Newspaper article International New York Times

New Thinking on A.D.H.D. Drugs ; Medication Works Best When Behavioral Therapy Is Tried First, Study Finds

Newspaper article International New York Times

New Thinking on A.D.H.D. Drugs ; Medication Works Best When Behavioral Therapy Is Tried First, Study Finds

Article excerpt

Experts said this approach could possibly change standard medical practice, which urges medications like Adderall and Ritalin as first- line treatments.

Children with attention-deficit problems improve faster when the first treatment they receive is behavioral -- like instruction in basic social skills -- than when they start immediately on medication, a new study has found. Beginning with behavioral therapy is also a less expensive option 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 like Adderall and Ritalin as first- line treatments, for the more than four million children and adolescents in the United States with a diagnosis of attention deficit hyperactivity disorder, or A.D.H.D.

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.

"We showed that the sequence in which you give treatments makes a big difference in outcomes," said William E. 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, like 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 A.D.H.D. diagnosis from ages 5 to 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 A.D.H.D. is based on a fairly simple system of rewards and consequences. Parents reward the good or cooperative acts they see; subtle things, like paying attention for a few moments, can earn a pat on the back or a "good boy. …

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