England has a new plan for helping children with ADHD: Treat the parents first.
With that, the National Institute for Health and Clinical Excellence is giving a big "Whoa, Nelly!" to the recent trend toward increased use of Ritalin in the United Kingdom, saying instead that the first response should be to give parents training on how to handle kids who are inattentive, hyperactive, or impulsive.
What would ADHD treatment look like here if the United States adopted the same national standard? With as many as 10 percent of children here medicated, that's no small question.
The news about England's new ADHD treatment standard comes at the same time that a new report says American children are three times more likely to be prescribed stimulant drugs like Ritalin than are children in Europe. American kids probably aren't more hyper than their European counterparts; indeed, international surveys have shown that there's ADHD in every corner of the world. There are a lot of reasons for the differences in prescribing among countries, including direct-to-consumer drug advertising, different government restrictions and insurance reimbursements, and most important, cultural beliefs. If an American doctor diagnosed a child with ADHD and recommended counseling, most parents would presume it was for the kid.
"Sometimes, parents make that presumption, but when you're talking about counseling—behavior management, proper rewards, consistency in parenting—it's really a parent-focused therapy," says Andrew Adesman, the chief of developmental and behavioral pediatrics at Schneider Children's Hospital in New Hyde Park, N.Y., who is active with CHADD, an advocacy organization for people with ADHD. In other words, change the parent's behavior, and the child's behavior will change, too. The parent training recommended is not specific to ADHD but rather teaches behavior management skills that could be used with all children: having realistic expectations for a child's behavior, clearly explaining goals and rules, identifying behavior that's inappropriate, and following through with sanctions for rule violations and rewards for good behavior.
Earlier this year, I spent a lot of time trying to figure out the secrets to raising great kids and learned that we know what works; it's just that in the heat of the moment, we parents often do the wrong thing. A lot of what works is counterintuitive. Scientists have conclusively proven that nagging doesn't work, for instance, but we all do it.
Saying that parents of a child with ADHD need training doesn't mean that the parents are the problem, Adesman says. "But maybe they need to change their approach to the child, or be more realistic. The parents can oftentimes improve the child's behavior."
That's of a piece with the controversial advice from Lawrence Diller, a pediatrician in Walnut Creek, Calif., whose books about children and ADHD include The Last Normal Child. Parents who create and enforce clear rules can often inspire a dramatic turnaround in child behavior, Diller says. The controversy comes because Diller argues that, with some children, discipline can also include spanking.
The British experts don't say never use Ritalin. Rather, they say it should be reserved for children with severe ADHD. Studies in the United States have shown that medication improves behavior faster than therapy in the short term. But for many families, parent training or family therapy can be the answer to the often-troubling question on Ritalin—yes or no?
Most health insurance doesn't provide nearly the same coverage for education and counseling as it does for pill-prescribing, and in some communities, it can be hard to impossible to find good services. Now that the powers in the U.K. have decreed that parent education comes first, that means that insurance will pay for it. Wouldn't it be a wonderful thing if American families had that same opportunity?