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Behavior Therapy May Lower Need for ADHD Drugs
By Salynn Boyles
Most kids who are treated for attention deficit hyperactivity disorder take stimulant medications, but new research suggests that the need for these drugs can be reduced dramatically in those who get behavioral therapy as well. When the two approaches were combined, the amount of medication needed to achieve the same results as drugs alone was reduced by two-thirds, researchers from the University at Buffalo reported. The study was also the first to test the effectiveness of a new ADHD patch containing methylphenidate, the stimulant also known as Ritalin. The study was funded by the patch's manufacturer, Shire Pharmaceuticals Group. Smaller Doses "One of the major findings of the study is that when using behavior modification, you can get away with tiny, tiny doses of medication, much lower than previously thought, says ADHD researcher William E. Pelham Jr. Pelham tells WebMD that the patch, which is not yet on the market, allows more dosing flexibility than oral medications because it can be put on and taken off when needed. The researchers write that studies have shown that behavioral therapy works to improve some ADHD symptoms. The improvements are comparable to low-dose stimulant medication, they add. However, not all researchers agree with the effectiveness of this approach to ADHD treatment. A Medical Debate: Drugs vs. Behavior Therapy The debate over how well behavioral approaches work in the treatment of ADHD is long and contentious. Behavioral therapy advocates like Pelham claim that far too many children are being overmedicated with stimulants like Ritalin, Adderall, and Concerta. On the other side of the argument are ADHD experts who say drug treatments have been shown in study after study to be far more effective than behavioral treatments. The largest and most widely publicized of these investigations was the National Institute of Mental Health-funded Multimodal Treatment Study (MTS), reported in 1999. But Pelham says the findings have been largely misinterpreted by the press and the medical establishment. "The ADHD community has embraced this study as proof that behavioral therapy is not effective, but that was not the finding at all," he says. "A combination of behavioral therapy and drugs was the most effective intervention in the study, followed by drugs alone." Combined Treatment Works Better In his newly reported study, researchers followed 27 children with ADHD, aged 6-12. The children participated in a highly intensive behavioral therapy program developed by Pelham almost a decade ago. The summer-treatment program includes both recreational and classroom components with a very high ratio of teachers to students. When used alone, the Ritalin patch and the intensive behavior modification were found to be equally effective treatments. When the two treatments were combined, however, children required much lower doses of medication -- as much as 67% less -- to achieve the same effects as high-dose medication used alone, Pelham says. He adds that a lower dosage of drugs means a lower risk of long-term drug-related side effects, which can include loss of appetite. "Long-term side effects of ADHD drugs are almost always related to dosage," Pelham says. "If you want to lower a child's dosages daily and throughout their lifetime, the best way to do that is to combine the medication with behavior modification." Treatment Approach Difficult to Replicate ADHD specialist Howard Abikoff, PhD, agrees that intensive behavior modification can be very effective while the child is getting the treatment. The problem, he says, is that highly intensive approaches like Pelham's summer program are difficult to replicate in real-world settings. Abikoff directs the Institute for ADHD and Related Disorders at the New York University Child Study Center. "Basically that means at home and in school," he tells WebMD. "When we try this approach outside of the summer-treatment program it is very difficult to achieve the same level of improvement in ADHD symptoms." Abikoff says drug therapy alone works well to normalize ADHD symptoms in just over half of children. "It is clear that in most children with severe symptoms, behavioral therapy alone is usually not sufficient," he says. "But children and their parents and teachers also need to learn management skills to help cope with the ADHD. Many kids have problems that medication doesn't address." By Salynn Boyles, reviewed by Brunilda Nazario, MD SOURCES: Pelham, W. Experimental and Clinical Psychopharmacology, May, 2005; vol 13, issue 2. William E. Pelham Jr., PhD, University at Buffalo Distinguished Professor, department of psychology; director, Center for Children and Families, University at Buffalo. Howard Abikoff, PhD, director, Institute for ADHD and Related Disorders, New York University Child Study Center.
