Imagine a treatment that could manage the behavior of a child with attention deficit disorder (ADD), make you a better parent, and enlist teachers to help him do well in school--all without the side effects of ADHD medications.
There is such a treatment. It’s called behavior therapy--a series of techniques to improve parenting skills and a child’s behavior.
“When I first diagnose a child with ADHD, I tell the parents they need to learn behavior techniques, whether I’m prescribing medication or not,” says Patricia Quinn, M.D., co-author of Understanding Women with AD/HD and When Moms and Kids Have ADD, and who has treated ADD patients in Washington, D.C., for more than 25 years.
“A pill decreases common ADHD symptoms like impulsivity and distractibility, but it doesn’t change behavior. A child on medication might be disinclined to punch someone, because he’s less impulsive, but he doesn’t know what to do instead. Behavior therapy fills in the blanks, by giving a child positive alternative behaviors to use.”
Quinn is not alone in prescribing behavior therapy for patients. According to the American Psychological Association, it should be the first line of treatment for children with ADHD who are under five years of age.
William Pelham, Ph.D., director of the Center for Children and Families at the State University of New York, goes further, suggesting that children of any age try it before medication.
“There’s clear evidence that a behavioral approach will work for the majority of children with ADHD,” says Pelham. “The benefit of using behavior therapy first is that, if a child also needs medication, he can often get by with a smaller dose.”
Recent evidence suggests that children who are put on medication first never try behavior therapy--or they try it years later, if medication has stopped working. According to a four-year study Pelham is conducting on medication and behavior therapy, at the University at Buffalo, “Parents who see that medication is working are less motivated to follow through with behavior therapy. That would be fine if the data showed that medication alone helped the long-term trajectory of ADHD kids. It doesn’t.”
According to Pelham, a child can take medication for 10 years, and the day you take him off of it--or he decides not to take it any more, as some 90 percent of teenagers do--the benefits stop. Then what? “It’s a lot harder to learn from scratch how to deal with a teenager who’s acting out than it is with a five-year-old who is acting out,” he says. “The parent has lost five or 10 years relying on medication and not dealing with problems that behavior therapy could have addressed.”
What Pelham doesn’t point out is that successfully implementing behavior therapy at home is hard work. It requires that you and your child change the way you interact with each other--and that you maintain those changes over time. Unlike the benefits of medication, behavioral improvements may not be apparent for weeks or months.
“The benefits a child receives from behavioral treatment are strongly influenced by the ability of the parent to consistently implement the program plan,” says Thomas E. Brown, Ph.D., assistant clinical professor of psychiatry at Yale University School of Medicine.
The Earlier, the Better
Although it’s never too late for a child to benefit from behavior therapy, evidence suggests that it works best when started early in the child’s life. Younger children generally have simpler problems, and these may be responsive to behavior therapy. For younger children, parent-child interactions aren’t ingrained and may be easier to change.
“Studies show that the average ADHD child has one to two negative interactions per minute with parents, peers, and teachers,” says Pelham. “If you extrapolate, that’s half a million negative interactions a year. Either you sit back and let your child have those negative experiences, or you intervene early and do something to stop them.”
Quinn suggests that the longer a parent interacts negatively with her child, the greater the chances he will develop secondary behaviors, like oppositional defiant disorder, anxiety and/or depression, and low self-esteem. “You can avoid such problems by treating early with behavior therapy.”
An intriguing new study suggests that using behavior therapy early in a child’s life may actually prevent ADHD or minimize its severity. Neuroscientists at the University of Oregon studied children ages 18 to 21 months old who had a gene called the “7 repeat allele,” which has been associated with ADHD. This gene is present in about 25 percent of children who have the condition.
The researchers observed the children’s behavior and their interactions with parents. They found that children whose parents scored highest in measures of “parent effectiveness” (gauged by how supportive they were and how well they interacted with their kids) were less likely to show symptoms of ADHD than children with the gene whose parents scored lower.
“It appears that, in children who have a genetic susceptibility to ADHD, things can be done to prevent it,” says Michael I. Posner, Ph.D., professor emeritus of psychology at the University of Oregon, who headed the study. “Good parenting may be part of that.”
“Although, in some cases, ADHD is inevitable, in a high percentage of children, ADHD occurs because of environmental influences, including the kinds of interactions they have with their parents early in life,” says James Swanson, Ph.D., professor of pediatrics at the University of California in Irvine.
Quinn disagrees. “Swanson seems to be saying that parents are the cause of ADHD,” she says. “Yet it’s been established that ADHD is a genetic or inherited disorder in a majority of cases. It is true that parents can make the condition worse or better. Employing appropriate parenting techniques is something they can do to make it better, and to modify the impact that ADHD behaviors have on the child and the family.”