Groundbreaking research by the late ADHD pioneer William E. Pelham, Jr. 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.
Transcript
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For many decades, stimulant medication was the first-line intervention for ADHD. In fact, it continues to be the most widely used intervention for childhood ADHD. More recently, however, a combined treatment approach which incorporates behavioral intervention into a child's treatment is becoming more common. What our studies suggest is that, in fact, behavioral intervention should be the first line of treatment for childhood ADHD, and then medication should be added if needed.
Our study focused on comparing a child's outcome based on how they started treatment. We randomly assigned children to start with behavioral intervention alone, or behavioral intervention in addition to a low dose of stimulant medication. After a few weeks, we removed the stimulant medication, and we looked at children's behavior. What we wanted to see next is whether the way in which children started their treatment impacted their behavior outcome.
What we were most shocked to find is that children who started on combined treatment, and then medication was withdrawn, had worse behavior than children who started with behavioral intervention alone. What we think is happening is that by combining medication with behavioral intervention, the medication is reducing the opportunity for a child to learn from their mistakes and behavior. It also reduces the opportunity for teachers and parents to teach a child how to self-correct their own behavior.
Medication and behavioral intervention, although they're both equally effective in treating childhood ADHD, work in different ways. Medication is very good at managing symptoms right away and somewhat reducing those symptoms, or eliminating them altogether, when the medication is working in the body. Behavioral intervention is much different. It teaches parents and teachers how to manage the child's behavior, and over time a child learns how to self-regulate and how to manage their behaviors.
At our Center for Children and Families, we welcome many families who are really trying to navigate a new diagnosis, for example like that of ADHD, and often ask us what the best course of treatment is for their child. What we recommend is seeking behavioral intervention first, and what that may look like is behavioral strategies for parents and perhaps some behavioral management strategies for the child's teacher and only once they have started with behavioral therapy would we then consider whether medication is a necessary component of their treatment.
Since it opened, the Center for Children and Families has strived to advance research in the mental health of children and adolescents. The program's founding director, Dr. William Pelham, embodied this mission as he worked for many decades on trying to improve the outcomes of children and adolescents with ADHD. I had the privilege of working with him for the past 10 years, and what I learned from working really closely with him is that children with ADHD benefit from behavioral interventions, and that it's our job to work with parents, teachers, and communities to not only give them the knowledge of how to implement these services, but also advocate for children to receive the behavioral interventions they need to be successful.
Thanks to Dr. Pelham, what we now know is behavioral interventions work, and the skills that children, parents, and teachers learn can last a lifetime.