Experts said results of the behavior-first approach, if replicated in larger studies, could change standard medical practice, which favors medication as first-line treatments.
Children with attention-deficit problems improve faster when the first treatment they receive is behavioral — such as instruction in basic social skills — than when they start immediately on medication, a new study has found. Beginning with behavioral therapy is also cheaper over time, according to a related analysis.
Experts said the efficacy of this behavior-first approach, if replicated in larger studies, could change standard medical practice, which favors stimulants such as Adderall and Ritalin as first-line treatments, for the more than 4 million children and adolescents in the United States with a diagnosis of attention deficit hyperactivity disorder, or ADHD.
The new research, published in two papers by the Journal of Clinical Child & Adolescent Psychology, found that stimulants were most effective as a supplemental, second-line treatment for those who needed it — and often at doses that were lower than normally prescribed.
The study is thought to be the first of its kind in the field to evaluate the effect of altering the types of treatment midcourse — adding a drug to behavior therapy, for example, or vice versa.
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“We showed that the sequence in which you give treatments makes a big difference in outcomes,” said William Pelham of Florida International University, a leader of the study with Susan Murphy of the University of Michigan.
“The children who started with behavioral modification were doing significantly better than those who began with medication by the end, no matter what treatment combination they ended up with.”
Other experts cautioned that the study tracked behavior but not other abilities that medication can quickly improve, such as attention and academic performance, and said that drugs remained the first-line treatment for those core issues.
“I think this is a very important study, and the take-home is that low-cost behavioral treatment is very effective,” said Mark Stein, a professor of psychiatry and pediatrics at the University of Washington, “but the irony is that that option is seldom available to parents.”
The study enrolled 146 children with an ADHD diagnosis ages 5-12 and randomly assigned half on a low dose of generic Ritalin. The other half received no medication, but their parents began attending group meetings to learn behavior-modification techniques.
Behavior modification for ADHD is based on a fairly simple system of rewards and consequences.
Parents reward the good or cooperative acts they see; subtle things, such as paying attention for a few moments, can earn a pat on the back or a “good boy.”
Completing homework without complaint might earn time on a smartphone. Parents withhold privileges, such as playtime or video games, or enforce a “time out” in response to defiance and other misbehavior.
And they learn to ignore irritating but harmless bids to win attention, such as making weird noises, tapping or acting like a baby.
The researchers had the children’s parents and teachers rate their behaviors, including recording disciplinary problems.