New study reinforces the benefits of behavioral therapy first for treating kids with ADHD
Findings suggest that beginning strictly with a behavioral therapy approach, without the addition of medication at that time, allows children a greater opportunity to develop self-regulation skills.
Groundbreaking research by ADHD pioneer William E. Pelham, Jr., who passed away last year, found that behavioral therapy – when used first – was less expensive and more effective than medication in treating children with ADHD.
Building on this foundation, a new study by Pelham's team at the FIU Center for Children and Families, published in Evidence-Based Practice in Child and Adolescent Mental Health, sought to explore whether adding medication to the initial behavioral therapy—known to be the most effective first-step treatment—would improve outcomes.
The findings revealed that children who started treatment with both behavioral therapy and medication showed more disruptive behaviors after the medication was discontinued compared to those who initially received only behavioral therapy and then added medication later in the treatment.
“We were shocked to discover that starting with a combined treatment approach could actually reduce the effectiveness of behavioral strategies,” said Marcela Ramos, research assistant professor and lead author of the study. “Introducing medication alongside behavioral therapy may limit children’s opportunities to fully engage with and benefit from behavior management techniques.”
The study involved 248 children, predominantly male (77%) and Hispanic (85%), who participated in CCF’s eight-week Summer Treatment Program, designed for children with ADHD and related challenges. Participants were randomly assigned to one of two groups: one group received intensive behavior therapy with medication, while the other received behavior therapy with a placebo. After three weeks, the groups switched treatments for three additional weeks.
The findings suggest that starting with medication might hinder the effectiveness of behavioral therapy by reducing opportunities for children to develop self-regulation skills. Children who began with the combined approach showed more behavioral issues after medication was withdrawn compared to those who started with behavioral therapy alone.
“Medication is often the first treatment choice for ADHD, but our results indicate that starting with behavioral therapy and then introducing medication could lead to better behavioral outcomes,” said Dr. Ramos. “These findings might prompt a re-evaluation of current ADHD treatment practices to achieve more lasting improvements in behavior.”
This study builds on the legacy of William E. Pelham, Jr., whose research and ADHD treatment approach – behavior therapy, medications and a combination of the two – is the foundation of today’s standard ADHD treatment. His recent studies also highlighted that ADHD medication alone does not improve classroom learning for children.
“For decades, Dr. Pelham’s groundbreaking research established the combined treatment approach as a standard in ADHD care, influencing clinical guidelines worldwide,” Dr. Ramos said. “Our recent findings suggest that the order in which treatments are administered could be crucial. This insight highlights the need for further research, and I am honored to continue building on Dr. Pelham’s legacy to enhance our understanding of ADHD treatment strategies.”
A legacy of research
“To give children with ADHD the best chance to thrive, I believe families, medical professionals, and educators should focus on behavioral and academic interventions first and add medication only if needed.” – William E. Pelham, Jr.