When children are diagnosed with attention deficit hyperactivity disorder (ADHD), the first treatment option is usually stimulant medications such as Ritalin or Adderall. The American Academy of Pediatrics recently issued new guidelines that confirm the central role of medications accompanied by behavioral therapy in the treatment of this condition.
However, some experts say they are disappointed because the new guidelines do not first recommend behavioral treatment for more children, as that could lead to better results, recent research suggests.
When Brody Knapp, 6, of Kansas City, Missouri, was diagnosed with ADHD last year, his father, Brett, was skeptical. He did not want his son to take pills.RELATED
"You hear that children lose their personality, and they become a shadow of themselves, and they are not that little sparkling one you love," said Brett Knapp. "I didn't want Brody to lose that, because he's an amazing child."
Brody's mother, Ashley, had other ideas: she is a school principal and she has ADHD herself. "At first, I was totally in favor of stimulants, just because I know what they can do to help with a neurological problem like ADHD," said Ashley Knapp.
The new guidelines of the American Academy of Pediatrics recommend that children with ADHD be examined for mental illnesses and closely monitored, but the treatment recommendations regarding medication are essentially the same as the previous guidelines published in 2011.
Any child older than 5 should start taking medication and receive behavioral therapy as soon as he is diagnosed. Children under 5 should start with behavioral treatment before taking any medication.
Even so, many experts fear that the role of medication in treatment is too great.
"It is true that when you watch television, you will not see many advertisements about behavioral treatments, but it is very possible that you will see some new ones about medications," said Dr. Carla Allan, an ADHD specialist at Children's Mercy in Kansas City and a member of the subcommittee of ADHD clinical practice guidelines. Allan is Brody's doctor and participated in the drafting of the latest guidelines. While he wants more ADHD patients to receive behavioral treatment, he said he agrees with the academy's decision to stand firm on his medication recommendations.
Other experts say the guidelines should have done more to prioritize behavioral treatments.
"I think it's a big mistake not only for the children we are trying to treat, but also for parents who would prefer to have behavioral interventions," said Erika Coles, a researcher.
of psychology from the Florida International University.
A behavioral intervention can vary from cognitive therapy to school support. It can be as simple as parents establishing a system of expectations reinforced by rewards or punishments.
These interventions are designed to teach children strategies that they can use daily to stay focused and reinforce social skills that may not develop when children struggle to concentrate.
After school, Ashley Knapp used behavioral techniques to have her son Brody concentrate on homework. This is supposed to help you internalize the discipline and "determination" needed to complete difficult tasks, but it's like being very aware of the details, he said.
"I don't like the idea of having to tell my children or anyone else what to do," he said. "I want them to think for themselves and make those safe decisions, but it's not yet possible with Brody."
But techniques such as entrusting him with the task of ordering toys or receiving a reward if he saves the legos after playing are helping, he admitted.
While AAP guidelines advise a combination of medications and behavioral treatment, research supporting this combination is problematic, according to Coles, because the two approaches have not been evaluated separately.
"If you look at the studies that conducted the combined treatment of medications and behavioral interventions, you cannot uncover what leads to the best outcome," Coles said.
A study published in 2016 in the Journal of Clinical Child & Adolescent Psychology explored the sequence of treatment methods and showed that children with ADHD between the ages of 5 and 12 who received behavioral treatment before starting the pills had fewer behavioral problems. than the children who took medication immediately.
A new study conducted by Coles went further. He found that children ages 5 to 13 with ADHD who first received therapy generally needed fewer medications. And 37% of children who received therapy first ended up not needing pills at all.
Reduce the need for medications
"Actually, what it suggests is that, if we use behavioral intervention as the first line of treatment, we can reduce or eliminate the need for medications in children with ADHD," Coles said.
Less medication also means fewer side effects. Some children have trouble sleeping, lose their appetite or experience personality changes, and there is not much research on what it means to take these medications for years, especially in a growing stage.
The studies that support therapy first are promising and convincing, but they are small. Coles' research looked at 127 children, while the 2016 study evaluated 146.
A spokesman for the ADHD Clinical Practice Guidelines subcommittee of the American Academy of Pediatrics said the group reviewed recent research that analyzed the use of therapy first, but found no evidence strong enough to justify a change in the guidelines.
However, both the academy and its critics agree that there are not enough children who receive adequate behavioral treatment. Only about 60% of children with ADHD in the country received some behavioral intervention outside of school, while 90% had received medications, according to a 2018 study published in the Journal of Pediatrics.
Numerous advocates point out that there are not enough trained therapists, interventions can take a long time for families and many families cannot afford it. Brody's family started only with behavioral treatments, but after four months he experienced a violent crisis, which made the family decide to give Brody some medications as well. Now take Concerta.
Brody's father said he agrees with that and that starting with therapy first gave him an idea of the problem. "It is not necessarily for the child," Brett Knapp said about the parent training he received. “It really is for parents, to realize what a child with ADHD is like. And having the perspective, I think it helped a lot to know how I need to interact, talk and work with my son. "
This story is part of a partnership that includes KCUR, NPR and Kaiser Health News.
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