Going the Behavior Route
Tuesday, May 2, 2006
What non-drug treatments work to combat attention-deficit hyperactivity disorder (ADHD)?
It's a question more parents are asking doctors, prompted by new concerns about the safety of medicines used to treat a problem that affects an estimated 4.4 million American children.
In the past three months, two advisory committees of the Food and Drug Administration have recommended that warning labels on ADHD drugs, most of them stimulants such as Ritalin, be strengthened because of their possible links to rare cardiac problems and vivid hallucinations often involving snakes or bugs.
Concerns about misuse and overprescription of ADHD drugs, many of them chemical cousins of amphetamines, are not new. But hope that the common neurobehavioral disorder could be effectively treated without medication was dealt a severe blow seven years ago when a landmark study of nearly 600 school-age children found that medications were the most effective treatment.
That study, funded by the National Institute of Mental Health, also found that the best outcomes, measured by parental satisfaction and some academic standards, were the result of "combination" treatment: medications that reduce hyperactivity and improve concentration, and behavior therapy to address some of the more subtle symptoms, such as difficulty with organizational and social skills.
While other non-drug treatments -- play therapy, cognitive therapy, psychotherapy and special diets -- have been regarded as promising, only behavioral treatment has been shown to work. But experts caution that it is an adjunct to, not a substitute for, medication.
Although ADHD specialists say they consider behavior therapy a key component of effective treatment and one that has inspired a recent resurgence of interest, many parents don't invest the time and effort necessary for it to be effective.
"There's so much lip service paid to [combined] treatments, but a lot of people just rely on medication alone," said William L. Coleman, a developmental pediatrician at the University of North Carolina who is chairman of the American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health. "We are a quick-fix society and we want results. There's a lot of time pressure on parents and on teachers."
A behavior therapy regimen can be developed by a pediatrician or a school psychologist or another mental health worker. Based on a structured system of rewards and consequences -- such as increased or decreased TV or video game privileges -- the program also includes changes in a child's environment to minimize distractions. Parents also receive training in how to give commands and ways to react when a child obeys or disobeys.
The goal is to incrementally teach children new ways of behaving by rewarding desired behavior, such as following directions, and eliminating undesired actions, such as losing homework, notes Ginny Teer, a spokeswoman for Children and Adults with Attention Deficit/Hyperactivity Disorder (CHAAD), a national advocacy group based in Landover.
Experts say behavioral therapy sounds easier than it is. Parents often "have an inappropriate expectation of what medications can do," observed Washington pediatrician Patricia Quinn, who has specialized in treating ADHD for more than 25 years. "Drugs don't improve self-esteem, time management or organizational skills. But the problem is that most parents don't have enough time or energy" for behavior therapy or are inconsistent about applying it. Sometimes, Quinn said, they make the regimen too complicated by imposing too many rules.
The trick, Quinn said, is to keep things simple, especially for younger children, which enables them to succeed, thereby reinforcing the desired behavior.
McLean child psychiatrist Thomas Kobylski compares ADHD to diabetes: Medications are necessary but not sufficient for both conditions. For optimal results, people with diabetes need to watch what they eat and to exercise, in addition to taking medication. Children with ADHD, he said, need medication as well as the skills that behavior therapy teaches to function well at home and at school.
There is an added benefit from combination treatment, said Kobylski, who is chairman of the Washington area chapter of the American Academy of Child and Adolescent Psychiatry. Studies have found that children treated with behavior therapy can take a lower dose of medication, Kobylski said.
Public relations executive Susannah Budington, who lives in Chevy Chase, began using behavior therapy several years ago, shortly after Allison, the oldest of her five children, was diagnosed with ADHD and started taking Concerta.
"She's such an enthusiastic, wonderful kid I would never want to medicate that away," said Budington. Concerta, she said, enables Allison to be less impulsive and more cooperative, but behavior therapy has helped the 12-year-old "operate as part of our family, to play soccer and to do things with her friends. It's extremely important."
One of the biggest problems, Budington said, has been getting Allison to do her homework without incessant reminders. One of the techniques Budington and her husband recently devised involves Allison's desire to get her ears pierced, something her parents have agreed that she can do when she turns 13. When Allison does her homework without prompting, she gets a chip she can use to move up the ear-piercing date by a week. Bad behavior means a week is added.
Trish White, a manager at CHAAD, said that the involvement of her son's school in his behavioral program has been critical to the progress he has made in the two years since a pediatrician told her he had ADHD. Once a child is diagnosed with the disorder, federal law requires that the school devise an individualized education plan that accommodates the disability. That plan often includes elements of behavioral treatment, but cooperation by teachers and school systems varies, experts say.
At his Anne Arundel County public school, White's 8-year-old son sits near the teacher to minimize distractions. When she senses his attention is wandering, she taps lightly on his desk to remind him to focus. Every day she sends home a simple, color-coded behavior chart telling his parents how his day went.
White said she uses daily behavior charts at home. When her son is helpful or gets along with his little sister, "he gets lots of hugs and kisses," she said.
"We continue to struggle," said White. Reading remains difficult for her son, she added, but he is better able to follow directions and seems more adept at making friends.
Quinn, who has seen concern about ADHD medications wax and wane during the years she has treated hundreds of children with the disorder, regards growing interest in behavior therapy as a positive development.
"Drugs," she said, "can only do so much." ·
Comments: email@example.com. Join Washington pediatrician and ADHD specialist Patricia Quinn for a Live Online chat today at 11 a.m. about behavioral therapy.