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Efficacy of Non Medical ADHD Treaments
This is very important review paper appeared in recent issue of the Journal of Clinical Child Psychology (Volume 27, 190-205). The authors of this paper review research that examines how effective non-medical treatments are for ADHD. They also raise very important points about the effectiveness of medication treatment of ADHD. I will try to highlight major conclusions that are reached by the authors.
Stimulant Medication Treatment
In regards to medication treatment, the authors emphasize that numerous studies have clearly documented the efficacy of pharmacological treatments for ADHD. Stimulant medications have been shown to have large, beneficial, effects on multiple domains of functioning in children with ADHD. In fact, the efficacy of stimulant medication treatment is so well-established, that it is the benchmark against which alternative treatments must be compared. Having made this general conclusion, however, the authors raise several caveats about medication treatment that are very very important to be aware of.
First, it is important to note that despite the positive effect of medication on children's daily classroom performance, evidence that stimulant medication results in long term positive changes in children's academic achievement does not yet exist. Similarly, although stimulant medication has been shown to reduce disruptive behavior and negative peers interactions in children with ADHD, there is also no evidence that medication yields long term gains in children's social relationships. The authors also emphasize that although between 70 and 80% of children with ADHD respond positively stimulant medication, for most children this does not result in their behavior being "normalized". In other words, even though medication often results in dramatic improvements, many children with ADHD will continue to exhibit important difficulties. It is for this reason, that medication alone is an insufficient treatment for many children with ADHD.
As is evident from the above discussion, the major limitation of medication therapy is that studies that have followed children treated with medication for periods up to five years have failed to demonstrate that the drugs improve children's long term prognosis. Thus, although dramatic short term improvements in children's academic, social, and behavioral functioning are frequently evident, this has not yet been shown to result in long term improvements in the same areas.
I would like to emphasize, as do the authors of this excellent paper, that an important reason for this may be the way that medication treatment is often conducted. For example, systematic efforts to evaluate the effectiveness of different doses and/or different medications in individual children are rarely done. As a result, many children who are taking medication do not receive either the dose or type of medication that would optimize benefits for them. This is a real shame, because several studies have shown that when careful efforts are made to identify the optimum dose and medication, the benefits received by children with ADHD are much greater.
In addition to this limitation in how medication is typically prescribed, an even more important problem may be the duration that children often receive it. For example, a survey of all prescriptions written in one NY county over a one-year period revealed that the vast majority of children for whom physicians prescribe stimulants received only one or two months worth of medication. This implies that many parents failed to have their child's prescription refilled, and that physicians may often fail to monitor this. If this is the case, as it unfortunately appears to be, it is little wonder that long term positive effects of medication treatment have yet to be conclusively demonstrated. Whether the more careful and appropriate use of medication will result in long-term gains for children with ADHD is currently under investigation in several well designed studies.
For those of you children are being treated with stimulant medication please do not conclude from the above discussion that medication is not helpful for children with ADHD. Although the authors of this paper do an excellent job of pointing out the problems with how such treatment is often conducted, they also note appropriately, that stimulant medication remains the most effective form of treatment for ADHD that has yet been investigated. Making sure that your child is receiving the optimum type and dose of medication for him or her, and then carefully monitoring the ongoing effectiveness of the medication, will significantly enhance the value of this form of treatment for your child. The ADHD Monitoring System that you received as a bonus with your subscription to ADHD RESEARCH UPDATE should be helpful to you in doing this ongoing monitoring.
Empirical Support For Psychosocial Treatments
What we know about how effective psychosocial treatments are for children with ADHD? Based on their extensive review of the research literature, the authors conclude that two types of nonmedical interventions have been demonstrated to be effective for children with ADHD. These two interventions are behavioral parent training and contingency management interventions in the classroom.
Before providing more information on these two types of effective treatment, it is important to note the other types of commonly used treatments for which there is no documented effectiveness. In mental health settings, treatments such as individual child therapy and play therapy are often utilized for children with ADHD, but there are no studies that support their efficacy.
Cognitive treatments which are designed teach children with ADHD to use self-talk, problem-solving strategies, and self-monitoring strategies to improve their behavior have also not been found to be effective. Cognitive treatments try to change children's behavior by helping them learn specific thinking strategies that will guide their behavior in different ways.
For example, a child with ADHD who tends to work quickly and carelessly would be taught how to remind himself to work slowly and carefully. This would occur by having the child learn to give himself private instructions before beginning his work. The child might be taught to say the following before starting:
Remember Now To Read The Directions Carefully Before Starting. I Have To Work Slowly And Not Rushed Through All The Problems. After I Finish Each Problem I Will Go Back And Check It To Make Sure I Did Not Make Any Careless Mistakes.
This approach to treating children with ADHD was initially thought to be quite promising. Unfortunately, several well conducted research studies have failed to demonstrate that this approach is effective. The conclusion that has been reached so far is that cognitive treatment of ADHD does not result in clinically important changes in the behavior and academic performance of children with ADHD.
