Survey: Parents view Exercise as more effective than Prescription Medications to treat children with ADHD

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Con­sid­er how research sup­port for ADHD treat­ments are typ­i­cal­ly estab­lished. The ‘gold-stan­dard’ approach would be a ran­dom­ized-con­trolled tri­al in which chil­dren with ADHD are ran­dom­ly assigned to the treat­ment or con­trol group. The treat­ment, what­ev­er it hap­pens to be, would be care­ful­ly imple­ment­ed in a research-based pro­to­col. If pos­si­ble, chil­dren in the con­trol con­di­tion would receive a place­bo treat­ment so that nobody is aware of which par­tic­i­pants were treat­ed and which were not. Mea­sures col­lect­ed on chil­dren before and after treat­ment would be com­pared so the researchers could deter­mine whether those get­ting the real treat­ment showed improve­ment rel­a­tive to con­trol par­tic­i­pants at a lev­el that was unlike­ly to have occurred by chance. If this were the case, empir­i­cal sup­port for the treat­ment would have been obtained. Were these find­ings repli­cat­ed in a sec­ond study, one could be con­fi­dent that the treat­ment is like­ly to yield pos­i­tive effects for chil­dren with ADHD.

While the ‘gold-stan­dard’ clin­i­cal research approach is the most valu­able for estab­lish­ing the sci­en­tif­ic sup­port for any treat­ment, it is not with­out short­com­ings as a guide for par­ents seek­ing treat­ment for their child. There are sev­er­al impor­tant rea­sons for this.

First, although the research-sup­port­ed treat­ment may be avail­able in the com­mu­ni­ty, it may not be imple­ment­ed in the same way as in the research stud­ies. For exam­ple, the rig­or with which med­ica­tion treat­ment is ini­ti­at­ed and mon­i­tored in com­mu­ni­ty set­tings is often quite dif­fer­ent from what occurs in clin­i­cal tri­als. The same could be said for behav­ioral ther­a­py and prob­a­bly for any oth­er treat­ment approach. Thus, the results obtained in com­mu­ni­ty set­tings may dif­fer from what the research reports.

Sec­ond, the out­comes col­lect­ed in research stud­ies may be nar­row­er than what par­ents care most about. For exam­ple, while doc­u­ment­ing that a par­tic­u­lar treat­ment sig­nif­i­cant­ly reduces core ADHD symp­toms is impor­tant, par­ents may care more about how treat­ment affects their child’s func­tion­ing more broad­ly. Will it help their child do bet­ter at school, be more suc­cess­ful social­ly, and get along bet­ter with sib­lings and par­ents? Many stud­ies do not con­sid­er this broad­er range of outcomes.

Third, out­comes in clin­i­cal tri­als often do not include longer-term fol­low-up of ini­tial treat­ment effects. It is also rel­a­tive­ly uncom­mon for treat­ments to be stud­ied over extend­ed peri­ods so the dura­tion of ben­e­fits can be reli­ably assessed. For par­ents con­cerned about the long-term impact of treat­ment for their child, the avail­able data is more lim­it­ed that one would like.

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How do different treatments really work in the community?

While not dis­count­ing the val­ue of care­ful­ly-con­trolled tri­als to estab­lish the research sup­port for dif­fer­ent ADHD treat­ments, it is also impor­tant to exam­ine how dif­fer­ent treat­ments work as per­ceived by par­ents who seek treat­ment for their child in their com­mu­ni­ty. What do par­ents who have tried dif­fer­ent ADHD treat­ments for their child say about how help­ful they found them to be? This pro­vides an impor­tant com­ple­ment to the pub­lished clin­i­cal tri­als data, and can help guide par­ents’ treat­ment choic­es for their child.

For this rea­son, I was pleased to learn of the sur­vey study recent­ly pub­lished by ADDi­tude Mag­a­zine that sum­ma­rized reports from near­ly 2500 par­ents about the treat­ments they had tried with their child and how effec­tive they per­ceived them to be. Par­ents were asked to report on all the treat­ment strate­gies they were using cur­rent­ly or had used in the past. Below is an abbre­vi­at­ed sum­ma­ry of some key find­ings for children.

How often are different treatments used?

Despite being infre­quent­ly rec­om­mend­ed by physi­cians and oth­er clin­i­cians, a wide-range of non-med­ical treat­ments were being used by par­ents for their child. Below are data on 10 dif­fer­ent treat­ment approach­es in descend­ing order of fre­quen­cy. The per­cent­ages sum to more than 100% because many par­ents were using mul­ti­ple treat­ments with their child and/or had used dif­fer­ent treat­ments in the past.

