Peggy Drexler: Study says modifying behavior before taking pills produces better outcomes
She says parents are quick to medicate kids when faced with hard work of a behavior plan
But parents owe it to their children to try behavioral modification first, Drexler says
Editor’s Note: Peggy Drexler is the author of “Our Fathers, Ourselves: Daughters, Fathers, and the Changing American Family” and “Raising Boys Without Men.” She is an assistant professor of psychology at Weill Medical College of Cornell University and a former gender scholar at Stanford University. The opinions expressed in this commentary are solely those of the author.
You likely first heard about attention-deficit disorder, or ADD, in the early 1980s when the condition came onto the popular radar under that label, and parents and teachers scrambled to learn about treatment.
What you may not realize is that in 2010, barely 30 years later, giving children drugs to treat what is now referred to as attention-deficit hyperactivity disorder, or ADHD, had become so prevalent that half of preschoolers diagnosed with it were popping pills for treatment.
Why? Pills are easy. And by the time many parents seek help for children with ADHD or other behavioral issues, they’re often at their wits’ end and seeking an immediate solution. They’ve read all the books; they’ve tried what they think is everything. They feel judged by schools and other parents for not being able to “control their kids.”
One 2012 study pointed to the stigma attached to ADHD – for those who have been diagnosed as well as those who are related to them. And so they think that medication is their next option. They think what’s happening with their child must be entirely chemical, because how else to explain their inability to fix it themselves?
But a new report from the world of child psychology has turned up something that is good news to those who preach the “treat the cause, not the symptom” brand of care: that children diagnosed with ADHD improve more quickly when their treatment involves behavior modification first, and then medication, rather than the other way around – which, of course, is the more common route.
How common? The Centers for Disease Control and Prevention notes that fewer than 1 in 3 children with ADHD receive both medication treatment and behavioral therapy.
The new research, published as two reports in the Journal of Clinical Child & Adolescent Psychology, found that children who began treatment with approaches – such as instruction in basic social skills, based on a simple, but specific, system of rewards and consequences – fared significantly better than those whose treatment began with a pharmaceutical, even if both treatments were ultimately combined into one therapy.
The cost of care was lower, too, since behavioral modification is less expensive than medication, if not entirely free.
And yet the standard approach for addressing ADHD has long been to medicate first. There’s a very American reason for this. Many people consider medication a first-line treatment for any ailment, from high blood pressure to high cholesterol. Nearly 3 of every 5 Americans now take a prescription drug. Why? Because they can. Pills are effective – and widely available.
But drugs for children? In the case of treating ADHD, medications such as Adderall and Ritalin have been called “miracle drugs” for a reason. Before these “psychostimulant medications,” most hyperactivity in children was treated with psychotherapy, based on the belief through most of the 20th century that behavioral disorders had no biological basis. But these days, stimulants are among the most prescribed medications for American adolescents and children.
This is largely because between 70% and 80% of children with ADHD respond positively to the drugs – that is, they accomplish the goal of increasing the levels of dopamine in the brain and, in turn, help to reduce symptoms of hyperactivity, inattentiveness and impulsivity. Recent research has even suggested that such drugs cannot only help treat the disorder but also normalize a child’s brain.
But these drugs are not exactly solving the problem; that is, they’re not reducing the incidence of ADHD. The number of children diagnosed with ADHD, already high, is growing. A 2014 report found that prescriptions for ADHD drugs were up nearly 28% among children.
At the same time, there’s a good chance that many children are over-prescribed, or prescribed “just in case”: According to the American Psychiatric Association, 5% of U.S. children have ADHD, but the CDC points to studies showing that diagnoses hover around 11%.
What the new study makes clear is that the behavioral modifications designed to help children with ADHD are not the standard behavioral modifications that work on other children, and that parents of children with ADHD do need help – and not just in pill form.
Some modifications as suggested by the researchers include rewarding a child’s cooperation or patience with verbal praise, such as “good job,” or acknowledging the complaint-free completion of a task like homework or chores with screen time or a special dessert. If a child misbehaves, certain privileges are withheld.
The researchers also encourage parents to resist a child’s play for negative attention, learning to ignore annoying habits such as humming, making noises or otherwise acting out. Pretty routine stuff, and tacks that many parents take already.
But there are some parents who aren’t able or willing to put in the time to enact such a behavioral modification plan, and indeed, for them, reaching for a pill is quicker. The study authors suggested that many parents of children who began treatment with medication were less interested in following up with behavior classes. Behavioral modification is a lot of work – a lot more than giving a kid a drug, at least.
What would help: greater awareness and conversation between parents, educators and health care professionals about early signs of ADHD and alternative treatments. Parents need information – and they must also educate themselves – about their options and where they can turn for help. And they should do this without delay once they notice symptoms.
At the same time, American parents need to adjust their expectations and know that no behavior in children – and especially not one linked to ADHD or any other physiological condition – will improve without consistent, long-term attention – their attention.
Pills can help. But they have greater impact in concert with other lifestyle changes that parents should step up and make – for the sake of their children.