ADHD — Treatment Through Behavior Therapy
Most experts recommend using both medication and behavior therapy to treat ADHD. There are many forms of behavior therapy, but all have a common goal — to change the child's physical and social environments to help the child improve his behavior. Under this approach, parents, teachers and other caregivers learn better ways to work with and relate to the child with ADHD. You will learn how to set and enforce rules, help your child understand what he needs to do, use discipline effectively, and encourage good behavior. Your child will learn better ways to control his behavior as a result. There are three basic principles to any behavior therapy approach: * Set specific goals. Set clear goals for your child such as staying focused on homework for a certain time or sharing toys with friends. * Provide rewards and consequences. Give your child a specified reward (positive reinforcement) when she shows the desired behavior. Give your child a consequence (unwanted result or punishment) when she fails to meet a goal. * Keep using the rewards and consequences. Using the rewards and consequences consistently for a long time will shape your child's behavior in a positive way. Table 3. Behavior Therapy Techniques Positive reinforcement Providing rewards or privileges in response to desired behavior. Child completes an assignment and is permitted to play on the computer. Time-out Removing access to desired activity because of unwanted behavior. Child hits sibling and, as a result, must sit for five minutes in the corner of the room. Response cost Withdrawing rewards or privileges because of unwanted behavior. Child loses free-time privileges for not completing homework. Token economy Combining reward and consequence. The child earns rewards and privileges when performing desired behaviors. She loses the rewards and privileges as a result of unwanted behavior. Child earns stars for completing assignments and loses stars for getting out of seat. The child cashes in the sum of her stars at the end of the week for a prize. Behavior therapy recognizes the limits that having ADHD puts on a child. It focuses on how the important people and places in the child's life can adapt to encourage good behavior and discourage unwanted behavior. It is different from play therapy or other therapies that focus mainly on the child and his emotions. As the child's primary caregivers, parents play a major role in behavior therapy. Parent training is available to help you learn more about ADHD and specific, positive ways to respond to ADHD-type behaviors. This will help your child improve. Taking care of yourself also will help your child. Being the parent of a child with ADHD can be tiring and trying. It can test the limits of even the best parents. Parent training and support groups made up of other families who are dealing with ADHD can be a great source of help. Learn stress-management techniques to help you respond calmly to your child. Seek counseling if you feel overwhelmed or hopeless. There are steps you can take to help your child succeed in controlling his behavior. These tips can be applied to everyday life in your house and can make a big difference for your child and family: * Keep your child on a daily schedule. Try to keep the time that your child wakes up, eats, bathes, leaves for school and goes to sleep the same each day. * Cut down on distractions. Loud music, computer games and television can be overstimulating to your child. Make it a rule to keep the TV or music off during mealtime and while your child is doing homework. Whenever possible, avoid taking your child to places that may be too stimulating, like busy shopping malls. * Organize your house. If your child has specific and logical places to keep his schoolwork, toys and clothes, he is less likely to lose them. Save a spot near the front door for his school backpack so he can grab it on the way out the door. * Reward positive behavior. Offer kind words, hugs or small prizes for reaching goals in a timely manner or good behavior. Praise and reward your child's efforts to pay attention. * Set small, reachable goals. Aim for slow progress rather than instant results. Be sure that your child understands that he can take small steps toward learning to control himself. * Help your child stay "on task." Use charts and checklists to track progress with homework or chores. Keep instructions brief. Offer frequent, friendly reminders. * Limit choices. Help your child learn to make good decisions by giving your child only two or three options at a time. * Find activities at which your child can succeed. All children need to experience success to feel good about themselves. * Use calm discipline. Use consequences such as time-out, removing the child from the situation, or distraction. Sometimes it is best to simply ignore the behavior. Physical punishment, such as spanking or slapping, is not helpful. Discuss your child's behavior with him when both of you are calm. In addition to parents and caregivers, your child's school is a key partner in providing effective behavior therapy for your child. In fact, these principles work well in the classroom for most students. Some successful classroom management techniques may include the following: * Keeping a set routine and schedule for activities * Using a system of clear rewards and consequences, such as a point system or token economy (see) Sending daily or weekly report cards or behavior charts to parents to inform them about the child's progress * Seating the child near the teacher * Using small groups for activities * Encouraging students to pause a moment before answering questions * Keeping assignments short or breaking them into sections * Close supervision with frequent, positive cues to stay on task Your child's school should work with you and your pediatrician to develop strategies to assist your child in the classroom. When a child has ADHD that is severe enough to interfere with the child's ability to learn, two federal laws offer help. These laws require public schools to cover the costs of evaluating the educational needs of the affected child and providing the needed services. The laws are: * The Individuals with Disabilities Education Act, Part B (IDEA) * Section 504 of the Rehabilitation Act of 1973 For more information order the complete booklet, "Understanding ADHD" from the American Academy of Pediatrics.
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