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Differing Views on Beginning Treatment for ADHD
Over the years the condition known as ADHD has been one of the most controversial diagnoses in child mental health. I came across an interesting article recently in a publication called "Point-Counterpoint: Controversial Issues Confronting the ADHD Specialist" that clearly indicates how aspects of this controversy continue to be alive and well.
The article featured interviews with two of the world's leading authorities on ADHD - Dr. William Pelham, a psychologist who teaches and conducts research on ADHD at the State University of New York in Buffalo, and Dr. Joseph Biederman, a Professor of Psychiatry at Harvard Medical School.
The focus of the interviews with each expert was how they felt the treatment of children with ADHD should best be managed. Dr. Pelham stated quite strongly that he believes behavioral interventions should be implemented first, and that medication be used as a secondary treatment if necessary. He based his position on research which suggests that medication does not alter the long term outcomes for children with ADHD. Because medication has not yet been shown to have long term positive effects, he believes it should not be the first treatment implemented.
According to Dr. Pelham, parent training should be an important part of treatment for EVERY child with ADHD. In his parent training program, which lasts from 8-16 sessions, parents are taught how to give effective commands, how to use appropriate punishment strategies, and how to use positive rewards to encourage good behavior.
Dr. Pelham also believes that every child with ADHD should get a daily report card at school, in which he or she receives grades from the teacher on how well important goals (e.g. completing work, following class rules) have been met. This report card is brought home each day, and depending on the marks received, the child is able to earn privileges at home. For example, for each goal with a satisfactory daily grade, the child might earn 15 minutes of TV time or computer time.
Dr. Biederman advocates a very different approach to managing the treatment of children with ADHD. He feels that because ADHD is a "brain disorder" with a strong biological basis, medication therapy should be started immediately. He believes it is difficult to know what other interventions will be necessary until one sees how effective medication can be for a particular child. This is because some children, if they are placed on the appropriate medication and have a good response, may have their behavior normalized to such a degree that additional interventions are not required. Making sure the child is deriving the optimum benefit from medication, and then carefully monitoring how the child does over time, are critically important to promoting the child's long term success.
After the child's behavior has been stabilized as well as possible via medication, other treatments may then be necessary to target difficulties that still remain. For example, many children with ADHD will continue to have social difficulties and may require specific assistance in this area. Behavioral problems at home, and/or conduct problems at school may also need to be specifically targeted. Dr. Biederman also feels that some parents may benefit from supportive therapy to help them with their concerns about their child having a chronic illness. Children may also benefit from supportive therapy to verbalize the frustrations of dealing on a daily basis with difficulties with teachers and peers.
For whatever it's worth, my own personal feeling on this issue is more in keeping with Dr. Biederman. In my own work, I have seen many children who responded so well to medication that there really weren't any significant issues left to address. As long as the child continues to do well, it is not clear to me why any additional treatments are necessary. The ESSENTIAL thing, though, is to make sure that there are not difficulties that still remain to be addressed, and to carefully follow the child to be sure that such problems are addressed should they emerge. All too often, this kind of careful, ongoing monitoring is just not done, which may be one important reason for why the long term impact of medication on children with ADHD still needs to be clearly demonstrated.
It is also important to note that in today's era of managed care, there are often real world barriers to providing the kind of behavioral treatment that Dr. Pelham advocates. Many insurance companies will simply not authorize 8 sessions of behavioral parent training, let alone the 16 sessions that is sometimes required. I have certainly felt the squeeze in recent years from the managed care industry, and it can be incredibly frustrating for providers not to be able to offer the appropriate level of care. I also know how difficult and frustrating this is for parents.
Finally, it needs to be stressed that given the disagreement on this matter by such experts, what approach parents feel most comfortable with is a VERY important consideration. Some parents I work with prefer to begin with behavioral interventions alone and see how things go. Others prefer to start medication right away. BOTH of these choices are quite reasonable alternatives. Just make sure that whatever you decide to do, there is a careful system in place so you know how effective the approach you decide on with your child's health care provider is being. If it is not working as well as it needs to be, make sure that you become aware of other options to try.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.