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What should come first to treat ADHD in children, behavior therapy or stimulant medication?

October 7, 2020 by Dr. David Rabiner

Stim­u­lant med­ica­tion treat­ment and behav­ior ther­a­py are cur­rent­ly the two child ADHD treat­ments with the strongest research sup­port. How­ev­er, when par­ents begin treat­ment for their child, or when pro­fes­sion­als are ini­ti­at­ing treat­ment with a new client, there is no research to guide the deci­sion of which approach to begin with.

Is it bet­ter to start with med­ica­tion treat­ment and add behav­ior ther­a­py if need­ed? Or, should behav­ior ther­a­py come first with med­ica­tion added if the child’s response is not suf­fi­cient? Or, is it always prefer­able to begin with com­bined treat­ment? Does the order in which treat­ment begins even make a dif­fer­ence? Dif­fer­ent pro­fes­sion­al orga­ni­za­tions have pub­lished dif­fer­ent rec­om­men­da­tions on this issue but none are based on research that has direct­ly exam­ined these fun­da­men­tal questions.

A study pub­lished in the Jour­nal of Clin­i­cal Child and Ado­les­cent Psy­chol­o­gy, Treat­ment sequenc­ing for child­hood ADHD: A mul­ti­ple-ran­dom­iza­tion study of med­ica­tion and behav­ioral inter­ven­tions, helps estab­lish whether ADHD treat­ment out­comes dif­fer depend­ing on whether med­ica­tion or behav­ior ther­a­py is tried first.

The Study:

Par­tic­i­pants were 152 chil­dren with ADHD ages 5 to 12. Chil­dren were ran­dom­ly assigned to begin treat­ment with either a rel­a­tive­ly low dose of stim­u­lant med­ica­tion or with low inten­si­ty behav­ior therapy.

A low dose of med­ica­tion was select­ed — most chil­dren received 10 mg per day of an extend­ed release stim­u­lant — to be con­sis­tent with how such treat­ment is typ­i­cal­ly deliv­ered in com­mu­ni­ty set­tings, e.g., start low, see how the child responds, and adjust upwards if need­ed. Behav­ior ther­a­py con­sist­ed on an 8‑week group par­ent train­ing pro­gram to help par­ents man­age their child’s behav­ior more effec­tive­ly; chil­dren them­selves received con­cur­rent social skills train­ing to pro­mote bet­ter peer relations.

As part of the par­ent train­ing pro­gram, par­ents learned how to imple­ment a Dai­ly Report Card (DRC) pro­gram that pro­vid­ed dai­ly feed­back from their child’s teacher about his/ her suc­cess in meet­ing impor­tant goals each day.

After 8 weeks, the child’s func­tion­ing at school and home was reeval­u­at­ed on a month­ly basis. If par­ent and teacher report indi­cat­ed the child was doing well, the child sim­ply con­tin­ued on the ini­tial treat­ment. Chil­dren who were doing well on meds con­tin­ued on their same dose. For chil­dren in the behav­ior ther­a­py group, par­ents con­tin­ued to imple­ment what they had learned and were offered month­ly boost­er sessions.

For chil­dren whose ADHD symp­toms and behav­iors were not ade­quate­ly man­aged, treat­ment changes were ini­ti­at­ed. Those who start­ed on meds had either their med­ica­tion treat­ment enhanced, e.g., high­er dose, a sec­ond dose after school, or the behav­ior ther­a­py pro­gram added to their med­ica­tion treat­ment. For chil­dren who start­ed with behav­ior ther­a­py, either low dose med­ica­tion was added or their behav­ioral treat­ment was inten­si­fied. Which treat­ment was added was also deter­mined at ran­dom rather than by par­ents’ choice.

By the end of the 12-month study, there were thus 6 groups of chil­dren: 1) Those who start­ed on meds and whose treat­ment did not change; 2) Those who start­ed on meds and moved to more indi­vid­u­al­ized med­ica­tion treat­ment; 3) Those who start­ed on meds but lat­er began behav­ior ther­a­py; 4) Those who start­ed with behav­ior ther­a­py and were main­tained on this ini­tial treat­ment; 5) Those who start­ed with behav­ior ther­a­py but moved to more inten­sive, indi­vid­u­al­ized behav­ior ther­a­py; and 6) Those who start­ed with behav­ior ther­a­py and who lat­er began tak­ing medication.