  • 67% — Pre­scrip­tion medication
  • 37% — Exercise
  • 36% — Vit­a­mins, min­er­als, or supplements
  • 29% — Diet/nutrition plan
  • 26% — ADHD coaching/counseling
  • 13% — Mind­ful­ness meditation
  • 10% — Behav­ior ther­a­py/­par­ent-train­ing classes
  • 5% — Neu­ro­feed­back with a clinician
  • 3% — Home-based brain training

It is inter­est­ing to con­sid­er this data in rela­tion to the cur­rent research sup­port for dif­fer­ent ADHD treat­ments. At this time, med­ica­tion and behav­ior ther­a­py have the strongest evi­dence base and are rec­om­mend­ed in treat­ment guide­lines from the Amer­i­can Acad­e­my of Pedi­atrics and the Amer­i­can Acad­e­my of Child and Ado­les­cent Psy­chi­a­try. It is thus note­wor­thy that many treat­ments with less sup­port are used more often than behav­ior ther­a­py. This may reflect chal­lenges that par­ents face in access­ing this treat­ment in their community.

How well do parents feel different treatments work?

As not­ed above, research from well-con­duct­ed treat­ment stud­ies are crit­i­cal to estab­lish the sci­en­tif­ic valid­i­ty of dif­fer­ent approach­es; how­ev­er, what par­ents say about how dif­fer­ent treat­ments actu­al­ly work is also impor­tant and may be use­ful in guid­ing par­ents’ deci­sions about treatment.

Below is the per­cent of par­ents who report­ed that each treat­ment type was either ‘Extreme­ly or Very Effec­tive’ in rank order of per­ceived effec­tive­ness.

  • 49% — Exercise
  • 41% — Pre­scrip­tion medication
  • 33% — ADHD coaching/counseling
  • 33% — Behav­ior man­age­men­t/­par­ent-train­ing classes
  • 30% — Neu­ro­feed­back with a clinician
  • 27% — Mind­ful­ness meditation
  • 24% — Diet/nutrition plan
  • 24% — Home-based brain training
  • 14% — Vit­a­mins, min­er­als, or supplements

Below is the con­verse of this data, i.e., the per­cent of par­ents who found each treat­ment ‘Not Very or Not At All Effective’.

  • 5% — Exercise
  • 13% — Behav­ior man­age­men­t/­par­ent-train­ing classes
  • 19% — ADHD coaching/counseling
  • 19% — Mind­ful­ness meditation
  • 26% — Pre­scrip­tion medication
  • 27% — Diet/nutrition plan
  • 27% — Neu­ro­feed­back with a clinician
  • 33% — Home-based brain training
  • 42% — Vit­a­mins, min­er­als, supplements

Sev­er­al aspects of these results are noteworthy.

First, exer­cise was the ADHD treat­ment approach that par­ents were most like­ly to see as effec­tive and least like­ly to be see as inef­fec­tive. What par­ents per­ceive about exer­cise is ahead of the cur­rent sci­ence, as research on exer­cise as an ADHD treat­ment remains lim­it­ed; I expect we will begin see­ing a num­ber of stud­ies on this top­ic appear­ing over the next sev­er­al years.

Sec­ond, although med­ica­tion is wide­ly regard­ed as the ADHD treat­ment with the strongest research sup­port, only a minor­i­ty of par­ents felt it was very effec­tive for their child. And, 26% of par­ents felt it was not effec­tive at all. This high­lights the lim­i­ta­tions of even well-researched treat­ments for ADHD.

Third, no treat­ment was regard­ed as very effec­tive by a major­i­ty of par­ents and all treat­ments were rat­ed as high­ly effec­tive by at least some par­ents. This high­lights the chal­lenge par­ents face in obtain­ing effec­tive ADHD treat­ment for their child, i.e., there is no sin­gle approach that is like­ly to be seen as very effec­tive for the major­i­ty of chil­dren. On the pos­i­tive side, there are a num­ber of approach­es that many par­ents found to be quite help­ful to their child. This sug­gests although the ini­tial treatment(s) imple­ment­ed not be suf­fi­cient­ly help­ful, oth­er approach­es may still yield results that par­ents believe are worth­while. Access­ing those treat­ments can be chal­leng­ing, how­ev­er, and many of these treat­ments may not be cov­ered by insurance.