Behavioral Parent Training
What about the treatments that have some demonstrated efficacy? Behavioral parent training typically involves teaching parents how to implement a consistent system of rewards and negative consequences to their child to encourage good behavior and to discourage inappropriate behavior. In typical behavioral treatment programs, parents are educated about ADHD and about effective behavioral management strategies. Parents are taught how to appropriately encourage and reward positive behavior and how to ignore and or punish inappropriate behavior. In addition therapists in such programs often work with the child's teacher develop classroom management strategies for the teacher to use, as well as daily report cards that provide feedback to parents on children's school performance. This daily feedback from the teacher provides a basis for either rewarding the child or for removing certain privileges. (See the last issue of ADHD RESEARCH UPDATE for more detailed information on setting up the daily report card system. In addition, a more extensive discussion of behavioral treatment can be found here.
The general approach to treatment outlined above has been shown in several studies to produce clinically important improvement in children with ADHD in both home and school settings. Although this is encouraging, the authors make a point stress that the improvements obtained with clinical behavioral interventions are typically not as long as those obtained with medication.
Contingency Management Interventions
In contrast to the type of behavioral treatment described above, contingency management approaches are characterized by more intensive interventions. Although contingency management approaches also rely on the use of positive and negative consequences as described above, they are implemented directly in the setting of interest by a highly trained and experienced individual.
For example, a child with ADHD might have an aide with him or her throughout the school day who would carefully monitor the child's performance, and give the child frequent feedback about how they were doing. The day might be divided into distinct 15 minute intervals with specific behavioral goals for each interval. At the end of each 15 minute segment the child will either gain or lose points depending on how well they did in meeting those goals. Depending on the number of points accumulated during the day, the child would be able to earn different rewards. Obviously this is a very intensive form of treatment, and is not something that can typically be done by the regular classroom teacher.
The positive effects of this type of intensive treatment are larger than for the approach to behavioral treatment previously described. As with more standard behavioral treatments, however, the effects of contingency management interventions are typically not as large as the effects of medication. The long term gains that are produced by such interventions, as opposed to more easily demonstrated initial improvements in children's behavior, also remain to be clearly documented. In addition, just like stopping a child's medication will eliminate the positive effects and lead to a return of the child's symptoms, the same holds true for contingency management interventions - once the program is stopped, it is very likely that the child's behavior will soon return to how it was before the program was implemented. In other words, this is certainly not a "permanent" cure.
Rewards Vs. Punishments
An interesting issue that the authors address concerns the relative importance of positive consequences and punishment in the behavioral treatment of children with ADHD. Based on their extensive review of the research literature, they conclude that prudent negative consequences (e.g. verbal reprimands backed up with time-out and loss of privileges) are an effective and necessary component of classroom behavioral interventions. In fact, the use of such negative consequences appears to be the critical aspect of this treatment. These need to be used judiciously, however, and are never intended to hurt or humiliate the child.
Summary And Conclusions
There is a lot of extremely important information in this paper and I would like close the discussion of it by trying to highlight the major conclusions reached by the authors.
So Far, No Form Of Treatment For Children With Adhd Has Been Shown To Be More Effective, Or Even As Effective, As Stimulant Medication.
Not all children benefit from medication, however, and some cannot tolerate the side effects. In addition, in many cases, medication is not administered in the careful manner that is necessary to optimize the benefits that the child can receive from it. The authors suggest that for many children, combining a low dose of stimulant medication with behavioral treatments may be the most effective and cost-effective treatment for ADHD. I will try to discuss this in greater detail in a future issue of ADHD RESEARCH UPDATE.
Apart From Stimulant Medications, Behavioral Parent Training And Contingency Management Interventions In The Classroom Are The Only Forms Of Treatment For Which Clearly Documented Empirical Support Has Been Obtained.
Obviously, there have been many other way for helping children with ADHD that have been proposed, and numerous other treatment approaches have been touted as being effective. There is an important difference, however, between anecdotal reports that a treatment approach has been helpful, and well controlled studies that provide data to support such claims. At this point, such data has only been provided for the treatments reviewed in this article.
What does that mean for parents who is considering alternative approach is to try and help their child? To me, it means approaching such alternatives with real caution and even skepticism. Personally, I would prefer to start with treatments that have been shown to be effective. If I had really tried treatments with my child, and found that they did not work, I would then consider other options.
I also want to emphasize, however, that just because other types of treatments have not been demonstrated to be effective yet, does not necessarily mean that they may not be helpful for some children. Different children may be helped by different treatments, and evidence for the effectiveness of other treatment approaches may emerge down the road. At this point, however, empirical support for treatments other than medication, behavioral parent training, and contingency management interventions has not been provided.
So Far, No Form Of Treatment Has Been Clearly Shown To Produce Long Term Gains In The Adjustment Of Children With Adhd.
Even for the empirically supported treatments reviewed in this article, it is important to emphasize that it is only short-term improvements that have been documented. In part, this may be because the well designed studies required to demonstrate long term gains have not yet really been done. Such studies are currently underway.
What this means, is that parents must be carefully monitoring how their child is doing over extended periods of time. One can not assume that just because a child has shown a good initial response to a treatment such as stimulant medication that everything will go well from there. Treatment needs to be ongoing and it's effectiveness needs to be continually monitored.
I hope that you will not read this and be discouraged - that is certainly not my intention. My own belief, based on experience in working with children and parents over a number of years, is that parents can make a tremendous difference in helping to promote their child's long-term success. By being aware and educated about how the best help children with ADHD, by carefully monitoring how their child is doing, and by making adjustments and modifications in their child's treatment when this appears necessary, parents can exert an important positive impact on their child long term development. It can help tremendously, of course, to find an experienced professional to assist you in this task.
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.