UB Expert Advocates Combining Behavior Therapy With Medication For Treatment of ADHD

BETHESDA, MD. -- Children with attention deficit hyperactivity disorder (ADHD) need to receive behavior modification therapy along with medication if treatment for the disorder is to be long-lasting, William E. Pelham, Jr., Ph.D., told the National Institutes of Health (NIH) Consensus Development Conference on Diagnosis and Treatment of ADHD in a presentation at NIH headquarters here on Monday (Nov. 16, 1998).

Pelham helped to plan the three-day conference and was one of 30 researchers invited to present their latest findings before a panel of scientists and lay people.

Based on information presented at the conference, the panel will prepare a draft consensus statement with treatment recommendations for physicians and consumers. The draft will be available on the Web at http://consensus.nih.gov .

The purpose of the consensus development conference was to review the current state of knowledge on diagnosis and treatment of ADHD and identify directions for future research. ADHD is the most common mental-health disorder of childhood, affecting 3-5 percent of the population.

A UB professor of psychology, Pelham is one of the leading researchers in ADHD in the U.S. He directs UB's ADHD program and conducts a highly successful behavior-modification summer program at the university for children with ADHD.

At the NIH conference, he provided an overview of current psychosocial (non-drug) interventions for the disorder -- approaches that have found a place in ADHD treatment because medication hasn't proven to be the answer for all children.

"Although it is very helpful for many children, current medication provides no long-term benefit," Pelham said. "If you stop taking it, you lose the benefit." He also noted that only a small minority of children who meet the criteria for ADHD actually receive medication for it, and that a survey of prescriptions in one New York county revealed that the vast majority of ADHD children for whom medication was prescribed received only 1-2 months worth of prescriptions.

"The implication is that many parents did not like the effects of the medication and did not have the prescriptions refilled," he added. "These data suggest that despite evidence that medication is effective in the short term in controlled studies, it is not being used appropriately in real life, which limits it effectiveness in the long term."

Shortcomings such as these justify examining the usefulness of psychosocial treatments, he said, adding that he believes neither treatment is the answer.

"A combination of treatments is best," he stated.

At the consensus development conference, Pelham presented a review of 60 studies on psychosocial interventions. Effectiveness of a treatment was measured using various criteria, depending on the study design, and included improvements in areas such as family functioning, classroom behavior, academic productivity and achievement, scores on cognitive tests and peer relationships. Evaluations were made by parents, children, teachers, peers and/or clinicians, depending on the study.

• Behavioral intervention in classroom settings is a well-established treatment, found to be effective in 23 studies and is widely used in school settings.

• Training parents to do behavioral interventions was found to be equally effective.

• Clinical behavior therapy of the type likely to be implemented by therapists in community mental-health, primary-care and private-practice settings results in clinically important improvement on multiple measures in home and school, although improvements are not as large as those obtained in medication studies.

• Psychosocial interventions are most effective when they are intensive, highly structured, closely monitored and include maintenance programs once gains have been achieved. This requires major commitments of parents and teachers. Ways to identify those parents and teachers who are least likely to comply with interventions are needed.

• Many psychosocial treatments used in mental-health settings, such as individual therapy and play therapy, have not been shown to be effective with ADHD children.

Pelham acknowledged that treating with medication is less expensive than intensive behavioral interventions, but that combining the two may be most effective. Behavioral modification can be less intense if a child is receiving medication, which lowers its cost, he noted. Such programs would not increase total health-care costs if implemented wisely, he said.

"We spend enormous amounts of money on child mental-health therapies that don't work," he added. "It's not a question of adding new money. It's a matter of allocating current resources to therapies that do work."