Summary and implications

In sum­ma­ry, results from this sur­vey pro­vide use­ful infor­ma­tion to par­ents seek­ing effec­tive ADHD treat­ment for their child that com­ple­ments what has been learned from research-based clin­i­cal tri­als. In par­tic­u­lar, the find­ings high­light that no treat­ment as cur­rent­ly offered in com­mu­ni­ty set­tings is like­ly to pro­duce ben­e­fits that most par­ents will be sat­is­fied and that per­sis­tence in find­ing what works best for one’s child may often be required. This, unfor­tu­nate­ly, can be dif­fi­cult for a vari­ety of rea­sons. As indi­cat­ed above, you can access a more com­plete sum­ma­ry of the find­ings, includ­ing reports from adults with ADHD on their own treat­ment expe­ri­ence, here.

Results from this sur­vey pro­vide a use­ful com­ple­ment to evi­dence from care­ful­ly-con­trolled clin­i­cal tri­als of ADHD treat­ment by offer­ing data on how par­ents who pur­sue dif­fer­ent ADHD treat­ments for their child expe­ri­ence the impact of those treat­ments. It is dis­cour­ag­ing that no sin­gle treat­ment was felt to be very effec­tive by most par­ents, but also encour­ag­ing in that a range of dif­fer­ent treat­ments were report­ed to work well by some par­ents. The chal­lenge, there­fore, is find­ing a treat­ment approach — or com­bi­na­tion of treat­ments — that is most effec­tive for indi­vid­ual chil­dren. That is not easy and is high­light­ed in this quote from one of the sur­vey participants:

“It is over­whelm­ing at times to try to do all of these treat­ments,” wrote one care­giv­er. “I feel par­ents are on their own… We would have ben­e­fit­ed from an inter­dis­ci­pli­nary team includ­ing pedi­a­tri­cian, ther­a­pist and teacher meet­ing once a year at least and have some­one coor­di­nate with us through­out the year to check in.”

There are lim­i­ta­tions to a sur­vey study like this that are impor­tant to rec­og­nize. First, this is not a nation­al­ly rep­re­sen­ta­tive sam­ple of par­ents but a con­ve­nience sam­ple com­prised of par­ents who chose to com­plete the sur­vey. These may be par­ents who are bet­ter informed about ADHD and its treat­ment than the over­all pop­u­la­tion of par­ents rais­ing a child with ADHD. How this may have affect­ed the results is unknown.

Anoth­er chal­lenge is that it is not pos­si­ble to know the details of the treat­ments actu­al­ly pro­vid­ed. A ben­e­fit of con­trolled clin­i­cal tri­als is that the treat­ment is clear­ly spec­i­fied, i.e., you know with con­fi­dence what treat­ment actu­al­ly entailed. That is not true for a study like this. As an exam­ple, results indi­cate that 49% of par­ents felt exer­cise was very help­ful to their child. What exer­cise-based inter­ven­tions entailed is unknown, how­ev­er, and would almost cer­tain­ly be high­ly vari­able across chil­dren. The same would be true for any of the treat­ments that were rated.

A final issue is that par­ents’ reports about the effec­tive­ness of their child’s treat­ment may be biased because par­ents who devote time and mon­ey for a par­tic­u­lar treat­ment may be inclined to view it as effec­tive, even if ‘more objec­tive’ out­come data would not sup­port this. This is why clin­i­cal tri­als go to great lengths to obtain infor­ma­tion on treat­ment out­come from indi­vid­u­als who are ‘blind’ as to whether study par­tic­i­pants are in a treat­ment or con­trol group. While this is an impor­tant con­cern, dis­count­ing par­ents’ per­cep­tions of treat­ment response is prob­lem­at­ic giv­en their inti­mate knowl­edge of their child. And, as not­ed above, there was not a sin­gle treat­ment rat­ed as very effec­tive by a major­i­ty of par­ents; this sug­gests that par­ents are dis­cern­ing in their rat­ings of treat­ment effec­tive­ness and unlike­ly to be biased towards see­ing any­thing they try as beneficial.

 

– Dr. David Rabin­er is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. He pub­lishes the Atten­tion Research Update, an online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD, and helped pre­pare the self-paced, online course How to Nav­i­gate Con­ven­tion­al and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment.

The Survey in Context