punishments but as opportunities for children to pause and gain better control of themselves.
The Medication Debate
During the 1990’s there was a spirited debate between those favoring medication and those advocating behaviorism, with each side citing studies supporting the efficacy of its preferred approach. The medication proponents reported research indicating that 70-80% of ADHD kids were helped by Ritalin and similar drugs while smaller percentages were helped by other prescriptions. Their opponents cited studies showing that multiple variations on the behaviorism model had produced outcomes that were consistently positive and (unlike those resulting from drugs) endured long after the treatment had ended. The percentages varied from study to study and were similar to or lower than those found with medication.
The most extensive study was conducted by the National Institutes of Mental Health in 1992 and followed up in 2001 and 2004. It concluded that children receiving medication management alone or in combination with behaviorism showed significantly more improvement than those receiving only behavioral interventions. It also showed that medication plus behavior mod was only slightly more successful than just the medication. In other words, according to this study the numbers favored the meds.
Over the years, a variety of other approaches have been tried with ADHD kids. All of those described below have been supported by one or more experimental studies. Therapists have often used cognitive behavioral approaches, which work to modify self-defeating behavior and the irrational thoughts associated with it. Therapists and schools have offered training in the skills needed for executive functioning, stress coping, emotional regulation, and socialization. Nutritionists and doctors have utilized diet management, citing a number of studies supporting the notion that there is a relationship between what kids eat and how they behave. Some psychologists have found success with the use of neurofeedback, which trains people to manage their own brain wave activity. Many professionals have recommended increased exercise.
When it comes to addressing ADHD in the school setting, the preferred approach is one that involves intervention and remediation tailored to the individual child. Under federal law, children diagnosed with ADHD are eligible to request an Individualized Education Plan, which begins with diagnostic testing and is developed by a team that includes parents, teachers, school psychologists, doctors, and therapists. An IEP guarantees careful evaluation and special help in school.
Medication…Yes or No?
For many parents of ADHD kids, the most difficult decision is whether or not to medicate. Some will decide that the potential benefits outweigh the possible side effects. Others will maintain that they do not want their children medicated with compounds intended not to treat disease but to change behavior. In my counseling practice, I argue neither for medication nor against it. But I do urge that parents make an informed decision, one reached only after considering information gathered from knowledgeable sources. I also recommend that they read an excellent book, Driven to Distraction, by Edward M. Hallowell, MD and John J. Ratey, MD. Finally, as I mentioned in Part I of this blog, I suggest considering treatment for the “collateral damage” of ADHD through child counseling, parent consultation, and family therapy.
If you would like to consult with me about someone who may have symptoms of ADHD, please contact me at 213.405.6745 or firstname.lastname@example.org. I will return your e-mail or phone call the same day.