ADHD Medication + Behavior Therapy = The Best Outcomes – ADDitude

What alternative ADHD treatments work to combat attention deficit hyperactivity disorder (ADHD)?

It’s a question more parents are asking doctors after a study, funded by the National Institute of Mental Health, found that the best outcomes — measured by parental satisfaction and some academic standards — were the result of “combination” treatment: ADHD medications that reduce hyperactivity and improve concentration, along with 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 ADHD diets — have been regarded as promising, only behavioral treatment has been shown to work.

Although ADHD specialists say they consider behavior therapy a key component of effective ADHD treatment and one that has inspired a recent resurgence of interest, few parents actually invest the necessary time and effort.

“There’s so much lip service paid to (combined) treatments, but a lot of people just rely on medication alone,” says William L. Coleman, M.D., 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.”

How Behavior Therapy Works

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 privileges — the program also includes changes in a child’s environment to minimize distractions. Parents also receive training in giving commands and reacting 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.

Parents often “have an inappropriate expectation of what medications can do,” observed pediatrician Patricia Quinn, M.D., who has specialized in treating ADHD in Washington, D.C., 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 says, they complicate the regimen with too many rules. The trick, Quinn says, is to keep things simple. Experiencing success reinforces the desired behavior.

Hand-in-Hand Treatments

Child psychiatrist Thomas Kobylski, M.D., of McLean, Virginia, compares ADHD to diabetes: Medications are necessary but not sufficient for either condition. For optimal results, people with diabetes need to watch what they eat and to exercise, in addition to taking medication. Children with ADHD, he says, need medication and behavior skills to function well at home and at school.

There is an added benefit from combination treatment, says 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 says.

Public relations executive Susannah Budington, who lives in Chevy Chase, Maryland, began using behavior therapy several years ago, shortly after Allison, the oldest of her five children, was diagnosed with ADHD and started taking a stimulant.

“She’s such an enthusiastic, wonderful kid. I would never want to medicate that away,” says Budington. Medication, she says, enables Allison to be less impulsive and more cooperative, but behavior therapy has helped the 12-year-old “operate as part of our family and to do things with her friends. It’s extremely important.”

One of the biggest problems, Budington says, 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.

In Sync With School

Trish White, a manager at CHAAD, says that involving her son’s school in his behavioral program has been critical to his progress during the two years since a pediatrician told her he had ADHD. Once a child is diagnosed with a disorder that affects his or her educational progress — including, in some cases, ADHD — federal law requires that the school devise an individualized education plan that accommodates the disability. For children with ADHD, that plan often includes elements of behavioral treatment, but cooperation by teachers and school systems varies, experts say.

At his Anne Arundel County, Maryland, public school, White’s eight-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 also 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 says.

But, White adds, “We continue to struggle.” Reading remains difficult for her son, but he is better at following 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 says, “can do only so much.”

© 2006, The Washington Post. Reprinted with permission.

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