Outcome measures:

The pri­ma­ry out­come mea­sure was an obser­va­tion of chil­dren’s class­room behav­ior made by trained observers. These observers vis­it­ed the class­room every 4 to 6 weeks and con­duct­ed 40 minute obser­va­tions of chil­dren’s behav­ior dur­ing aca­d­e­m­ic tasks. Dur­ing each obser­va­tion, they not­ed all instances of rule-break­ing behav­ior, e.g., non­com­pli­ance with teacher requests, dis­rupt­ing oth­ers, leav­ing seat with­out per­mis­sion, etc. In the analy­sis report­ed below, the final obser­va­tion dur­ing the school year was used as the pri­ma­ry outcome.

A num­ber of oth­er mea­sures were also col­lect­ed includ­ing the num­ber of times each child was removed from the class­room for dis­ci­pli­nary rea­sons, as well as par­ent and teacher behav­ior ratings.

Based on the above design, three pri­ma­ry research ques­tions were addressed.

  1. Does ini­ti­at­ing ADHD treat­ment with low dos­es of med­ica­tion or behav­ioral ther­a­py pro­duce bet­ter child out­comes at the end of the school year in terms of their class­room behavior?
  2. If a child is start­ed on med­ica­tion treat­ment, and the ini­tial reg­i­men is not ade­quate, is it bet­ter to adjust med­ica­tion treat­ment or stick with the ini­tial med­ica­tion regime and add behav­ioral therapy?
  3. If a child is start­ed on behav­ioral ther­a­py and the treat­ment response is not suf­fi­cient, is it bet­ter to add low dose med­ica­tion or inten­si­fy the behav­ioral treatment.

Results:

A com­plex study like this reports many results; what is sum­ma­rized below are what I feel are the most impor­tant over­all findings.

1. On aver­age, chil­dren who start­ed on behav­ioral ther­a­py were doing bet­ter at the end of the school year than chil­dren who start­ed with med­ica­tion. Those who start­ed with behav­ior ther­a­py had an aver­age of 8.4 class­room rule vio­la­tions per hour com­pared to 12.6 rules vio­la­tions per hour for chil­dren start­ed on med­ica­tion. They also tend­ed to expe­ri­ence few­er removals from class for dis­ci­pli­nary vio­la­tions, 1.6 vs. 3.1. Group dif­fer­ences for par­ent and teacher rat­ings were not significant.

2. For chil­dren who began on med­ica­tion treat­ment and who did not respond suf­fi­cient­ly, enhanc­ing med­ica­tion treat­ment was sub­stan­tial­ly more help­ful than adding behav­ior ther­a­py. Com­pared to adding behav­ior ther­a­py, adapt­ing the med­ica­tion treat­ment result­ed in sig­nif­i­cant­ly few­er class­room rule vio­la­tions and out-of-class dis­ci­pli­nary events.  In fact, the group for whom behav­ior ther­a­py was added to med­ica­tion had the worst out­comes of all. This may have been because when med­ica­tion was start­ed first, par­ents were high­ly unlike­ly to engage in behav­ior ther­a­py when it was added. Thus, these chil­dren essen­tial­ly remained on a sin­gle treat­ment that was not suf­fi­cient, as their med­ica­tion was not adjust­ed in the study.

3. For chil­dren who began with behav­ior ther­a­py and respond­ed insuf­fi­cient­ly, there was not clear advan­tage to inten­si­fy­ing the behav­ior ther­a­py or adding low dose stim­u­lant med­ica­tion — both yield­ed ben­e­fits that var­ied across the dif­fer­ent out­come measures.

Summary and implications:

These results have direct rel­e­vance for clin­i­cal prac­tice as the treat­ments employed were not high-pow­ered ver­sions of med­ica­tion and behav­ior ther­a­py that are dif­fi­cult to obtain out­side a research con­text. Instead, the rel­a­tive­ly low-dose treat­ment strate­gies are ones that can be imple­ment­ed in schools, pri­ma­ry care, and com­mu­ni­ty men­tal health settings.

The authors argue that their find­ings raise seri­ous ques­tions about the com­mon approach to begin­ning ADHD treat­ment with med­ica­tion alone. They sug­gest that begin­ning with a low-inten­si­ty behav­ioral treat­ment is pre­ferred because it was asso­ci­at­ed with bet­ter end of school year out­comes. When behav­ior ther­a­py is not suf­fi­cient, either inten­si­fy­ing this approach or adding low dose stim­u­lant med­ica­tion is like­ly to pro­duced improved child outcomes.

