The drugs of choice among most pediatricians, psychiatrists and others treating children with ADHD are stimulants like Adderall and Ritalin — which have earned an almost mythical reputation for their ability to help children do better in school, and which some teens and college students abuse to gain an edge in academics. But the long-term effects of those drugs on a young brain and body have not been well studied, and the side effects can be numerous, including poor appetite, sleeplessness, irritability and slowed growth.
"Until we know more the recommendation is to first refer parents of children under 6 years of age who have ADHD for training and behavior therapy," Anne Schuchat, CDC principal deputy director, said in a call with reporters on Tuesday.
As recently as a decade ago, ADHD — a neurodevelopmental issue that may cause children to be overly active, have trouble focusing or be unable to control their actions — was something that many providers hesitated to diagnose before the early elementary years. At one end of the spectrum are children who are extra wiggly and unable to sit still during music hour at the library and talk nonstop. At the more severe end are those who are recklessly jumping down flights and running into oncoming traffic. Many experts argued that it can be impossible to distinguish the normal behavior of a boundlessly energetic preschooler still learning to navigate the world from one who has a medical condition that requires intervention.
That attitude has changed dramatically. Today about 2 million of the more than 6 million children with ADHD were diagnosed as at ages 2 to 5 — triggering impassioned debate about whether this represents a true rise in the prevalence of the condition or the diagnostic pressures on doctors due to unrealistic demands in schools or stressed-out parents obsessed with having a perfect child.
While ADHD medications do not always work perfectly for everyone, in many cases they take effect almost instantly. Behavior therapy, on the other hand, can take many months to have an impact and often requires significant trial and error to figure out which strategies work. The CDC, in new documents issued for parents of children with ADHD, acknowledged that behavior therapy "can take more time, effort and resources than medicine." However, the agency noted that studies show it can also "be longer lasting."
Behavior therapy encompasses a wide range of interventions from counseling to eight-week boot camps for parents to learn how to better manage difficult behaviors.
Georgina Peacock, director of the CDC’s human development and disability division, said that experts recommend parent- or teacher-led behavior therapy for children with ADHD at this age as opposed to therapies like Applied Behavior Analysis, which focuses on the child and is considered by some to be the gold standard for treating children on the autism spectrum. Peacock explained that adult-led therapy can have a two-fold benefit: It helps strengthen the bond between a parent and a child and gives parents a toolkit to help them learn positive ways to set limits, impose appropriate consequences and improve communication.
"It's like having your own personal coach for dealing with challenging behaviors," she said.
But such therapy services aren't available in all communities and many insurance companies don't cover behavioral therapy for children with ADHD, making it highly expensive to have ongoing, long-term therapy for a child.
CDC officials said Tuesday that they hope this will change.
"One of our points of raising this awareness today is to let insurers know this evidence has been reviewed carefully. ... We really feel this is an appropriate intervention that ought to be covered," Schuchat said.
ADHD in its most severe form can be very serious. Studies have shown that children with the condition have higher rates of dropping out of school or having sustaining injuries that can take them to emergency rooms. Even when it's milder, children who have trouble completing tasks or concentrating can be at risk for low self-esteem.
Treatment guidelines for kids with ADHD, first described in the diagnostic manual for psychiatrists in 1980 as attention deficit disorder, have been a moving target over the years and vary dramatically by country. The United States is somewhat of an anomaly because its recommendations allow for medication as a first-line treatment for children with ADHD ages 6 to 18; many other countries recommend trying a mix of lifestyle changes, counseling and behavior therapy before moving on to drugs.
But the most recent U.S. guidelines, issued by the American Academy of Pediatrics in 2011, represent a movement towards nonmedical interventions.
In past recommendations issued in 2000 and 2001, parents were given a choice between drugs and behavioral therapy. In the 2011 version, parents were told they should "preferably" be using medication and behavioral therapy at the same time.
The section geared at the youngest children, ages 4-5, was even more explicit about the potential benefits of parent- or teacher-led behavior therapy as the first line of treatment. Only if that therapy does not provide "significant improvement" or the child has "moderate to severe" symptoms, should doctors prescribe medications, according to the recommendations.
CDC officials emphasized that they know behavioral therapy is not a "practical" option for some and that it is working with parents to try to expand the availability and accessibility of the treatments through things like future online resources.