Early Behavior Therapy Found to Aid Children With A.D.H.D.

From The New York Times

By Benedict Carey
February. 17, 2016

Children with attention-deficit problems improve faster when the first treatment they receive is behavioral — like instruction in basic social skills — than when they start immediately on medication, a new study has found. 

William E. Pelham helped lead a new study about treatment
options for children with attention-deficit problems. Above,
Dr. Pelham at a summer camp focusing on social skills training.
Credit: Florida International University

Beginning with behavioral therapy is also a less expensive option over time, according to a related analysis.

Experts said the efficacy of this behavior-first approach, if replicated in larger studies, could change standard medical practice, which favors stimulants like Adderall and Ritalin as first-line treatments, for the more than four million children and adolescents in the United States with a diagnosis of attention deficit hyperactivity disorder, or A.D.H.D.

The new research, published in two papers by the Journal of Clinical Child & Adolescent Psychology, found that stimulants were most effective as a supplemental, second-line treatment for those who needed it — and often at doses that were lower than normally prescribed.

Jacqueline Vaquer of Miami and her husband took their son Alec, who received an A.D.H.D. diagnosis at age 5, to a behavior-modification course and learned, among other things, how to reduce his wandering in class.

“We created a boundary around his desk with tape, and the teacher kept track of how often he crossed it,” Ms. Vaquer said. Each week, she said, “if he reduced the number of checks, he got a small reward, like a toy or his favorite dessert — frozen yogurt with M&Ms,” she said. Alec, 6, is now able to sit still for long periods in class and has not gone on medication, his mother said.

After two months, the yearlong study took an innovative turn. If a child had not improved, he or she was randomly assigned one of two courses: a more intense version of the same treatment, or an added supplement, like adding a daily dose of medication to the behavior modification. About two-thirds of the children who began with the behavior therapy needed a booster, and about 45 percent of those who started on medication did.

But the behavior-first group had an average of four fewer rules violations an hour at school than the medication-first group.

One likely reason, the study authors wrote, was parents of children who started on drug treatment were less interested in following up with the behavior classes, which involved eight group sessions over the year and one individualized lesson.

“The behavioral modification is a lot of work, and they may have thought, ‘Well, it won’t make that much difference,’” Dr. Pelham said.

In a separate paper, Dr. Pelham and a different set of authors compared the costs of the different treatment sequences, taking into account the price of drugs, doctors’ time and parents’ time.

Having children and their parents begin with behavioral treatment and follow with medication, if needed, cost an average of $700 less annually per child than treatment as usual, in which a doctor writes prescriptions and periodically monitors behavior, the team found.

The analysis did not account for the psychological cost to parents — in terms of a child’s tantrums, slammed doors and hurled tableware — of carrying out behavioral techniques.