ADHD Medication: Can Your Child Go Without?

Behavioral therapy for ADHD—and parent retraining, too—can be good alternatives to medication.

Video: ADHD

Video: ADHD

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"Parent training is much more work," Pelham agrees. "It's a pain. But being a parent is a pain."

Teaching kids life skills. It's time to start thinking about new ways to treat ADHD, says Howard Abikoff, director of the Institute for Attention Deficit Hyperactivity and Behavior Disorders at the New York University Child Study Center. "Do we have enough evidence-based treatments to say we know how to deal with the problems in these folks' lives?" he asks. "I don't think so."

Many children with ADHD struggle with social skills, such as waiting for their turn to talk instead of interrupting or keeping their temper instead of dissing teachers. Increasingly, programs are trying to solve that problem with behavioral treatments that offer rigorously tested skills training. Duke University Medical Center's ADHD program, for one, offers classes for third to fifth graders on listening and following directions, homework, organizational skills, effective communication, and problem-solving. ADHD therapeutic summer programs, including the Summer Treatment Programs founded by Pelham, as well as ADHD summer camps offer skills training at a level that might not be available closer to home. Mary Alvord, a clinical psychologist in Rockville, Md., offers weekly group sessions using cognitive behavioral therapy to help children with ADHD improve their social skills. "We also mix in kids with social anxiety," Alvord says. "They provide excellent modeling opportunities and support for one another."

Abikoff is halfway through a National Institute of Mental Health-funded clinical trial to test whether children with ADHD can be taught to become better at organizing, time management, and planning, three skills that many continue to struggle with as working adults. "If you've ever looked in the book bag of some of these children, it's quite remarkable," Abikoff says. "Even if the kids are doing everything in the classroom that we've worked on with them, it's still possible that they'll come home and they don't have it," Abikoff says. "We try to provide them with reminders at the point where it's critical to remember—something attached to the zipper of their book bag. It's the last thing they do before they walk out."

Finding the right help for your child. Scientists now know that ADHD takes different forms, and those differences are probably rooted in brain physiology. For instance, about 20 percent of children get no benefit from stimulant medications, but right now the only way to find out who does is by trying the drugs. Someday there may be a simple test that will tell parents just what form of ADHD their child has and what treatment will work best. For now, alas, finding the right fit is all too often lots of trial, too much error. Just one example: Doctors and therapists often recommend "talk" or "play" therapy for the child, even though there is no evidence that it helps with ADHD. Indeed, behavioral treatments that teach skills to parents or children are the only nonmedical form of ADHD therapy with solid scientific evidence that they work.

In the 1990s, the National Institute of Mental Health tried to weigh the relative benefits of the two most common treatments for ADHD: stimulant drugs and behavioral treatments, including parent training. The Multimodal Treatment Study of Children with ADHD followed 579 grade-schoolers for 14 months. Some got stimulants, and some got behavioral therapy that included parent training, teacher training, and a summer camp that taught the kids social skills. A third group got both medication and the behavioral intervention. A fourth group had treatments chosen by their parents in the community. At the end, the children in all four groups were doing better. Parents and teachers rated the medication-only group as having many fewer symptoms of inattention and hyperactivity/impulsivity. But they rated the children who got behavioral treatment as doing better on aggressive behavior, peer relations, parent-child relations, and academic achievement. Since the first results were published in 1999, researchers have been arguing strenuously over whether the study proves that medication or treatment without medication is best.