In con­trast, if treat­ment begins with med­ica­tion and is insuf­fi­cient, adding behav­ior ther­a­py is not effec­tive because par­ents are unlike­ly to fol­low through on the physi­cian’s rec­om­men­da­tion. This may result in inten­si­fy­ing med­ica­tion treat­ment as the only viable option. Chil­dren treat­ed this way are like­ly to be main­tained on high­er dos­es of med­ica­tion than would be nec­es­sary if behav­ioral treat­ment was start­ed first, thus increas­ing the risk of adverse side affects and the pre­ma­ture ter­mi­na­tion of treatment.

Because of this, the authors sug­gest that chil­dren with ADHD should receive a step­wise approach to treat­ment, begin­ning with low inten­si­ty behav­ior ther­a­py and increas­ing inten­si­ty or adding low dose med­ica­tion only if nec­es­sary. They con­clude that this would be a cost-effec­tive pub­lic health approach for treat­ing child­hood ADHD.

This is an impres­sive study with impor­tant find­ings. As with any study, how­ev­er, the find­ings would be impor­tant to repli­cate and there are lim­i­ta­tions that need to be con­sid­ered. For me, the largest con­cern is that despite efforts to pro­vide treat­ments sim­i­lar to how they are offered in com­mu­ni­ty set­tings, the extent to which these find­ings can be gen­er­al­ized to real world set­tings is uncer­tain. There are sev­er­al rea­sons for this.

First, in this study chil­dren’s ongo­ing response to treat­ment was sys­tem­at­i­cal­ly mon­i­tored on a month­ly basis so that addi­tion­al treat­ment could be imple­ment­ed if indi­cat­ed. Research has shown, how­ev­er, that such sys­tem­at­ic mon­i­tor­ing is rarely done in pri­ma­ry care settings.

Sec­ond, there are many fam­i­lies who begin their child on a com­bi­na­tion of med­ica­tion treat­ment and behav­ior ther­a­py, as mul­ti­modal treat­ment is often rec­om­mend­ed as the pre­ferred approach. In this study, how­ev­er, this was nev­er done. As a result, we don’t learn whether begin­ning with com­bined med­ica­tion and behav­ioral treat­ment may be supe­ri­or to start­ing with either in isolation.

Third, par­ents did not choose which treat­ment their child start­ed with, or how treat­ment was aug­ment­ed if their child’s response was not suf­fi­cient. Instead, ran­dom assign­ment was used to deter­mine what treatment(s) chil­dren received.

While this ran­dom­iza­tion is an essen­tial part of a con­trolled study, in com­mu­ni­ty set­tings, par­ents decide what ini­tial and sub­se­quent treat­ment their child receives. Thus, find­ing that par­ents were unlike­ly to engage in behav­ior ther­a­py when it fol­lowed an insuf­fi­cient response to med­ica­tion may not reflect what hap­pens when par­ents them­selves decide to include behav­ior ther­a­py. It does high­light, how­ev­er, that physi­cians need to be very care­ful about assum­ing par­ents will fol­low through on refer­rals to behav­ioral ther­a­py they may make.

Final­ly, I was sur­prised that no assess­ments of chil­dren’s aca­d­e­m­ic work and school per­for­mance were includ­ed. Instead, all out­come mea­sures were focused on behavior.

The authors note sev­er­al of the above lim­i­ta­tions them­selves and will no doubt try to address them in sub­se­quent work. These lim­i­ta­tions not with­stand­ing, this is an impres­sive and clin­i­cal­ly rel­e­vant study that may con­tribute to an impor­tant recon­sid­er­a­tion of how chil­dren with ADHD are typ­i­cal­ly treated.

– 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.

The Study in Context:

  • A brief sleep inter­ven­tion can bring mea­sur­able and sus­tained ben­e­fits to chil­dren with ADHD
  • Study finds com­bined phar­ma + non-phar­ma treat­ment most ben­e­fi­cial to help youth with ADHD address long-term aca­d­e­m­ic difficulties
  • Hav­ing ADHD costs $1.1 mil­lion in low­er life­time earn­ings, even when “treat­ed”
  • What are cog­ni­tive abil­i­ties and how to boost them?

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Filed Under: Attention & ADD/ADHD, Brain/ Mental Health, Education & Lifelong Learning Tagged With: AD/HD-treatments, behavior, behavior-therapy, classroom behavior, medication-treatment, stimulant medication

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