Most kids who are treated for attention deficit hyperactivity disorder take stimulant medications, but new research suggests that the need for these drugs can be reduced dramatically in those who get behavioral therapy as well.
When the two approaches were combined, the amount of medication needed to achieve the same results as drugs alone was reduced by two-thirds, researchers from the University at Buffalo reported.
The study was also the first to test the effectiveness of a new ADHD patch containing methylphenidate, the stimulant also known as Ritalin. The study was funded by the patch's manufacturer, Shire Pharmaceuticals Group.
Smaller Doses
"One of the major findings of the study is that when using behavior modification, you can get away with tiny, tiny doses of medication, much lower than previously thought, says ADHD researcher William E. Pelham Jr.
Pelham tells WebMD that the patch, which is not yet on the market, allows more dosing flexibility than oral medications because it can be put on and taken off when needed.
The researchers write that studies have shown that behavioral therapy works to improve some ADHD symptoms. The improvements are comparable to low-dose stimulant medication, they add. However, not all researchers agree with the effectiveness of this approach to ADHD treatment.
A Medical Debate: Drugs vs. Behavior Therapy
The debate over how well behavioral approaches work in the treatment of ADHD is long and contentious. Behavioral therapy advocates like Pelham claim that far too many children are being overmedicated with stimulants like Ritalin, Adderall, and Concerta.
On the other side of the argument are ADHD experts who say drug treatments have been shown in study after study to be far more effective than behavioral treatments.
The largest and most widely publicized of these investigations was the National Institute of Mental Health-funded Multimodal Treatment Study (MTS), reported in 1999.
But Pelham says the findings have been largely misinterpreted by the press and the medical establishment.
"The ADHD community has embraced this study as proof that behavioral therapy is not effective, but that was not the finding at all," he says. "A combination of behavioral therapy and drugs was the most effective intervention in the study, followed by drugs alone."
Combined Treatment Works Better
In his newly reported study, researchers followed 27 children with ADHD, aged 6-12. The children participated in a highly intensive behavioral therapy program developed by Pelham almost a decade ago. The summer-treatment program includes both recreational and classroom components with a very high ratio of teachers to students.
When used alone, the Ritalin patch and the intensive behavior modification were found to be equally effective treatments.
When the two treatments were combined, however, children required much lower doses of medication -- as much as 67% less -- to achieve the same effects as high-dose medication used alone, Pelham says.
He adds that a lower dosage of drugs means a lower risk of long-term drug-related side effects, which can include loss of appetite.
"Long-term side effects of ADHD drugs are almost always related to dosage," Pelham says. "If you want to lower a child's dosages daily and throughout their lifetime, the best way to do that is to combine the medication with behavior modification."
Treatment Approach Difficult to Replicate
ADHD specialist Howard Abikoff, PhD, agrees that intensive behavior modification can be very effective while the child is getting the treatment. The problem, he says, is that highly intensive approaches like Pelham's summer program are difficult to replicate in real-world settings.
Abikoff directs the Institute for ADHD and Related Disorders at the New York University Child Study Center.
"Basically that means at home and in school," he tells WebMD. "When we try this approach outside of the summer-treatment program it is very difficult to achieve the same level of improvement in ADHD symptoms."
Abikoff says drug therapy alone works well to normalize ADHD symptoms in just over half of children.
"It is clear that in most children with severe symptoms, behavioral therapy alone is usually not sufficient," he says. "But children and their parents and teachers also need to learn management skills to help cope with the ADHD. Many kids have problems that medication doesn't address."
By Salynn Boyles, reviewed by Brunilda Nazario, MD
SOURCES: Pelham, W. Experimental and Clinical Psychopharmacology, May, 2005; vol 13, issue 2. William E. Pelham Jr., PhD, University at Buffalo Distinguished Professor, department of psychology; director, Center for Children and Families, University at Buffalo. Howard Abikoff, PhD, director, Institute for ADHD and Related Disorders, New York University Child Study Center.
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